Marietta, GA, USA
N8DX
CESSNA 500
The private pilot departed on an instrument flight rules flight plan in his twin-engine turbojet airplane. The flight was uneventful until the air traffic controller amended the flight plan, which required the pilot to manually enter the new routing information into the GPS. A few minutes later, the pilot told the controller that he was having problems with the GPS and asked for a direct route to his destination. The controller authorized the direct route and instructed the pilot to descend from 22,000 ft to 6,000 ft, during which time the sound of the autopilot disconnect was heard on the cockpit voice recorder (CVR). During the descent, the pilot told the controller that the airplane had a steering problem and was in the clouds. The pilot was instructed to descend the airplane to 4,100 ft, which was the minimum vectoring altitude. The airplane continued to descend, entered visual meteorological conditions, and then descended below the assigned altitude. The controller queried the pilot about the airplane's low altitude and instructed the pilot to maintain 4,100 ft. The pilot responded that he was unsure if he would be able to climb the airplane back to that altitude due to steering issues. The controller issued a low altitude warning and again advised the pilot to climb back to 4,100 ft. The pilot responded that the autopilot was working again and that he was able to climb the airplane to the assigned altitude. The controller then instructed the pilot to change to another radio frequency, but the pilot responded that he was still having a problem with the GPS. The pilot asked the controller to give him direct routing to the airport. A few minutes later, the pilot told the controller that he was barely able to keep the airplane straight and its wings level. The controller asked the pilot if he had the airport in sight, which he did not. The pilot then declared an emergency and expressed concerns related to identifying the landing runway. Afterward, radio contact between the controller and the pilot was lost. Shortly before the airplane impacted the ground, a witness saw the airplane make a complete 360° roll to the left, enter a steep 90° bank to the left, roll inverted, and enter a vertical nose-down dive. Another witness saw the airplane spiral to the ground. The airplane impacted the front lawn of a private residence, and a postcrash fire ensued. The pilot held a type rating for the airplane, but the pilot's personal logbooks were not available for review. As a result, his overall currency and total flight experience in the accident airplane could not be determined. The airplane was originally certified for operations with a pilot and copilot. To obtain an exemption to operate the airplane as a single pilot, a pilot must successfully complete an approved single-pilot exemption training course annually. The accident airplane was modified, and the previous owner was issued a single-pilot conformity certificate by the company that performed the modifications. However, there was no record indicating that the accident pilot received training under this exemption. Several facilities that have single-pilot exemption training for the accident airplane series also had no record of the pilot receiving training for single-pilot operations in the accident airplane. Therefore, unlikely that the pilot was properly certificated to act as a single-pilot. The GPS was installed in the airplane about 3.5 years before the accident. A friend of the pilot trained him on how to use the GPS. The friend said that the pilot generally was confused about how the unit operated and struggled with pulling up pages and correlating data. The friend of the pilot had flown with him several times and indicated that, if an air traffic controller amended a preprogrammed flight plan while en route, the pilot would be confused with the procedure for amending the flight plan. The friend also said the pilot depended heavily on the autopilot, which was integrated with the GPS, and that he would activate the autopilot immediately after takeoff and deactivate it on short final approach to a runway. The pilot would not trim the airplane before turning on the autopilot because he assumed that the autopilot would automatically trim the airplane, which led to the autopilot working against the mis-trimmed airplane. The friend added that the pilot was "constantly complaining" that the airplane was "uncontrollable." A postaccident examination of the airplane and the autopilot system revealed no evidence of any preimpact deficiencies that would have precluded normal operation. This information suggests that pilot historically had difficulty flying the airplane without the aid of the autopilot. When coupled with his performance flying the airplane during the accident flight without the aid of the autopilot, it further suggests that the pilot was consistently unable to manually fly the airplane. Additionally, given the pilot's previous experience with the GPS installed on the airplane, it is likely that during the accident flight the pilot became confused about how to operate the GPS and ultimately was unable to properly control of the airplane without the autopilot engaged. Based on witness information, it is likely that during the final moments of the flight the pilot lost control of the airplane and it entered an aerodynamic stall. The pilot was then unable to regain control of the airplane as it spun 4,000 ft to the ground.
HISTORY OF FLIGHTOn March 24, 2017, at 1924 eastern daylight time, a Cessna 500, N8DX, collided with terrain in a residential neighborhood near Marietta, Georgia. The private pilot was fatally injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to Shelter Charter Services Inc., which was operating the airplane as a Title 14 Code of Federal Regulations Part 91 business flight. Visual meteorological conditions existed near the accident site at the time of the accident. The flight was operated on an instrument flight rules (IFR) flight plan. The flight originated from Cincinnati Airport–Lunken Field (LUK), Cincinnati, Ohio, about 1812, and was destined for Fulton County Airport–Brown Field (FTY), Atlanta, Georgia. The pilot, who was based in Atlanta, was returning home from a business trip. The airplane was equipped with a cockpit voice recorder (CVR); the recording started about 1853. The air traffic control (ATC) transcript showed that, at 1851:36, when the airplane was level at 23,000 ft, a controller with the Atlanta Air Route Traffic Control Center (ARTCC) advised the pilot of an amendment to his original flight plan. Ten seconds later, the controller provided new routing information. The controller repeated the new routing at 1852:50 and 1855:17, and the pilot correctly read back the information at 1855:25. The airplane was equipped with a Garmin GTN 750 unit that provided navigation, radio tuning, and other capabilities. Aural clicks and the sound of knobs turning were heard on the CVR consistent with the pilot attempting to enter the new routing into the Garmin GTN 750 GPS. At 1858:57, the controller instructed the pilot to descend the airplane to 22,000 ft, and the pilot acknowledged this instruction. At 1859:04, the pilot told the controller, "I'm having a little trouble with my ah GPS did you give me direct (unintelligible) on that arrival." The controller then asked the pilot to repeat his request, and the pilot said, "I'm having difficulty with my GPS it's not picking up this arrival and I was wondering if you can give me uh direct routing then instead of going to the arrival." At 1859:46, the controller cleared the airplane direct to FTY and, at 1900:10, instructed the pilot to descend the airplane to 11,000 ft; the pilot acknowledged this information. About three minutes later the CVR recorded the pilot saying, "I have no idea what's going on here." At 1907:42, the controller instructed the pilot to descend the airplane to 6,000 ft, and the pilot acknowledged this instruction. At 1910:26, the CVR recorded a sound similar to the autopilot disconnecting. At 1911:02, the pilot told the controller that the airplane was descending though 8,000 ft but was experiencing a "steering problem" and that he could not "steer the aircraft very well." The pilot then mentioned that the airplane was "in the clouds." At 1914:29, the controller instructed the pilot to descend the airplane to 4,100 ft, the minimum vectoring altitude. The airplane continued to descend, during which time the airplane entered visual meteorological conditions. At 1915:44, the controller told the pilot that the airplane had descended to an altitude of 3,600 ft, which was 500 ft below the minimum vectoring altitude, and instructed the pilot to maintain an altitude of 4,100 ft. At 1915:52, the pilot said, "Yeah I understand I'm going back up but an I have no…I have very little steering on here and I have mountains (around me) Atlanta doesn't have mountains." The controller then issued a low altitude warning and advised the pilot again to climb the airplane to 4,100 ft. The pilot responded that he had his "autopilot back…so it gives me stability." At 1917:21, the controller instructed the pilot to change to another Atlanta ARTCC frequency; afterward, the pilot reported that the airplane was at 4,100 ft. At 1917:54, the controller confirmed that the airplane was at 4,100 ft and instructed the pilot to contact Atlanta approach control on a frequency of 121.0 MHz. The pilot reported, at 1918:21 and 1918:26, that "I can't get to one two one point zero" and that, "I'm having a problem with my ah Garmin." At 1918:33, the pilot asked the controller to "take me in"; the controller agreed. About 1 minute later, the pilot told the controller that he was "just barely able" to keep the airplane straight and its wings level. The pilot also indicated that he was unsure if he would be able to make a right turn into the airport. At 1921:17, the controller told the pilot that the airport was 2 to 3 miles on a heading of 177°, and the pilot responded that he thought that he had a heading of 177° but did not have the airport in sight. At 1922:09, the controller asked the pilot if he wanted to declare an emergency, and the pilot said, "I'm not sure and I think I oughta declare an emergency just in case." The pilot then asked the controller to have the FTY control tower "turn up" the runway's landing lights, and the controller acknowledged this request. At 1923:09, the pilot asked the controller, "what runway am I running into…is the runway going sideways." The controller responded that runway 8 was the active runway. At 1923:44, the pilot said, "well I've got my landing gear down but I don't know." This statement was the last communication from the pilot to the Atlanta ARTCC controller. At 1923:55, the CVR recorded the pilot straining. At 1924:00, the pilot is heard on the CVR saying, "..it's going down, it's going down" followed by the sound of the autopilot disconnect tone. At 1924:07, the Terrain Awareness and Warning System (TAWS) announced "sink rate, sink rate" followed by "pull up, pull up." The CVR recording ended at 1924:19. Data recovered from the TAWS unit, which is part of the onboard enhanced ground proximity warning system (EGPWS), recorded the two warnings heard on the CVR. The first warning, a Mode 1 Sinkrate warning, occurred when the airplane was at an altitude of 4,000 ft and on a heading of 160°. The airplane's descent rate increased from approximately 0 ft per minute (fpm) to approximately 8,500 fpm. About three seconds later, as the descent rate increased, and a Mode 1 Pull Up warning was triggered at an altitude of 2,900 ft. The data ended approximately 7 seconds later with a recorded descent rate of almost 12,000 fpm. Several witnesses observed the airplane before the accident. A witness, who was a professional pilot, stated that he observed the airplane flying level on a southerly heading about 1,000 ft below the cloud layer. The witness said that there was nothing unusual about the airplane until it made "a complete 360 degree roll" to the left before entering a steep 90° bank to the left. He described the turn as similar to a "military high key turn." The witness also said that the airplane then rolled inverted and entered a sudden vertical nose-down dive. He further said, "the plane entered a slow counterclockwise spiral…as it started its dive" that continued until the airplane disappeared behind a building. Another witness stated that she observed the airplane make a "barrel roll" with the nose of the airplane "slightly elevated." She then observed a second roll and stated that the airplane slowed before its nose began to point down and the airplane spiraled downward counterclockwise. PERSONNEL INFORMATIONThe pilot, age 78, held a private pilot certificate with ratings for airplane single-engine land, single-engine sea, multiengine land, and instrument airplane. He purchased the airplane in May 2001 and received a Cessna 500 type rating in 2002. The pilot's last Federal Aviation Administration (FAA) third-class medical certificate was issued on September 27, 2016, with the limitation that he possesses glasses for near/intermediate vision. At that time, he did not report his total flight time; his previous medical application (dated September 18, 2013) indicated a total flight experience of 6,000 hours and 50 flight hours in the previous 6 months. The pilot's logbooks were not available for review. As a result, the pilot's overall currency and total flight experience in the accident airplane could not be verified. The Cessna 500 was originally certified to be operated with a pilot and copilot. The FAA can delegate an exemption to an authorized training facility to approve pilots to operate several aircraft, including the Cessna 500, with a single pilot. To qualify for single-pilot operations, a pilot must successfully complete an FAA-approved single-pilot authorization training course annually. The previous owner of the accident airplane had been issued a single-pilot conformity certificate by Sierra Industries, Ltd, of Uvalde, Texas, which had performed earlier modifications to the airplane. However, no record indicated that the accident pilot received training under Sierra Industries' exemption. Several training facilities that have the single-pilot exemption training for the Cessna 500 were contacted to see if they had provided such training to the pilot, but none of those facilities had any record showing that the pilot had been trained for and granted single-pilot authority. A friend of the pilot, who was a flight instructor and an airplane mechanic and had flown with the pilot several times, stated that he repeatedly told the pilot that he needed to fly with a copilot. The pilot said that he preferred to fly alone. The pilot also told his friend that he did not need a single-pilot exemption because the airplane had been given a single-pilot exemption with the Sierra Industries modification. The friend of the pilot said that he had conducted postmaintenance test flights on the accident airplane and instructed the pilot on operating the Garmin GTN 750, which had been installed in the airplane about 3.5 years before the accident. The Garmin GTN 750 was a more advanced upgrade from the KLN-90 GPS that the pilot had previously been using "for years." The friend said that the pilot was "very confused" with the Garmin GTN 750 unit's operation and would struggle "pulling up pages" and "correlating all the data." If ATC amended a preprogrammed flight plan while en route, the pilot would get confused and not know how to amend the flight plan. The friend said that the pilot was "very dependent on the autopilot" and would activate it immediately after takeoff and then deactivate it on short final approach to land. The friend also said that the pilot "never" trimmed the airplane before turning on the autopilot, which resulted in the airplane "fighting" the autopilot. As a result, the pilot was "constantly complaining" that the airplane was "uncontrollable." The friend further stated that the pilot "always assumed" that the autopilot would automatically trim the airplane. In addition, the friend said that he flew to Savannah, Georgia, once to "fix" the airplane because the pilot insisted that it was uncontrollable. When the friend arrived and flew the airplane, he quickly realized that the airplane was not trimmed properly and that there was nothing wrong with the autopilot. AIRCRAFT INFORMATIONThe accident airplane was an eight-seat business jet powered by two Pratt & Whitney Canada JT15-1A turbofan engines. The airplane had a Sierra Industries' Eagle wing modification and wing extension. The airplane had been retrofitted with JetTech LLC Supplemental Type Certificate (STC) No. ST02427LA on August 28, 2013. The STC replaced and upgraded the flight panel instruments to a Garmin GTN 750 display that supported navigation/mapping, radio tuning, weather display, and terrain/traffic awareness. The unit's navigation capabilities allowed waypoints to be entered that could be used to build and store flight plans for future use. In addition to the touchscreen features, the unit had concentric knobs for data input and radio tuning. Communication and navigation radio information was shown on the top portion of the display. For radio tuning, the unit had electronic touchscreen "tabs" that provided recent, nearby, and saved radio frequencies. The radio frequency could also be adjusted using the large and small knobs on the lower right corner of the display. When information was entered using the Garmin GTN 750 touchscreen, an aural "click" sound was annunciated. The JetTech LLC STC integrated the Garmin GTN 750 display with a Sperry (now Honeywell) SPZ-500C autopilot/flight director instrument system. When engaged, the autopilot, with the use of the integrated flight director, coupled to the selected modes and flew the airplane automatically while the pilot monitored the autopilot performance on flight instruments. The autopilot/flight director instrument system provided automatic flight control in the pitch, roll, and yaw axes with manual, automatic, and semiautomatic flight maneuvering options available to the pilot. According to Honeywell, the autopilot would automatically disconnect in flight if there were a loss of the vertical or directional gyros, a loss of valid 28-volt power to the autopilot or gyros, or a failure of the autopilot torque-limiter. Honeywell also stated that a pilot could disconnect the autopilot in flight using one of the following seven actions: •Press the AP TRIM DISC button •Press the vertical gyro FAST ERECT button •Press the compass LH-RH switch •Press the AP TEST button •Select AP Go-Around mode •Pull the autopilot AC or DC circuit breaker •Use manual electric elevator trim The airplane was also equipped with a Bendix/King (now Honeywell) KGP560 GA EGPWS. The airplane's maintenance was being managed by CESCOM, which is a division of CAMP Systems, the exclusive factory-endorsed maintenance program for Cessna aircraft. This is a continuous airworthiness maintenance program, which is a combined program of maintenance and inspections. The airplane's maintenance logbooks were not located. The mechanic who had been maintaining the airplane for about 1 year before the accident stated that he would perform maintenance as needed per the CESCOM maintenance program. The last Phase 5 Inspection was done in 2016, and the post-maintenance flight test found no items related to the circumstances of the accident. The mechanic stated that he had never seen the airplane's maintenance logbooks and that he would prepare maintenance entries in the CESCOM system. He further stated that he would either give the physical entries for the logbooks directly to the pilot or leave them in the airplane. The mechanic said that he last spoke with the pilot about 2 weeks before the accident. The mechanic reported that, at that time, the pilot told him that "the airplane was flying better than ever." The mechanic indicated that the pilot had not mentioned any maintenance issues regarding the autopilot, gyro instruments, the Garmin GTN 750, or the flight controls. The mechanic further indicated that the only time that the pilot had mentioned the Garmin GTN 750 was when he had asked the mechanic to help find a pilot in the Atlanta area that could help him become more comfortable using the unit. METEOROLOGICAL INFORMATIONThe weather conditions reported at Cobb County International Airport–McCollum Field, located about 3 miles west of the accident site, at 1947 (23 minutes after the accident) were as follows: wind from 160° at 8 knots, visibility 10 statute miles, overcast ceiling at 5,500 ft, temperature 21°C, dew point 9°C, and altimeter setting 30.28 inches of mercury. AIRPORT INFORMATIONThe accident airplane was an eight-seat business jet powered by two Pratt & Whitney Canada JT15-1A turbofan engines. The airplane had a Sierra Industries' Eagle wing modification and wing extension. The airplane had been retrofitted with JetTech LLC Supplemental Type Certificate (STC) No. ST02427LA on August 28, 2013. The STC replaced and upgraded the flight panel instruments to a Garmin GTN 750 display that supported navigation/mapping, radio tuning, weather display, and terrain/traffic awareness. The unit's navigation capabilities allowed waypoints to be entered that could be used to build and store flight plans for future use. In addition to the touchscreen features, the unit had concentric knobs for data input and radio tuning. Communication and navigation radio i
The pilot's failure to maintain adequate airspeed while manually flying the airplane, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall. Contributing to the accident was the pilot's inability control the airplane without the aid of the autopilot.
Source: NTSB Aviation Accident Database
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