Waterford, MI, USA
N3829G
CESSNA 310R
The airplane, operated by an on-demand cargo carrier and flown by a newly hired pilot, was on a positioning flight when it impacted trees and terrain about 1,500 ft short of the runway during a straight-in instrument landing system (ILS) approach. Night instrument flight rules (IFR) conditions prevailed with recorded weather observations that were below the minimum visibility specified for the approach. Radar data showed that while on the final segment of the ILS approach, the airplane's approach was unstabilized in speed and position along the glidepath. The shallow angle of the wreckage path and its length were consistent with controlled flight into terrain. Examination of the wreckage revealed no anomalies that would have precluded normal aircraft operation. The pilot had undergone company training provided by the company's president, who was also the director of operations, and the chief pilot; these two individuals were the only company instructors approved by the Federal Aviation Administration (FAA) to provide Part 135 training in accordance with the company training manual. However, the majority of the pilot's flight training in the accident airplane make and model was during a flight with a company pilot who was not approved by the FAA to provide Part 135 instruction. Further, although company records stated that the pilot met the training requirements for ground and flight training in accordance with the company training manual, the minimum flight times in the accident airplane make and model were not met and the method of ground instruction was not followed in accordance with the company training manual. A review of the weather for the pilot's previous company flights showed that he had not flown in actual conditions that were at approach minimums at night, similar to those at the time of the accident. The chief pilot stated that higher approach weather minimum limitations were placed upon the pilot and that company dispatchers watched most new pilots' minimums until they got more experience with the company. However, although the dispatch manager indicated he was aware of weather limitations for the pilot, he stated that the dispatchers had no means of routinely communicating with the pilots inflight, and he could not recall when there had been any other pilots with weather limitations. Furthermore, there was no FAA-approved program or policy within the company operations specifications or other manual for higher approach minimum limitations based upon experience for company pilots of piston engine powered airplanes such as the accident airplane.
HISTORY OF FLIGHTOn January 10, 2014, about 1948 eastern standard time, a Cessna 310R, N3829G, impacted trees and terrain about 1,500 feet west of the approach end of runway 9R (6,521 feet by 150 feet, asphalt) at Oakland County International Airport (PTK), Pontiac, Michigan, during a straight-in instrument landing system (ILS) approach to runway 9R. Night instrument meteorological conditions (IMC) prevailed at the time of the accident. The commercial pilot sustained fatal injuries. The airplane was destroyed by impact forces and a post impact fire. The airplane was registered to and operated by Royal Air Freight, Inc. as flight RAX907 under the provisions of 14 Code of Federal Regulations Part 91. The positioning flight was operating on an instrument rules flight plan and departed from Fulton County Airport-Brown Field (FTY), Atlanta, Georgia, about 1701, and was destined to PTK. During an interview with the National Transportation Safety Board (NTSB) Investigator-In-Charge (IIC), the pilot's wife stated that on the afternoon of January 6, 2014, her husband received a phone call from Royal Air Freight, Inc. to fly a flight to either Fargo, North Dakota or Atlanta, Georgia. After his departure for the trip on January 6, 2014, she had not seen him, and they communicated solely by text messages since that time. He was to return via a flight to Ohio. She said that a January 8, 2014 text message from her husband said that Royal Air Freight, Inc. dispatch told him to get a hotel room. A January 9, 2014 text message stated that he was to fly from Ohio to Minneapolis and that he would arrive in Pontiac, Michigan at 1800. At 1945, her husband sent a text message that described his frustration with Royal Air Freight, Inc.'s scheduling and that "there was a major lack of communication" from Royal Air Freight, Inc. About an hour later, he sent a text message saying that the airplane he was to fly, N3829G, was broken. The pilot's wife said that they had planned a trip to Florida, which they were to depart for on January 11, 2014. They had planned to pick up a car rental in Detroit, Michigan on January 11, 2014 at 0900 and were to drive to Florida. They had purchased airline tickets for their return trip from Florida. She stated that she requested time off from her employment about two months before the trip. A maintenance facility in Atlanta, Georgia, issued a maintenance work order dated January 10, 2014 for N3829G, which stated the right engine starter was inoperative, and the left tire pressure was low. The right engine starter was removed and replaced with an overhauled starter, and the subsequent operational check of the starter was "good". The left tire was filled with nitrogen. On January 10, 2014, a filed instrument flight plan was activated for RAX907 for a flight from FTY to PTK with a proposed departure time of 1650 and a cruise altitude of 7,000 feet mean sea level (msl). The filed alternate airport for the flight was Bishop International Airport (FNT), Flint, Michigan, which was about 22.9 nautical miles (nm) northwest of PTK. The estimated time en route was 2 hours 28 minutes. On January 12, 2014, the NTSB IIC and the Federal Aviation Administration (FAA) Coordinator met with the Royal Air Freight, Inc. chief pilot and the director of operations. During that meeting, the chief pilot stated that they did not know how much fuel was on board when N3829G departed for PTK, and they did not know the alternate airport for the flight. The chief pilot said that "the pilots file their own flight plans." According to the Royal Air Freight, Inc. General Operations Specifications and Operations Specifications, Royal Air Freight, Inc. retains all responsibility for the operational control of aircraft operations, and thus the safety of each flight conducted under its certificate and operations specification, including the actions or inactions of all its direct employees and agents. Flight locating procedures required that the pilot-in-command of a flight give the dispatcher or a responsible person within Royal Air Freight, Inc. all information in a visual flight rules flight plan. (FAA Form 7233-1, "Flight Plan," contains an entry block for fuel on board and for alternate airport(s)). On January 10, 2014, at 1658, RAX907 departed FTY and was provided initial air traffic control (ATC) radar service by Atlanta Terminal Radar Approach Control. RAX907 was provided ATC services by numerous TRACONs and air route traffic control centers (ARTCC) en route before being transferred to Detroit TRACON at 1922. According to FAA transcripts, the flight was uneventful. Prior to RAX907's approach to PTK, another Royal Air Freight, Inc. flight, which was a Learjet 35A, RAX131, had flown the ILS runway 9R approach without incident. A written statement from the captain of RAX131, stated in part: "Received PTK ATIS as [vertical visibility] 200 [feet], ½ mile visibility, wind [from] 160 [degrees at] 10 [knots]. After check-on with Detroit approach we heard an aircraft being vectored for the approach at PTK, so we listened to the PTK tower [frequency] on [the] secondary radio. He was given [runway visual range (RVR)] of 2,200 [feet] for 9R by the tower. We were vectored for the approach and when we checked on was given [RVR] of 2,000 [feet] for [runway] 9R and wind from 180 [degrees at] 10 [knots]. During the initial part of the approach the winds were strong out of the south. It was smooth, but took a 20 degree angle to maintain the localizer. At approximately 1,800 feet we encountered light to moderate chop and started losing the crosswind. No noticeable changes in airspeed but took out almost all of the crab angle to maintain the localizer. At approximately 1,250 feet, [the second-in-command] called approach lights in sight. I responded with continue, and almost immediately Alex called green lights, runway in sight 12 o'clock. We continued and landed normally. Crosswind correction was minimal, no major airspeed/power changes noticed. As we were exiting the runway at the end, left on "U", we heard RAX907 call the tower. Do not remember if the tower issued any weather, did hear them tell RAX907 that he was following a Challenger on a 2 mile final." At 1922, RAX907 checked in with Detroit TRACON while descending out of 4,900 feet for 4,000 feet. RAX907 was provided radar vectors for the ILS runway 9R approach. After being given a descent to 3,000 feet and a final radar vector to a heading of 060 degrees, the Detroit TRACON controller cleared RAX907 for the ILS runway 9R approach at 1940, and two minutes later directed the pilot to contact PTK tower. At 1942, RAX907 checked in with the PTK air traffic control tower and was issued a landing clearance to runway 9R following a Challenger on a 2-mile final. RAX907 was issued an RVR of 2,000 feet for runway 9R. RAX907 acknowledged the landing clearance and advised they were looking for the traffic. The controller issued the surface wind. There were no further communications between RAX907 and ATC. The captain of the Challenger stated in part: "Weather was reported 2,000 [feet] RVR and vertical visibility 200 [feet]. There was no icing, turbulence or wind shear during the approach only light rain. Intercepting the localizer we had a 42 knot wind out of the south that required at least a 20 degree crab angle. Proceeding down the glide slope the winds diminished gradually and our crab angle was approximately 5 degrees at 300 feet. I called approach lights (MALSR) in sight at 100 feet above minimums and observed them at the 1130 position relative to our nose. At minimums I called runway in sight and we landed. The approach was flown with the autopilot on until minimums. I did not know of the accident until ground control announced the airport was closed while we were exiting the taxiway…" PERSONNEL INFORMATIONThe pilot, age 32, held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. Prior to November 26, 2013, he accumulated a total flight time of approximately 1,907.8 hours, of which 422.3 hours were in multiengine airplanes, 74.7 hours were in actual meteorological conditions, and 109.4 hours were at night. He was employed by Royal Air Freight, Inc., as a Cessna 310 pilot after passing his Part 135 airman checkride on December 19, 2014. After the checkride, all of the flights he had flown were in Royal Air Freight, Inc. Cessna 310R airplanes, over four trips/days, which had 11 flights totaling about 40.5 hours. The pilot's logbook showed that during his pilot training for a pilot-in-command position in Cessna 310 airplanes at Royal Air Freight, Inc. he accumulated 7.2 hours of flight time in night conditions, of which 5.4 hours were accumulated in a Cessna 310R during a December 10, 2014 flight that was flown by a Royal Air Freight, Inc. company pilot who was not a company instructor. The remaining 1.8 hours of night flight time was in a Falcon 20 airplane while in the right seat of the airplane. The amount of flight time in actual IMC during his pilot training (0.2 hours were during the checkride) was 6.0 hours, of which 4.3 hours were in Cessna 310R airplanes. Of the 4.3 hours, 3.4 hours were accumulated during the December 10, 2013 trip flown by the company pilot. There was no record showing that the pilot had flown an instrument approach in a Cessna 310 airplane, in actual night IMC to precision approach weather minimums during his training, checkride, or subsequent flights. The pilot did not have an FAA record of any previous accidents, incidents, or enforcement actions. Certificate and Ratings of the Pilot On March 15, 2005, the pilot was issued a private pilot certificate with a single-engine land rating after passing the examination for the certificate/rating on his first attempt. The total flight time that was reported at the time of examination was 59 hours. He passed the private pilot airplane airman knowledge test, private pilot, on his second attempt and received a score of 88. On November 11, 2005, the pilot was issued an airplane single-engine instrument rating after passing the examination for the rating on his first attempt. The total flight time that was reported at the time of examination was 155 hours. He passed the instrument airplane rating airman knowledge test, private pilot, on his first attempt and received a score of 87. On March 29, 2006, the pilot was issued a commercial pilot certificate with a single-engine land rating after passing the examination on his first attempt. The total flight time that was reported at the time of examination for the certificate/rating was 288 hours. He passed the commercial pilot airplane airman knowledge test on his first attempt and received a score of 88. Pre-employment Interview of the Pilot The pilot's wife stated that her husband sent resumes in order to apply for a pilot position in late October 2013 and/or early November 2013. One operator that received a resume was contacted by the NTSB IIC and that operator stated that the pilot was not offered employment because there were no positions available at the time of the pilot's application. A second operator that was contacted by the NTSB IIC stated they wanted the pilot to have more experience and therefore did not offer him employment after interviewing the pilot. The pilot's wife stated that Royal Air Freight, Inc. called her husband in November 2013. She said that her husband's interview with Royal Air Freight, Inc. was a "working flying" interview, which was on November 25 or November 26, 2014. She said the interview started about 1100 or 1200. She said that she received a text from her husband at 1827 that he finished the interview. She believed that the interview was with the chief pilot. She said that her husband told her that the interview with Royal Air Freight, Inc. was "informal", "laid back," and there was "no dress code." She said that the second operator with whom he interviewed had a uniform requirement and that it was "more formal" and "corporate." She said that she believed that her husband met with the Royal Air Freight, Inc. director of operations during the interview at Royal Air Freight, Inc. During a post-accident interview of the Royal Air Freight, Inc. director of operations with the NTSB IIC, the FAA Coordinator/Safety Inspector, and an FAA Safety Inspector, the director of operations stated they there were trying to fill the position occupied by the pilot because they have always been short of Cessna 310 pilots. When asked if the pilot was the only pilot that was interviewed for a Cessna 310 pilot position, the director of operations said that he did not recall and that the chief pilot was "kind of handing that." The director of operations stated that he believed he talked to the pilot when he was at Royal Air Freight, Inc. for the interview after the chief pilot had talked to him. The director of operations was asked by the NTSB IIC if he recalled what was discussed with the pilot when he met with him; the director of operations responded "not really." The director of operations stated that he knew the chief pilot flew with the pilot during the interview and that he (the director of operations) talked to the chief pilot about how the flight went when they returned, and the chief pilot "just mentioned [the pilot] did a really good job." The director of operations said that they normally conduct pilot interviews in which they fly with applicants on the same day to determine if the applicant can "fly or not." The director of operations said that the interview lasted "quite a while," and only he and the chief pilot talked to the pilot. The director of operations said the decision to hire the pilot was made on the day after his interview. Training and Checking of the Pilot According to the pilot's wife, the training that her husband received from Royal Air Freight, Inc. was "relaxed," because they would train him when they "felt like it" or he would "come along for a ride" She felt that the training was not standardized. It took longer for her husband to complete his [training] for his checkride. She said that he would get "critiqued" during his training at Royal Air Freight, Inc. and he was accepting of these critiques and was not defensive about them. The director of operations and chief pilot were the only company personnel authorized by the FAA to provide Part 135 airman training and checks in accordance with the Royal Air Freight, Inc. "Aircraft Training Manual" that was approved by the FAA Detroit Flight Standards District Office. Training and checking of a pilot to fly a specific aircraft make and model was to be conducted in that make and model of aircraft. The approved general training areas and facilities for ground instruction were company buildings, ramps, hangers, maintenance areas and aircraft. Ground instruction curriculum segments were not to be conducted in flight. The Aircraft Training Manual stated that a "hood" was to be used for instrument flight maneuvers. The chief pilot stated during a post-accident interview that during the pilot's training, a hood was not used, but instead, the pilot's baseball cap was used as the view limiting device to simulate IMC. During the January 12, 2014 meeting with the director of operations and the chief pilot, the chief pilot was asked by the NTSB IIC if they had training records for the accident pilot that would show the date, the flight time, the aircraft used, the instructor that provided instruction, and the description of training for each of the pilot's training flights. The chief pilot stated that they did not have such a record, were not required to keep records of individual training flights, and were only required to provide a certificate of training. The NTSB IIC then requested that such a record be provided. The Royal Air Freight, Inc. "New Hire Training" record for the pilot stated that he completed the curriculum segments for Cessna 310/402 aircraft. This record's entries stated that he met the minimum times for "turbine/piston" aircraft cited in the FAA approved training manual (there were higher minimum times for pilot training for "jet" aircraft). The minimum flight times were spec
The pilot's controlled flight into terrain during an instrument landing system approach at night in instrument flight rules conditions. Contributing to the accident were the operator's inadequate training of the pilot, the operator's failure to provide a level of oversight commensurate to the pilot's experience, and the pilot's lack of operational experience in actual night instrument conditions in the make and model of the airplane.
Source: NTSB Aviation Accident Database
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