ATL96FA017

NTSB accident investigation · Cessna 402A · Avon Park, FL · December 5, 1995

Accident · FatalField investigationFinal report
Date
December 5, 1995, 06:32 local (11:32 UTC)
Place
Avon Park, FL
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N402RLCessna 402A
Weather
Instrument (IMC) · Dawn
Status
Completed · report September 19, 1996
Report
Approved by Office Director
FAA report
19951205043379A
Case key
3636

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The failure of the pilot to maintain the proper climb rate and direction of flight following takeoff, resulting in a collision with obstacles. The reason for the loss of control and subsequent unusual attitude ground impact was not determined.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with objectTakeoff - initial climb
Weather condition - low ceiling
Weather condition - obscuration
Weather condition - fog
Proper climb rate - not maintainedPilot in commandCause
Object - wire,transmission
Loss of control - in flightManeuvering
Reason for occurrence undetermined
In flight collision with terrain/waterDescent - uncontrolled

Analysis

After takeoff at dawn on a foggy morning, the airplane collided with electrical transmission wires about one mile from the end of the runway, on an extended line about 50 degrees left of the extended runway centerline. The left wing tip fuel tank (left main) was partially severed from the airplane, breaching the tank. Additionally, the top of the vertical stabilizer and rudder were severed, and a portion of the windscreen was separated. A suggestion was made by the operator that the autopilot trim may have been improperly set, precipitating a nose pitch down upon engagement of the autopilot during the climb. The airplane continued to fly for about 20 minutes, then impacted in a steep right wing down attitude into a densely wooded area that was surrounded by open terrain. The ensuing fire precluded any determination of engine malfunction, systems' discrepancies, or wire strike damage to the left propeller. No determination of pilot incapacitation was possible because of the post impact fire. Based upon the ground witness statement, the left engine was probably inoperative following the wire strike. The impact attitude was inconsistent with a decreasing speed loss of control with the left engine inoperative. However, the flight control trim settings, left main fuel tank selected, and throttle quadrant settings all may have been indicative of pilot incapacitation that precluded proper emergency procedure response. Additionally, the airplane impacted into a densely wooded area surrounded by flatter terrain absent of tall obstacles.

Factual narrative

History of the Flight

On December 5, 1995, about 0632 eastern standard time, a Cessna 402A, N402RL, collided with an electrical transmission line, during the initial climb after take off at Avon Park, Florida. The airplane was operated by Missionary Aviation Ministries under the provisions of Title 14 CFR Part 91, and visual flight rules. Instrument meteorological conditions prevailed. An instrument flight plan was filed the previous evening, but was not activated after take off. The airline transport pilot, and the pilot rated passenger, were fatally injured. The airplane was destroyed by impact forces, and a post impact fire. The flight was originating from runway 22 at the Avon Park Municipal Airport, at the time of the accident.

At 2118, December 4, 1995, a person who identified himself as N402RL, contacted the Miami Automated International Flight Service Station via telephone and requested a flight briefing from Avon Park, Florida to Port-au-Prince, Haiti, proposing to depart Avon Park at 0630 on December 5, 1995. Following the weather briefing, the person filed an instrument flight rules flight plan to Moss Town, Exuma Island, Bahamas. [Transcript attached].

According to the operator, the flight was destined for Haiti to deliver food, clothing, and medicine, with a planned intervening stop in the Bahamas for fuel. Witnesses that were located about 1/2 mile from the end of runway 22, reported hearing an explosion. The forward, upper portion of a wing tip tank, later identified as the left tip tank, an antenna, a rudder cap, and the vertical stabilizer cap were found beneath separated power lines. According to the local electrical power company, electrical power was interrupted at the site of the separated power lines at 0632, December 5, 1995.

Citizens reported seeing a low flying airplane about 0645 on December 5, to the Highlands County Sheriff's Office, who was responsible for the local search of the airplane. The reports were of a twin engine airplane flying at low altitude, with one engine operating at a very high speed. One of the citizen reports came from an emergency medical technician (EMT) who was also a pilot, familiar with twin engine Cessna airplanes. The reported sightings were in the Lake Placid, Florida area, with the last sighting made by the EMT, who indicated that the airplane was headed north. Lake Placid is located about 20 nautical miles south of Avon Park. The wreckage was discovered about six miles north of the last reported sighting.

The wreckage of the airplane was found the next day about 4.5 miles southwest of Sebring Air Terminal, which is about 14 miles southeast of Avon Park Municipal Airport. The burned wreckage was scattered about 60 feet, through dense woods.

Personnel Information

A logbook for the pilot was not located. According to Federal Aviation Administration Airman Certification Records, the pilot held an airline transport pilot (ATP) certificate with an airplane multiengine rating. He held commercial pilot privileges for airplane single engine land, and private privileges for glider. His initial ATP certificate was issued July 12, 1977. The initial multiengine land rating was issued following a flight check in a Piper PA-30 on November 21, 1974.

On April 23, 1993, the pilot added a multiengine rating to his previously issued flight instructor's certificate. On April 19, 1993, he received a notice of disapproval of application for the flight instructor airplane multiengine rating. The notice of disapproval indicated that upon reapplication he would be reexamined on multiengine operations, takeoffs & climbs, stalls, performance maneuvers, emergencies, and approach and landings.

The pilot was issued a second class medical certificate on September 28, 1995, with the limitation that the holder shall possess correcting glasses for near vision while exercising the privileges of his airman certificate. The application listed his occupation as retired.

According to an affidavit obtained from the insurance adjuster, the pilot received a Biennial Flight Review on November 7, 1994, in a Piper PA-28-161 Warrior. A signed statement provided by the operator of 402RL indicated that the pilot successfully completed an instrument competency check on October 18, 1995, in a single engine Cessna airplane. Another statement indicated that the pilot received night currency flight with a flight instructor, in a Cessna 172, also on October 18, 1995.

During the review of the FAA's airman certification file regarding the pilot, it was noted that on his application for the airplane multiengine additional instructor rating on April 23, 1993, he had listed 2,439 pilot in command flight hours. On his additional aircraft rating application for a multiengine rating dated November 21, 1974, the pilot listed 1,762 pilot in command flight hours. The pilot's application for his medical certificate dated September 28, 1995, indicated that his total flight hours were 2,700, with zero hours within the previous six months.

The operator, who is a certificated flight instructor, stated that he provided the pilot with a two hour familiarization flight in N402RL on December 12, 1994. Between December 12, 1994, and January 13, 1995, the operator stated that he provided 52 hours of additional instruction in the airplane, during flights to and from Haiti. No information regarding the pilot's flight hours between January 13, 1995, and October 31, 1995, was available. On October 31, 1995, according to the operator, he provided a route check and airplane systems check to the pilot, during a ten hour flight to Haiti and the return to Avon Park. The operator stated that in November, 1995, the pilot flew N402RL between Avon Park and Haiti on the 7th, 16th, 21st, and the 30th. Each trip involved about ten flight hours.

According to the operator, the pilot rated passenger was allowed to accompany the flight to obtain experience with multiengine airplanes. According to FAA records he possessed a private pilot certificate with airplane single engine land and instrument ratings. He received a third class medical certificate on February 17, 1994, with no limitations.

Additional personnel information is contained in this report on page 3 under the heading First Pilot Information, and Supplement E.

Aircraft Information

According to the operator, the aircraft logs and records were on the airplane at the time of the accident. He reported that the last annual inspection of the airplane was accomplished by Engles Air Service, Inc. in Lake Wales, Florida.

During a telephone interview, the owner of Engles Air Services, Inc. stated that N402RL had an annual inspection on June 30, 1995. At that time, the airplane's total hours were approximately 11,500. He did not recall the engine hours, and did not have any work orders, because the inspection had been completed at no cost to Missionary Aviation Ministries. His check of the airworthiness directives applicable to the airplane indicated that the wing spar required an inspection, which was conducted by QC Laboratories, Inc. The work order for the inspection indicated that an eddy current inspection of the lower spar cap fittings was performed with no discrepancies noted.

The operator reported that, at takeoff, the airplane had 140 gallons (about 840 pounds) of 100/130 octane aviation gasoline and had been loaded with approximately 1200 pounds of cargo in boxes. According to the operator, the boxes were filled, then weighed. No record of the weight manifest was retained. He also reported that the occupants weighed about 200 pounds, each. FAA records recorded the occupants weights as 243 pounds for the pilot and 175 pounds for the pilot rated passenger. The airplane's weight and balance form was not located. The cargo was destroyed by fire, and could not be weighed. The gross weight and empty weight of the airplane was listed in a like make

Aircraft

Registration
N402RL
Reported as
Cessna 402A
Category
Airplane
Serial number
402A-0051
Airframe hours
11,512
Engine
Continental TSIO-520, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Other work use · Part 91
Registered owner
Missionary Aivation Ministries
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 30, 1995
Departed
AVO
Destination
MYEF · Exeuma, AO
Flight plan
IFR
Airport
AVO · Avon Park Municipal, runway 22, 4,000 × 75 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
57
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
2,700 total · 104 in this make and model

Weather

Conditions
Instrument (IMC) · Dawn
Wind
350° at 4 knots
Visibility
0.25 statute miles
Lowest ceiling
100 ft
Temperature
57 °F, dew point 57 °F
Altimeter
30.00 inHg
Observed at
GIF, 30 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.