Pilot Debrief

CESSNA 210L near Clay, AL — 2014-02-15

Final reportERA14FA120
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Date
2014-02-15
Location
Clay, AL, USA
Airport
BHM
Aircraft
CESSNA 210L
Registration
N732EJ
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilot's failure to maintain control of the airplane while being vectored to intercept the localizer during night instrument meteorological conditions (IMC). Contributing to the accident was the operator's inadequate dispatch procedures, which did not prevent the pilot from flying beyond his duty day, flying at night for which he was not current, or flying in IMC for which he was not qualified by the company.

Contributing factors

Contributing to the accident was the operator's inadequate dispatch procedures, which did not prevent the pilot from flying beyond his duty day, flying at night for which he was not current, or flying in IMC for which he was not qualified by the company.

NTSB narrative

The pilot departed on the first leg of a revenue flight after the end of civil twilight but diverted to another airport because of adverse weather at the intended destination. Once the weather conditions improved, the pilot departed and proceeded to the first destination where he landed uneventfully; at that time, the pilot had been on duty for about 14 hours. After landing, the pilot did not call the company's director of operations as he was reportedly instructed to do when the flight was dispatched. One witness at the airport reported that the pilot seemed anxious, which the individual attributed to his being late and not because of the weather. The pilot obtained weather information for the second destination from a friend (who was a flight instructor) and subsequently departed on the visual flight rules (VFR) flight to his second destination. At the time of departure, the destination forecast was a ceiling of 1,500 ft and visibility of 6 miles. After establishing contact with the approach controller, the pilot was informed that the airport was operating under instrument flight rules (IFR). The controller asked the pilot his intention, and the pilot replied that he wanted an IFR clearance. The pilot confirmed with the controller that he was capable and qualified for IFR flight and was provided an IFR clearance. The pilot was instructed to turn right to intercept the localizer at a 30-degree angle and was cleared for the instrument landing system runway 24 approach. (Postaccident examination confirmed that one navigation receiver was set to that approach.) The airplane then banked left, and, during portions of the turn, the bank rate was three times greater than a standard banked turn, and the pilot began flying in an east-northeasterly direction while descending. The bank angle reduced and was changing at the end of the radar data. About 2 seconds after the last radar return, the pilot stated, "say again for two echo Juliet." This response likely indicated that he was not prepared for the approach clearance instructions or was distracted by cockpit duties. The controller immediately instructed the pilot to level the wings and climb, but there was no reply. A performance study indicated that the airplane made a left bank of about 60 degrees (a rate of turn of about 11 degrees per second) during the last seconds of flight before it crashed about 0.3 mile from the last radar target. The airplane was fragmented after impacting trees and terrain on a magnetic heading of about 284 degrees. Postaccident examination of the airplane revealed that the flaps and landing gear were retracted, and there was no evidence of preimpact failure or malfunction of the airframe, flight controls, or engine. There were no reported issues with the localizer at the airport following the accident. Although one witness reported hearing a sputtering sound coming from the engine likely about the time that the flight was being vectored by the air traffic controller on the downwind leg, the pilot did not advise the controller of any problems during that or any subsequent portion of the flight. Additionally, a witness who was located less than 1/2 nautical mile from the accident site reported that the engine sound was steady. Further, a cut portion of tree made by the propeller was consistent with the engine developing power. Although windshear advisories were in effect and windshear was reported from a flight crew about 29 minutes after the accident, the wind encountered by the airplane at the time of the accident likely would not have caused the pilot to turn in a direction opposite that instructed by the controller. The pilot was reportedly in good health, and his communications with the controller indicated that he likely was not impaired at the time of the accident. Although the autopilot programmer/computer was too badly damaged to functionally test, the steeply banked turn opposite that instructed by the air traffic controller was likely the result of pilot input and not the result of an autopilot malfunction. The roll servo was tested, and the lowest reported override force was slightly less than the lowest limit. Thus, if the autopilot had commanded greater than 90 percent of a standard-rate turn, the pilot would have been able to easily override the roll servo. It could not be determined if the engine-driven vacuum pump was operating or the standby vacuum system was engaged; however, the electrically driven instruments, such as the turn coordinator, and flight instruments consisting of the airspeed indicator, altimeter, and vertical speed indicator would have provided the pilot with roll and pitch information. Although the pilot was instrument-rated and had recently passed his instrument proficiency check, he was only qualified to fly VFR in revenue operations. He was also not current to fly at night, which was unknown to company personnel at the time of dispatch. In addition, although the flights could have been completed within the pilot's duty day if there were no delays, company personnel should have recognized that weather was causing delays and that the pilot was continuing to fly beyond his duty day. Thus, the company's dispatch procedures were lacking in that they allowed the pilot to fly in night, instrument meteorological conditions beyond his duty day, and company personnel were seemingly unaware that he initiated the flight and was not current to fly at night.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot should have aborted approach due to worsening weather conditions.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 45 docket documents
View NTSB final reportView NTSB docket

Docket documents45

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