CEN18FA107

NTSB accident investigation · Cessna 441 · Rossville, IN · February 23, 2018

Accident · FatalField investigationFinal report
Date
February 22, 2018, 19:39 local (Feb 23, 2018, 00:39 UTC)
Place
Rossville, IN
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N771XWCessna 441
Defining event
Enroute-climb to cruise: Loss of control in flight
Weather
Instrument (IMC) · Night
Status
Completed · report November 6, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
Textron Aviation, FAA, Honeywell
FAA report
20180222000059A
Case key
96777

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

On this page

Probable cause

An in-flight loss of control for reasons that could not be determined based on the available evidence.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 441: 6 casesAll aircraft: 9,295 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedCessna 441: 1 caseAll aircraft: 2,247 casesProbable cause
AircraftAircraft › Aircraft systems · MalfunctionCessna 441: 1 caseAll aircraft: 63 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airline transport pilot and two passengers departed in the twin-engine, pressurized airplane on a business flight in night instrument meteorological conditions. Shortly after takeoff, the airplane began to deviate from its assigned altitude and course. The controller queried the pilot, who responded that the airplane was "… a little out of control." After regaining control of the airplane, the pilot reported that he had experienced a "trim issue." The airplane continued on course and, about 13 minutes later, the pilot again reported a trim malfunction and said that he was having difficulty controlling the airplane. The flight's heading and altitude began to deviate from the course for the last 8 minutes of radar data and became more erratic for the last 2 minutes of radar data; radar and radio communication were subsequently lost at an altitude of about 18,300 ft in the vicinity of the accident site. Several witnesses reported hearing the airplane flying overhead. They all described the airplane as being very loud and that the engine sound was continuous up until they heard the impact. The airplane impacted a field in a relatively level attitude at high speed. The wreckage was significantly fragmented and the wreckage path extended about 1/4 mile over several fields. Examination of the available airframe and engine components revealed no anomalies that would have precluded normal operation of the airplane. The accident airplane was equipped with elevator, rudder, and aileron trim systems; however, not all components of the trim system and avionics were located or in a condition allowing examination. Although the airplane was equipped with an electric elevator trim and autopilot that could both be turned off in an emergency, the investigation could not determine which trim system the pilot was reportedly experiencing difficulties with. It is likely that the pilot was unable to maintain control of the airplane as he attempted to address the trim issues that he reported to air traffic control.

Factual narrative

The Cessna 441 Conquest II is an eight to ten-place, twin-engine airplane, with a pressurized cabin and retractable tricycle landing gear. The airplane is certificated as a normal category airplane, with a maximum operating altitude of 35,000 ft. The main cabin entry door is located on the left side of the airplane, aft of the wing and common to the aft portion of the cabin. The airplane is equipped with an icing protection system including: pneumatic deice devices (boots) for the wings and stabilizers, and electrical deice elements for the propeller, windshield, pitot tubes, and stall warning sensor. Flight into known icing conditions is approved, except for severe icing conditions. The airplane is powered by two Honeywell TPE331-10N turboprop engine that can produce 715 shaft horsepower at 2,000 rpm. The engine design featured an integral gearbox, two stage centrifugal compressor, reverse flow annular combustor, and a three-stage axial flow. The propellers were Hartzell propeller assemblies with four-blade, hydraulically actuated, constant speed design configuration, with feathering and reverse pitch capability. Ponderosa Aviation LLC purchased the airplane on October 13, 2017. Phase 2, 3, & D inspections were accomplished on the airframe and engines on November 1, 2017, at a total aircraft time of 6,907.5 hours. At the time of this inspection, the time since overhaul of both engines was 2,095.6 hours. The last entry in the airframe logbook was dated February 19, 2018, which documented the removal and replacement of the left horizontal situation indicator (HSI) at an aircraft total time of 6,972.7 hours. The maintenance records show that both elevator trim tab actuators were disassembled, cleaned, inspected, primed and reinstalled on October 23, 2017. The person who coordinated the maintenance of the airplane stated the only open discrepancy he was aware of was an issue with a fluctuating oil pressure indication. He stated that the oil pressure had been checked and it was ok, but they were still trying to determine why there was a fluctuating indication. The airplane was fueled with 230 gallons of Jet A fuel before the flight. On February 22, 2018, at 1939 eastern standard time, A Cessna 441 Conquest II airplane, N771XW, impacted terrain following a loss of control in Rossville, Indiana. The airline transport rated pilot and two passengers were fatally injured, and the airplane was destroyed. The airplane was registered to and operated by Ponderosa Aviation LLC under the provisions of Title 14 Code of Federal Regulations Part 91 as a business flight. Night instrument meteorological conditions prevailed for the flight, which was operating on an instrument flight plan. The flight originated from the Eagle Creek Airpark (EYE), Indianapolis, Indiana, about 1920, with an intended destination of the Green Bay Austin Straubel International Airport (GRB), Green Bay, Wisconsin. After takeoff the pilot contacted Indianapolis departure control and wascleared direct to the Boiler (BVT) VHF Omni-directional Range & Tactical Air Navigation (VORTAC) system. About a minute after the pilot checked in on the frequency, the airplane deviated from its assigned altitude and course, and the controller received a Standard Terminal Automation Replacement System (STARS) Minimum Safe Altitude Warning (MSAW) for the airplane. The controller queried the pilot regarding his heading and altitude. The pilot stated the airplane was "… a little out of control." The controller asked the pilot if he needed assistance and there was no reply. The controller then asked the pilot what his altitude was, and the pilot replied that he was at 5,500 ft and he asked for a block altitude and a heading of 090°. The controller instructed the pilot to maintain at or above 5,000 ft, and to fly any heading that he needed. The pilot then requested a block altitude of 4,500 ft to 5,000 ft. The controller instructed the pilot to remain at or above 4,000 ft on a heading of 090°. The pilot then turned the airplane to a heading of 090° and explained to the controller that he had a trim problem and difficulty controlling the airplane, but that he had the airplane back to straight and level. The pilot was issued a turn to a heading of 310° direct to BVT, followed by a clearance to climb and maintain 13,000 ft. The pilot was then instructed to contact the Chicago Air Route Traffic Control Center (ZAU). The pilot checked in with ZAU57 sector stating that he was climbing from 10,600 ft to 13,000 ft. The pilot was cleared to climb to FL200 (20,000 ft) followed by a climb to FL230 (23,000 ft) direct to GRB. The pilot was instructed to change frequencies to ZAU46 sector. The pilot then transmitted that he needed to get control of the airplane and "… my trim kind of going out on me." Communications and radar contact were then lost. The last radar data was in the vicinity of the accident site and the last altitude data recorded was 18,300 ft. Several witnesses reported hearing the airplane flying overhead. They all described the airplane as being very loud and that the engine sound was continuous up until they heard the impact. An autopsy on the pilot was conducted on February 25, 2018, by the Indiana Forensic & Surgical Pathology at the request of the Carroll County, Indiana Coroner's Office. The pilot's cause of death was attributed to injuries sustained in the aircraft accident. Toxicology testing performed by the FAA Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, was negative for carbon monoxide, cyanide, and ethanol. The testing was negative for drugs in the testing profile. Two Airmen's Meteorological Information notices (AIRMET) that covered the route of flight were in effect at the time of the accident. AIRMET SIERA called for instrument meteorological conditions with ceilings below 1,000 ft and 3 statute miles of visibility with precipitation, mist, and fog. AIRMET TANGO called for moderate turbulence between18,000 ft and 35,000 ft. The pilot held an airline transport pilot certificate with a multi-engine and Eclipse 500 ratings. The certificate listed commercial privileges for single-engine land airplanes. He also held a flight instructor certificate with airplane single-engine, airplane multi-engine, and instrument airplane ratings. The instructor certificate was issued May 23, 2017. The pilot's logbook contained entries between September 13, 2004, and January 20, 2018. The pilot had logged a total flight time of 2,248.3 hours of which 454.6 hours were in Cessna 441 airplanes. The pilot held a Federal Aviation Administration (FAA) second-class medical certificate issued March 30, 2017. The medical certificate contained the limitation, "Must wear corrective lenses." The pilot's last flight review was on February 2, 2017, in a Cessna 441 airplane. The pilot was hired by Ponderosa Aviation LLC to fly the airplane for the company. The first flight logged in the accident airplane was on December 20, 2017, with 24.2 hours logged before the accident. The pilot had received unusual attitude and upset training in February 2016. The Honeywell enhanced ground proximity warning system (EGPWS) was examined and downloaded at the Honeywell facility in Redmond, Washington, on March 20, 2018. The EGPWS does not record continuous flight history; it is an event driven recording. The version of the terrain database on the unit was not the most current version. No terrain warnings were recorded at the end of the flight and some of the recorded data was invalid. The radar data ground track showed the airplane made a turn to the west followed by a turn to the north shortly after takeoff. The airplane then made a 270 ° left turn before heading east. The airplane then turned to the northwest as it continued to climb. The airplane then entered a sweeping right turn before entering a 450° turn and rolling out on a northerly heading. The ground track then turned northeasterly before ending. The accident site was located about 0.34 miles north of the town of Rossville, Indiana. The airplane impacted terrain in a plowed field (upper field) which was soft and muddy. A shallow linear disruption of the dirt was present which was about 250 ft in length. The impact mark was present up to the crest of a slight incline where the main pieces of wreckage began. Trees bordered the east end of the field and just beyond the tree line was a tree-covered hill which descended about 50 ft at a slope of about 50°. The trees on the hillside were about 80 to 100 ft tall. At the bottom of the hill was an 8 - 10 ft wide creek. The east bank of the creek was treelined and beyond the trees were two open fields (lower fields) which were divided by a row of small trees and brush. The wreckage was scattered in the upper field, down the hillside, and into the lower fields. The entire wreckage path was about ¼ mile in length. The wreckage path in the upper field was scattered after the initial terrainimpact point and along a magnetic heading of about 110°. The first pieces of wreckage along the path were the nose baggage doors. The upper left engine cowling and the rudder were the next major pieces of wreckage along the path followed by the outboard section of the left wing, the elevators, and the outboard section of the right wing. Both outboard flaps and the right-wing inboard flap were found in the upper field along with pieces of the left inboard flap. The vertical stabilizer, the cockpit wiring bundle, and the cockpit flight controls including the throttle quadrant were the major pieces of wreckage found on the hillside. The wreckage located in the lower field consisted of the fragmented pressure vessel, the aft pressure bulkhead, the left and right engines, both propellers, avionics, pieces of the instrument panel, all three-landing gear, and a section of the left wing between the aileron and the engine. The left engine was the main piece of wreckage that was located furthest from the initial impact in the upper field. A postaccident examination was conducted by the National Transportation Safety Board (NTSB) investigator-in-charge, and FAA inspectors, with the assistance of a representative of the engine and airplane manufacturers. The examination did not reveal any anomalies consistent with a preimpact failure or malfunction. A detailed summary of the examination is included in the docket associated with the investigation.

Aircraft

Registration
N771XW
Reported as
Cessna 441 (NO SERIES)
Category
Airplane
Serial number
441-0065
Built
1978
Airframe hours
6,907.5
Engine
Honeywell TPE331-10N-53, 715 horsepower, turbo prop
Damage
Destroyed
Flight
Business · Part 91
Operator
Ponderosa Aviation LLC
Registered owner
Ponderosa Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · November 1, 2017 · 65 hours before
Departed
EYE · Indianapolis, IN
Destination
GRB · Green Bay, WI
Flight plan
IFR

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
35
Injuries
Fatal
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
2,248.3 total · 454.6 in this make and model · 1,732.8 as pilot in command · 22.3 in the last 90 days

Weather

Conditions
Instrument (IMC) · Night
Wind
120° at 3 knots
Visibility
10 statute miles
Lowest ceiling
1,500 ft overcast
Temperature
45 °F, dew point 41 °F
Altimeter
30.37 inHg
Observed at
LAF, 17 nm away

Docket · 19

The files NTSB released with the investigation on October 16, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 67.8 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.