Pilot Debrief

CESSNA 441 near Argyle, TX — 2015-02-05

Final reportCEN15FA136
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Date
2015-02-05
Location
Argyle, TX, USA
Airport
DTO
Aircraft
CESSNA 441
Registration
N441TG
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's failure to maintain adequate airspeed during the instrument approach in night instrument meteorological conditions, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall/spin at a low altitude.

NTSB narrative

The instrument-rated commercial pilot was approaching the destination airport after a cross-country flight in night instrument meteorological conditions. According to radar track data and air traffic control communications, while receiving radar vectors to the final approach course, the pilot did not always immediately comply with assigned headings and, on several occasions, allowed the airplane to descend below assigned altitudes. According to airplane performance calculations based on radar track and GPS data, the pilot made an engine power reduction about 2.5 minutes before the accident as he maneuvered toward the final approach fix. Following the engine power reduction, the airplane's airspeed decreased from 162 to 75 knots calibrated airspeed, and the angle of attack increased from 2.7° to 14°. About 4 miles from the final approach fix, the airplane descended below the specified minimum altitude for that segment of the instrument approach. The tower controller subsequently alerted the pilot of the airplane's low altitude, and the pilot replied that he would climb. At the time of the altitude alert, the airplane was 500 ft below the specified minimum altitude of 2,000 ft mean sea level. According to airplane performance calculations, 5 seconds after the tower controller told the pilot to check his altitude, the pilot made an abrupt elevator-up input that further decreased airspeed, and the airplane entered an aerodynamic stall. A witness saw the airplane abruptly transition from a straight-and-level flight attitude to a nose-down, steep left bank, vertical descent toward the ground, consistent with the stall. Additionally, a review of security camera footage established that the airplane had transitioned from a wings-level descent to a near-vertical spiraling descent. A postaccident examination of the airplane did not reveal any anomalies that would have precluded normal operation during the accident flight. Although the pilot had monocular vision following a childhood injury that resulted in very limited vision in his left eye, he had passed a medical flight test and received a Statement of Demonstrated Ability. The pilot had flown for several decades with monocular vision and, as such, his lack of binocular depth perception likely did not impede his ability to monitor the cockpit instrumentation during the accident flight. The pilot had recently purchased the airplane, and records indicated that he had obtained make and model specific training about 1 month before the accident and had flown the airplane about 10 hours before the accident flight. The pilot's instrument proficiency and night currency could not be determined from the available records; therefore, it could not be determined whether a lack of recent instrument or night experience contributed to the pilot's difficulty in maintaining control of the airplane.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot did not initiate turn to assigned heading after altitude alert.

NTSB coding

Evidence available

  • Video
  • FDR / data
  • ADS-B / radar
  • Photos
  • 36 docket documents
View NTSB final reportView NTSB docket

Docket documents36

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