ERA18LA002

NTSB accident investigation · Cessna 182 · San Juan, PR · October 2, 2017

Accident · FatalLimited investigationFinal report
Date
October 2, 2017, 10:48 local (14:48 UTC)
Place
San Juan, PR
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N9021XCessna 182
Defining event
Approach-VFR pattern final: Aircraft wake turb encounter
Weather
Visual (VMC) · Day
Status
Completed · report July 8, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20171002019929A
Case key
96126

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 distance from helicopters during the approach for landing, resulting in an encounter with wake turbulence and subsequent loss of control.

Findings · 3

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.

Performance/control parameters: pitch controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 182D: 1 caseAll aircraft: 526 casesProbable cause
Turbulence: wake turbulenceEnvironmental issues › Conditions/weather/phenomena · Effect on operationCessna 182D: 1 caseAll aircraft: 47 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

The private pilot and pilot-rated passenger were approaching the airport for landing during a personal flight; the tower controller cleared the airplane to land behind a flight of two Blackhawk helicopters. The passenger reported that he and the pilot visually acquired the helicopters and were instructed by the controller to perform s-turns for spacing during final approach. As the airplane crossed the runway threshold, the passenger noted that the helicopters were clearing the runway. The airplane then encountered a "heavy downdraft" followed by a "burst" that pitched the airplane to the left. The pilot subsequently initiated a go-around, during which the airplane encountered another "burst," pitched up, rolled inverted, and collided with the ground between the runway and taxiway. The passenger reported that there were no mechanical anomalies with the airplane and that the engine was performing normally. The pilot died in the hospital the day after the accident. Although the controller cleared the airplane for landing following the helicopters, Federal Aviation Administration guidance on wake turbulence avoidance states that, if a pilot accepts a clearance to visually follow a preceding aircraft, the pilot accepts responsibility for both separation and wake turbulence avoidance. The circumstances of the accident are consistent with the airplane encountering wake turbulence from the landing helicopters, and it is likely that, had the pilot maintained greater separation from the helicopters or conducted a go-around earlier, the airplane would not have encountered the wake vortices that resulted in the loss of control.

Factual narrative

HISTORY OF FLIGHT On October 2, 2017, about 1048 Atlantic standard time, a Cessna 182D, N9021X, was substantially damaged when it impacted terrain during landing at Fernando Luis Ribas Dominicci Airport (SIG), San Juan, Puerto Rico. The private pilot was fatally injured and a pilot-rated passenger was seriously injured. The airplane was privately owned and operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Day, visual meteorological conditions prevailed, and no flight plan was filed for the flight, which originated at Cyril E. King Airport (STT), Charlotte Amalie, United States Virgin Islands, about 1015. According to the air traffic controller, the pilot was cleared to land on runway 9 behind a flight of two Blackhawk helicopters. The pilot reported that he had the helicopters in sight. While on short final for landing, the pilot was given clearance to land after the helicopters had cleared the runway at the Bravo 4 intersection. The controller reported that the airplane was still airborne passing the Bravo 2 intersection and touched down about 500 ft before the Bravo 3 intersection. The airplane then bounced and came to rest in inverted in the grass between the runway and taxiway. According to the Federal Aviation Administration (FAA), air traffic voice communications were not recorded due to hurricane damage to equipment. The pilot-rated passenger, who was in the right seat, reported that, approaching SIG for landing, he heard the tower controller tell a Cessna 172 to go around, clear a Cessna Citation to land, and clear a pair of Blackhawk helicopter to land behind the Citation. The accident pilot turned onto the base leg of the traffic pattern and was subsequently cleared to land behind the helicopters. After turning final, he and the pilot noted some turbulence that they assumed was from the helicopters. The tower controller then instructed the pilot to complete s-turns. The passenger estimated that the helicopters would still be in a hover taxi over the runway when they arrived over the threshold, so the pilot asked the controller to confirm that they were still cleared to land; the controller responded that the airplane was cleared to land. As the airplane crossed the runway threshold, the Blackhawks were turning off of the runway. The pilot and passenger immediately felt a "heavy downdraft" and thought that the airplane would hit the runway hard. As the airplane was about to touch down, it encountered another "burst," which pitched the airplane hard to the left. They announced that they were going around, and the pilot turned the airplane to the right. As the pilot added power, the airplane encountered another burst and pitched "straight up." About 50-100 ft above the ground, the airplane rolled inverted and impacted the grass between the taxiway and runway with "full power." The passenger stated that there were no mechanical issues with the airplane and that the engine performed normally during the accidentsequence. PERSONNEL INFORMATION The pilot held a private pilot certificate with ratings for airplane single- and multiengine land. According to the FAA, the pilot held a second-class medical certificate with no limitations, issued on May 9, 2017. On the application for that medical certificate, he reported 1,057 total hours of flight experience, including 58 hours during the previous 6 months. The pilot's personal logbook(s) were not located. The pilot-rated passenger held a private pilot certificate with an airplane single-engine land rating. According to the FAA, he held a second-class medical certificate with no limitations, issued on July 14, 2016. On the medical certificate application, he reported 165 total hours of flight experience, including 52 hours during the previous 6 months. AIRCRAFT INFORMATION The high-wing, single-engine, four-seat airplane was equipped with fixed, tricycle landing gear and a Continental 230-horsepower reciprocating engine fitted with a McCauley two-bladed, constant-speed propeller. The airplane's maintenance records were not located after the accident. METEOROLOGICAL INFORMATION At 1835, the SIG recorded weather included wind from 120° at 10 knots, 10 statute miles visibility, scattered clouds at 3,000 ft, broken clouds at 8,000 ft, temperature 29°C, dew point 25°C, and an altimeter setting of 29.98 inches of mercury. WRECKAGE AND IMPACT INFORMATION Due to the aftermath of Hurricane Maria and the closure of the San Juan FAA Flight Standards District Office during the weeks following the hurricane, no detailed examination of the wreckage was performed. Review of photographs provided by the airport manager indicated that the airplane came to rest inverted in the grass area between the runway and taxiway. Structural damage was observed on the fuselage, empennage, and both wings. There was no fire. MEDICAL AND PATHOLOGICAL INFORMATION The pilot died in the hospital the day after the accident. The Commonwealth of Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico, performed the autopsy. The cause of death was attributed to severe bodily trauma. The FAA's Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. Testing was negative for carbon monoxide and ethanol. Testing was positive for the following emergency treatment medications, all found in the aortic blood: atropine; midazolam and its metabolite, hydroxymidazola; and lidocaine. Sildenafil was also found in the aortic blood. ADDITIONAL INFORMATION FAA Advisory Circular (AC) 90-23G, Aircraft Wake Turbulence, explains air traffic controller and pilot procedures regarding wake turbulence avoidance: 8. VORTEX AVOIDANCE PROCEDURES. a. Air Traffic Control (ATC) Responsibilities. Air traffic controllers apply procedures for separating instrument flight rules (IFR) aircraft that include required wake turbulence separations. However, if a pilot accepts a clearance to visually followa preceding aircraft, the pilot accepts responsibility for both separation and wake turbulence avoidance. 11. PILOT RESPONSIBILITY. e. Techniques for Lighter Aircraft. Pilots operating lighter aircraft behind aircraft producing strong wake vortices should consider the following techniques to assist in avoiding wake turbulence and should be aware of the wind direction and speed along the final approach path: 1) If the pilot of the smaller following aircraft has visual contact with the preceding, larger aircraft and also with the runway, the pilot may further adjust the flightpath to avoid possible wake vortex turbulence by: (a) Flying slightly above the glidepath and maintain that glidepath to a touchdown point beyond the touchdown point of the larger preceding aircraft. (b) Establishing a line of sight to a touchdown point that is above and beyond the larger preceding aircraft. (c) When possible, noting the touchdown point of the larger preceding aircraft and adjusting your touchdown point as necessary.

Aircraft

Registration
N9021X
Reported as
Cessna 182 (D)
Category
Airplane
Serial number
18253421
Built
1961
Engine
Cont Motor O-470-L, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
STT · Charlotte Amali
Destination
SIG · San Juan, PR
Airport
SIG · Fernando Luis Ribas Dominicci, runway 09, 5,539 × 100 ft, asphalt
Equipment
Unknown

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
48
Injuries
Fatal
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 2, Without waivers/limitations
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
1,057 total
Role
Pilot-rated passenger
Age
43
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Seat
Right
Flight hours
165 total

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 10 knots
Visibility
10 statute miles
Lowest ceiling
8,000 ft broken
Temperature
84 °F, dew point 77 °F
Altimeter
29.97 inHg
Observed at
SIG

Docket · 6

The files NTSB released with the investigation on April 11, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.3 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.