Pilot Debrief

CESSNA 310R near Waterford, MI — 2014-01-11

Final reportCEN14FA110
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Date
2014-01-11
Location
Waterford, MI, USA
Airport
PTK
Aircraft
CESSNA 310R
Registration
N3829G
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

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.

Contributing factors

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.

NTSB narrative

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.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have aborted the approach due to low visibility conditions.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 64 docket documents
View NTSB final reportView NTSB docket

Docket documentsshowing 50 of 64

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