CHI02FA067

NTSB accident investigation · Cessna 402B · Bronson, MI · January 23, 2002

Accident · FatalField investigationFinal report
Date
January 23, 2002, 07:35 local (12:35 UTC)
Place
Bronson, MI
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N371JDCessna 402B
Weather
Instrument (IMC) · Dawn
Status
Completed · report August 26, 2003
Report
Approved by Office Director
Parties
Cessna Aircraft Company, FAA-South Bend, Indiana-FSDO, Teledyne Continental Motors
FAA report
20020123000959A
Case key
54060

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 maneuver to avoid the utility wire while maneuvering resulting in an inadvertent stall and subsequent impact with the ground. Factors were the pilot's inadvertent activation of the elevator trim, resulting in a loss of control during flight in instrument meteorological conditions, as a result of pilot's lack of knowledge concerning the operation of the autopilot system. Another factor was the utility wire.

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.

Loss of control - in flightCruise
Autopilot - not understoodPilot in commandFactor
Elevator trim - inadvertent activationPilot in commandFactor
Loss of control - in flightEmergency descent/landing
Maneuver to avoid obstructions - performedPilot in commandCause
Object - otherFactor
Stall - inadvertentPilot in commandCause
In flight collision with terrain/waterEmergency descent/landing
Terrain condition - ground

Analysis

The aiplane was destroyed when it impacted the ground while maneuvering at a low altitude following a loss of control in instrument meteorological conditions. The airplane was on a flight in instrument meteorological conditions when radar and voice contact were lost. Prior to the loss of communication, controllers advised the pilot to check altitude. At this point, the radar data shows that the airplane was about 400 feet below the assigned altitude. Subsequently, the pilot said, "roger sir my auto pilot i just cut off uh correcting immediately." This was the last received transmission from the pilot. The radar data shows that the airplane then began a descending right turn at an average rate of descent of 1,276 feet per minute. This descent was followed by a climbing left turn with an average rate of climb of 5,423 feet per minute. The radar data shows that the radius of the left turn continued to decrease until radar contact was lost about 500 feet above the last assigned altitude. A witness who saw the airplane just prior to impact described the airplane maneuvering beneath the clouds prior to pulling up sharply and then pitching down and impacting the ground. There was a utility wire and associated poles running across the airplane's fight path in the field where the wreckage was located. The airplane exploded and burned upon impact. No anomalies were found with the airplane or associated systems. The autopilot section of the Pilot 's Operating Handbook states, "Sustained elevator overpower will result in the autopilot trimming against the overpower force." The result is that if up elevator pressure is applied with the autopilot engaged, the autopilot will trim the airplane nose down.

Factual narrative

History of flight

On January 23, 2002, about 0735 eastern standard time, a Cessna 402B, N371JD, piloted by a commercial pilot, was destroyed when it impacted the ground near Bronson, Michigan. A witness described the airplane maneuvering at a low altitude just prior to impact. The 14 CFR Part 91 positioning flight was operating on an instrument flight rules flight plan in instrument meteorological conditions. The pilot, who was the sole occupant, was fatally injured. The business flight originated from the Kirsch Municipal Airport (IRS), Sturgis, Michigan, about 0730 and was bound for the Ann Arbor Municipal Airport (ARB), Ann Arbor, Michigan.

A witness to the accident described the airplane flying south about 200 feet above the ground and then turning back to the north. He said that he saw the airplane making a descending left turn back to the west when the airplane pulled up sharply and then pitched nose down and impacted the ground. He said there was a large explosion and fireball.

The airplane impacted the ground at coordinates 41 degrees 53.845 minutes north, 85 degrees 11.005 minutes west.

Personell information

The pilot held commercial pilot and flight instructor certificates with single and multi-engine airplane, and instrument airplane ratings. Records show that the pilot completed an initial competency check as required by 14 CFR Part 135 on March 15, 2001, in a Cessna 310 airplane. On October 15, 2001, the pilot completed a competency check in the Cessna 402B airplane.

Company paperwork indicates that the pilot had accumulated 1,800 hours total flight experience, 800 hours cross-country flight experience, 150 hours night flight experience, 125 hours total instrument experience, 100 hours of in-flight instrument experience, and 50 hours of night cross-country flight experience as of the date of the competency check in the Cessna 402B. The pilot's personal flight log was not recovered.

The pilot's first class medical certificate was issued on August 01, 2001. No limitations were listed on the medical certificate.

Aircraft information

The airplane was a Cessna model 402B aircraft. The 402B is a low-wing twin-engine airplane with an aluminum primary structure. Two 300-horsepower Teledyne Continental Motors model TSIO-520-E engines powered the airplane. The airplane was configured to carry eight occupants including the two pilot stations.

Maintenance records show that an annual inspection was completed on the airplane on October 3, 2001, at a total time of 7,239.2 hours time in service, and a 100-hour inspection was performed on December 21, 2001, at a total time of 7,339.0. The right engine had accumulated 3,406.3 total hours time in service, and 1,273.3 hours since being overhauled on March 6, 1997. The left engine had accumulated 884.9 hours time in service since undergoing a factory rebuild on May 16, 1998. Logbook records show that the engines had undergone a 100-hour inspection on December 21, 2001. At the time of the 100-hour inspection, the right and left engines had accumulated 1,373.1 hours, and 983.8 hours time in service respectively.

The airplane was equipped with a Cessna model 400B Nav-O-Matic autopilot system.

Meteorological information

The weather reporting station located at the departure airport, IRS, about 13 nautical miles southwest of the accident site, recorded the following observations:

Observation time: 0655

Wind direction: 200 degrees magnetic

Wind speed: 9 knots

Visibility: 7 statute miles

Sky condition: 1,000 feet overcast

Temperature: 4 degrees Celsius

Dew point: 2 degrees Celsius

Altimeter Setting: 29.82 inches of Mercury

Observation time: 0737

Wind direction: 200 degrees magnetic

Wind speed: 9 knots

Visibility: 4 statute miles with mist

Sky condition: 600 feet overcast

Temperature: 4 degrees Celsius

Dew point: 3 degrees Celsius

Altimeter Setting: 29.82 inches of Mercury

Observation time: 0757

Wind direction: 200 degrees magnetic

Wind speed: 8 knots

Visibility: 3 statute miles with mist

Sky condition: 400 feet overcast

Temperature: 4 degrees Celsius

Dew point: 3 degrees Celsius

Altimeter Setting: 29.82 inches of Mercury

The weather reporting station located at the Branch County Memorial Airport, Coldwater, Michigan, about 6 nautical miles east of the accident site, recorded the following observations:

Observation time: 0715

Wind direction: 210 degrees magnetic

Wind speed: 9 knots

Visibility: 7 statute miles

Sky condition: 1,000 feet overcast

Temperature: 6 degrees Celsius

Dew point: 6 degrees Celsius

Altimeter Setting: 29.81 inches of Mercury

Observation time: 0735

Wind direction: 210 degrees magnetic

Wind speed: 8 knots gusting to 15 knots

Visibility: 5 statute miles with mist

Sky condition: 800 feet overcast

Temperature: 6 degrees Celsius

Dew point: 6 degrees Celsius

Altimeter Setting: 29.81 inches of Mercury

Observation time: 0755

Wind direction: 210 degrees magnetic

Wind speed: 9 knots

Visibility: 4 statute miles with mist

Sky condition: 600 feet overcast

Temperature: 6 degrees Celsius

Dew point: 6 degrees Celsius

Altimeter Setting: 29.81 inches of Mercury

Communications

The aircraft was in communication with the Kalamazoo, Michigan, Air Traffic Control Tower, Arrival Radar East position (ARE). The following excerpts are from transcripts of the recorded conversations between ARE and N371JD. The full transcripts are appended to this report.

0720:26 N371JD (unintelligible) *(three) seven one juliet delta

0720:46 ARE twin cessna seven er three seven one juliet delta kalamazoo how soon and which runway

0720:52 N371JD ah three seven one juliet delta be runway one eight ready in two minutes

0720:57 ARE roger have a full route clearance to ann arbor when you're ready

0721:02 N371JD three seven one juliet delta go ahead

0721:05 ARE eh twin cessna three seven one juliet delta is cleared to ann arbor via direct litchfield and the cruxx four arrival maintain three thousand departure will be on one two one point two squawk three one seven zero

0721:25 N371JD o k cleared to ann arbor via the litchfield crutch four arrival three thousand feet one two one point two and three one seven zero in the box

0721:36 ARE twin cessna one juliet delta readback is correct hold for release call me when you're number one ready to depart

0721:42 N371JD cessna one juliet delta roger

0724:45 N371JD kalamazoo (unintelligible) *(three seven one) juliet delta's ready to go runway one eight

0726:11 ARE twin cessna one juliet delta i'm sorry you said you were ready to go

0726:14 N371JD one juliet delta thats affirmative ready on one eight

0726:17 ARE roger you're released left turn on course to litchfield maintain three thousand the altimeter two niner eight zero

0726:24 N371JD o k left turn on course to litchfield three thousand three seven one juliet delta

0729:27 N371JD kalamazoo---three---

0729:34 ARE *(twin) cessna three seven one juliet delta kalamazoo departure ident please maintain three thousand

0729:39 N371JD identing---(unintelligible)

0730:22 ARE twin cessna one juliet delta squawk three one seven zero please thirty one seventy

0730:27 N371JD uh thirty one seventy standby

0730:32 N371JD my transponder does read three one seven zero what are you seeing on your screen

0730:36 ARE i got three three seven zero try that uh second digit again

0730:43 N371JD how's that

0730:45 ARE *(stand) by

0730:46 ARE traffic three seven one juliet delta's try

Aircraft

Registration
N371JD
Reported as
Cessna 402B
Category
Airplane
Serial number
402B1322
Airframe hours
7,339
Engines
Teledyne Continental TSIO-520-E, 300 horsepower, reciprocatingTeledyne Continental TSIO-520-E, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Operator
Riley Aviation Inc
Registered owner
Riley Aviation, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · December 21, 2001
Departed
IRS · Sturgis, MI
Destination
ARB · Ann Arbor, MI
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
29
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
October 15, 2001
Seat
Left
Toxicology
Performed
Flight hours
1,800 total

Weather

Conditions
Instrument (IMC) · Dawn
Wind
200° at 9 knots
Visibility
4 statute miles
Lowest ceiling
600 ft overcast
Temperature
39 °F, dew point 37 °F
Altimeter
29.81 inHg
Observed at
IRS, 13 nm away

Docket · 34

The files NTSB released with the investigation on June 18, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 15.0 MB in all.

Supplement AItem 1 · .PDF · 110 KBSupplement BItem 2 · .PDF · 140 KBMaterials Laboratory Factual Report 03-026, Combustion HeaterItem 3 · .PDF · 5.7 MBWitness Statements and Record of InterviewItem 4 · .PDF · 298 KBWeather InformationItem 5 · .PDF · 974 KBATC TranscriptsItem 6 · .PDF · 278 KBMichigan State Police ReportItem 7 · .PDF · 444 KBRadar PlotsItem 8 · .PDF · 465 KBPilots Operating Handbook Autopilot SupplementItem 9 · .PDF · 494 KBAutopilot Servo Examination ReportItem 10 · .PDF · 282 KBPilot InformationItem 11 · .PDF · 964 KBAircraft InformationItem 12 · .PDF · 56 KBAirplane Maintenance RecordsItem 13 · .PDF · 326 KBToxicological ReportItem 14 · .PDF · 47 KBStatement of Party Representatives to NTSB InvestigationItem 15 · .PDF · 318 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 16 · .PDF · 116 KBPhoto 1. Overall View of WreckageItem 17 · .PDF · 228 KBPhoto 2. Overall View of WreckageItem 18 · .PDF · 229 KBPhoto 3. Overall View of WreckageItem 19 · .PDF · 226 KBPhoto 4. Overall View of WreckageItem 20 · .PDF · 225 KBPhoto 5. Overall View of WreckageItem 21 · .PDF · 226 KBPhoto 6. View of Initial Impact PointItem 22 · .PDF · 229 KBPhoto 7. View of Initial Impact Point and WreckageItem 23 · .PDF · 228 KBPhoto 8. View of Initial Impact Point and WreckageItem 24 · .PDF · 229 KBPhoto 9. Left Engine and NacelleItem 25 · .PDF · 227 KBPhoto 10. Left Engine and NacelleItem 26 · .PDF · 219 KBPhoto 11. Right Engine, Nacelle, and WingItem 27 · .PDF · 225 KBPhoto 12. Recovered Gyroscope CoresItem 28 · .PDF · 224 KBPhoto 13. Left Engine Magneto'sItem 29 · .PDF · 218 KBPhoto 14. Right Engine Magneto'sItem 30 · .PDF · 216 KBPhoto 15. HSI Gyroscope CoreItem 31 · .PDF · 217 KBPhoto 16. Instrument FacesItem 32 · .PDF · 218 KBPhoto 17. Upper Spark Plugs From Right EngineItem 33 · .PDF · 218 KBPhoto 18. Upper Spark Plugs From Left EngineItem 34 · .PDF · 228 KB

FAA reports on this event · 1

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