# NTSB ATL04FA051: Cessna 414, N1592T, Greeneville, TN, December 11, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 11, 2003, 10:47 local (15:47 UTC) - Place: Greeneville, TN - Coordinates: 36.21389, -82.813888 - Nearby events: https://openairdocs.org/map.md?lat=36.2139&lon=-82.8139&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal, 1 serious - Status: Completed, report December 28, 2004 - Report: Approved by Office Director - Parties: Cessna Aircraft, Mc Cauley Propeller Systems, Nashville FSDO-03, Teledyne Continental - NTSB case key (mKey): 58474 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL04FA051 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58474/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58474 - Page: https://openairdocs.org/ntsb/ATL04FA051 ## Probable cause The pilot's failure to maintain airspeed while maneuvering in icing conditions on a circling approach for landing resulting in an inadvertent stall and collision with trees and terrain. A factor in the accident was a partial loss of engine power due to the pilot's failure to activate the alternate induction air system, and exceeding the maximum landing weight of the airplane. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, maneuvering - weather condition - icing conditions (contributing factor) - induction air control,alternate air/door - not activated (contributing factor) - Loss of control - in flight, maneuvering - airspeed(vso) - not maintained, pilot in command (cause) - stall - inadvertent, pilot in command - aircraft weight and balance - exceeded, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - object - tree(s) - terrain condition - ground ## Analysis The pilot was on a circling approach for landing in instrument icing conditions. The landing gear were extended and the flaps were lowered to15 degrees. The alternate air induction system was not activated. The surviving passenger stated when the airplane came out of the clouds and the airplane started to buffet and shake. The pilot was heard to state on the UNICOM frequency by the fixed base operator and a lineman, "Emergency engine ice." The airplane was observed to make a 60-degree angle of bank and collided with trees and terrain. The Pilot's Operating Handbook states the airplane will stall at 129 miles per hour with the landing gear and flaps down at 15-degrees. The maximum landing weight for the Cessna 414 is 6,430 pounds. The total aircraft weight at the crash site was 6,568.52 pounds. Witnesses who knew the pilot stated the pilot had flown one other known flight in icing conditions before the accident flight. ## Factual narrative HISTORY OF FLIGHT On December 11, 2003, at 1047 eastern standard time, a Cessna 414, N1592T, registered to Young Forever Inc., operated by Young Forever Inc., and Saunders Advisory Group as a 14 CFR Part 91 business flight, collided with trees and terrain during a circling approach to runway 23 at Greeneville-Greene County Municipal Airport, Greeneville, Tennessee. Instrument meteorological conditions prevailed and an instrument flight rules flight plan was filed. The airplane was destroyed and there was a post-crash fire. The commercial pilot and three passengers were fatally injured. A pilot-rated passenger sustained serious injuries. The flight originated from Port Columbus International Airport, Columbus, Ohio, on December 11, 2003, at 0915. A witness, who was located next to a mailbox at 3055 Whitehouse Road, stated he observed a twin-engine airplane, with the landing gear down, in straight and level flight between 200-250 feet above the ground. He initially thought the airplane had departed from the Greeneville Airport. The airplane was heading almost due north when it made a sharp left turn; estimated at a 60-degree angle of bank. The airplane collided with trees and the ground followed by a ball of fire. The surviving passenger stated the pilot delayed the takeoff from Columbus, Ohio, due to icing conditions. They departed Columbus and encountered icing conditions while in instrument conditions. The pilot informed him to keep a look out for ice on the leading edges of the wings and engine nacelles. The pilot did not want more than 1/4 inch of ice on the surfaces. The pilot inflated the deicing boots two times during the climb and applied propeller anti ice. He did not see the pilot apply alternate air. They leveled off at 6,000 feet and were flying above the clouds. Upon reaching York VOR, the pilot requested and received clearance to climb to 8,000 feet to avoid clouds along their route of flight. The pilot informed him that he wanted to remain up as long as he could to stay out of the ice, and the pilot wanted to descend rapidly to keep from building up any ice. Tri Cities Approach Control cleared them to descend to 4,600 feet and to expect the Localizer 5 approach at Greeneville. They leveled off at their assigned altitude, and the pilot commented that he did not understand why ATC was keeping them in the clouds. A short time later the controller started vectoring them for the localizer approach and descended them to a lower altitude. The airplane started building up ice and the pilot activated the propeller ice, deice boots, and sprayed the windshield. The pilot contacted Greeneville UNICOM and obtained the weather and runway information. They performed the before landing check, intercepted the localizer, and the pilot lowered the landing gear and extended flaps one notch. The pilot made a call on the UNICOM frequency and informed them they were the localizer inbound. The passenger stated he continued to look for ice. They broke out of the clouds at 1,700 AGL. The airport was to his right and below. About the same time the airplane came out of the clouds, the airplane started to buffet and shake. He asked the pilot, "What is it? What is it?" The pilot stated, "I think I know what it is." The pilot applied full throttle, full rpm, and mixture full rich. It appeared that the pilot was attempting to get some power to establish a climb while the airplane was descending. The passenger stated he knew they were going to crash, and he started removing the approach plate holders from both control yokes. The pilot made a "May Day" call. The airplane started going to the left and the mountain tops were getting closer. He turned around and instructed the passengers to fasten their seatbelts tighter and to put a coat or a blanket over their face. He turned around and tightened his lap belt and shoulder harness. The treetops were closer and the pilot made a comment as they collided with the mountain. PERSONNEL INFORMATION Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the commercial pilot was issued a commercial pilot certificate on November 2, 2000, with ratings for airplane single engine land, airplane multiengine land, and instrument airplane. In addition the pilot held a flight instructor certificate issued on June 17, 2003, with ratings for airplane single engine land, airplane multiengine land, and instrument airplane. The pilot also held an advanced ground instructor certificate issued on September 11, 2000. The pilot held a first class medical certificate issued on June 13, 2003, with the restriction must wear corrective lenses. The pilot's biennial flight review was conducted on September 12, 2002, and his last instrument proficiency flight check was conducted on September 13, 2002, at SIMCOM. Review of the pilot's logbook revealed his first flight in the Cessna 414 was on April 12, 2002. The pilot's last logbook entry was on December 6, 2003. The pilot's total time including the flight from Tampa, Florida, to the accident site is 4,845 hours. The pilot had a total of 341.5 multiengine hours. The pilot had flown 160.1 hours in the Cessna 414 of which 155.7 hours were as pilot-in-command. The pilot had flown one flight in the Cessna 414 in icing conditions before the accident flight. The pilot's last logbook instrument flight in the Cessna 414 was on November 24, 2003. AIRCRAFT INFORMATION The Cessna 414 airplane is equipped with a deice boot system that provides protection to the wings, horizontal stabilizer and vertical stabilizer. The system is manually controlled. The complete inflation and deflation cycle will last approximately 30 seconds. The Cessna 414 Owners Manual states that when ice has accumulated to about 1/2 inch thick on the leading edges, that the deicing switch should be turned on. The manual states in a NOTE, "Since wing, horizontal stabilizer and vertical stabilizer deice boots alone do not provide adequate protection for the entire aircraft, known icing conditions should be avoided wherever possible. If icing is encountered, close attention should be given to the pitot static system, propellers, induction systems, and other components subject to icing." No discrepancies pertaining to the deice boots were written in the airframe logbook. The Cessna 414 airplane is equipped with a alcohol windshield deice system, which consists of an alcohol tank, a pump, left and right-hand dispersal tubes, and a switch breaker. No discrepancies pertaining to the windshield deice, were written in the airframe logbook. A work order obtained from Lane Aviation, Columbus, Ohio, revealed the airplane underwent maintenance on December 10, 2003, for a broken wire on the right main landing gear. The left and right main down lock switches were replaced at Hobbs time was 2770.6. The airplane was topped off with 98 gallons of 100 low lead fuel on December 10, 2003. A review of the airframe maintenance records revealed that RAM Aircraft Corporation overhauled the left and right engines on September 25, 2000. The left and right engines and left and right McCauley Propeller systems were installed on October 16, 2000, at Hour Meter 2307. The aircraft total time was 4,640 hours. The last annual inspection was conducted on July 20, 2003, at Hobbs Meter 2702.4. The airplane had flown 69.8 hours since the last annual inspection and had 4,989.2 total airframe hours at the time of the accident. The total time since the RAM conversion was 465.2 hours at the time of the accident. The pitot static system pressure test and transponder test were completed on March 28, 2003. METEOROLOGICAL INFORMATION The Greeneville 1100 weather observation was wind was 260-degrees at 8 knots, gusting to 14 knots, visibility 10 miles, ceiling overcast at 900 feet, temperature 32-degrees Fahrenheit, dew point temperature 29-degrees Fahrenheit, altimeter 29.97. The Area Fo ## Aircraft - Registration: [N1592T](https://openairdocs.org/deregistered/N1592T-2004-09-07), registration cancelled 2004-09-07, S/N 414-0372, built 1972 (OpenAirDocs) - Reported make and model: Cessna 414 - Registry model: [Cessna 414](https://openairdocs.org/model/cessna-414) (registry code 2075908) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 414-0372 - Airframe hours: 4989 - Engines: Continental TSIO-520-NB 335 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Business, Part 91 - Operator: Saunders Advisory Group - Registered owner: Young Forever Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 20, 2003, 70 hours before - Departed: CMH, Columbus, OH - Destination: GCY, Greeneville, TN - Flight plan: IFR - Airport: GCY, Greeneville-Greene County Muni, runway 23, 6,302 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review September 12, 2002; seat: left; toxicology performed; flight hours: 4,845 total, 160 in this make and model, 4,721 as pilot in command, 99 in the last 90 days, 40 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 260° at 8 knots, gusting 14 - Visibility: 10 statute miles - Lowest ceiling: 900 ft overcast - Temperature: 32 °F, dew point 30 °F - Altimeter: 29.96 inHg - Observed at: GCY, 1 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 20031211037469A](https://openairdocs.org/incident/20031211037469A), Dec 11, 2003: Cessna 414, Greenville, TN, Destroyed, 4 fatal. (-23) Cross country flight from columbus, Ohio, to Greenville, TN. The pilot in command, david jochman was cleared for a localizer approach to runway 5 at… ## Docket (40 files) The files NTSB released with the investigation on October 20, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58474. 41.8 MB in all. - Meteorology 5 - Factual Report of Group Chairman (item 1, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204070&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Pilot Logbook (item 2, .PDF, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420234&FileExtension=.PDF&FileName=Pilot%20Logbook-Redacted.PDF - Airplane Logbook (item 3, .PDF, 10.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420235&FileExtension=.PDF&FileName=Airplane%20Logbook-Redacted.PDF - Supplement A (item 4, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215532&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 5, .PDF, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215533&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement E (item 6, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215534&FileExtension=.PDF&FileName=Supplement%20E-Redacted.PDF - Wreckage Diagram (item 7, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215535&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Witness Statements (item 8, .PDF, 492 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420236&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Wreckage Release (item 9, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420237&FileExtension=.PDF&FileName=Wreckage%20Release-Redacted.PDF - ATC Transcripts (item 10, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420238&FileExtension=.PDF&FileName=ATC%20Transcripts-Redacted.PDF - Approach Plate Track Plot From Indianapolis Center (item 11, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216382&FileExtension=.PDF&FileName=Approach%20Plate%20Track%20Plot%20From%20Indianapolis%20Center-Master.PDF - Flight Track From Indianapolis Center (item 12, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216388&FileExtension=.PDF&FileName=Flight%20Track%20From%20Indianapolis%20Center-Master.PDF - Last 5 Minute of Flight Track Indianapolis Center (item 13, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216389&FileExtension=.PDF&FileName=Last%205%20Minute%20of%20Flight%20Track%20Indianapolis%20Center-Master.PDF - FAA Personnel Statement (item 14, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420239&FileExtension=.PDF&FileName=FAA%20Personnel%20Statement-Redacted.PDF - Photo 1 - View looking from vicinity of crash site (A) back towards witness location (B) approach end of runway 23 at Greenville (item 15, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219560&FileExtension=.PDF&FileName=Photo%201%20-%20View%20looking%20from%20vicinity%20of%20crash%20site%20(A)%20back%20towards%20witness%20location%20(B)%20approach%20end%20of%20runway%2023%20at%20Greenville-Master.PDF - Photo 2 - View looking toward N1592T crash site (A) witness location (B) vicinity of crash site (item 16, .PDF, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219561&FileExtension=.PDF&FileName=Photo%202%20-%20View%20looking%20toward%20N1592T%20crash%20site%20(A)%20witness%20location%20(B)%20vicinity%20of%20crash%20site-Master.PDF - Photo 3 - Front view of N1592T at crash site inverted (item 17, .PDF, 479 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219562&FileExtension=.PDF&FileName=Photo%203%20-%20Front%20view%20of%20N1592T%20at%20crash%20site%20inverted-Master.PDF - Photo 4 - Right front side view of N1592T at rest inverted (item 18, .PDF, 461 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219563&FileExtension=.PDF&FileName=Photo%204%20-%20Right%20front%20side%20view%20of%20N1592T%20at%20rest%20inverted-Master.PDF - Photo 5 - Right rear view of N1592T at rest inverted (item 19, .PDF, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219565&FileExtension=.PDF&FileName=Photo%205%20-%20Right%20rear%20view%20of%20N1592T%20at%20rest%20inverted-Master.PDF - Photo 6 - Left view of N1592T at rest inverted (item 20, .PDF, 475 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219566&FileExtension=.PDF&FileName=Photo%206%20-%20Left%20view%20of%20N1592T%20at%20rest%20inverted-Master.PDF - Photo 7 - View of N1592T separated 6 feet of left wing inboard of the left wing tip (item 21, .PDF, 448 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219567&FileExtension=.PDF&FileName=Photo%207%20-%20View%20of%20N1592T%20separated%206%20feet%20of%20left%20wing%20inboard%20of%20the%20left%20wing%20tip-Master.PDF - Photo 8 - Left side view of N1592T at rest inverted (item 22, .PDF, 499 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219568&FileExtension=.PDF&FileName=Photo%208%20-%20Left%20side%20view%20of%20N1592T%20at%20rest%20inverted-Master.PDF - Photo 9 - Left forward side view of N1592T at rest inverted (item 23, .PDF, 473 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219569&FileExtension=.PDF&FileName=Photo%209%20-%20Left%20forward%20side%20view%20of%20N1592T%20at%20rest%20inverted-Master.PDF - Photo 10 - Front view of N1592T nose baggage area looking rearward to the aft pressure bulkhead with the airplane at rest inverted (item 24, .PDF, 495 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219570&FileExtension=.PDF&FileName=Photo%2010%20-%20Front%20view%20of%20N1592T%20nose%20baggage%20area%20looking%20rearward%20to%20the%20aft%20pressure%20bulkhead%20with%20the%20airplane%20at%20rest%20inverted-Master.PDF - Photo 11 - View of N1592T right engine at rest inverted with separated right propeller assembly located underneath the engine assembly (item 25, .PDF, 493 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219572&FileExtension=.PDF&FileName=Photo%2011%20-%20View%20of%20N1592T%20right%20engine%20at%20rest%20inverted%20with%20separated%20right%20propeller%20assembly%20located%20underneath%20the%20engine%20assembly-Master.PDF - Photo 12 - View of N1592T separated 8 foot section of the right wing separated outboard of the right engine nacelle (item 26, .PDF, 495 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219573&FileExtension=.PDF&FileName=Photo%2012%20-%20View%20of%20N1592T%20separated%208%20foot%20section%20of%20the%20right%20wing%20separated%20outboard%20of%20the%20right%20engine%20nacelle-Master.PDF - Photo 13 - View of N1592T separated right propeller assembly (item 27, .PDF, 495 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219574&FileExtension=.PDF&FileName=Photo%2013%20-%20View%20of%20N1592T%20separated%20right%20propeller%20assembly-Master.PDF - Photo 14 - View of N1592T right engine after being separated from the airframe (item 28, .PDF, 498 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219576&FileExtension=.PDF&FileName=Photo%2014%20-%20View%20of%20N1592T%20right%20engine%20after%20being%20separated%20from%20the%20airframe-Master.PDF - Photo 15 - View of N1592T left engine during recovery (item 29, .PDF, 496 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219577&FileExtension=.PDF&FileName=Photo%2015%20-%20View%20of%20N1592T%20left%20engine%20during%20recovery-Master.PDF - Photo 16 - View of N1592T separated left propeller assembly (item 30, .PDF, 489 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219579&FileExtension=.PDF&FileName=Photo%2016%20-%20View%20of%20N1592T%20separated%20left%20propeller%20assembly-Master.PDF - Photo 17 - View of N1592T left and right alternate induction air system controls found in the closed position (item 31, .PDF, 459 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219581&FileExtension=.PDF&FileName=Photo%2017%20-%20View%20of%20N1592T%20left%20and%20right%20alternate%20induction%20air%20system%20controls%20found%20in%20the%20closed%20position-Master.PDF - AWOS Weather GCY (item 32, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219582&FileExtension=.PDF&FileName=AWOS%20Weather%20GCY-Master.PDF - Extract Cessna 414 POH (item 33, .PDF, 881 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219584&FileExtension=.PDF&FileName=Extract%20Cessna%20414%20POH-Master.PDF - Extract Greenville Police Report (item 34, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420240&FileExtension=.PDF&FileName=Extract%20Greenville%20Police%20Report-Redacted.PDF - Fuel Receipt Lane Aviation (item 35, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219587&FileExtension=.PDF&FileName=Fuel%20Receipt%20Lane%20Aviation-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 36, .PDF, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420241&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Teledyne Continental Engine Reports (item 37, .PDF, 9.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420245&FileExtension=.PDF&FileName=Teledyne%20Continental%20Engine%20Reports-Redacted.PDF - McCauley Propeller Teardown Report (item 38, .PDF, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420243&FileExtension=.PDF&FileName=McCauley%20Propeller%20Teardown%20Report-Redacted.PDF - Work Order Lane Aviation (item 39, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420244&FileExtension=.PDF&FileName=Work%20Order%20Lane%20Aviation-Redacted.PDF - Weight and Balance Computations (item 40, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40220528&FileExtension=.PDF&FileName=Weight%20and%20Balance%20Computations-Master.PDF From the NTSB's public API. 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