# NTSB ERA10LA105: Cessna 172S, N5118J, Greenbush, ME, January 4, 2010

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Limited investigation · Final report
- Date: January 4, 2010, 10:54 local (15:54 UTC)
- Place: Greenbush, ME
- Coordinates: 45.126388, -68.629165
- Nearby events: https://openairdocs.org/map.md?lat=45.1264&lon=-68.6292&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed, report October 21, 2010
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: Cessna Aircraft Company, FAA/FSDO
- NTSB case key (mKey): 75218
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA105
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75218/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75218
- Page: https://openairdocs.org/ntsb/ERA10LA105

## Probable cause

The pilot's improper decision to attempt a transoceanic flight in turbulent, icing conditions, with an overweight airplane that was not approved for moderate turbulence and not equipped with deicing systems. Contributing to the accident was the pilot's personal pressure to return home.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 172S, 41 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2072439), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Aircraft capability: maximum weight](https://openairdocs.org/ntsb-findings/01061035): Aircraft › Aircraft oper/perf/capability · Not specified (probable cause); cases with it: [Cessna 172S, 6 cases](https://openairdocs.org/ntsb-findings/01061035/cases.md?model=2072439), [All aircraft, 152 cases](https://openairdocs.org/ntsb-findings/01061035/cases.md)
- [Temp/humidity/pressure: conducive to structural icing](https://openairdocs.org/ntsb-findings/03031025): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Cessna 172S, 1 case](https://openairdocs.org/ntsb-findings/03031025/cases.md?model=2072439), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/03031025/cases.md)
- [Turbulence](https://openairdocs.org/ntsb-findings/03032000): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Cessna 172S, 1 case](https://openairdocs.org/ntsb-findings/03032000/cases.md?model=2072439), [All aircraft, 92 cases](https://openairdocs.org/ntsb-findings/03032000/cases.md)
- [Personality/attitude: motivation/respond to pressure](https://openairdocs.org/ntsb-findings/02021025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 172S, 2 cases](https://openairdocs.org/ntsb-findings/02021025/cases.md?model=2072439), [All aircraft, 53 cases](https://openairdocs.org/ntsb-findings/02021025/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-cruise: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Cessna 172S, 11 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=2072439), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md)
- [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 172S, 49 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072439), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172S, 118 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072439), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The pilot was attempting an instrument flight rules (IFR) transoceanic ferry flight in a new Cessna 172S. The flight had been delayed several days due to weather, and the pilot was anxious to return home to the United Kingdom, as his daughter was having surgery. The airplane was equipped with an approved auxiliary fuel tank, which resulted in a gross weight that was 30 percent higher than the published maximum gross weight for the airplane. The higher gross weight was also approved under a special airworthiness certificate; however, the operating limitations for that certificate included, "15. Avoid moderate to severe turbulence." Additionally, the pilot contacted a flight service station and was aware of airmen's meteorological information (AIRMET)s for IFR conditions, moderate turbulence below 11,000 feet, and moderate ice below 13,000 feet, with the freezing level ranging between the surface and 2,500 feet. All three AIRMETS were in effect at the time of departure and the pilot was also aware of cloud and precipitation locations. The airplane flew about 25 miles northeast of the departure airport, then reversed course when the pilot could no longer maintain an altitude of 6,000 feet mean sea level (msl) and was having difficulty controlling the airplane in turbulence and icing conditions. The airplane flew approximately 7 miles after the course reversal, descending to 1,200 feet msl, until radar contact was lost. A witness reported that the airplane flew overhead about 100 to 200 feet above ground level, with continuous engine noise, until it impacted a river. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. Light snow and drizzle prevailed at the time of departure.

## Factual narrative

HISTORY OF FLIGHT On January 4, 2010, at 1054 eastern standard time, a Cessna 172S, N5118J, owned and operated by American King Air Services, Inc., was substantially damaged when it impacted the Penobscot River, near Greenbush, Maine. The certificated commercial pilot was killed. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the planned flight to Goose Bay Airport (CYYR), Goose Bay, Newfoundland, Canada. The flight originated from Bangor International Airport (KBGR), Bangor, Maine, about 1018. The ferry flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to information obtained from the Federal Aviation Administration (FAA), the operator intended to ultimately deliver the airplane to a customer in Russia. The airplane was flown uneventfully from Independence, Kansas, to KBGR. An additional fuel tank was installed at KBGR for a flight across the Atlantic Ocean. About 20 minutes after takeoff, the flight was transferred to FAA Boston Center. The pilot contacted Boston Center at 1040, and advised that he was at 6,000 feet mean sea level (msl), climbing to 9,000 feet msl. The controller at Boston Center acknowledged the transmission and provided the local altimeter setting. A few seconds later, the pilot requested to stop the climb at 7,000 feet msl, which the controller approved. About 5 minutes later, the controller queried the pilot and asked if he was going to climb to 7,000 feet msl. The pilot replied, "...I'm down to fifty feet a minute, I'd like to level off at six (until we get some speed back)," followed by "(I'm) a bit heavy." The controller approved the level-off at 6,000 feet msl. About 3 minutes later, at 1049:55, the controller queried the pilot again. The controller noted that it appeared the pilot was having difficulty holding altitude, and that the minimum "IFR altitude" in the area was 3,700 feet msl. The pilot responded "...some severe turbulence." The controller asked the pilot his intentions, and the pilot replied that he was "having control difficulties." The controller then asked the pilot if he would like to return to KBGR, and the pilot replied "affirmative." The pilot contacted the FAA Bangor terminal radar approach control (TRACON) at 1053, and was instructed by the approach controller to "...proceed direct to the bangor vor, expect visual approach to runway three three..." The pilot acknowledged the clearance, stating "...we're in extreme turbulence with ninety over ninety degree banks." The controller subsequently asked the pilot to maintain 1,800 feet msl and the pilot replied that he was currently maintaining 2,300 feet msl. At 1054:40, the controller advised the pilot that there was a small, closed airport about 11 miles ahead of the airplane's current position; however, no further communications were received from the accident airplane. Review of radar data revealed that the airplane traveled about 25miles northeast of KBGR, and then reversed course near Enfield, Maine. The airplane reached a maximum altitude of 6,000 feet msl, and had descended to about 2,000 feet msl after completing the course reversal. The airplane flew approximately 5 miles after the course reversal, descending to 1,200 feet msl, until radar contact was lost. The last radar target was recorded about 1/4 mile northwest of the accident site, at 1054:39, with an associated altitude of 1,200 feet msl. A witness reported that the airplane flew overhead about 100 feet above ground level, with continuous engine noise, until the sound of impact. The airplane impacted the Penobscot River near Olamon Island, at an elevation of approximately 120 feet msl. PERSONNEL INFORMATION The pilot, age 77, held a commercial pilot certificate, with ratings for airplane multiengine land and instrument airplane. He also held a private pilot certificate, with ratings for airplane multiengine land, airplane single-engine land, airplane single-engine sea, and instrument airplane. His most recent FAA first-class medical certificate was issued on February 4, 2008. At that time, the pilot reported a total flight experience of 14,604 hours. The pilot's logbooks were not recovered. According to one of the pilot's employers, as of February 21, 2008, the pilot reported a total flight experience of 14,248 hours; of which, approximately 9,500 hours were in single-engine airplanes and 2,000 hours in instrument meteorological conditions. Several witnesses at KBGR reported that the pilot was anxious to return home to the United Kingdom. His daughter was having surgery and his wife had been in a minor automobile accident. AIRCRAFT INFORMATION The four-seat, high-wing, fixed-gear airplane, serial number 172S10931, was manufactured in 2009. It was issued an FAA standard airworthiness certificate on March 26, 2009. On November 18, 2009, the airplane was registered to the owner/operator. It was powered by a Lycoming IO-360, 180-horsepower engine. The aircraft logbooks were not recovered. The Hobbs meter was located in the wreckage, and indicated that the airplane had accumulated 46.8 total hours of operation since new. On December 24, 2009, a fixed based operator (FBO) at KBGR completed installation of an auxiliary fuel tank and the airplane was issued an FAA special airworthiness certificate. The FBO computed a weight and balance for the ferry flight, which included a maximum gross takeoff weight of 3,315 pounds. The weight was 30 percent higher than the 2,550 pounds published in the pilot operating handbook, and was approved under an FAA special airworthiness certificate. The FBO also provided an FAA-approved special airworthiness certificate operating limitations. Review of the limitations revealed, "15. Avoid moderate to severe turbulence." The FBO also performed an engine oil and filter change on December 30, 2009, at a Hobbs time of 45.3 hours. Subsequent to the maintenance, FBO personnel completed asuccessful engine run-up, with no anomalies noted. METEOROLOGICAL INFORMATION According to data obtained from Lockheed Martin, the pilot telephoned about 0840 and filed an IFR flight plan with the Miami Flight Service Station (FSS). After filing the flight plan, the pilot remarked to the FSS briefer that he had been stuck at KBGR for 1 week. The briefer then confirmed that the pilot had airmen's meteorological information (AIRMET)s Sierra, Zulu, and Tango for the route of flight. The pilot replied that he did have that information. The briefer subsequently asked, "okay, do you need any weather for the route of flight." The pilot asked about cloud tops, and the briefer provided information about the position of clouds. The pilot then remarked that he might have to turn back due to clouds and did not request any further weather information. The three AIRMETs that the FSS briefer mentioned were in effect at the time of the accident. Sierra was in effect for IFR conditions and mountain obscuration. Tango was in effect for moderate turbulence below 11,000 feet. Zulu was in effect for moderate ice below 13,000 feet with the freezing level ranging between the surface and 2,500 feet. The reported weather at KBGR, at 1053, was: wind from 310 degrees at 8 knots, gusting to 17 knots; visibility 10 miles; overcast ceiling at 2,600 feet; temperature 3 degrees Celsius; dew point –2 degrees Celsius; altimeter 29.35 inches of mercury. The subsequent surface observation reported that snow began at 1059, with an associated visibility of 3 miles. Additionally, two witnesses at KBGR reported light snow and mist prevailed when the pilot departed. WRECKAGE AND IMPACT INFORMATION The airplane came to rest upright, and at the time of recovery only the tail was visible above the ice-covered water. For recovery purposes, the wreckage was cut into several small pieces and dragged uphill from the stream, using a tractor, winches and straps. Due to strap bundling to facilitate recovery and damage caused during the recovery, flight control cable continuity could not be completely confirmed. Control cable continuity was confirmed from the tailcone to the empennage flight control surfaces. All examined cables exhibited signatures of overload or were cut by recovery crews. The flaps were retracted and the flap actuator was in the retracted position. The fuselage and wing leading edges were crushed aft, and the fuselage was spilt. The cabin mounted ferry fuel tank was breached in two places and exhibited hydraulic deformation. The straps mounting the ferry tank remained intact, but due to deformation of the fuel tank and airframe, it did not remain in place. The ferry tank fuel line was plumbed into the airplane system between the fuel selector and the fuel strainer. No anomalies were noted to the fuel system. The engine did not remain attached to the firewall. The propeller was bent aft and remained attached to the crankshaft flange. The oil sump separated from the engine. AnFAA inspector rotated the propeller by hand and noted that it could not be rotated through 360 degrees, consistent with impact damage. The inspector also noted compression in all cylinders and continuity throughout the ignition system. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the State of Maine Medical Examiner’s Office, Augusta, Maine, on January 5, 2010. The autopsy report noted the cause of death as "blunt force trauma." Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. The results were negative for drugs and alcohol. ADDITIONAL INFORMATION Further review of the special airworthiness operating limitations revealed, "7. This aircraft must be loaded in such a manner that the center of gravity (CG) shall remain within the limits specified in the FAA ACO Small Airplane Directorate's letter issued for that particular make and model aircraft." An inquiry to the FAA aircraft certification office (ACO) revealed that no such letter existed, as operating limitations were already contained in the type certificate data sheet (TCDS) for the make and model airplane. Review of the TCDS revealed in part, "…(3) Forward and aft center of gravity limits may not be exceeded," and "…Flight characteristics and performance at the increased weights have not been evaluated." No additional guidance on CG at increased weights was obtained. The FAA ACO planned to add further information to item number 7, indicating that if the operating limits are already contained in the TCDS, a letter is not required from the ACO. According to a representative from the airplane manufacturer, extrapolation of the CG envelope in the make and model airplane's pilot operating handbook revealed that the accident airplane may have been loaded near the very aft end of the envelope, but still within limits; however, the manufacturer never tested CG at such an increased weight.

## Aircraft

- Registration: [N5118J](https://openairdocs.org/deregistered/N5118J-2010-05-03), registration cancelled 2010-05-03, S/N 172S10931, built 2009 (OpenAirDocs)
- Reported make and model: CESSNA 172S
- Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs)
- Registry engine: [Lycoming IO-360-L2A](https://openairdocs.org/engine/lycoming-io-360-l2a) (registry code 41597, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 172S10931
- Engines: LYCOMING IO-360-L2A 180 horsepower reciprocating
- Damage: Substantial damage
- Flight: Ferry, Part 91
- Operator: American King Air Services, Inc.
- Registered owner: American King Air Services, Inc.
- Airworthiness certificate: Standard, Normal
- Departed: KBGR, Bangor, ME
- Destination: CYYR, Goose Bay
- Flight plan: IFR
- Airport: KOLD, Dewitt Field

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 77; injuries: fatal; commercial, private; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 1, with waivers/limitations; seat: left; toxicology performed; flight hours: 14,248 total, 13,932 as pilot in command

## Weather

- Conditions: Visual (VMC), Day
- Wind: 310° at 8 knots, gusting 17
- Visibility: 10 statute miles
- Lowest ceiling: 2,600 ft overcast
- Temperature: 37 °F, dew point 28 °F
- Altimeter: 29.35 inHg
- Observed at: KBGR, 20 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 20100104026089A](https://openairdocs.org/incident/20100104026089A), Jan 4, 2010: Cessna 172S, Greenbush, ME, Destroyed, 1 fatal. The portland Maine FSDO was notified by bgr ATC an aircraft (N5118J) was missing. N5118J had departed bgr for goose bay (cyyr) on an IFR flight plan in IMC…

## Docket (21 files)

The files NTSB released with the investigation on July 9, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75218. 17.4 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329067&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Witness Statements and FAA Interview Summaries (item 2, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329050&FileExtension=.PDF&FileName=Witness%20Statements%20and%20FAA%20Interview%20Summaries-Redacted.PDF
- Excerpts From Police Report (item 3, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330475&FileExtension=.PDF&FileName=Excerpts%20From%20Police%20Report-Master.PDF
- Exceprts From ATC Transcripts (item 4, .PDF, 6.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329047&FileExtension=.PDF&FileName=Exceprts%20From%20ATC%20Transcripts-Redacted.PDF
- FSS Transcript (item 5, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329048&FileExtension=.PDF&FileName=FSS%20Transcript-Redacted.PDF
- Radar Plots and Data (item 6, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329049&FileExtension=.PDF&FileName=Radar%20Plots%20and%20Data-Master.PDF
- Engine Logbook Entry (item 7, .PDF, 718 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329058&FileExtension=.PDF&FileName=Engine%20Logbook%20Entry-Redacted.PDF
- Special Airworthiness Certificate (item 8, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329060&FileExtension=.PDF&FileName=Special%20Airworthiness%20Certificate-Redacted.PDF
- Special Airworthiness Certificate Operating Limitations (item 9, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329059&FileExtension=.PDF&FileName=Special%20Airworthiness%20Certificate%20Operating%20Limitations-Redacted.PDF
- Revised Weight and Balance (item 10, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329061&FileExtension=.PDF&FileName=Revised%20Weight%20and%20Balance-Master.PDF
- Pilot Flight Time Information (item 11, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329054&FileExtension=.PDF&FileName=Pilot%20Flight%20Time%20Information-Master.PDF
- Correspondence From Cessna Representative (item 12, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331307&FileExtension=.PDF&FileName=Correspondence%20From%20Cessna%20Representative-Master.PDF
- Correspondence From FAA Inspector (item 13, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330474&FileExtension=.PDF&FileName=Correspondence%20From%20FAA%20Inspector-Master.PDF
- Weather Reports (item 14, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330472&FileExtension=.PDF&FileName=Weather%20Reports-Master.PDF
- Toxicological Report (item 15, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329055&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 16, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329057&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Photo - Main Wreckage (Courtesy of FAA) (item 17, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329062&FileExtension=.PDF&FileName=Photo%20-%20Main%20Wreckage%20(Courtesy%20of%20FAA)-Master.PDF
- Photo - Main Wreckage Recovered (Courtesy of FAA) (item 18, .PDF, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331310&FileExtension=.PDF&FileName=Photo%20-%20Main%20Wreckage%20Recovered%20(Courtesy%20of%20FAA)-Master.PDF
- Photo - Engine (Courtesy of FAA) (item 19, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329063&FileExtension=.PDF&FileName=Photo%20-%20Engine%20(Courtesy%20of%20FAA)-Master.PDF
- Photo - Opposite Side View of Engine (Courtesy of FAA) (item 20, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331311&FileExtension=.PDF&FileName=Photo%20-%20Opposite%20Side%20View%20of%20Engine%20(Courtesy%20of%20FAA)-Master.PDF
- Photo - Hobbs Meter (Courtesy of Cessna) (item 21, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329064&FileExtension=.PDF&FileName=Photo%20-%20Hobbs%20Meter%20(Courtesy%20of%20Cessna)-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.

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