Clay, AL, USA
N732EJ
CESSNA 210L
The pilot departed on the first leg of a revenue flight after the end of civil twilight but diverted to another airport because of adverse weather at the intended destination. Once the weather conditions improved, the pilot departed and proceeded to the first destination where he landed uneventfully; at that time, the pilot had been on duty for about 14 hours. After landing, the pilot did not call the company's director of operations as he was reportedly instructed to do when the flight was dispatched. One witness at the airport reported that the pilot seemed anxious, which the individual attributed to his being late and not because of the weather. The pilot obtained weather information for the second destination from a friend (who was a flight instructor) and subsequently departed on the visual flight rules (VFR) flight to his second destination. At the time of departure, the destination forecast was a ceiling of 1,500 ft and visibility of 6 miles. After establishing contact with the approach controller, the pilot was informed that the airport was operating under instrument flight rules (IFR). The controller asked the pilot his intention, and the pilot replied that he wanted an IFR clearance. The pilot confirmed with the controller that he was capable and qualified for IFR flight and was provided an IFR clearance. The pilot was instructed to turn right to intercept the localizer at a 30-degree angle and was cleared for the instrument landing system runway 24 approach. (Postaccident examination confirmed that one navigation receiver was set to that approach.) The airplane then banked left, and, during portions of the turn, the bank rate was three times greater than a standard banked turn, and the pilot began flying in an east-northeasterly direction while descending. The bank angle reduced and was changing at the end of the radar data. About 2 seconds after the last radar return, the pilot stated, "say again for two echo Juliet." This response likely indicated that he was not prepared for the approach clearance instructions or was distracted by cockpit duties. The controller immediately instructed the pilot to level the wings and climb, but there was no reply. A performance study indicated that the airplane made a left bank of about 60 degrees (a rate of turn of about 11 degrees per second) during the last seconds of flight before it crashed about 0.3 mile from the last radar target. The airplane was fragmented after impacting trees and terrain on a magnetic heading of about 284 degrees. Postaccident examination of the airplane revealed that the flaps and landing gear were retracted, and there was no evidence of preimpact failure or malfunction of the airframe, flight controls, or engine. There were no reported issues with the localizer at the airport following the accident. Although one witness reported hearing a sputtering sound coming from the engine likely about the time that the flight was being vectored by the air traffic controller on the downwind leg, the pilot did not advise the controller of any problems during that or any subsequent portion of the flight. Additionally, a witness who was located less than 1/2 nautical mile from the accident site reported that the engine sound was steady. Further, a cut portion of tree made by the propeller was consistent with the engine developing power. Although windshear advisories were in effect and windshear was reported from a flight crew about 29 minutes after the accident, the wind encountered by the airplane at the time of the accident likely would not have caused the pilot to turn in a direction opposite that instructed by the controller. The pilot was reportedly in good health, and his communications with the controller indicated that he likely was not impaired at the time of the accident. Although the autopilot programmer/computer was too badly damaged to functionally test, the steeply banked turn opposite that instructed by the air traffic controller was likely the result of pilot input and not the result of an autopilot malfunction. The roll servo was tested, and the lowest reported override force was slightly less than the lowest limit. Thus, if the autopilot had commanded greater than 90 percent of a standard-rate turn, the pilot would have been able to easily override the roll servo. It could not be determined if the engine-driven vacuum pump was operating or the standby vacuum system was engaged; however, the electrically driven instruments, such as the turn coordinator, and flight instruments consisting of the airspeed indicator, altimeter, and vertical speed indicator would have provided the pilot with roll and pitch information. Although the pilot was instrument-rated and had recently passed his instrument proficiency check, he was only qualified to fly VFR in revenue operations. He was also not current to fly at night, which was unknown to company personnel at the time of dispatch. In addition, although the flights could have been completed within the pilot's duty day if there were no delays, company personnel should have recognized that weather was causing delays and that the pilot was continuing to fly beyond his duty day. Thus, the company's dispatch procedures were lacking in that they allowed the pilot to fly in night, instrument meteorological conditions beyond his duty day, and company personnel were seemingly unaware that he initiated the flight and was not current to fly at night.
HISTORY OF FLIGHTOn February 14, 2014, about 2221 Central Standard Time, a Cessna 210L, N732EJ, crashed in a heavily wooded area near Clay, Alabama. The commercial pilot and one passenger were fatally injured. The airplane was destroyed. The airplane was registered to and operated by Southern Seaplane, Inc., under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as a non-scheduled, domestic, cargo flight. Instrument meteorological conditions prevailed in the area at the time and an instrument flight rules (IFR) clearance had been obtained by the pilot from air traffic control. The flight originated from Jackson-Medgar Wiley Evars International Airport (JAN), Jackson, Mississippi, about 2106 CST, and was destined for Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama. Earlier that day, an individual with Mississippi Organ Recovery Agency (MORA) contacted Southern Seaplane, Inc., located in Belle Chasse, LA, and spoke with the accident pilot about a request to transport specimens from Stennis International Airport (HSA), Bay St Louis, Mississippi, to BHM and then to JAN. The trip was to depart HSA at 1800 CST, and arrive at BHM before 2000 CST. The pilot in turn contacted the company Director of Operations (DO) and discussed the trip. According to the company DO, the accident pilot expressed an interest to fly the trip, and the DO indicated he would have been within his duty day at the estimated landing time at Birmingham, and he had experience flying blood and organs for MORA in the past. The DO also indicated that the accident pilot asked him if he could take his wife along, which he agreed to because of the significance of the day. The DO reported that the accident pilot called him about 5 minutes later and said he had checked the weather and determined weather would be moving into BHM, so it was decided to fly to JAN first. He informed the pilot to ask the representative of MORA if it was acceptable to fly into JAN first instead of BHM. He also instructed the pilot to call him when he was on the ground at JAN to discuss the weather and reportedly told him if the weather was bad to have the MORA representative drive the blood samples to BHM. According to company records, the flight departed Southern Seaplane Airport (65LA), Belle Chasse, LA, on a 14 CFR Part 91 positioning flight between 1730 and 1736 CST, and proceeded to HSA where the pilot landed uneventfully about 1804 (end of civil twilight was later determined to occur in that area at 1810). After landing he was provided with specimens and the pilot informed the individual that provided the specimens of the estimated time of arrival at both airports but that the times were depending on the weather conditions. The person on the ground at HSA who provided the specimens to the pilot reported observing him spend 5 to 7 minutes in a room with computers that provided weather information. The flight departed HSA about 1835 (approximately 25 minutes after the end of civil twilight), but landed at Magee Municipal Airport (17M), Magee, Mississippi. The company DO reported that the pilot texted him at 1914, and informed him that he had landed there to wait out the storm at JAN, and at 1925, the pilot communicated with an individual with MORA and advised him that he was unable to proceed to JAN because of adverse weather in the Jackson, Mississippi, area. Also while at 17M, at 1944 CST, the pilot called a friend of his who is a certified flight instructor (CFI) and whom had given him an instrument proficiency check (IPC) flight several months earlier. During that call the pilot stated that he was flying a Cessna 210 for a blood run, and was waiting at 17M for thunderstorms to clear. The CFI reported he checked the weather and saw why the pilot had landed. During the phone call the CFI checked the METARS at JAN and also at BHM, noting at that time that the METARS for BHM indicated the ceiling was between 3,500 or 4,000 feet. He also checked the terminal area forecast (TAF) for BHM which indicated the ceiling would be dropping to 1,500 feet and wind gusts to 29 or 30 knots possibly higher were expected. The CFI told the pilot to expect a rough trip based on the winds, and to expect an ILS Runway 24 Approach at BHM based on the wind. The accident pilot did not mention any health issues, and the CFI reported he (accident pilot) seemed upbeat during the phone call. There was no further conversation between the CFI and the accident pilot. The DO reported the flight was delayed longer than expected; the flight departed 17M between 2008 and 2010. The pilot proceeded to JAN and landed uneventfully about 2050. After landing, a toxicology box of specimens was offloaded, and the individual who received them asked the pilot if he was going to BHM, to which he replied that he was if the weather cooperated. The company DO reported the pilot did not contact him as instructed. The individual who was given the specimens reported that although she had never met the pilot before, to her he appeared anxious. She also reported that the pilot repeatedly apologized for being late and attributed his anxiousness to being tardy, rather than being due to the weather. According to a chronological summary of flight communications with JAN Air Traffic Control Tower, at 2103, the pilot contacted ground control requesting visual flight rules (VFR) flight following to BHM, to be flown at either 3,500 or 5,500 feet mean sea level (msl). The pilot was advised to maintain VFR at or below 5,000 feet msl, and was assigned a discrete transponder code of 1546. At 2106, the flight was cleared for takeoff, and after takeoff air traffic control (ATC) communications were transferred several facilities while proceeding towards BHM. At 2145, the pilot established contact with the R14 sector of the Memphis Air Route Traffic Control Center and advised the controller that he was at 5,500 feet. The controller provided the pilot the altimeter setting for BHM, which he acknowledged, but the controller did not communicate with the pilot after that time. The controller did coordinate with the next facility, which was the Atlanta Air Route Traffic Control Center (ARTCC); however, the controller did not instruct the pilot to establish contact with that facility. The Atlanta ARTCC also did not establish contact with the pilot, but the controller did coordinate with the next facility, which was the BHM ATCT. There was no record of any contact by the pilot with any ATC facility between about 2145, and 2208:04; between 2154 and 2206, radar data from Birmingham ATCT indicates that the flight proceeded in a northeasterly direction while flying about 5,600 feet msl (slight altitude deviations were noted). The radar data indicates that between 2206 and 2208, the flight descended from 5,800 to 4,300 feet msl while continuing in a northeasterly direction. The transcription of communications from Birmingham ATCT indicates that at 2208:04, the pilot established contact with the facility. The controller immediately provided the altimeter setting and informed the pilot that the airport was IFR, and asked him to advise he had automated terminal information service (ATIS) Golf. The controller also asked the pilot to state his intentions. The pilot stated that he had ATIS information Golf, and requested local IFR clearance for an ILS approach to runway 24. The controller asked the pilot, "just uh for the tapes just need to make sure are you capable and qualified of IFR flight" to which he replied, "affirmative." At 2208:32, the controller cleared the flight to BHM via radar vectors on a 55-degree heading, and to maintain 4,000 feet. Radar data indicates the flight continued in an east-northeasterly flight track with altitude deviations minus 200 feet to plus 200 feet from the assigned altitude noted, although between 2213:28 and 2218:26, with the exception of 1 radar return, the airplane maintained a constant altitude of 4,000 feet msl. At 2217:57, the controller instructed the pilot to turn right to heading 090 degrees and to descend to and maintain 3,000 feet, which he acknowledged. The radar data indicates the groundspeed at that time was approximately 160 knots. About 2218:16, the radar data indicates a turn to an easterly direction occurred and the airplane began descending. About 2219:18, while at 3,400 feet msl, the controller instructed the pilot to turn to right to heading 150 degrees, which he responded, "one five zero echo Juliet." At 2219:30, a position relief briefing occurred. During this briefing the controller being relieved informed the relieving controller in part, of the active runways, aircraft that were on approach were breaking out about 100 feet above minimums, and there was no icing. Between 2219:18, and 2220:13, the airplane continued on a flight track of approximately 103 degrees magnetic and descended from 3,400 to approximately 3,000 feet, then about 2220:13, a change to a flight track of approximately 149 degrees was noted and the groundspeed increased to 190 knots. At 2220:38, the controller instructed the pilot to turn right to heading 210 degrees, and advised him that the flight was 3.5 miles from HUKEV and to maintain 2,800 feet until established on the localizer, cleared for the ILS runway 24 approach. The radar data indicated that at the completion of the controller's approach clearance instruction at approximately 2220:46, the airplane was at 2,700 feet msl, and then turned left flying in a northeasterly flight track. According to the NTSB Radar Study, plotting of the radar targets onto an instrument approach plate indicated the airplane turned left flying nearly over the outbound course of the procedure turn. At 2220:54, the airplane was lost from radar at 2,400 feet msl; the airplane at that time was located at 33 degrees 42.166 minutes North latitude and 086 degrees 33.533 minutes West longitude. About 2 seconds after the last radar target, the pilot stated, "say again for two echo juliet." About 2221:00, the controller informed the pilot that it appeared he was in a turn to the north, and advised him to level the wings, maintain 2,800 feet, or climb to 3,000 feet; there was no reply from the pilot. A copy of the NTSB Radar Study and radar data used for the study are contained in the NTSB public docket. A witness who was located about .8 nautical mile north of the flight path of the airplane as it proceeded on an east-southeasterly direction, and 3.3 nautical miles northwest of the accident site reported that she and her husband were inside their house, and she heard an engine making a sputtering sound as if it were not getting fuel or there was water in the fuel. She reported that the engine "cut off totally and then restarted." By sound the airplane was heading 220 degrees, and turned left while over her house. She reported that by sound the airplane was low but she never saw it. She was not sure if it was raining at the time, and reported the wind had been blowing. She has lived in the house 6 years and airplanes do fly frequently over her house. She reported that the sputtering sound continued while in the turn. Another witness located less than ½ nautical mile north of the accident site and familiar with airplanes reported after 2200, he heard the sound of a low flying airplane based on the sound level. It got his attention enough to walk out onto his patio and while he did not see the airplane, he guessed by the sound that it was flying in a direction that was determined to be 250 degrees. He said the sound faded and he then heard a "thump" sound but there was nothing more; and no explosion. He did not see any lights and was not sure what occurred. He reported it was not raining at the time, and he was not sure if it was cloudy or overcast. He estimated the total time he heard the airplane was for 30 seconds. He reported that the engine sound was steady or constant and there was no sputtering. He did not recall the wind at the time, and did not call 911 to report what he heard. The following day he informed law enforcement about what he heard. The airplane crashed during night conditions. The accident site was located about .3 nautical mile and 311 degrees from the last radar target. FAA air traffic control tower personnel contacted law enforcement at 2234:45, alerting of the airplane being lost from radar. The following day about 0910 CST, a request was made to the Jefferson County Sheriff Department to use their helicopter to search for the wreckage. The helicopter crew became airborne at 0944 CST, and the wreckage was spotted at 1327 CST. The helicopter crew directed ground personnel to the accident site location. PERSONNEL INFORMATIONThe pilot, age 44, held a commercial pilot certificate with airplane single engine land, airplane multi-engine land, and instrument airplane ratings, and also held a certified flight instructor certificate with airplane single engine rating. He held a 2nd class medical certificate with no limitations issued May 3, 2013. He also held a Statement of Demonstrated Ability (SODA) last issued February 28, 2008, due to an issue with his left hand. The flight test for the SODA was conducted in a Cessna 172 with an FAA operations inspector present. A review of his airman file revealed he obtained his private pilot certificate with airplane single engine land rating on January 30, 2007. He failed his first instrument airplane rating checkride on April 8, 2008, for Area VI (A) titled Non-Precision Approach, but subsequently passed his instrument checkride the following day. He then obtained his commercial pilot certificate with airplane single engine land and instrument airplane ratings on June 10, 2009. Further review of his airman file revealed he twice failed the practical or oral portions for certified flight instructor (CFI), and once failed the checkride adding a multi-engine rating onto his commercial pilot certificate; however, he subsequently passed both and was issued the appropriate certificate and/or rating. On January 13, 2013, he renewed his CFI which expired on March 31, 2015. The co-owner of the operator reported that the pilot was hired on April 28, 2012, to fly cargo in a Cessna 210. A review of the pilot's training file revealed his initial flight check in accordance with (IAW) 14 CFR Part 135.293 and 135.299 occurred on May 1, 2012. The Airman Competency/Proficiency Check form indicates the result was "Approved"; however, the instrument proficiency check IAW 14 CFR Part 135.297 was not complied with, and a note on the form indicates, "Initial VFR checkride." According to the company DO, he flew 5 days a week until the contract with the customer ended on July 31, 2012. After that, he flew when flights became available. When his recurrent training became due on May 31, 2013, he was put on inactive duty because of a lack of volume of flights. The "Monthly Flight and Duty Time Log" for January 2014, indicates he was requalified on January 15, 2014, and since then, was scheduled 7 days on followed by 7 days off. Paperwork provided by the operator indicated that as of January 17, 2014, the pilot had 901 hours total time, 115 hours instrument. His last "Initial and Recurrent Pilot Testing Requirements" IAW 14 CFR Part 135.293, and his last "Pilot-In-Command: Line Checks, Routes and Airports" IAW 14 CFR Part 135.299 occurred on January 17, 2014. The flight duration was listed as 1.0 hour and was flown in the accident airplane. The airman competency/proficiency check form associated with the latest checks indicate the instrument proficiency check IAW 14 CFR Part 135.297 was not complied with, and a note on the form indicates, "pilot not 297 qualified VFR only." The result of the flight check was indicated to be "Approved." The pilot was qualified to fly in visual flight rules (VFR) only and to act as pilot-in-command of Cessna 210L airplanes. A review of copies of his first and second pilot logbooks that contained entries from January 19, 2007, to the last entry dated February 14, 2014 (documenting his adding a seaplane rating to his commercial pilot certificate earlier that day), revealed he logged a total time including the carry over time from the first pilot logbook of approximately 923 hours (corrected for minor
The pilot's failure to maintain control of the airplane while being vectored to intercept the localizer during night instrument meteorological conditions (IMC). Contributing to the accident was the operator's inadequate dispatch procedures, which did not prevent the pilot from flying beyond his duty day, flying at night for which he was not current, or flying in IMC for which he was not qualified by the company.
Source: NTSB Aviation Accident Database
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