CEN18LA146

NTSB accident investigation · Cessna T303 · Pine Ridge, SD · April 24, 2018

Accident · Minor injuriesLimited investigationFinal report
Date
April 24, 2018, 10:00 local (16:00 UTC)
Place
Pine Ridge, SD
Injuries
3 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9746CCessna T303
Defining event
Enroute-descent: Structural icing
Weather
Instrument (IMC) · Day
Status
Completed · report May 29, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA
FAA report
20180424004259A
Case key
97102

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 airplane’s inadvertent encounter with severe icing conditions during descent, which resulted in structural icing, the pilot’s inability to maintain altitude, and an emergency landing. Contributing to the accident was an incomplete preflight weather briefing.

Findings · 5

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.

Temp/humidity/pressure: conducive to structural icingEnvironmental issues › Conditions/weather/phenomena · Ability to respond/compensateCessna T303: 1 caseAll aircraft: 103 casesProbable cause
Ceiling/visibility/precip: freezing rain/sleetEnvironmental issues › Conditions/weather/phenomena · Ability to respond/compensateCessna T303: 1 caseAll aircraft: 26 casesProbable cause
AircraftAircraft › Aircraft structures · Capability exceededCessna T303: 1 caseAll aircraft: 72 casesProbable cause
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleCessna T303: 1 caseAll aircraft: 1,310 casesProbable cause
Planning/preparation: weather planningPersonnel issues › Task performance · Not specifiedCessna T303: 1 caseAll aircraft: 156 casesProbable cause

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

Before the air taxi flight, the commercial pilot obtained a weather briefing via the company computer system and reviewed the weather information with the company chief pilot. The pilot stated that based on the computer briefing, which did not include icing conditions, he was aware of the forecasted weather conditions along the route of flight and at the intended destination. However, the briefing was incomplete as it did not contain any in-flight weather advisories, which would have alerted the pilot of moderate icing conditions expected over the flight route in the form of AIRMET Zulu. After takeoff and during the climb to 12,000 ft mean sea level (msl), the airplane encountered light rime ice, and the pilot activated the de-ice equipment with no issues noted. After hearing reports of better weather at a lower altitude, the pilot requested a descent to between 5,000 and 6,000 ft. During the descent to 6,000 ft msl and with the airplane clear of ice, the airplane encountered light to moderate icing conditions. The pilot considered turning back to another airport but could not get clearance until the airplane was closer to his destination. Shortly thereafter, the pilot stated that it felt “like a sheet of ice fell on us” as the airplane encountered severe icing conditions. The pilot applied full engine power in an attempt to maintain altitude. The airplane exited the overcast cloud layer about 500 ft above ground level. The pilot chose to execute an off-airport emergency landing because the airplane could not maintain altitude. During the landing, the landing gear separated; the airplane came to rest upright and sustained substantial damage to the wings and fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation and that the airplane was within its maximum gross weight. Structural icing was observed on the airframe after the landing. Based on the weather information, which indicated the probability of icing between 5,000 and 9,000 ft over the region and a high threat of supercooled large droplets between 5,000 and 7,000 ft, it is likely that the airplane, which was equipped for flight in icing conditions, inadvertently encountered severe icing conditions consistent with supercooled large droplets, which resulted in structural icing that exceeded the airplane’s capabilities to maintain altitude.

Factual narrative

On April 24, 2018, about 1000 mountain daylight time, a Cessna T303 airplane, N9746C, impacted terrain during an emergency off-airport landing after encountering severe icing conditions near Pine Ridge, South Dakota. The commercial pilot and two passengers sustained minor injuries, and one passenger was not injured. The airplane sustained substantial damage to the wings and fuselage. The airplane was registered to and operated by Aberdeen Flying Service, Aberdeen, South Dakota, as a Title 14 Code of Federal Regulations Part 135 on-demand air taxi flight. Day instrument meteorological conditions (IMC) prevailed, and an instrument flight rules flight plan was filed for the flight. The flight departed Aberdeen Regional Airport (ABR), Aberdeen, about 0930 central daylight time, and was destined for the Pine Ridge Airport (IEN), Pine Ridge, South Dakota. Prior to the flight, the pilot obtained a weather briefing via the company computer system and reviewed the weather information with the company chief pilot. The pilot stated that based on the computer briefing, which did not include icing conditions, he was aware of the forecasted weather conditions along the route of flight and at the intended destination. After takeoff and during the climb to 12,000 ft mean sea level (msl), the airplane encountered light rime ice, and the pilot activated the de-ice equipment with no issues noted with the equipment. After crossing over the Pierre Regional Airport (PIR), Pierre, South Dakota, the pilot heard via the radio reports of better weather at a lower altitude, and the pilot requested a descent to between 5,000 and 6,000 ft. During a descent to 6,000 ft msl, the airplane encountered light to moderate icing conditions. Prior to the descent, the airplane was clear of ice accumulation. The pilot thought about turning back to PIR but could not get clearance until the airplane was closer to IEN due to poor radio coverage. Shortly thereafter, the pilot stated it felt "like a sheet of ice fell on us" as the airplane encountered severe icing conditions. The pilot applied full engine power in an attempt to maintain altitude. The airplane exited the overcast cloud layer about 500 ft above ground level (agl). The pilot decided to execute an off-airport emergency landing because the airplane could not maintain altitude. The airplane touched down in a field about 25 miles from IEN. During the emergency landing, the landing gear separated, and the airplane came to rest upright. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation, and the airplane was below its maximum gross weight. A review of photograph images obtained by the operator confirmed the airplane retained structural icing after the landing. At 0852, the IEN Automated Surface Observation System (ASOS), located 19 miles west-southwest of the accident site, reported wind from 350° at 15 knots gusting to 22 knots, 5 miles visibility inunknown precipitation and mist, ceiling overcast at 1,200 ft agl, temperature 2° C, dew point 1° C, altimeter 30.43 inches of mercury (Hg). At 0952, IEN ASOS reported wind from 360° at 11 knots gusting to 20 knots, 6 miles visibility in unknown precipitation and mist, ceiling overcast at 1,300 ft agl, temperature 2° C, dew point 1° C, altimeter 30.45 inches of Hg. The National Weather Service Aviation Weather Center Current Icing Products, which were available online for the preflight briefing, reported the probability of icing at 5,000 ft, 7,000 ft, and 9,000 ft, as follows: the probability indicated a greater than 75% probability of icing over South Dakota from below 5,000 ft through 9,000 ft. In addition, the icing intensity was depicted as light to moderate intensity, with a high threat of Supercooled Large Droplets at 5,000 ft and 7,000 ft over the region. The preflight weather briefing did not include any inflight weather advisories, which would have alerted the pilot of moderate icing conditions expected over the flight route in the form of airmen's meteorological information (AIRMET) Zulu that was issued at 0700 and valid for 0900. AIRMET Zulu included moderate ice between 5,000 ft and flight level 180 with conditions continuing beyond 0900. The preflight weather briefing did include a pilot report which indicated light rime icing conditions encountered by a commercial airplane climbing through IMC conditions between 3,500 ft and 10,000 ft. There was no current significant meteorological information (SIGMET) to prohibit the flight from operating at the time of the accident. According to the Federal Aviation Administration's Instrument Flying Handbook FAA-H-8083-15B; Chapter 10 on page 10-24: "The very nature of flight in IMC means operating in visible moisture such as clouds. At the right temperatures, this moisture can freeze on the aircraft, causing increased weight, degraded performance, and unpredictable aerodynamic characteristics. Understanding avoidance and early recognition followed by prompt action are the keys to avoiding this potentially hazardous situation … Structural icing is a condition that can only get worse."

Aircraft

Registration
N9746C
Reported as
Cessna T303 (NO SERIES)
Category
Airplane
Serial number
T30300210
Built
1983
Airframe hours
8,929
Engines
Cont Motor TSIO-520-AE, 250 horsepower, reciprocatingCont Motor LTSIO-520-AE, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Aberdeen Flying Service
Registered owner
Aberdeen Flying Service
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 30, 2018 · 6 hours before
Departed
ABR · Aberdeen, SD
Destination
Pine Ridge, SD
Flight plan
IFR
Equipment
Auto-pilot, Stall warning system

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
28
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
January 19, 2018
Seat
Left
Restraint
3-point
Flight hours
4,602 total · 5,655 in this make and model · 4,403 as pilot in command · 45 in the last 90 days · 30 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
360° at 11 knots, gusting 20
Visibility
6 statute miles
Lowest ceiling
1,300 ft overcast
Temperature
36 °F, dew point 34 °F
Altimeter
30.45 inHg
Observed at
IEN, 25 nm away

Docket · 6

The files NTSB released with the investigation on November 6, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.3 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.