CESSNA 560 near Warm Springs, OR — 2021-01-09

Final reportWPR21LA082

Date: 2021-01-09
Location: Warm Springs, OR, USA
Aircraft: CESSNA 560
Registration: N3RB
Category: Airplane
Highest injury: Fatal
Fatalities: 1
Phase of flight: Climb

Probable cause

A loss of airplane control due to pilot incapacitation for reasons that could not be determined.

NTSB narrative

During the first 15 minutes of the flight, the pilot of the complex, high performance, jet airplane appeared to have difficulty maintaining the headings and altitudes assigned by air traffic controllers, and throughout the flight, responded intermittently to controller instructions. After reaching an altitude of 27,000 ft, the airplane began to deviate about 30° right of course while continuing to climb. The controller alerted the pilot, who did not respond, and the airplane continued to climb. Two minutes later, the airplane entered a tight, spiraling descent that lasted 8 minutes until the airplane impacted the ground at high speed in a right-wing-low attitude. The airplane was highly fragmented on impact; however, examination did not reveal any evidence of structural failure, in-flight fire, a bird strike, or a cabin depressurization event, and both engines appeared to be producing power at impact. Although the 72-year-old private pilot had extensive flight experience in multiple types of aircraft, including jets, he did not hold a type rating in the accident airplane, and the accident flight was likely the first time he had flown it solo. He had received training in the airplane about two months before the accident but was not issued a type rating and left before the training was complete. During the training, he struggled significantly in high workload environments and had difficulty operating the airplane’s avionics suite, which had recently been installed. He revealed to a fellow pilot that he preferred to “hand fly” the airplane rather than use the autopilot. The airplane’s heading and flight path before the spiraling descent were consistent with the pilot not using the autopilot; however, review of the flight path during the spiraling descent indicated that the speed variations appeared to closely match the airplane’s open loop phugoid response as documented during manufacturer flight tests; therefore, it is likely that the pilot was not manipulating the controls during that time. Review of the pilot’s medical history uncovered a number of conditions and medications that the pilot had not reported to the Federal Aviation Administration. The severity of injuries precluded obtaining any useful information regarding natural disease during autopsy, and no toxicology was performed. None of the pilot’s known medical conditions or medications would have directly caused incapacitation, but the pilot may have had undiagnosed disease or had some acute event that would have incapacitated him. His age, gender, high blood pressure, and hypertension placed him at risk for a heart attack or stroke. While the available evidence is consistent with a loss of airplane control following pilot incapacitation, the reason for his incapacitation could not be determined.

Analysis

Primary failure mode: Human factors
First missed decision gate: Pilot should have recognized and corrected navigation errors earlier.

CESSNA 560 near Warm Springs, OR — 2021-01-09

Probable cause

NTSB narrative

Analysis

NTSB coding

Evidence available

Docket documents18