# NTSB ATL04FA049: Cessna 441, N441W, Vestavia Hills, AL, December 10, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 10, 2003, 14:20 local (20:20 UTC) - Place: Vestavia Hills, AL - Coordinates: 33.416389, -86.806945 - Nearby events: https://openairdocs.org/map.md?lat=33.4164&lon=-86.8069&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 28, 2005 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Honeywell Engines, Systems & Services, FAA - Birmingham FSDO - 09 - NTSB case key (mKey): 58448 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL04FA049 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58448/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58448 - Page: https://openairdocs.org/ntsb/ATL04FA049 ## Probable cause The pilot's failure to maintain adequate airspeed during climb in icing conditions, which resulted in an inadvertent stall / spin of the airplane and subsequent uncontrolled descent and collision with terrain. A factor was the accumulation of airframe ice. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, climb - to cruise - preflight planning/preparation - inadequate, pilot in command - weather condition - icing conditions - Loss of control - in flight, climb - to cruise - airspeed - not maintained, pilot in command (cause) - stall/spin - inadvertent, pilot in command - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ravine ## Analysis The flight was climbing from 5,000 to 10,000 feet and the pilot obtained a maximum altitude of 6,300 feet. The airplane then began to lose altitude and deviate off course. The pilot declared a mayday and reported the airplane was in a spin. Several witnesses near the accident site reported hearing airplane engine noises and seeing the airplane descend from the clouds in a nose-down spiral to the ground. Two AIRMETs were valid at the time of the accident and included the accident location: "AIRMET TANGO update 3 for turbulence ... . Occasional moderate turbulence below a flight level of 18,000 feet due to wind shear ... ." "AIRMET ZULU update 2 for ice and freezing level ... . Occasional moderate rime and/or mixed icing in clouds and precipitation below 8,000 feet." Two pilots who departed in separate Beech 200 airplanes about the time of the accident airplane stated they encountered "moderate rime" icing between 5,000 and 6,000 feet, and one pilot reported instrument metrological conditions and light turbulence between 1,800 to 6,000 feet. Examination of the airplane revealed no evidence of airframe or engine malfunction. The de-ice ejector flow control valves for the left wing, right wing, and empennage pneumatic boots were removed for examination, and all valves functioned when power was supplied. ## Factual narrative HISTORY OF FLIGHT On December 10, 2003, at 1420 central standard time, a Cessna 441, N441W, registered to and operated by Warrington Development Corp., descended in a spin and collided into a creek ravine in a residential area in Vestavia Hills, Alabama. The flight was operated under the provisions of Title 14 CFR Part 91 with an instrument flight rules (IFR) plan filed. Instrument meteorological conditions prevailed at flight altitude. The airline transport pilot and the passenger received fatal injuries, and the airplane was destroyed. The flight departed Birmingham, Alabama, at 1412 on December 10, 2003. According to a witness, the pilot arrived at the airport around 0900 and "stayed on the computers all morning" checking the weather. The witness stated the pilot also spoke with arriving pilots about the weather they encountered on approach to the airport. According to records from the Anniston Automated Flight Service Station (AFSS), the pilot telephoned at 1142 and obtained a weather briefing for a flight from Birmingham, Alabama, to Venice, Florida, and telephoned again minutes later to file an IFR plan for the flight. According to air traffic control records, the flight was cleared for takeoff from runway 24 at 1412 and was cleared to climb on runway heading to an altitude of 5,000 feet. The flight departed, and the pilot contacted the departure controller at 1416 and reported the flight was level at 5,000 feet. The controller cleared the flight to climb to 10,000 feet and turn to proceed on course. A review of radar data revealed the flight initiated a climbing left turn, then continued to climb on course. The radar data revealed the flight obtained a maximum altitude of 6,300 feet at 1418:13, then began to lose altitude and deviate off course toward the left. At 1418:50, the pilot stated to the controller, "mayday mayday mayday four one whiskey I'm coming out of the sky." At 2018:57, the pilot stated, "(unintelligible) severe buf (unintelligible)," and at 1419:10, "we're in a spin." No further radio contact was received from the flight. Several witnesses near the accident site reported hearing airplane engine noises and seeing the airplane descend from the clouds in a nose-down spiral. An off-duty police officer near the accident site stated the airplane's descent angle was "straight down ... it wasn't gaining any distance." The officer stated the airplane hit trees and he lost sight of it, then he saw a fireball and black smoke. He drove toward the smoke and saw the airplane nose-down in a creek with "intense" ground fires burning near the front of the airplane. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate for airplane multi-engine land and commercial pilot privileges for airplane single-engine land, rotorcraft-helicopter, and instrument helicopter. The pilot held a first class medical certificate issued August 2003 with no waivers or limitations. The pilot's log book was not recovered for examination. An insurance application signed by the pilot dated October 3, 2003, was found at the accident site. On the application, the pilot reported 4350 civilian flight hours, which included 3900 hours in multi-engine fixed-wing aircraft and 1485 hours in multi-engine turbo-prop aircraft; the pilot also reported 424 total hours in the Cessna 441, with 0 hours pilot-in-command time in any aircraft within the preceding 12 months. A FlightSafety International Professional Pilot Proficiency Card for the pilot was signed by an examiner dated November 5, 2003; the card stated the pilot "has demonstrated competence to serve as pilot in command of CE-441." AIRCRAFT INFORMATION The Cessna 441, serial number 441-0181, was manufactured in 1980 and was equipped in January 1998 with two AlliedSignal (Honeywell) TPE331-10N-512S turboprop engines (serial numbers P-77109C and P-77107C) and two four-bladed McCauley propellers. The engines and propellers were installed in accordance with Supplemental Type Certificate SA5682NM. According to records provided by a maintenance facility, a Phase 2 inspection was completed September 30, 2003; the Phase 2 inspection included a 100-hour inspection of both engines. An entry dated September 14, 2003, in a trip log for the airplane recorded 5906.3 hours airframe total time, 1615.4 hours left engine total time, and 1625.8 hours right engine total time. A trip log entry dated December 10, 2003, recorded 5933.0 hours airframe total time, 1643.1 hours left engine total time, and 1653.5 hours right engine total time. According to records provided by a fueling facility, the airplane's main fuel tanks were topped off with 289.2 gallons of fuel prior to departure. A review of the Cessna Aircraft Company Information Manual for the Model 441 revealed in Section 2, Limitations, Ice Protection Equipment (Flight in Icing Conditions): "This airplane is approved for flight into icing conditions, as defined by the FAA, if the following equipment is installed and operational. 1 Heated stall warning vane or optional angle-of-attack lift sensor vane. 2. Heated pitot/static sources (2). 3. Wing and empennage deice boot system. 4. Windshield anti-ice system. 5. Propeller deice system (2). 6. Engine inlet anti-ice system (2). 7. Left wing deice light. 8. Outside air temperature indicator." METEOROLOGICAL INFORMATION The surface weather observing station at Birmingham International Airport reported at 1353 winds were from 270 degrees at 13 knots, visibility 10 statute miles with light rain, sky condition overcast at 2,200 feet above ground level, temperature 3 degrees centigrade, dew point 1 degree centigrade, altimeter setting 29.77 inches. The report contained the following remarks: rain began 33 minutes after the hour, ice pellets began 38 minutes after the hour and ended 53 minutes after the hour. A review of Flight Service Station data revealed two AIRMETs were valid at the time of the accident and included the accident location: "AIRMET TANGO update 3 for turbulence ... . Occasional moderate turbulence below a flight level of 18,000 feet due to wind shear associated with a strong surface low-pressure system and middle- to upper-level low." "AIRMET ZULU update 2 for ice and freezing level ... . Occasional moderate rime and/or mixed icing in clouds and precipitation below 8,000 feet." A review of PIREPs revealed at 1357, a "CRJ" crew reported light to moderate rime icing during climb between 3,000 and 6,000 feet, and, at 1509, a "B737" crew reported light to moderate rime icing during descent between 6,000 and 2,700 feet. Two pilots who departed in separate Beech 200 airplanes about the time of the accident airplane stated they encountered "moderate rime" icing between 5,000 and 6,000 feet. One of the pilots estimated his airplane accumulated approximately 1/4 inch of rime ice in 45 seconds as the airplane climbed between 5,000 and 6,000 feet. The pilot stated he cycled the airplane's de-ice boots, which successfully cleared the ice accumulation. The pilot also reported "solid IMC" and light turbulence in the cloud layer between 1,800 to 6,000 feet. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed the airplane came to rest upright in a creek at the bottom of a wooded ravine in a residential and commercial area 9.2 nautical miles southwest of the Birmingham International Airport. Trees within 20 feet of the wreckage displayed fresh breaks and scrapes. Wreckage debris was found primarily in immediate proximity to the fuselage. A strong odor of fuel was present, and fuel was recovered from the creek and soil by hazmat personnel. The nose and cockpit areas were crushed aft to the forward cabin and were found under and against a concrete area of the creek embankment. The fuselage and cabin floor were buckled, the forward pressure bulkhead was crushed aft into the cockpit, and the cockpit floor was crushed against the bottom of the i ## Aircraft - Registration: [N441W](https://openairdocs.org/deregistered/N441W-2006-05-22), registration cancelled 2006-05-22, S/N 441-0181, built 1980 (OpenAirDocs) - Reported make and model: Cessna 441 - Registry model: [Cessna 441](https://openairdocs.org/model/cessna-441) (registry code 2076020) (OpenAirDocs) - Registry engine: [AiResearch TPE331 series](https://openairdocs.org/engine/airesearch-tpe331-series) (registry code 01514, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 441-0181 - Airframe hours: 5933 - Engines: AlliedSignal TPE331-10N 715 horsepower turbo prop; AlliedSignal TPE331-10N 715 horsepower turbo prop - Damage: Destroyed - Fire: On-Ground - Flight: Executive/Corporate, Part 91 - Registered owner: Warrington Development Corp. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 30, 2003, 26.7 hours before - Departed: KBHM, Birmingham, AL - Destination: KVNC, Venice, FL - Flight plan: IFR - Airport: KBHM, Birmingham International, runway 24, 10,000 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; commercial, airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: helicopter, airplane; medical: class 1, without waivers/limitations; last flight review July 5, 2004; seat: left; toxicology performed; flight hours: 8,378 total, 424 in this make and model, 4,582 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 270° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: 2,200 ft overcast - Temperature: 37 °F, dew point 34 °F - Altimeter: 29.77 inHg - Observed at: KBHM, 9 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20031210034899A](https://openairdocs.org/incident/20031210034899A), Dec 10, 2003: Cessna 441, Birmingham, AL, Destroyed, 2 fatal. (-23) On December 10, 2003, at 1420 CST, a Cessna 441, N441W, registered to and operated by warrington development corporation, collided with the ground… ## Docket (25 files) The files NTSB released with the investigation on February 24, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58448. 7.6 MB in all. - Supplement A (item 1, .PDF, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226399&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226400&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement S (item 3, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226401&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Pilot Information/Log Book (item 4, .PDF, 417 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420259&FileExtension=.PDF&FileName=Pilot%20Information%2FLog%20Book-Redacted.PDF - Witness Statements (item 5, .PDF, 304 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420262&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Fueling Record (item 6, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420255&FileExtension=.PDF&FileName=Fueling%20Record-Redacted.PDF - Maintenance Work Orders (item 7, .PDF, 764 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420256&FileExtension=.PDF&FileName=Maintenance%20Work%20Orders-Redacted.PDF - Police Report (item 8, .PDF, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420261&FileExtension=.PDF&FileName=Police%20Report-Redacted.PDF - Radar Plots (item 9, .PDF, 169 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226398&FileExtension=.PDF&FileName=Radar%20Plots-Master.PDF - Trip Log (item 10, .PDF, 807 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226402&FileExtension=.PDF&FileName=Trip%20Log-Master.PDF - Weather Data (item 11, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226403&FileExtension=.PDF&FileName=Weather%20Data-Master.PDF - Weather - NTSB Factual Report (item 12, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226404&FileExtension=.PDF&FileName=Weather%20-%20NTSB%20Factual%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420257&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 14, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420263&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report - Passenger (item 15, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420258&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Passenger-Redacted.PDF - Toxicological Report - Pilot (item 16, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420260&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Pilot-Redacted.PDF - Photo 1 Fuselage from nose looking aft (item 17, .PDF, 428 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226407&FileExtension=.PDF&FileName=Photo%201%20Fuselage%20from%20nose%20looking%20aft-Master.PDF - Photo 2 Left Wing and Engine (item 18, .PDF, 447 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226408&FileExtension=.PDF&FileName=Photo%202%20Left%20Wing%20and%20Engine-Master.PDF - Photo 3 Right Wing and Engine (item 19, .PDF, 372 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226409&FileExtension=.PDF&FileName=Photo%203%20Right%20Wing%20and%20Engine-Master.PDF - Photo 4 Fuselage left side (item 20, .PDF, 415 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226410&FileExtension=.PDF&FileName=Photo%204%20Fuselage%20left%20side-Master.PDF - Photo 5 Empennage left side (item 21, .PDF, 365 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226411&FileExtension=.PDF&FileName=Photo%205%20Empennage%20left%20side-Master.PDF - Photo 6 Empennage right side (item 22, .PDF, 385 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226412&FileExtension=.PDF&FileName=Photo%206%20Empennage%20right%20side-Master.PDF - Photo 7 Left Cockpit Console (item 23, .PDF, 346 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226413&FileExtension=.PDF&FileName=Photo%207%20Left%20Cockpit%20Console-Master.PDF - Photo 8 Left Propeller Blades (item 24, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226415&FileExtension=.PDF&FileName=Photo%208%20Left%20Propeller%20Blades-Master.PDF - Photo 9 Right Propeller Blades (item 25, .PDF, 450 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226416&FileExtension=.PDF&FileName=Photo%209%20Right%20Propeller%20Blades-Master.PDF From the NTSB's public API. 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