CHI02FA074

NTSB accident investigation · Cessna 441 · Winfield, KS · January 30, 2002

Accident · FatalField investigationFinal report
Date
January 30, 2002, 13:59 local (19:59 UTC)
Place
Winfield, KS
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N441ARCessna 441
Weather
Instrument (IMC) · Day
Status
Completed · report May 30, 2003
Report
Approved by Office Director
Parties
Cessna Aircraft Company, FAA, Honeywell
FAA report
20020130002359A
Case key
54098

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 pilot's spatial disorientation resulting in a loss of control and collision with the ground. Additional factors included the pilot operating the airplane with known deficiencies and the instrument flight conditions.

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
Flight/nav instruments,attitude gyro - unreliable
Autopilot/flight director - unreliable
Operation with known deficiencies in equipment - performedPilot in commandFactor
Aircraft control - not maintainedPilot in commandCause
Weather condition - cloudsFactor
Spatial disorientationPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

Impact forces and fire destroyed the airplane when it impacted the terrain after a loss of control during cruise flight. The pilot received a weather brief by AFSS prior to departure concerning the IFR conditions along the route of flight, which included, rain, freezing rain, icing, turbulence, and snow. The cloud tops were forecast to be 25,000 feet. The pilot filed a flight plan with a cruise flight level of 28,000 feet. About 32 minutes after takeoff, at 1345:58, the pilot reported he had an attitude gyro problem and that he was hand flying the airplane. The airplane's altitude remained at about 28,000 feet for the next seven minutes. At 1352:46, the pilot stated he had an emergency, but at 1352:53, the pilot stated, "Uh it came back on never mind." At 1353:26, the pilot stated, "I need to get to uh anywhere I can get a visual." At 1353:56, the airplane was cleared to climb to 31,000 feet, and radar data indicated the airplane was currently at 27,000 feet. The radar data indicated the airplane went into a series of steep descents and climbs over the next 4.5 minutes until radar contact was lost at 2,500 feet. The pilot of a commercial airline who was flying in the same sector as the accident airplane reported that he heard the accident pilot state that he was in a spin. The commercial airline pilot stated they were flying at 33,000 feet and were "barely above the tops" of the clouds. The airplane impacted the terrain in a steep nose down attitude and burst into flames. The engines, flight controls, and flight instruments did not exhibit any pre-existing anomalies. A witness reported that two days prior to the accident, the pilot had advised him that the airplane's attitude gyro was having problems. There was no record that the pilot had the attitude gyro inspected prior to the accident. A witness reported the pilot routinely flew with the autopilot engaged soon after takeoff. He reported that he had never observed the pilot hand-fly the airplane in instrument conditions.

Factual narrative

History of flight

On January 30, 2002, at 1359 central standard time, a Cessna 441, N441AR, was destroyed when it impacted terrain in a pasture near Winfield, Kansas. The private pilot and passenger received fatal injuries. The 14 CFR Part 91 personal flight departed the Springdale Municipal Airport (ASG), Arkansas, at 1314 en route to the Garfield County Regional Airport (RIL), Rifle, Colorado, on an instrument flight plan.

The pilot received two weather briefings from the Jonesboro Automated Flight Service Station (AFSS) on the day of the accident. The first weather briefing occurred between 0622 and 0632 and the second between 1130 and 1140. During the first weather briefing, the AFSS briefer provided the pilot with the current in-flight weather advisories concerning instrument flight (IFR) conditions, mountain obscuration, icing, and turbulence. The pilot was advised of the rain, freezing rain, and snow along the proposed route of flight. The pilot inquired about the cloud tops and was briefed that the forecast cloud tops were 25,000 feet. The pilot filed an IFR flight plan with a cruise flight level of 28,000 feet (FL 280).

At 1133, the pilot called AFSS for a weather update. The AFSS briefer reported the current weather included a mixture of precipitation that ranged from moderate rain to freezing rain, snow, and an area of freezing rain that extended about 70 miles along the route, and then changed over to snow. The pilot asked about the location of the freezing level and cloud tops. The briefer reported that the freezing level was at 12,000 feet across Oklahoma, but there were freezing conditions at the surface with freezing rain. The briefer indicated the only pilot report he had over northwestern Arkansas was over a hour old and it indicated the top of the first layer was at 8,000 feet, with a higher overcast layer at 9,500 feet with tops 11,000 feet with higher cirraform clouds above. Over central Oklahoma the clouds tops were in the 11,000 feet - 13,500 feet range based on pilot reports, with cirraform clouds above.

A witness reported that the pilot had checked the weather on the morning of the accident. He reported that the pilot was aware of the en route weather conditions. He reported the pilot had said the cloud tops were at 22,000 feet and that he would be flying at 29,000 feet.

N441AR departed ASG at 1314. At 1326:38, N441AR was cleared to climb to FL 280. Radar data indicated that N441AR leveled off at FL 280 at 1331:57 on a direct heading of about 288 degrees to RIL.

At 1345:58, N441AR reported to the FAA's Kansas City Air Route Traffic Control Center (ARTCC), "Uh yeah I'm an attitude gyro problem I'm hand flying um might be a few hundred feet deviation here and there."

At 1346:05, The ARTCC position R27 controller asked, "November one alpha romeo roger and you you'll be able to maintain flight level two eight zero correct?"

At 1346:10, N441AR responded, "Yeah I'll be able to maintain it just might be there's nothing wrong here I just want to let you know I might be off a hundred feet here and there."

At 1346:16, R27 stated, "November one alpha romeo roger if you need a block altitude you'll need to advise me if not uh you need to maintain flight level two eight zero."

At 1346:24, N441AR asked, "Two eight zero do you have any blocks?'

At 1346:28, R27 responded, "November one alpha romeo maintain flight level two seven zero through flight level two eight zero."

Radar data indicated that N441AR's altitude remained at FL 280 +/- 100 feet between 1345:58, when N441AR first indicated he was hand flying the airplane, and 1352:30, when R27 asked, "November one alpha romeo you are doing okay with the block altitude there correct?"

At 1352:34, N441AR responded, "I think that will work for me I'm just hand flying it so far it works (laughing).

At 1352:37, R27 stated, "November one alpha romeo roger contact Kansas city center one three three point two and they're uh they're aware that your auto pilot's out."

At 1352:46, N441AR reported, "An four four one alpha romeo I got uh an emergency here." Radar data indicated that N441AR's had descended to 27,300 feet, but had maintained a northwesterly heading.

At 1352:51, R27 responded, "November one alpha romeo understand you do have an emergency?"

At 1352:53, N441AR reported, "Uh it came back on nevermind." Radar data indicated that N441AR was in a left turn and its altitude was approximately 27,000 feet."

At 1353:17, N441AR reported, "And uh four four one alpha romeo I need to get to uh anywhere I can get a visual." Radar data indicated that N441AR's altitude was about 26,500 feet.

At 1353:26, R27 stated, "And November one alpha romeo let me see if I can get a tops report right quick for you there you want to go down."

At 1353:33, N441AR responded, "I'll go up." Radar data indicated N441AR's altitude was about 26,400 feet and it had turned back to a northwest heading.

At 1353:34, R27 asked, "One alpha romeo you want to go up sir?"

At 1353:36, N441AR responded, "Where it's visual."

At 1353:37, R27 stated, "Okay I think we're blocking each other November one alpha romeo do you wish to climb sir?"

At 1353:42, N441AR responded, "Uh unless there is any vfr below anywhere."

At 1353:51, R27 stated, "I'm not aware of any here just a second."

At 1353:51, R27 stated, "One alpha romeo climb and maintain flight level three one zero."

At 1353:56, N441AR responded, "Three one zero alpha romeo." Radar data indicated N441AR's altitude was about 27,000 feet.

At 1354:44, N441AR transmitted, "What's my airspeed?"

At 1354:46, N441AR transmitted, "I got to pull up I got to pull up baby." Radar data indicated that N441AR's altitude was approximately 19,000 feet.

At 1354:56, N441AR transmitted, "I need to go up need to go up." Radar data indicated that N441AR's altitude was approximately 18,000 feet.

At 1354:58, N441AR transmitted, "What do I do?"

At 1354:59, N441AR transmitted, "You're okay you're okay."

At 1355:00, N441AR transmitted, "We're headings headings okay now."

At 1355:03, N441AR transmitted, "Our heading up just pull it up."

At 1355:29, radar data indicated that N441AR's altitude was about 21,300 feet.

At 1355:34, R27 stated, "November one alpha romeo are you doing okay now?"

At 1355:37, N441AR responded, "I'm gonna I'm having trouble maintaining this level here." Radar data indicated that N441AR's altitude was approximately 18,000.

At 1355:43, R27 stated, "November one alpha romeo can you give me your altitude now sir?"

At 1355:45, N441AR responded, "Teen thousand."

At 1355:47, R27 stated, "Eighteen thousand."

At 1356:19, R27 asked, "November one alpha romeo are uh you still with me?" Radar data indicated that N441AR's altitude was about 15,000 feet.

At 1356:21, N441AR stated, "Yep."

At 1356:22, radar data indicated that N441AR's altitude was about 14,500 feet.

At 1356:29, N441AR transmitted, "We're back up."

At 1356:33, N441AR stated, "No gyro for one alpha romeo quickly no gyro headings for alpha romeo." Radar data indicated that N441AR's altitude was about 16,800 feet.

At 1356:38, R27 stated, "November one alpha romeo."

At 1356:40, N441AR stated, "Give me a no gyro for one alpha romeo quickly."

At 1356:43, R27 stated, "Okay November one alpha romeo just fly your present heading present heading will be just fine."

At 1356:47, N441AR stated, "Left or right."

At 1356:51, R27 stated, "November one alpha romeo just present heading uh no turns now just present heading." Radar data indicated that N441AR's altitude was about 13,700 feet.

At 1356:58, N441AR stated, "Okay now I got it."

At 1357:40, R27 asked, "November one alpha romeo how do you hear center?" Radar data indicated that N441AR's altitude was about 7,600 feet.

At 1358:08, N441AR stated, "Romeo give me." There were no further recorded rad

Aircraft

Registration
N441AR
Reported as
Cessna 441
Category
Airplane
Serial number
441-0148
Airframe hours
3,529.9
Engine
Honeywell TPE-331-10N, 635 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Registered owner
Chrysalis, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · May 13, 2001 · 54.8 hours before
Departed
ASG · Springdale, AR
Destination
RIL · Rifle, CO
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
60
Injuries
Fatal
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,500 total

Weather

Conditions
Instrument (IMC) · Day
Wind
10° at 15 knots
Visibility
1.75 statute miles
Lowest ceiling
1,400 ft overcast
Temperature
23 °F, dew point 21 °F
Altimeter
30.04 inHg
Observed at
ICT, 37 nm away

Docket · 55

The files NTSB released with the investigation on April 21, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 67.9 MB in all.

Supplement CItem 1 · .PDF · 253 KBSupplement DItem 2 · .PDF · 302 KBMeteorology 5 - Factual Report of Group ChairmanItem 3 · .PDF · 315 KBMeteorology Factual Report - Attachments 1-17Item 4 · .PDF · 19.0 MBMaterials Laboratory Factual ReportItem 5 · .PDF · 134 KBRecorded Aircraft Radar StudyItem 6 · .PDF · 12.5 MBRecord of InterviewItem 7 · .PDF · 491 KBMap of Accident Site and Wreckage DiagramItem 8 · .PDF · 139 KBATC TranscriptsItem 9 · .PDF · 806 KBNTSB Medical Officer Pertinent Medical InformationItem 10 · .PDF · 132 KBPilot Flight Training RecordsItem 11 · .PDF · 1.2 MBHoneywell Protocol For Inspection of Pilot's Gyro Horizon IndicatorItem 12 · .PDF · 242 KBInstrument Panel DiagramItem 13 · .PDF · 81 KBCD InformationItem 14 · .PDF · 18 KBToxicological ReportsItem 15 · .PDF · 101 KBStatement of Party Representatives to NTSB InvestigationItem 16 · .PDF · 315 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 17 · .PDF · 138 KBPhoto 1. Main Wreckage Viewed To The WestItem 18 · .PDF · 886 KBPhoto 2. Main WreckageItem 19 · .PDF · 910 KBPhoto 3. Right Wing and EngineItem 20 · .PDF · 913 KBPhoto 4. Right Engine and Propeller and Bottom of TailconeItem 21 · .PDF · 81 KBPhoto 5. Right Engine and Propeller and Bottom of TailconeItem 22 · .PDF · 81 KBPhoto 6. Left EngineItem 23 · .PDF · 77 KBPhoto 7. Bottom of the Leading Edge of the Right WingItem 24 · .PDF · 83 KBPhoto 8. View of the Left Wing and Left Engine NacelleItem 25 · .PDF · 912 KBPhoto 9. View of the Main Wreckage Looking to the SoutheastItem 26 · .PDF · 934 KBPhoto 10. Right Wing Top Surface PanelItem 27 · .PDF · 929 KBPhoto 11. Left Wing Lower Surface PanelItem 28 · .PDF · 909 KBPhoto 12. Bottom Side of the Left WingItem 29 · .PDF · 903 KBPhoto 13. Left PropellerItem 30 · .PDF · 922 KBPhoto 14. Blade 1, Left PropellerItem 31 · .PDF · 924 KBPhoto 15. Blade 2, Left PropellerItem 32 · .PDF · 912 KBPhoto 16. Blade 1, Right PropellerItem 33 · .PDF · 929 KBPhoto 17. Blade 2, Right PropellerItem 34 · .PDF · 920 KBPhoto 18. Blade 3, Right PropellerItem 35 · .PDF · 856 KBPhoto 19. Blade 4, Right PropellerItem 36 · .PDF · 877 KBPhoto 20. Airspeed Indicator FaceItem 37 · .PDF · 868 KBPhoto 21. Power QuadrantItem 38 · .PDF · 902 KBPhoto 22. Elevator Trim Chain Inside Power QuadrantItem 39 · .PDF · 401 KBPhoto 23. Elevator Trim ActuatorsItem 40 · .PDF · 890 KBPhoto 24. Copilot's YokeItem 41 · .PDF · 930 KBPhoto 25. Pilot's YokeItem 42 · .PDF · 369 KBPhoto 26. Pilot's HSI Gyro NSD 360 CapsuleItem 43 · .PDF · 117 KBPhoto 27. Pilot's HSI Gyro HousingItem 44 · .PDF · 112 KBPhoto 28. Pilot's HSI GyroItem 45 · .PDF · 114 KBPhoto 29. Burned and Charred Components of Pilot's Attitude GyroItem 46 · .PDF · 163 KBPhoto 30. Ring Housing of Pilot's Attitude GyroItem 47 · .PDF · 141 KBPhoto 31. Pilot's Attitude Gyro. Electric Gyro. Improperly Photographed With HSI Data Plate and LabelItem 48 · .PDF · 115 KBPhoto 32. Copilot's Directional Gyro HousingItem 49 · .PDF · 113 KBPhoto 33. Copilot's Directional GyroItem 50 · .PDF · 96 KBPhoto 34. Burned and Charred Copilot's Gyro and HousingItem 51 · .PDF · 140 KBPhoto 35. Copilot's Charred Attitude Gyro and HousingItem 52 · .PDF · 106 KBPhoto 36. Copilot's Attitude Gyro and Housing BaseItem 53 · .PDF · 101 KBHoneywell Teardown Report of Two Model TPI331-10N turpoprop EnginesItem 54 · .PDF · 10.4 MBTeardown Report of One Honeywell Inc. Gyro Horizon Indicator, Model GH-14Item 55 · .PDF · 1.8 MB

FAA reports on this event · 1

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