ERA12LA290

NTSB accident investigation · Cessna 421C · April 19, 2012

Accident · FatalLimited investigationFinal report
Date
April 19, 2012, 12:08 local (17:08 UTC)
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N48DLCessna 421C
Defining event
Enroute-cruise: Unknown or undetermined
Weather
Visual (VMC) · Day
Status
Completed · report October 29, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA Tampa FSDO
FAA report
20120419007169A
Case key
83434

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

Pilot incapacitation, which resulted in the pilot’s inability to maintain airplane control and the airplane’s subsequent ocean impact.

Findings · 1

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.

Impairment/incapacitationPersonnel issues › Physical · PilotCessna 421C: 1 caseAll aircraft: 40 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

According to a statement provided by the Jacksonville Center air traffic control (ATC) facility, the pilot contacted ATC while at flight level 270. About 25 minutes later, the airplane began to deviate from the ATC-assigned altitude and route. The controller’s attempts to contact the pilot were unsuccessful. The North American Aerospace Defense Command launched military fighter aircraft to intercept the airplane. The military pilots reported that the airplane was circling in a left turn at a high altitude and low airspeed and that its windows were partially frosted over. They also reported that the pilot was slumped over in the cockpit and not moving. They fired flares, and the pilot continued to be unresponsive. The airplane circled for about 3 hours before it descended into the Gulf of Mexico and sank. The pilot and airplane were not recovered. Review of the pilot’s Federal Aviation Administration medical records did not reveal any recent medical conditions that would have deemed him unfit to fly.

Factual narrative

On April 19, 2012, at 1208 eastern daylight time, a Cessna 421C, N23PH, registered to and operated by a private pilot, collided with the water in the Gulf of Mexico. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91 and an instrument flight rules flight plan was filed. Visual meteorological conditions prevailed. The private pilot was fatally injured and the airplane received substantial damage. The flight departed Slidell Airport (ASD), Slidell, Louisiana, at 0643 central daylight time. According to Jacksonville Center air traffic control (ATC), the pilot contacted the ATC at approximately 0715 central daylight time at flight level 270. Approximately 20 minutes later, the airplane began to deviate from the ATC assigned altitude and route. Attempts by the ATC controller to contact the pilot were unsuccessful. The North American Aerospace Defense Command launched military fighter aircraft to intercept the airplane. The military pilots reported that the airplane was circling in a left hand turn at a high altitude, at low airspeed, and its windows partially frosted over. In addition, they reported that the pilot was slumped over in the cockpit and not moving. They fired flares and the pilot remained unresponsive. The airplane circled for approximately three hours before it descended into the Gulf of Mexico. The airplane immediately filled with water and sank.The pilot, age 65, held a private pilot certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on December 20, 2010. At that time, he reported a total flight experience of 2,350 hours. The pilot's logbook was not recovered for examination. The seven-seat, low-wing, retractable-gear airplane, serial number 421C0511, was manufactured in 1978, and was purchased by the pilot on May 15, 1996. It was powered by two Continental GTSIO-520-L 375-horsepower engines each equipped with a three-bladed McCauley propeller assembly. Copies of maintenance records entries were obtained from the maintenance facility that conducted the last annual inspection and flight test. A review of the maintenance records revealed the airplane’s most recent annual inspection was performed on June 22, 2011, at a total airframe time of 4,659.2 hours. A review of the aircraft delivery documents revealed that the service ceiling was 30,200 feet. The aircraft was delivered with the optional cabin altitude control knob and the standard 11 cubic foot oxygen bottle, as opposed to a larger 114.9 cubic foot oxygen bottle. There was an annunciator light that illuminated when the cabin altitude exceeded 10,000 feet. The aircraft pressurization altitude was checked to an altitude of 13,000 feet at the time of the last annual inspection. It was also noted that there were no oxygen masks onboard the aircraft at the time of inspection. The reportedweather at Mobile Regional Airport, Alabama, (MOB), which was located approximately 190 nautical miles northwest of the accident site, at an elevation 219 feet, at 1156, was: wind 350 degrees at 6 knots, visibility 10 statute miles;, scattered clouds at 2,800 feet, temperature 25 degrees Celsius (C), dew point 14 degrees C, and altimeter 29.99 inches of mercury. The airplane was last reported 190 nautical miles southeast of Mobile, Alabama. The wreckage and pilot were not recovered. A review of the pilot’s FAA medical file did not reveal any recent medical conditions that would have deemed him unfit to fly.

Aircraft

Registration
N48DL
Reported as
Cessna 421C
Category
Airplane
Serial number
421C0511
Airframe hours
4,659
Engines
Continental GTSIO-520-L, 375 horsepower, reciprocatingContinental GTSIO-520-L, 375 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Lee H Aviation Inc
Registered owner
Lee H Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 22, 2011
Departed
ASD · Slidell, LA
Destination
SRQ · Sarasota, FL
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
65
Injuries
Fatal
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Flight hours
2,350 total

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 52 °F
Altimeter
30.01 inHg
Observed at
ASD, 190 nm away

Docket · 11

The files NTSB released with the investigation on August 7, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.1 MB in all.

FAA reports on this event · 1

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