ERA19FA283

NTSB accident investigation · Cessna 421 · Deland, FL · September 29, 2019

Accident · FatalClass 3 · FieldFinal report
Date
September 29, 2019, 16:00 local (20:00 UTC)
Place
Deland, FL
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N731PFCessna 421
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Continental Motors, Textron Aviation
FAA report
20190929018389A
Case key
100340

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, which resulted in a collision with terrain. Contributing was the pilot’s lack of training and experience in the accident airplane make and model.

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 421: 1 caseAll aircraft: 9,295 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 421: 1 caseAll aircraft: 1,269 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 owner of the airplane had purchased the airplane with the intent to resell it after repairs had been made. As part of that process, a mechanic hired by the owner had assessed the airplane’s condition, proposed the necessary repairs to the airplane’s owner, and had identified a pilot who would, once the repairs and required inspection annual inspection had been completed, fly the airplane from where it was located to where the owner resided. While the mechanic had identified a potential pilot for the relocation flight, he had not yet completed the repairs to the airplane, nor had he completed the necessary logbook entries that would have returned the airplane to service. The pilot-rated passenger onboard the airplane for the accident flight, was the pilot who had been identified by the mechanic for the relocation flight. Review of the pilot-rated passenger’s flight experience revealed that he did not possess the necessary pilot certificate rating, nor did he have the flight experience necessary to act as pilot-in-command of the complex, high-performance, pressurized, multi-engine airplane. Additionally, the owner of the airplane had not given the pilot-rated-passenger, or anyone else, permission to fly the airplane. The reason for, and the circumstances under which the pilot-rated passenger and the commercial pilot (who did hold a multi-engine rating) were flying the airplane on the accident flight could not be definitively determined, although because another passenger was onboard the airplane, it is most likely that the accident flight was personal in nature. Given the commercial pilot’s previous flight experience, it is also likely that he was acting as pilot-in-command for the flight. One witness said that he heard the airplane’s engines backfiring as it flew overhead, while another witness located about 1 mile from the accident site heard the accident airplane flying overhead. The second witness said that both engines were running, but they seemed to be running at idle and that the flaps and landing gear were retracted. The witness saw the airplane roll to the left three times before descending below the tree line. As the airplane descended toward the ground, the witness heard the engines make “two pop” sounds. The airplane impacted a wooded area about 4 miles from the departure airport, and the wreckage path through the trees was only about 75-feet long. While the witnesses described the airplane’s engines backfiring or popping before the accident, the postaccident examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Additionally, examination of both propeller blades showed evidence of low rotational energy at impact, and that neither propeller had been feathered in flight. Given the witness statement describing the airplane “rolling three times” before it descended from view toward the ground, it is most likely that the pilot lost control ofthe airplane and while maneuvering. It is also likely that the pilot’s lack of any documented previous training or flight experience in the accident airplane make and model contributed to his inability to maintain control of the airplane. Toxicology testing was performed on the pilot’s chest cavity blood. The results identified 6.7 ng/ml of delta-9-tetrahydracannabinol (THC, the active compound in marijuana) as well as 2.6 ng/ml of its active metabolite, 11-hydroxy-THC and 41.3 ng/ml of its inactive metabolite delta-9-carboxy-THC. Because the measured THC levels were from cavity blood, it was not possible to determine when the pilot last used marijuana or whether he was impaired by it at the time of the flight. As a result, it could not be determined whether effects from the pilot’s use of marijuana contributed to the accident circumstances.

Factual narrative

On September 29, 2019, about 1600 eastern daylight time, a Cessna 421, N731PF, was substantially damaged when it impacted trees and terrain near DeLand Municipal Airport (DED), DeLand, Florida. The commercial pilot, pilot-rated passenger, and aft-seated passenger were fatally injured. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight. The owner of the airplane stated that he purchased the airplane on June 21, 2019, and that planned to make repairs and resell the airplane. The airplane was based at DED at the time of purchase and had not undergone an annual inspection for several years. The owner hired a mechanic to make the necessary repairs and conduct an annual inspection of the airplane. During the inspection, the mechanic informed the owner that the left tachometer generator and the fuel gauges were inoperative and that other items also needed repair or replacement. Once the work was done and the annual inspection was signed off, the mechanic would find a pilot to transport the airplane to Texas, where the owner resided. The mechanic subsequently found a pilot who he thought would be able to fly the airplane to Texas (the pilot-rated passenger). The mechanic stated that he had not completed the repairs to the airplane or signed off the airplane’s annual inspection at the time of the accident flight. The airplane owner stated that he did not know the pilot or the passengers and that he was not aware that the airplane was being flown at that time. A witness in the vicinity of the accident site shortly before the accident stated that he heard the airplane fly overhead at an altitude of about 2,000 ft and described the engines as sounding “rough.” About 10 minutes later, he observed the airplane overhead at an altitude of 1,000 ft and heard the engine “sputtering and backfiring.” According to another witness who was about 1-mile away from the accident site, he heard the accident airplane flying very low overhead. He then observed the airplane banking to the left and said that both engines seemed to be running at “low idle.” As he continued to watch the airplane, he noticed that the flaps and landing gear were retracted. The witness also observed the airplane roll to the left three times before descending below the tree line. As the airplane descended toward the ground, the engines made “two pop” sounds. The witness saw no smoke coming from the airplane during the descent. The airplane crashed in a heavily wooded area and a post-impact fire ensued. The pilot, age 27, held a commercial pilot certificate with ratings for single-engine land, multiengine land, and instrument airplane. The pilot also held a flight instructor certificate with an airplane single-engine rating. His Federal Aviation Administration (FAA) first-class medical certificate was issued June 4, 2018. A review of the pilot’s logbook revealed that the last entrywas dated May 29, 2019. The total pilot-in-command time entered was 500 hours, including about 40 hours of multiengine airplane flight time. The logbook did not show that the pilot had received any instruction or had logged any previous flight experience in the Cessna 421. While the pilot did have an endorsement in his logbook for the operation of high-performance airplanes, he did not have an endorsement for the operation of complex airplanes. The pilot-rated passenger, age 32, held a private pilot certificate with a rating for airplane single-engine land. His FAA third-class medical certificate was issued on April 12, 2019. A review of his pilot logbook revealed a total of 155 flight hours, all in single-engine airplanes. A review of the airplane’s maintenance records revealed that the airplane received its last annual inspection on February 15, 2014, at a Hobbs meter time of 858 hours. The Hobbs meter reading at the time of the 2019 examination was 862 hours. The main wreckage was located about 4 nautical miles from DED on a 230° magnetic heading. The wreckage path was about 75 ft in length from the first broken tree branch, which was about 75 ft high, to the location where the airplane came to rest at the base of a tree in an upright position. There were freshly broken branches at the wreckage site. All flight control surfaces were located at the accident site. The cockpit section of the airplane was crushed, and a tree trunk extended from the bottom of the fuselage to the top of the right side of the cockpit. The fuselage exhibited crush damage to the aft pressure bulkhead. The empennage was broken away from the fuselage at the aft pressure bulkhead and remained partially attached by flight control cables. The vertical and horizontal stabilizers remained attached to the empennage. The vertical stabilizer was buckled, and the rudder was attached at the lower attachment points. The rudder was broken in two parts; the lower section containing the rudder trim was buckled, and the upper section was also buckled and partially attached to the remaining rudder assembly. Examination of both engines and their components revealed no anomalies that would have prevented normal operation or production of the rated horsepower. Examination of both propellers revealed the presence of witness marks that showed contact between the blade counterweights and the propeller hub, which were consistent with the propellers being at a low pitch position (and not feathered) during impact. Additionally, the damage to the propeller hubs and their assemblies, as well as the twisting, bending, and paint scuffing observed on the propeller blades, were all consistent with relatively low rotational energy at impact. The Office of the Medical Examiner, Daytona Beach, Florida, performed an autopsy on the pilot and pilot-rated passenger. Their cause of death was blunt force trauma. For the pilot, toxicology testing performed at the FAA Forensic Sciences Laboratory identified inchest cavity blood samples, 6.7 ng/ml of delta-9-tetrahydracannabinol (THC, the active compound in marijuana), 2.6 ng/ml of its active metabolite 11-hydroxy-THC, and 41.3 ng/ml of its inactive metabolite delta-9-carboxy-THC. In addition, 12.5 ng/ml of THC, 390 ng/ml of 11-hydroxy-THC, and 734.5 ng/ml of delta-9-carboxy-THC were found in urine samples. The tests were negative for carbon monoxide and ethanol. For the pilot-rated passenger, toxicology testing performed at the FAA Forensic Sciences Laboratory was negative for carbon monoxide, ethanol, and drugs.

Aircraft

Registration
N731PF
Reported as
Cessna 421 (Undesignat)
Category
Airplane
Serial number
421-0164
Built
1968
Airframe hours
858
Engines
Continental GTSIO-520-D, 375 horsepower, reciprocatingContinental GTSIO-520-D, 375 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 15, 2014 · 4 hours before
Departed
DED · Deland, FL
Destination
DED · Deland, FL
Airport
DED · Deland Muni-Sidney H Taylor Fi
Equipment
Stall warning system

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
27
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
500 total · 0 in this make and model · 185 as pilot in command
Role
Pilot-rated passenger
Age
32
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Seat
Right
Restraint
3-point
Toxicology
Performed
Flight hours
155 total

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 7 knots
Visibility
10 statute miles
Lowest ceiling
4,800 ft broken
Temperature
84 °F, dew point 73 °F
Altimeter
30.07 inHg
Observed at
DED, 4 nm away

Docket · 16

The files NTSB released with the investigation on October 5, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 64.6 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.