DEN08FA078

NTSB accident investigation · Cessna P206 · Mount Vernon, MO · April 19, 2008

Accident · FatalField investigationFinal report
Date
April 19, 2008, 16:15 local (21:15 UTC)
Place
Mount Vernon, MO
Injuries
2 fatal, 2 serious, 3 uninjured
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N2537XCessna P206
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report December 28, 2008
Report
Approved by Office Director
Parties
FAA Flight Standards District Office
FAA report
20080419832129A
Case key
67890

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

The pilot's failure to maintain adequate airspeed, resulting in an inadvertent stall/spin. Contributing factors in this accident were the entanglement of the parachute in the elevator control system, reducing the pilot's ability to regain control.

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.

Action: incorrect action performancePersonnel issues › Action/decision · PilotCessna P206: 1 caseAll aircraft: 1,386 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna P206: 2 casesAll aircraft: 1,681 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

Surviving skydivers said that as the airplane was climbing to the jump altitude of 10,500 feet agl, the stall warning horn sounded intermittently several times. They paid no particular attention to it because they had heard it on previous flights. When the airplane reached the jump altitude, the pilot signaled for one of the parachutists to open the door. When she did, she told the pilot that the airplane had overshot the drop zone by approximately 1 mile. As the pilot started a right turn back towards the drop zone, the stall warning horn sounded again, then the airplane "rolled off on its right wing" and entered a spin. The skydivers became disoriented and nauseated. Four skydivers managed to bail out safely, but one of them broke her right leg when she struck the right horizontal stabilizer after exiting the airplane. The reserve parachute on the fifth skydiver deployed and became entangled around the tail of the airplane. She sustained fatal injuries. The sixth skydiver was unable to exit the airplane and was found inside, fatally injured. The pilot was seriously injured. Ground witnesses reported hearing the engine RPMs decrease, then saw the airplane spinning. Somewhere between 1,000 and 5,000 feet, the airplane leveled out for a few seconds and witnesses saw a parachute wrapped around the tail. The airplane then spun or dove to the ground. Downloaded data from the onboard GPS and Automated Activation Devices worn by three of the skydivers corroborated these accounts.

Factual narrative

History of flight

On April 19, 2008, approximately 1615 central daylight time, a Cessna P206, N2537X, registered to and operated by Freefall Express Skydiving, Inc., and piloted by a commercial pilot, was destroyed when it struck trees and impacted terrain following an in-flight loss of control near Mount Vernon, Missouri. Visual meteorological conditions prevailed at the time of the accident. The skydiving flight was being conducted under the provisions of Title 14 CFR Part 91 without a flight plan. The pilot and one parachutist were seriously injured, two parachutists were fatally injured, and three parachutists were not injured. The local flight originated from the Mount Vernon Municipal Airport (2MO) approximately 1530.

Written statements were received from all four surviving parachutists, and two of them were interviewed in person. The following is a summary of their accounts. As the airplane was climbing to the jump altitude of 10,500 feet agl (above ground level), the stall warning horn sounded intermittently several times. The parachutists said they paid no particular attention to it because they had heard it on previous flights. When the airplane reached the jump altitude, the pilot signaled for one of the parachutists to open the door. When she did, she told the pilot that the airplane had overshot the drop zone by approximately 1 mile. As the pilot started a right turn back towards the drop zone, the stall warning horn sounded again, then the airplane "rolled off on its right wing" and entered a spin. One parachutist wrote, "We were spinning so fast, it was difficult for me to tell what direction we were facing or in what direction we were spinning. I was holding on to the pilot's seat with my left hand, the door frame with my right hand, my head was touching the ceiling, my feet on the floor, and I was being forced to the back of the plane." A second parachutist wrote, "We were holding on to each other. I felt sick from the spinning." A third parachutist said the force of the spin pushed her against the cabin. The pilot told everyone to move aft, "to transfer our weight to the tail of the airplane." Three parachutists exited the airplane and parachuted to safety. A fourth parachutist broke her right leg when she struck the right horizontal stabilizer after exiting the airplane. Because she was disoriented, she said she activated her reserve parachute and landed safely. The reserve parachute on the fifth parachutist deployed and became entangled around the tail of the airplane. She sustained fatal injuries. The sixth parachutist was unable to exit the airplane and was found inside, fatally injured. The pilot was airlifted to Mercy St. John's Hospital in Springfield, Missouri.

Seven ground witnesses submitted written statements. One witness said he heard the engine RPMs decrease, "[an] indication that the [air]plane [was] slowing down for the skydivers to jump." Then he saw the airplane "falling nose down and spinning." He said that approximately 5,000 feet, the airplane seemed to slow or stop spinning and he observed four skydivers in the sky. Approximately 3,000 feet, he noticed "a white parachute on the tail of the plane." Approximately 2,000 feet the airplane leveled out on a westerly heading and appeared to climb. Then it started "spinning and heading nose down again." Another ground witness observed the same sequence of events, but estimated the altitude of the airplane to be between 500 and 1,000 feet when she saw the fifth parachute. "It appeared to inflate and then collapse." She said the airplane made a 90 degree turn to the west and she could see the parachute was attached to the tail. "The plane then angled 45 degrees toward the ground and fell nose first."

A third ground witness saw the airplane "spiraling downward, nose first, and out of control. The pilot was able to pull the plane out from the downward spiral" between 2,000 to 3,000 feet, and it appeared to climb, then "it began to spiral nose first again." That is when the witness noticed a "white reserve [para]chute caught on the tail of the plane." Another ground witness saw the airplane "in a head-down spin. The plane leveled out and flew normal for a few seconds, and then a white parachute seemed to come out beside the plane and catch on the tail. The plane then began another series of spins." She said the parachute "appeared to come put of the door and inflate beside the plane."

Personnel (crew) information

The pilot, age 32, held a commercial pilot certificate with airplane single/multiengine land and instrument ratings, dated September 2, 2007. He also held a first class airman's medical certificate, dated October 24, 2007, with the limitation, "Must wear corrective lenses." A photostatic copy of the pilot's logbook was submitted for examination. It contained entries from July 13, 2000, to April 6, 2008. According to this document, the pilot began his flight training at Elmdale Airpark (6F4), Abilene, Texas. He made his first solo flight on October 19, 2001, and received his private pilot license on August 10, 2002. During this time, the pilot had no less than 18 lessons involving 18.2 hours of various stalls and slow flight.

On November 12, 2006, the pilot enrolled in Pan Am Flight Training Academy's instrument and commercial curriculums at Deer Valley Airport (DVT), Phoenix, Arizona. The chief flight instructor failed to respond to this investigator's request for an interview. According to the pilot's logbook, he failed the instrument rating practical test on February 26, 2007, then passed it on March 14, 2007. During this time, the pilot was given no less than 6 lessons involving 7.9 hours of various stalls and slow flight. He failed the commercial multiengine practical test on July 24, 2007, then passed it on July 31, 2007. During this time, the pilot was given no less than 12 lessons involving 17.4 hours of various stalls and slow flight. He failed the commercial single-engine practical test on August 31, 2007, then passed it on September 2, 2007. During this time, the pilot was given no less than 2 lessons involving 1.9 hours of various stalls and slow flight. At no time during his training in either Abilene or Phoenix was the pilot given spin instruction. According to the various FAA practical test guides, only flight instructor applicants are required to have spun an airplane (or had a spin demonstrated).

On November 15, 2007, he was given a Freefall Express Skydiving checkout in the Cessna 182. Between that date and April 5, 2008, he logged 66 hours in the Cessna 182, all of which was flying skydivers. On April 6, 2008, he flew skydivers in the Cessna P206 and logged 8.5 hours. This was the last recorded entry in his logbook. As of that date, the pilot had logged the following flight time (in hours):

Total Time, 320.5

Single engine, 278.5

Multiengine, 42.0

Pilot-in-command, 222.3

Instruction received, 236.3

Night, 55.0

Actual instruments, 4.0

Simulated instruments, 73.5

Flight simulator, 30.0

Cross-country, 73.6

Aircraft information

N2537X, a model P206 (s.n. P206-0037), was manufactured by the Cessna Aircraft Company, and received its FAA airworthiness certificate on December 11, 1964. It was equipped with a Continental IO-520-F-9 engine (s.n. 553089), driving a McCauley 3-blade, all-metal, constant speed propeller (m.n. D3A34C402). According to the aircraft's maintenance records, the last annual inspection of the airframe and 100-hour inspections of the engine and propeller were accomplished on May 18, 2007, at a tachometer time of 3,227.9 hours. At the time of the accident, the airframe and engine had accumulated 4,302.7 and 4,394.2 hours, respectively. The engine and propeller had accumulated 1,621.7 and 440.95 hours since major overhaul.

According to the FAA principal airworthiness inspector who had been recently assigned to Freefall Express Skydiving, neither the engine nor the propeller were cer

Aircraft

Registration
N2537X
Reported as
Cessna P206
Category
Airplane
Serial number
P206-0037
Airframe hours
4,303
Engine
Continental IO-520-F-9, 300 horsepower, reciprocating
Damage
Destroyed
Flight
Skydiving · Part 91
Registered owner
Freefall Express Skydiving, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 1, 2007 · 296 hours before
Departed
2MO · Mount Vernon, MO
Destination
2MO

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
32
Injuries
Serious
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
September 2, 2007
Seat
Left
Toxicology
Performed
Flight hours
321 total · 10 in this make and model · 222 as pilot in command · 39 in the last 90 days · 14 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 45 °F
Altimeter
29.94 inHg
Observed at
SGF

FAA reports on this event · 1

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

Other investigations on N2537X · 1

Matched to the same aircraft by N-number and date.