CEN20LA122

NTSB accident investigation · Cessna 208 · LaCrosse, KS · March 17, 2020

Accident · FatalClass 3 · LimitedFinal report
Date
March 17, 2020, 09:19 local (14:19 UTC)
Place
LaCrosse, KS
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N274PMCessna 208
Defining event
Enroute-cruise: Medical event
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Textron Aviation, FAA
FAA report
20200317001339A
Case key
101080

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 infight loss of control as a result of pilot impairment, the cause of which could not be determined.

Findings · 2

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.

Impairment/incapacitationPersonnel issues › Physical · PilotCessna 208B: 1 caseAll aircraft: 40 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 208B: 3 casesAll aircraft: 1,269 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

The pilot was conducting a Part 135 on-demand cargo flight in instrument meteorological conditions. After executing a second missed approach, he informed air traffic control (ATC) of his intentions to divert to an airport located about 36 miles to the southeast. About 7 minutes after executing the second missed approach, the pilot began making unintelligible radio communications that ATC characterized as very garbled and difficult to understand, “almost hypoxic.” ATC then instructed the pilot to utilize oxygen. About 19 minutes after the second missed approach, ATC informed the pilot that the airplane had descended 1,600 ft, not following assigned course vectors or instructions and asked if everything was alright, to which no response was received. After attempting to relay communications through other airplanes in the area, an unintelligible response was received from the accident airplane. ATC then made numerous transmissions to the accident pilot urging him to utilize oxygen and open a window. No further communications were received from the accident airplane. A witness reported that he saw the airplane descend out of a low overcast cloud layer at a high rate of descent. The airplane then abruptly transitioned into a steep climb before re-entering the clouds. A few seconds later, he heard the airplane impact terrain and responded to the accident site. The sudden change in communications from the pilot indicates a possible impairment. When combined with the ATC data, the witness account, and the lack of any mechanical irregularities or malfunctions with the airplane, it is likely the pilot experienced difficulty controlling the airplane due to impairment. While the pilot was at an increased risk for an acute cardiovascular event, the extremely limited available medical evidence leaves no way to quantify that risk and no evidence regarding whether such an event occurred. As a result, whether the pilot was incapacitated by an acute medical event cannot be determined from the available medical information.

Factual narrative

A review of archived air traffic control (ATC) communications revealed that around 0906, the pilot began making unintelligible radio communications that air traffic controllers stated were unreadable. At 0914, ATC contacted another airplane operated by Planemasters to inquire if that pilot knew the condition of the radio in the accident airplane. The controller said “he sounds very garbled and difficult to understand almost uh almost hypoxic but that's impossible since he's at seven thousand feet uh is there something with the radio in that airplane do you know anything off the top of your head?” About 0915, the controller asked the accident pilot if he was turning directly to GBD. After an unintelligible response from the pilot, the controller stated “alright plane master sixteen seventy it's very difficult to understand there might be something wrong with uh your cockpit or your pressurization plane master sixteen seventy oxygen oxygen.” About a minute later, the pilot was more easily understood and the controller stated that he “sounded way better.” About 0918, ATC made the following transmission with no response from the pilot: “plane master sixteen seventy you've lost uh sixteen hundred feet and uh going off your course is everything alright?” No response was received from the pilot. After attempting to relay communications through other airplanes in the area, about 0920, an unintelligible response was received from the accident airplane. ATC then made numerous transmissions to the accident pilot urging him to utilize oxygen and open a window. No further communications were received from the accident airplane. On March 17, 2020, about 0919 central daylight time (CDT), a Cessna 208B, N274PM, was destroyed when it was involved in an accident near La Crosse, Kansas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand cargo flight. The Planemasters Ltd. flight, PMS1670, was operated on an instrument flight rules flight plan from Wichita Dwight D Eisenhower National Airport (ICT), Wichita, Kansas, to Hays Regional Airport (HYS), Hays, Kansas. A review of Federal Aviation Administration air traffic control (ATC) communications and commercially available radar and Automatic Dependent Surveillance-Broadcast (ADS-B) data revealed that the flight departed ICT about 0751 CDT. About 0831, the radar and ADS-B data were lost as the airplane descended through 4,000 ft while vectored for the instrument landing system (ILS) approach to runway 34. Shortly thereafter, the pilot executed a missed approach, and about 0843, the airplane was re-acquired by radar and ADS-B. The pilot stated to ATC his intention to attempt the ILS approach to runway 34 a second time. About 0853, radar and ADS-B data were again lost as the airplane descended on the instrument approach. About 0859, the airplane was re-acquired by radar northwest of HYS. At that time, the pilot stated his intention to divert toGreat Bend Airport (GBD), Great Bend, Kansas, located about 36 nautical miles to the southeast. The radar and ADS-B data showed the airplane began a turn to the south toward GBD while climbing to about 7,000 ft. About 0918, the airplane began a descent and left turn. The last radar and ADS-B targets were observed about 0918:48. A witness located about .68 miles northwest of the accident site reported first hearing the airplane and thought it was a crop duster. When he went outside, he saw the airplane descend out of a low overcast cloud layer at a high rate of descent. The airplane then abruptly transitioned into a steep climb before re-entering the clouds. A few seconds later, he heard the airplane impact terrain and responded to the accident site. According to the autopsy performed by the XXIV Judicial District of Kansas Deputy Coroner, the cause of death was fragmentation of the body by blunt impact and the manner of death was accident. There was extensive damage; the brain and majority of the heart were not available for examination. The pathologist reported the presence of hypertensive cardiovascular disease based on the microscopic appearance of the kidneys. No other significant natural disease was identified. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified atorvastatin and trimethoprim in liver and muscle tissues. Neither of these drugs are considered impairing. At 0825, the HYS automated weather observation service (AWOS) reported, in part, wind from 080° at 11 knots, visibility 1 statute mile, and overcast clouds at 200 ft above ground level. At 0841, the HYS AWOS indicated that visibility had dropped to ¼ statute mile in fog. At the time of the accident, the pilot had accumulated over 9,100 total flight hours, of which 400 were in the Cessna 208. Additionally, the pilot had accumulated about 700 hours in actual instrument meteorological conditions. The wreckage was discovered in a field with the airplane’s tail and wings visible above ground. The forward fuselage and engine section buried several feet under the terrain, consistent with a near-vertical, high-speed impact. The main landing gear was bent aft towards the tail with the left and right main wheels protruding from the ground. The smell of Jet-A fuel was present at the accident site. A post-accident wreckage examination revealed no mechanical irregularities or malfunctions with the airplane that would have precluded normal operation.

Aircraft

Registration
N274PM
Reported as
Cessna 208 (B)
Category
Airplane
Serial number
208B0705
Built
1998
Engine
Pratt & Whitney PT6A SER, 675 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Operator
Planemasters Ltd
Registered owner
Planemasters Ltd
Airworthiness certificate
Standard, Normal
Departed
ICT · Wichita, KS
Destination
HYS · Hays, KS
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
56
Injuries
Fatal
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
December 13, 2019
Seat
Right
Toxicology
Performed
Flight hours
9,900 total

Weather

Conditions
Instrument (IMC) · Day
Wind
70° at 10 knots
Visibility
0.25 statute miles
Lowest ceiling
200 ft overcast
Temperature
37 °F, dew point 36 °F
Altimeter
30.26 inHg
Observed at
KHYS, 21 nm away

Docket · 10

The files NTSB released with the investigation on April 6, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.2 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.