# NTSB ATL96FA074: Cessna P210N, N6427W, Marathon, FL, April 1, 1996 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 1, 1996, 02:58 local (07:58 UTC) - Place: Marathon, FL - Coordinates: 24.7093, -81.079467 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=24.7093&lon=-81.0795&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report August 29, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 3649 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL96FA074 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3649/pdf - Page: https://openairdocs.org/ntsb/ATL96FA074 ## Probable cause failure of the pilot to maintain sufficient altitude during an over-water approach at night. Factors relating to the accident were darkness and pilot fatigue. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, descent - light condition - dark night (contributing factor) - terrain condition - water - altitude - not maintained, pilot in command (cause) - fatigue(flight and ground schedule), pilot in command (contributing factor) ## Analysis During an over-water arrival at night, the pilot reported that the destination airport was in sight, and he canceled his VFR advisories. The controller acknowledged, advised the pilot to squawk 1200, and told him that a frequency change was approved. The pilot acknowledged at 0257:10, then there was no further radio communication with the pilot. At 0257:08, the encoded altimeter showed the airplane was at 1,200 feet, and radar data showed the airplane was descending with a ground speed of 183 to 189 knots. The final radar targets showed the airplane had descended to 200 feet, the heading was about 213 degrees, and the ground speed had increased to nearly 200 knots. Subsequently, the airplane descended into the water about 7 nautical miles north-northeast of the airport. The wreckage was recovered, and examination of the flight controls revealed no evidence of preimpact failure or malfunction. The landing gear and flaps were found retracted. The engine was recovered, and after replacement of components that were not recovered, the engine was started and operated normally. The propeller was recovered almost 1 year and 4 months after the accident; examination of it revealed no evidence of preimpact failure or malfunction. The airplane owner said that at about 1900 hours, before departing on the 1st leg of the flight, the pilot advised that he was tired due to his work/flying schedule. The owner stated that he was not aware that the pilot was going to fly the airplane after that conversation. ## Factual narrative HISTORY OF FLIGHT On April 1, 1996, about 0258 eastern standard time, a Cessna P210N, N6427W, registered to a private individual, crashed into the Florida Bay, north-northeast of Marathon, Florida. Visual meteorological conditions prevailed near the area at the time and no flight plan was filed for the 14 CFR Part 91 business flight. The airplane was substantially damaged and the commercial-rated pilot and pilot-rated passenger were fatally injured. The flight originated about 0200 from the Palm Beach International Airport, West Palm Beach, Florida. After departure while in contact with the Miami Air Route Traffic Control Center (ARTCC), at 0245.04, the pilot advised the controller "air shuttle 384 we're gonna start our descent into marathon." The controller acknowledged the request and advised the pilot to maintain VFR which the pilot acknowledged. The flight continued and at 0256.46, the pilot advised the controller that "..marathon in sight cancel VFR flight following and ah can we get you on this frequency on the way out." The controller advised yes and told the pilot to squawk VFR, and frequency change was approved." The pilot acknowledged this then the controller advised the pilot the frequency to contact the controller after departure from Marathon, which the pilot acknowledged at 0257.10. There was no further radio contact with the accident flight and there were no known witnesses to the accident. Review of the Miami ARTCC Data Analysis Reduction Tool (DART) Log and Track Sort radar data each about 6 seconds apart for the assigned discrete transponder code revealed that from 0241.32, to 0245.26, the reported altitude from the encoding altimeter remained at 8,400 feet though the assigned altitude was 8,500 feet. The heading between those times varied between 209 degrees and 204 degrees with the ground speed varying between 150 knots and 161 knots. About 0245.32, which was about 28 seconds after the pilot reported beginning his descent into Marathon, the radar data indicates the beginning of a descent which averaged about 525 feet per minute (fpm) over the next 8 minutes with an increase in the ground speed to a maximum of 180 knots over that time. The heading varied between that time from 202 degrees to a maximum of 210 degrees. Review of the radar data over the next 3 minutes revealed that the descent rate increased to an average of 800 fpm with a maximum ground speed of 183 knots and an average heading of 207 degrees. The remaining six radar hits each about 6 seconds apart beginning at 0256.325 and ending at 0257.08 or about 35.5 seconds later, indicates that the airplane descended from 1,700 feet to 1,200 feet. The ground speed increased from 183 knots to 189 knots and the heading only changed one degree only once during that time. There was no further discreet radar targets after 0257.08, which was 22 seconds after the pilot was advised by the controller to squawk VFR, and 2 seconds before the pilot's last ATC recorded communication. The last discreet radar target was located 10.3 nautical miles and 205 degrees to the Marathon Airport. Review of the Miami ARTCC National Track Analysis Program (NTAP) for non-discreet transponder code 1200 (not correlated) near the area of the last position of the assigned discreet transponder code revealed 3 radar targets. The first target at an altitude of 800 feet was 22 seconds after the last discreet target and was located 1.11 nautical miles from the last discreet target. The next non-discreet radar target 13 seconds later was located .72 nautical miles from the previous target at an altitude of 600 feet. The final radar target 24 seconds later was at an altitude of 200 feet. The heading and groundspeed changes between the first to second and second to third targets were 195 degrees and 213 degrees and 199.4 knots and 199.5 knots respectively. The airplane crash site was located 249 degrees and .42 nautical mile from the last non-discreet radar target. PERSONNEL INFORMATION Information pertaining to the first pilot is contained on page 3 of the NTSB Factual Report-Aviation. Additionally, he was an FAA certificated airframe and powerplant mechanic and was employed as such by Florida Gulf Airlines. Before the accident flight he had flown company airplanes to ferry parts and perform maintenance on airplanes away from the main base located in Jacksonville, Florida. Additionally, according to the owner of the airplane, he had talked with the pilot about 1900 hours the day before the accident and the pilot thanked him for the use of his airplane, which the owner gave his permission. The pilot also told the owner that he was "...very tired because he had been working and flying a lot of hours, and that he was glad he was going on vacation that following Monday." The owner stated that he was not aware the pilot was going to fly his airplane after the conversation. Additionally, review of paperwork found in the airplane (mesa airlines, inc., daily aircraft trip log No. 446844) revealed that on March 31, 1996, the first leg of several was initiated at 2135 hours, and ended at 2218 hours, from Jacksonville to Gainesville, Florida. The remarks section for that flight indicates "340 radar." The second leg began at 2318 hours and ended at 0109 hours, for a flight from Gainesville to West Palm Beach, Florida. The remarks section for that flight indicates "59 rt n1." The accident flight was not logged. Information pertaining to the pilot-rated passenger is contained in Supplement E. Additional information was provided by her roommate. On March 31st, she was called by company personnel to accompany the pilot on a round trip flight to Gainesville. After arriving at the company she was advised that the flight would continue to West Palm Beach, then to Marathon. She had previously advised her roommate that after flying with the accident pilot, she felt uncomfortable flying with him in part because he flew without paying much attention to what he was doing. She discussed this with the Assistant Chief Pilot who advised her that he knew the accident pilot was a kamikaze pilot but the company would limit her flying with the accident pilot. AIRCRAFT INFORMATION Information pertaining to the airplane is contained in the NTSB Factual-Report, Aviation, and in Supplements A and B. Review of the aircraft logbooks revealed that on May 9, 1990, an auxiliary fuel tank was installed in each wing of the airplane. The total usable quantity of both tanks combined is 32.5 gallons. The total usable fuel quantity of the wing fuel tanks is 87 gallons. The pitot static system was inspected on June 16, 1994. According to the owner of the airplane, it was not equipped with a radar altimeter or standby altimeter. The airplane information manual indicates that the yellow arc airspeed range is from 167-200 knots indicated airspeed. METEOROLOGICAL INFORMATION Information pertaining to the weather is contained on pages 3 and 4 of the Factual Report-Aviation. Calculations indicate that the illumination of the moon at the crash site area was 92 percent. A weather observation taken at 0257, from the Key West International Airport, indicates in part that the wind was from 050 degrees at 4 knots. The crash site was located 44 nautical miles from the Key West airport. COMMUNICATIONS A transcript of communication with the Miami Air Route Traffic Control Center is an attachment. There was no record of the pilot declaring an emergency with the controller though 2-way communications were maintained until about 1 minute 12 seconds before impact with the water. There was no record of the pilot squawking 7700. WRECKAGE AND IMPACT The wreckage was recovered and taken to a nearby facility for examination which revealed that all airframe components necessary to sustain flight were attached or partially attached to the airfr ## Aircraft - Registration: [N6427W](https://openairdocs.org/deregistered/N6427W-1997-03-25), registration cancelled 1997-03-25, S/N P21000776 (OpenAirDocs) - Reported make and model: Cessna P210N - Registry model: [Cessna P210N](https://openairdocs.org/model/cessna-p210n) (registry code 2073454) (OpenAirDocs) - Category: Airplane - Serial number: P21000776 - Airframe hours: 1865 - Engines: Continental TSIO-520-AF 285 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Registered owner: Edward Andrews, Jr. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 13, 1995, 68 hours before - Departed: PBI, WEST PALM BEACH, FL - Destination: MTH, FL - Airport: MTH, Marathon ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 27; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane, helicopter; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 1,720 total, 29 in this make and model, 1,481 as pilot in command, 119 in the last 90 days, 44 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 50° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 70 °F - Altimeter: 29.00 inHg - Observed at: EYW, 44 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 19960401005699A](https://openairdocs.org/incident/19960401005699A), Apr 1, 1996: Cessna P210N, Marathon, FL, Destroyed, 2 fatal. Crashed into water while on approach. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.