# NTSB CHI02FA067: Cessna 402B, N371JD, Bronson, MI, January 23, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 23, 2002, 07:35 local (12:35 UTC) - Place: Bronson, MI - Coordinates: 41.897499, -85.183334 - Nearby events: https://openairdocs.org/map.md?lat=41.8975&lon=-85.1833&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report August 26, 2003 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, FAA-South Bend, Indiana-FSDO, Teledyne Continental Motors - NTSB case key (mKey): 54060 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI02FA067 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54060/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54060 - Page: https://openairdocs.org/ntsb/CHI02FA067 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, cruise - autopilot - not understood, pilot in command (contributing factor) - elevator trim - inadvertent activation, pilot in command (contributing factor) - Loss of control - in flight, emergency descent/landing - maneuver to avoid obstructions - performed, pilot in command (cause) - object - other (contributing factor) - stall - inadvertent, pilot in command (cause) - In flight collision with terrain/water, emergency 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](https://openairdocs.org/deregistered/N371JD-2002-07-02), registration cancelled 2002-07-02, S/N 402B1322, built 1978 (OpenAirDocs) - Reported make and model: Cessna 402B - Registry model: [Cessna 402B](https://openairdocs.org/model/cessna-402b) (registry code 207590P) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 402B1322 - Airframe hours: 7339 - Engines: Teledyne Continental TSIO-520-E 300 horsepower reciprocating; Teledyne 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; injuries: fatal; 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 ## 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 20020123000959A](https://openairdocs.org/incident/20020123000959A), Jan 23, 2002: Cessna 402B, Sturgis, MI, No damage, 1 fatal. (.19) 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… ## Docket (34 files) The files NTSB released with the investigation on June 18, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54060. 15.0 MB in all. - Supplement A (item 1, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184615&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184616&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Materials Laboratory Factual Report 03-026, Combustion Heater (item 3, .PDF, 5.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40178505&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2003-026,%20Combustion%20Heater-Master.PDF - Witness Statements and Record of Interview (item 4, .PDF, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382803&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Record%20of%20Interview-Redacted.PDF - Weather Information (item 5, .PDF, 974 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184618&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - ATC Transcripts (item 6, .PDF, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184619&FileExtension=.PDF&FileName=ATC%20Transcripts-Master.PDF - Michigan State Police Report (item 7, .PDF, 444 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382804&FileExtension=.PDF&FileName=Michigan%20State%20Police%20Report-Redacted.PDF - Radar Plots (item 8, .PDF, 465 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184720&FileExtension=.PDF&FileName=Radar%20Plots-Master.PDF - Pilots Operating Handbook Autopilot Supplement (item 9, .PDF, 494 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184622&FileExtension=.PDF&FileName=Pilots%20Operating%20Handbook%20Autopilot%20Supplement-Master.PDF - Autopilot Servo Examination Report (item 10, .PDF, 282 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184623&FileExtension=.PDF&FileName=Autopilot%20Servo%20Examination%20Report-Master.PDF - Pilot Information (item 11, .PDF, 964 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382805&FileExtension=.PDF&FileName=Pilot%20Information-Redacted.PDF - Aircraft Information (item 12, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184627&FileExtension=.PDF&FileName=Aircraft%20Information-Master.PDF - Airplane Maintenance Records (item 13, .PDF, 326 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382807&FileExtension=.PDF&FileName=Airplane%20Maintenance%20Records-Redacted.PDF - Toxicological Report (item 14, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382808&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 15, .PDF, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382811&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 16, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382812&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1. Overall View of Wreckage (item 17, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184632&FileExtension=.PDF&FileName=Photo%201.%20%20Overall%20View%20of%20Wreckage-Master.PDF - Photo 2. Overall View of Wreckage (item 18, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184633&FileExtension=.PDF&FileName=Photo%202.%20%20Overall%20View%20of%20Wreckage-Master.PDF - Photo 3. Overall View of Wreckage (item 19, .PDF, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184634&FileExtension=.PDF&FileName=Photo%203.%20%20Overall%20View%20of%20Wreckage-Master.PDF - Photo 4. Overall View of Wreckage (item 20, .PDF, 225 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184635&FileExtension=.PDF&FileName=Photo%204.%20%20Overall%20View%20of%20Wreckage-Master.PDF - Photo 5. Overall View of Wreckage (item 21, .PDF, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184636&FileExtension=.PDF&FileName=Photo%205.%20%20Overall%20View%20of%20Wreckage-Master.PDF - Photo 6. View of Initial Impact Point (item 22, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184637&FileExtension=.PDF&FileName=Photo%206.%20%20View%20of%20Initial%20Impact%20Point-Master.PDF - Photo 7. View of Initial Impact Point and Wreckage (item 23, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184638&FileExtension=.PDF&FileName=Photo%207.%20%20View%20of%20Initial%20Impact%20Point%20and%20Wreckage-Master.PDF - Photo 8. View of Initial Impact Point and Wreckage (item 24, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184639&FileExtension=.PDF&FileName=Photo%208.%20%20View%20of%20Initial%20Impact%20Point%20and%20Wreckage-Master.PDF - Photo 9. Left Engine and Nacelle (item 25, .PDF, 227 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184640&FileExtension=.PDF&FileName=Photo%209.%20%20Left%20Engine%20and%20Nacelle-Master.PDF - Photo 10. Left Engine and Nacelle (item 26, .PDF, 219 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184641&FileExtension=.PDF&FileName=Photo%2010.%20%20Left%20Engine%20and%20Nacelle-Master.PDF - Photo 11. Right Engine, Nacelle, and Wing (item 27, .PDF, 225 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184642&FileExtension=.PDF&FileName=Photo%2011.%20%20Right%20Engine,%20Nacelle,%20and%20Wing-Master.PDF - Photo 12. Recovered Gyroscope Cores (item 28, .PDF, 224 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184643&FileExtension=.PDF&FileName=Photo%2012.%20%20Recovered%20Gyroscope%20Cores-Master.PDF - Photo 13. Left Engine Magneto's (item 29, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184644&FileExtension=.PDF&FileName=Photo%2013.%20%20Left%20Engine%20Magneto%27s-Master.PDF - Photo 14. Right Engine Magneto's (item 30, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184645&FileExtension=.PDF&FileName=Photo%2014.%20%20Right%20Engine%20Magneto%27s-Master.PDF - Photo 15. HSI Gyroscope Core (item 31, .PDF, 217 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184646&FileExtension=.PDF&FileName=Photo%2015.%20%20HSI%20Gyroscope%20Core-Master.PDF - Photo 16. Instrument Faces (item 32, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184647&FileExtension=.PDF&FileName=Photo%2016.%20%20Instrument%20Faces-Master.PDF - Photo 17. Upper Spark Plugs From Right Engine (item 33, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184648&FileExtension=.PDF&FileName=Photo%2017.%20%20Upper%20Spark%20Plugs%20From%20Right%20Engine-Master.PDF - Photo 18. Upper Spark Plugs From Left Engine (item 34, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184649&FileExtension=.PDF&FileName=Photo%2018.%20%20Upper%20Spark%20Plugs%20From%20Left%20Engine-Master.PDF 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.