CHI03FA041

NTSB accident investigation · Cessna 208B · Rockford, IL · December 18, 2002

Accident · FatalField investigationFinal report
Date
December 17, 2002, 22:51 local (Dec 18, 2002, 04:51 UTC)
Place
Rockford, IL
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N277PMCessna 208B
Weather
Instrument (IMC) · Night
Status
Completed · report April 28, 2004
Report
Approved by Office Director
Parties
Federal Aviation Administration, Cessna Aircraft Company, NTSB
FAA report
20021217035639A
Case key
56227

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 failure to maintain control of the airplane during the ILS approach. Factors associated with the accident were the low ceilings, high winds, crosswind, and wind shear conditions that existed.

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 flightApproach - faf/outer marker to threshold (ifr)
Light condition - dark night
Weather condition - low ceilingFactor
Weather condition - high windFactor
Weather condition - crosswindFactor
Weather condition - windshearFactor
Aircraft control - not maintainedPilot in commandCause
In flight collision with objectDescent - uncontrolled
Object - tree(s)
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The airplane collided with trees and terrain following a loss of control during an Instrument Landing System (ILS) approach at night. The impact occurred approximately 2.1 miles from the approach end of the runway. A witness reported hearing the airplane at "mid-throttle" as it flew over. He then heard the power increase followed by the impact. The witness stated there was no precipitation at the time of the accident and there were "severe winds, mostly from the south, shifting volatile directly from the east." He also stated the visibility was "extremely poor." Statements were received from five pilots who landed in transport category airplanes around the time of the accident. Three of these pilots reported experiencing a crosswind that varied from 15 to 50 knots during the approach. Four of the pilots reported airspeed fluctuations that varied between +/- 8 knots to +/- 10 knots during the approach. Three of the pilots reported breaking out of the clouds between 200 and 300 feet agl. Radar data indicates the airplane was high on the glideslope until it entered a rapid descent from an altitude of about 2,300 feet. Examination of the airframe, engine, and propeller governors failed to reveal any failures/malfunctions that would have resulted in the loss of control.

Factual narrative

History of flight

On December 17, 2002, at 2251 central standard time, a Cessna 208B, N277PM, operated by Planemasters LTD as flight 1627 (PMS1627), collided with the trees and terrain while on the Instrument Landing System (ILS) Runway 7 approach to the Greater Rockford Airport (RFD), Rockford, Illinois. The pilot received fatal injuries and the airplane was destroyed. The 14 CFR Part 135 non scheduled domestic cargo flight was transporting cargo for United Parcel Service (UPS) at the time of the accident. The flight was operating in instrument meteorological conditions on an instrument flight rules (IFR) flight plan. The flight departed Decatur, Illinois, at 2154.

A Trip Log that was provided by Planemasters shows the pilot departed the DuPage Airport (DPA), West Chicago, Illinois, at 1835, on December 16, 2002, en route to the Decatur Airport (DEC), Decatur, Illinois, where he landed at 1935. He then departed DEC at 2150 en route to RFD, where he landed at 2245. The trip continued with a departure from RFD at 0355 on December 17, 2002, en route to the Williamson County Regional Airport (MWA), Marion, Illinois, where he landed at 0550. The pilot then departed MWA at 0705 en route to DEC, arriving at 0750. The pilot then took off from DEC at 2154.

At 2230:47, PMS1627 contacted RFD approach control and reported being at 6,000 feet with information Zulu. The approach controller issued the ILS Runway 7 approach to PMS1627.

At 2233:42, PMS1627 was issued a 10 degree heading change for vectors to base. The pilot acknowledged this transmission.

At 2236:48, the approach controller instructed PMS1627 to fly a heading of 310 degrees and to descend to and maintain 3,000 feet. The pilot acknowledged this transmission.

At 2243:15, the approach controller instructed PMS1627 to turn left to a heading of 290 degrees. The pilot acknowledged this transmission.

At 2243:59, the approach controller asked PMS1627 if he could operate at 170 knots. The pilot responded, "ah be pushing it sir." The controller then asked if he could maintain 150 knots. The pilot responded affirmatively.

At 2244:37, the approach controller issued a heading of 320 degrees and a caution for wake turbulence. The pilot acknowledged this transmission.

At 2245:42, PMS1627 was instructed to turn to a heading of 120 degrees to intercept the localizer. The pilot acknowledged this transmission.

At 2248:48, the approach controller instructed the pilot to turn back left to a heading of 120 degrees to join the localizer. The pilot acknowledged the transmission.

At 2249:30, PMS1627 was cleared for the ILS Runway 7 approach.

At 2249:42, PMS1627 was instructed to contact the tower.

At 2250:58, PMS1627 contacted the tower. The local controller issued the winds as 140 degrees at 18 knots and PMS1627 was cleared to land. The pilot acknowledged this transmission. This was the last contact with PMS1627.

At 2252:09, the local controller issued the winds as 110 degrees at 15 knots.

At 2252:47, the local controller instructed PMS1627 to report being on the runway.

Between 2253:03 and 2254:28, the local controller made four attempts to contact PMS1627. At 2256:22, the local controller asked UPS487 if they would look for a Cessna 208 when they were taxiing in. At 2301:40, UPS487 reported to local controller that their operations stated a Planemaster had landed just prior to them and that it was over at the remote ramp by the terminal.

At 2257, the Winnebago County Sheriff's Police received a report of the airplane crash. Officers met with the caller who directed them to the area where he heard the noise. The officers began searching the area. They stated they were able to smell a strong odor of fuel in the area. The Sergeant in charge of the investigation reported that at 2303, a 911 dispatcher contacted the RFD control tower regarding the call they received reporting an accident. The tower personnel advised the dispatcher that they were missing an airplane. At 2309, the tower advised the dispatcher, that they had located the airplane on the airport. The Sheriff's Police continued to search the area. The Sergeant stated that at 0045 the tower contacted the Sheriff's Police and stated that they were in fact missing a Cessna 208. The Sheriff's Police located the wreckage at 0053. (See ATC Group Chairman's Factual Report for additional details.)

The witness who called the Sheriff's Police stated during an interview that he lives approximately 2 miles west of the airport and one-half mile north of the accident site. He stated he has lived there for 14 years, so he is accustomed to the sound of airplanes. He stated he heard the airplane fly over at a "mid-throttle" power setting. He then heard a sound for about 3 seconds that he likened to an airplane "falling" with the same engine sounds as before. He then heard the engine sound increase "when the pilot throttled it." Based on the sound, he estimated the airplane was about 70 feet above the ground. He heard the increase in engine noise for about 4 to 5 seconds followed by the sound of the airplane hitting, then silence. He stated the sounds were south of his location. The witness stated there was no precipitation at the time of the accident and there were "severe winds, mostly from the south, shifting volatile directly from the east." He also stated the visibility was "extremely poor."

Personnel information

The pilot received a private pilot certificate with a single engine land rating on September 30, 1994. On November 20, 1996, the pilot failed the flight portion of an instrument airplane check ride. The pilot took the test again, passed, and was issued an instrument airplane rating on December 21, 1996. On June 7, 1999, the pilot failed the flight portion of his commercial pilot check ride. He retested and passed on July 31, 1999. On April 13, 2001, the pilot was issued a multi-engine rating on his commercial pilot certificate.

On February 15, 2002, the pilot was issued a Federal Aviation Administration second class medical certificate. The medical certificate contained a limitation for corrective lenses.

The pilot had been employed at Planemasters LTD since March 2002. The aircraft operator provided a Pilot Profile, which was last updated on November 19, 2002. The profile indicates the pilot had a total flight time of 1,841 hours, of which 1,686 hours were pilot-in-command. The profile also indicated the pilot had 1,497 hours of Cessna 208 flight time, 257 hours of actual instrument time, and 1,065 hours of night flight time.

A computer-generated logbook was provided by Planemasters LTD, which showed the pilot flew 19.8 hours between November 19, 2002 and November 26, 2002. The log indicated 16.9 of these hours were in a Cessna 208, 2.4 hours were instrument flight time, and 13.8 hours were at night.

A Pilot Duty Record provided by Planemasters LTD showed the pilot flew 11.3 hours between December 9, 2002 and the date of the accident.

The Pilot Ground Training Log provided by Planemasters LTD indicates the pilot received recurrent training on August 21, 2002. The type aircraft is listed as a Cessna 208 and the remarks state "135 PIC Oral." The remarks section on a Pilot Flight Training Log for this same date states "135 PIC Checkride."

Aircraft information

The aircraft was a single engine Cessna 208B, s/n 208B0143. In February 2001, the aircraft registration number was changed from N9648B to the current number of N277PM. The Hobbs meter in the airplane indicated a time of 5,320.2 hours. The airplane was maintained in accordance with an Approved Aircraft Inspection Program (AAIP). Records show the last maintenance performed on the airplane was on November 21, 2002, when the Bendix/King radar was repaired. On this date the aircraft total time was listed as 10,119.6 hours.

The engine was a Pratt & Whitney PT6-A-

Aircraft

Registration
N277PM
Reported as
Cessna 208B
Category
Airplane
Serial number
208B0143
Airframe hours
10,120
Engine
Pratt & Whitney PT6-A-114, 675 hp, turbo prop
Damage
Destroyed
Flight
Part 135
Registered owner
Planemaster, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · November 21, 2002
Departed
DEC · Decatur, IL
Destination
RFD · Rockford, IL
Flight plan
IFR
Airport
RFD · Greater Rockford Airport, runway 7, 10,000 × 150 ft

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
42
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
August 21, 2002
Seat
Right
Toxicology
Performed
Flight hours
1,872 total · 1,525 in this make and model · 1,717 as pilot in command · 31 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Wind
110° at 17 knots, gusting 20
Visibility
1.25 statute miles
Lowest ceiling
300 ft overcast
Temperature
19 °F, dew point -0 °F
Altimeter
29.78 inHg
Observed at
RFD, 1 nm away

Docket · 59

The files NTSB released with the investigation on February 26, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 21.0 MB in all.

Meteorology - Factual Report of Group ChairmanItem 1 · .PDF · 4.2 MBMeteorology - Attachment 1Item 2 · .PDF · 1.5 MBATC - Factual Report of Group ChairmanItem 3 · .PDF · 194 KBATC - Attachment 1: Daily Record of Facility OperationItem 4 · .PDF · 57 KBATC - Attachment 2: Facility Layout ChartItem 5 · .PDF · 39 KBATC - Attachment 3: Flight Progress StripItem 6 · .PDF · 17 KBATC - Attachment 4: ATC TranscriptsItem 7 · .PDF · 156 KBATC - Attachment 5: Accident/Incident Notification RecordItem 8 · .PDF · 60 KBATC - Attachment 6: Controller Personnel StatementsItem 9 · .PDF · 177 KBATC - Attachment 7: Refresher Training ItemsItem 10 · .PDF · 2.2 MBATC - Attachment 9: RFD Minimum Safe Altitude Warning System ActivationsItem 11 · .TXT · 1 KBWitness Statements and Record of InterviewsItem 12 · .PDF · 249 KBWreckage DiagramItem 13 · .PDF · 15 KBATC and FSS Information and TranscriptsItem 14 · .PDF · 659 KBWinnebago County Sheriff's Department ReportItem 15 · .PDF · 774 KBRockford ILS Runway 7 Approach PlateItem 16 · .PDF · 47 KBRadar Data & PlotsItem 17 · .PDF · 528 KBAircraft Flight RecordsItem 18 · .PDF · 180 KBLoad Manifest, Trip Log, and Navigation LogItem 19 · .PDF · 130 KBDecatur Aviation Fuel LogItem 20 · .PDF · 58 KBPilot Records and LogsItem 21 · .PDF · 846 KBSummary of Engine TeardownItem 22 · .PDF · 92 KBSummary of Propeller Governor ExaminationItem 23 · .PDF · 102 KBToxicological ReportItem 24 · .PDF · 49 KBStatement of Party Representatives to NTSB InvestigationItem 25 · .PDF · 309 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 26 · .PDF · 195 KBPhoto 1. Aerial View of Airport in Relation to the Accident SiteItem 27 · .PDF · 452 KBPhoto 2. View From River Bank Looking Toward Main WreckageItem 28 · .PDF · 230 KBPhoto 3. Pieces of Propeller Blades Found Along Wreckage PathItem 29 · .PDF · 464 KBPhoto 4. View From Main Wreckage Looking Back Through TreesItem 30 · .PDF · 181 KBPhoto 5. View of EngineItem 31 · .PDF · 228 KBPhoto 6. Right Wing and FuselageItem 32 · .PDF · 171 KBPhoto 7. Scattered WreckageItem 33 · .PDF · 195 KBPhoto 8. Right Side of FuselageItem 34 · .PDF · 227 KBPhoto 9. Top and Left Side of FuselageItem 35 · .PDF · 216 KBPhoto 10. Right Side of Fuselage in HangarItem 36 · .PDF · 225 KBPhoto 11. Front Left Side View of N277PMItem 37 · .PDF · 227 KBPhoto 12. View of Aft Fuselage on N277PMItem 38 · .PDF · 223 KBPhoto 13. Left Elevator of N277PMItem 39 · .PDF · 216 KBPhoto 14. Aft View of Separated EmpennageItem 40 · .PDF · 213 KBPhoto 15. Right Side of Separated EmpennageItem 41 · .PDF · 216 KBPhoto 16. Left Side of Separated EmpennageItem 42 · .PDF · 221 KBPhoto 17. Rudder and Right Elevator DamageItem 43 · .PDF · 225 KBPhoto 18. Cable Tears Through Lower Aft BulkheadItem 44 · .PDF · 217 KBPhoto 19. Elevator and Rudder CablesItem 45 · .PDF · 774 KBPhoto 20. Outboard Section of Left WingItem 46 · .PDF · 223 KBPhoto 21. Inboard Section of Left WingItem 47 · .PDF · 227 KBPhoto 22. Overall View of Right WingItem 48 · .PDF · 223 KBPhoto 23. Right WingItem 49 · .PDF · 222 KBPhoto 24. Right WingItem 50 · .PDF · 223 KBPhoto 25. Right WingItem 51 · .PDF · 228 KBPhoto 26. Propeller Hub With Fractured BladesItem 52 · .PDF · 223 KBPhoto 27. Pieces of Propeller BladesItem 53 · .PDF · 227 KBPhoto 28. Power QuadrantItem 54 · .PDF · 224 KBPhoto 29. Cracks on Mounting Plate on Propeller GovernorItem 55 · .PDF · 226 KBPhoto 30. Marks on Drive Gear Side of Mounting Plate on Propeller GovernorItem 56 · .PDF · 209 KBPhoto 31. Damage to Drive Gear and Idler Gear Socket on Propeller GovernorItem 57 · .PDF · 220 KBPhoto 32. Damage to Drive Gear Socket on Propeller GovernorItem 58 · .PDF · 218 KBPhoto 33. EngineItem 59 · .PDF · 181 KB

FAA reports on this event · 1

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