Pilot Debrief

CESSNA 501 near Detroit Lakes, MN — 2012-12-08

Final reportCEN13FA101
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Date
2012-12-08
Location
Detroit Lakes, MN, USA
Aircraft
CESSNA 501
Registration
N212M
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Initial climb

Probable cause

A loss of airplane control due to an undetermined avionics malfunction and the pilots’ inattention, which resulted in excessive airframe forces during the unusual attitude recovery. The reason for the avionics malfunction could not be determined because postaccident testing did not reveal any anomalies that would have precluded normal operation.

NTSB narrative

While climbing on a night, instrument departure, with the autopilot most likely engaged, the airplane entered into an unusual attitude. Although both pilots recalled a left climbing turn that transitioned into a left descending spiral, air traffic control radar information indicated a right climbing turn that transitioned into a right descending spiral. Both pilots stated that their attention had been focused away from the attitude indicators during the time immediately before the unusual attitude began. The pilot-in-command disconnected the autopilot and recovered the airplane by referencing the standby instruments. During the recovery, as the pilot pulled up from the nose-low attitude, both wings sustained structural damage. Examination of the airplane revealed that the nose radome quick release latches were not water tight and that gaps in these latches allowed precipitation to enter the forward avionics bay. Although, avionics testing did not reveal any anomalies consistent with an uncommanded flight maneuver by the autopilot, moisture conditions were not introduced during any of the tests. While it is possible that the moisture caused a malfunction of the avionics, it could not be definitively determined.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilots should have monitored attitude indicators more closely during climb.

NTSB coding

Evidence available

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

Docket documents16

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