# NTSB FTW03FA054: Cessna 402C, N402ME, Lewisville, TX, December 4, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 4, 2002, 06:16 local (12:16 UTC) - Place: Lewisville, TX - Coordinates: 33.169723, -97.032218 - Nearby events: https://openairdocs.org/map.md?lat=33.1697&lon=-97.0322&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 30, 2005 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Teledyne Continental Motors, FAA Flight Standards District Office - NTSB case key (mKey): 56156 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW03FA054 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56156/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56156 - Page: https://openairdocs.org/ntsb/FTW03FA054 ## Probable cause The failure of the attitude indicator, and the pilot's failure to maintain aircraft control as a result of spatial disorientation following the failure of the attitude indicator. Contributing factors were a low ceiling, clouds, and dark night conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, maneuvering - flight/nav instruments,attitude gyro - failure (cause) - Loss of control - in flight, maneuvering - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (contributing factor) - weather condition - clouds (contributing factor) - weather condition - low ceiling (contributing factor) - light condition - dark night (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The twin-engine airplane impacted the ground during an uncontrolled descent while maneuvering in dark night instrument meteorological conditions in the vicinity of Lewisville, Texas. The commercial pilot contacted the approach controller and stated that his attitude indicator was "not helping" and needed "a little bit of help with trying to keep it straight." The pilot was instructed by approach control to maintain an altitude of 3,000 feet msl. The approach controller confirmed with the pilot that he could not fly headings, and instructed the pilot to turn right. Seconds afterwards, the pilot was instructed to turn left and the controller would tell him when to stop the turn. The pilot acknowledged. There were no further communications between the pilot and air traffic control. The airplane initially impacted in a near vertical attitude into a wooded area adjacent to a rural paved road, slid across the road, and impacted a residence. Radar data showed that the airplane's magnetic heading was erratic throughout the 5-minute flight. The gyro instruments found at the accident site were the co-pilot's direction gyro (vacuum), a turn and bank indicator (electric), and the pilot's attitude indicator (vacuum). The gyros were disassembled, and visually examined. The co-pilot's direction gyro examination revealed rotation signatures on the gyro and the gyro housing. The turn and bank indicator revealed a "faint" rotational signature on the gyro. The pilot's attitude indicator gyro had no rotational signatures, and exhibited blunt impressions corresponding to the gyro buckets on the inside of the gyro-housing wall. A maintenance repair data plate ("Functional Tested") was found on the attitude indicator's instrument housing dated 12/2/02. Due to the extent of the fire damage, no instrument readings could be obtained. Seven days prior to the accident flight, a company pilot who flew the accident airplane reported that the pilot's attitude indicator (part number 102-0041-04, serial number 92B0346) "rotated" and the flight was aborted. The next day, the attitude indicator was removed and bench checked, cleaned, and adjusted. The attitude indicator was reinstalled and an operational check on the ground was performed. Three days prior to the accident the pilot's attitude indicator was again removed for an overhaul. According to company maintenance personnel, the attitude indicator was reinstalled the night prior to the morning of the accident, and an operational check on the ground was performed. Radar data showed that the aircraft did not stabilize on a particular heading throughout the flight. Physical evidence showed that the pilot's attitude gyro was not "spooled" at the time of impact. ## Factual narrative HISTORY OF FLIGHT On December 4, 2002, approximately 0616 central standard time, a Cessna 402C twin-engine airplane, N402ME, operating as TexStar Flight 114 (TXZ114) impacted the ground during an uncontrolled descent while maneuvering in the vicinity of Lewisville, Texas. The airplane was registered to Agnew Corporation of Denton, Texas, and operated by Tex Star Air Freight Inc., of Denton, Texas. The commercial pilot, who was the sole occupant, was fatally injured. Dark night Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the Title 14 Code of Federal Regulations Part 91 positioning flight. The flight originated from the Denton Municipal Airport (DTO), Denton, Texas, at 0611, and its intended destination was Dallas Love Field (DAL), Dallas, Texas. The airplane was hangared at a maintenance facility located at DTO for an attitude indicator overhaul on December 3, 2002. On the morning of the accident, the airplane was fueled at 0550, and scheduled to depart at 0600. At 0608, the pilot obtained an IFR clearance from DTO to DAL, via direct, with vectors 090, and was instructed to maintain an altitude of 3,000 feet mean sea level (msl). The flight departed from Runway 35 at 0611. At 0614:33, the pilot contacted the approach controller and stated that his attitude indicator was "not helping" and needed help with "trying to keep" the aircraft "straight." The pilot was instructed to maintain an altitude of 3,000 feet msl. The approach controller verified that the pilot was unable to fly headings, and instructed the pilot to "turn right." At 0615:12, the pilot was instructed by the controller to "turn left," and the controller stated that he would tell him when to stop the turn. The pilot acknowledged. There were no further communications between the pilot and air traffic control (ATC). The last discernable radar return was at 0615:43, which revealed that the airplane was at an altitude of 2,200 feet msl, on a heading of 113 degrees, descending at a ground speed of 194 knots. The airplane initially impacted a wooded area adjacent to a rural paved road. From the initial impact point, the airplane slid forward for approximately 100 feet, crossed a paved road and came to rest in the garage of a private residence. The airplane was severely fragmented, and a post-impact fire consumed the airplane. There were no reported ground injuries. The occupants of the residence that the airplane impacted stated that they "heard and felt" the impact into their house. A neighbor reported that he heard an airplane fly low overhead prior to the sound of the impact. There were no reported eyewitnesses to the accident. PERSONNEL INFORMATION The pilot was employed by Tex Star Air Freight Inc., since July 26, 2002, and held a commercial pilot certificate with ratings for single and multi-engine land, and instrument airplane. He was a certified flight and instrument instructor in single and multi-engine airplanes. His most recent Federal Aviation Administration (FAA) first-class medical certificate was issued on August 9, 2002, with a limitation to wear corrective lenses. The pilot's personal flight logbooks were not recovered. The operator reported that he had approximately 1,290 total flight hours, 238 hours of which were in multi-engine airplanes. The operator also reported that the pilot had completed 402C initial training on August 7, 2002. According to FAA records, the pilot did not have any previous flight violations. AIRCRAFT INFORMATION Manufactured in 1979, the Cessna 402C, serial number 402C0010, was owned and registered to Agnew Corporation, of Denton, Texas, on April 23, 2002. The airplane was operated by Tex Star Air Freight Inc., of Denton, Texas, an on-demand CFR Part 135 operation. The airplane was configured for cargo. According to entries in the aircraft logbook, the last annual inspection was completed on October 3, 2002. The airframe total time as of this log entry was 16,366.9 hours. Entries in the logbook showed that the last 100-hour inspection was completed on November 13, 2002. The airframe total time as of this log entry was 16,464.6 hours. The airplane was powered by two Teledyne Continental Motor TSIO-520-VB(1) series engines. According to entries in the engine logbook, the last 100-hour inspection was completed on November 13, 2002. At the time of the inspection, the right engine, serial number 811162-R, had accumulated 1,388.9 hours since its last overhaul on June 12, 2000. The left engine, serial number 516344, had accumulated 165.1 hours since its last overhaul on August 5, 2002. Both engines were equipped with McCauley model 3AF32C505 three-blade propeller assemblies. At the time of the last 100-hour inspection on November 13, 2002, the right propeller had accumulated a total of 1,907.3 hours since its last overhaul, and the left propeller had accumulated a total of 97.7 hours since its last overhaul. Derived from interviews and an examination of logbooks and company records, the airplane was scheduled to depart from San Antonio, Texas on November 26, 2002. A company pilot reported that the pilot's attitude indicator (part number 102-0041-04, serial number 92B0346) "rotated" and the flight was aborted. On November 27, 2002, the pilot flew visual flight rules (VFR) conditions to Denton, and stated that the attitude indicator was "OK." That same day, Aerospace Instrument Support (AIS), Denton, Texas removed the attitude indicator and bench checked, cleaned, and adjusted it. The attitude indicator was reinstalled and an operational check on the ground was performed. On December 1, 2002, the pilot's attitude indicator was removed for an overhaul, and delivered to AIS on December 2, 2002. AIS stated they would be done with the attitude indicator in one day. According to company maintenance personnel, the attitude indicator was reinstalled the night of December 3, 2002, and an operational check on the ground was performed. METEOROLOGICAL INFORMATION The automated surface observing station DTO, 9.5 nautical miles northwest of the accident site, at 0604 reported winds from 350 degrees at 9 knots, visibility 7 statute miles, skies broken at 600 feet, overcast skies at 1,200 feet, temperature 4 degrees Celsius, dew point minus 4 degrees Celsius, and an altimeter setting of 30.11 inches of Mercury. The Investigator-In-Charge (IIC) calculated the density altitude to be approximately minus 797 feet. The moon phase was a new moon, and civil twilight did not begin until 0650. COMMUNICATIONS The following transcripted excerpts cover the Dallas-Fort Worth Terminal Radar Approach Control (TRACON), Flight Data position for the time period from December 4, 2002, 0606 to 0609. The times have been converted from coordinated universal time to central standard time. Agencies Making Transmissions: Abbreviations: TexStar 114 TXZ114 DFW TRACON, Flight Data FD-1 0606:06 TXZ114 good morning regional clearance texstar one fourteen 0606:30 FD-1 calling clearance delivery say again 0606:34 TXZ114 ah yes sir good morning texstar one fourteen 0606:37 FD-1 texstar one fourteen regional approach good morning 0606:40 TXZ114 yes sir texstar one fourteen's ah runway three five at denton like to pick up ifr dallas love 0606:55 FD-1 texstar one fourteen standby just a second how soon before you're ready to depart 0607:00 TXZ114 texstar one fourteen depart ah as soon as possible 0607:03 FD-1 all right just a second 0607:55 FD-1 texstar one fourteen i have your clearance now 0607:58 TXZ114 texstar one fourteen ready to copy 0608:00 FD-1 texstar one fourteen cleared from denton to dallas love heading via vectors enter controlled airspace fly heading zero niner zero that is vectors to love maintain three thousand departure frequency is one on ## Aircraft - Registration: [N402ME](https://openairdocs.org/deregistered/N402ME-2017-03-06), registration cancelled 2017-03-06, S/N 402C0010, built 1979 (OpenAirDocs) - Reported make and model: Cessna 402C - Registry model: [Cessna 402C](https://openairdocs.org/model/cessna-402c) (registry code 207590R) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 402C0010 - Airframe hours: 16464.6 - Engines: Continental TSIO-520-VB1 325 horsepower turbo prop - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Operator: Tex Star Air Freight Inc., doing business as TexStar AirFreight - Registered owner: Agnew Corporation - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, November 13, 2002 - Departed: DTO, Denton, TX - Destination: DAL, Dallas, TX - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 24; injuries: fatal; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review October 31, 2001; seat: left; toxicology performed; flight hours: 1,290 total ## Weather - Conditions: Instrument (IMC), Night - Wind: 350° at 9 knots - Visibility: 7 statute miles - Lowest ceiling: 1,200 ft overcast - Temperature: 39 °F, dew point 39 °F - Altimeter: 30.11 inHg - Observed at: DTO, 9 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 20021204034159A](https://openairdocs.org/incident/20021204034159A), Dec 4, 2002: Cessna 402C, Lewisville, TX, Destroyed, 1 fatal. (-23) On December 4, 2002, at approximately 0616 local time, a Cessna 402C multiengine airplane, N402ME, operated by tex star air freight inc., of denton,… ## Docket (26 files) The files NTSB released with the investigation on January 20, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56156. 28.9 MB in all. - ATC Plot (item 1, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224305&FileExtension=.PDF&FileName=ATC%20Plot-Master.PDF - ATC Aircraft Accident Package (item 2, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376533&FileExtension=.PDF&FileName=ATC%20Aircraft%20Accident%20Package-Redacted.PDF - Aircraft Records (item 3, .PDF, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376534&FileExtension=.PDF&FileName=Aircraft%20Records-Redacted.PDF - Checkrides (item 4, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376535&FileExtension=.PDF&FileName=Checkrides-Redacted.PDF - Cessna Report (item 5, .PDF, 534 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376549&FileExtension=.PDF&FileName=Cessna%20Report-Redacted.PDF - Photo 1 Accident Site (item 6, .PDF, 749 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224392&FileExtension=.PDF&FileName=Photo%201%20%20Accident%20Site-Master.PDF - Photo 2 Accident Site (item 7, .PDF, 724 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224393&FileExtension=.PDF&FileName=Photo%202%20%20Accident%20Site-Master.PDF - Photo 3 Pilot's Attitude Indicator (item 8, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224394&FileExtension=.PDF&FileName=Photo%203%20%20Pilot%27s%20Attitude%20Indicator-Master.PDF - Photo 4 Pilot's Attitude Indicator Top Side (item 9, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224396&FileExtension=.PDF&FileName=Photo%204%20%20Pilot%27s%20Attitude%20Indicator%20Top%20Side-Master.PDF - Photo 5 Pilot's Attitude Indicator Top Opened (item 10, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224397&FileExtension=.PDF&FileName=Photo%205%20%20Pilot%27s%20Attitude%20Indicator%20Top%20Opened-Master.PDF - Photo 6 Pilot's Attitude Indicator Opened (item 11, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224398&FileExtension=.PDF&FileName=Photo%206%20%20Pilot%27s%20Attitude%20Indicator%20Opened-Master.PDF - Photo 7 Pilot's Attitude Indicator Gyro Opened (item 12, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224399&FileExtension=.PDF&FileName=Photo%207%20%20Pilot%27s%20Attitude%20Indicator%20Gyro%20Opened-Master.PDF - Photo 8 Pilot's Attitude Indicator Data Plate (item 13, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224400&FileExtension=.PDF&FileName=Photo%208%20%20Pilot%27s%20Attitude%20Indicator%20Data%20Plate-Master.PDF - Photo 9 Pilot's Attitude Indicator Gyro and Housing Pieces (item 14, .PDF, 738 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224401&FileExtension=.PDF&FileName=Photo%209%20%20Pilot%27s%20Attitude%20Indicator%20Gyro%20and%20Housing%20Pieces-Master.PDF - Photo 10 Pilot's Attitude Indicator Gyro (item 15, .PDF, 672 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224402&FileExtension=.PDF&FileName=Photo%2010%20%20Pilot%27s%20Attitude%20Indicator%20Gyro-Master.PDF - Photo 11 Pilot's Attitude Indicator Stationary Impact Marks Inside Gyro Housing (item 16, .PDF, 649 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224404&FileExtension=.PDF&FileName=Photo%2011%20%20Pilot%27s%20Attitude%20Indicator%20Stationary%20Impact%20Marks%20Inside%20Gyro%20Housing-Master.PDF - Photo 12 Pilot's Attitude Indicator Closeup of Impact Marks Inside Gyro Housing (item 17, .PDF, 681 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224405&FileExtension=.PDF&FileName=Photo%2012%20%20Pilot%27s%20Attitude%20Indicator%20Closeup%20of%20Impact%20Marks%20Inside%20Gyro%20Housing-Master.PDF - Photo 13 Electric Turn and Bank Indicator (item 18, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224407&FileExtension=.PDF&FileName=Photo%2013%20%20Electric%20Turn%20and%20Bank%20Indicator-Master.PDF - Photo 14 Electric Turn and Bank Indicator Opened (item 19, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224408&FileExtension=.PDF&FileName=Photo%2014%20%20Electric%20Turn%20and%20Bank%20Indicator%20Opened-Master.PDF - Photo 15 Turn and Bank Indicator Opened (item 20, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224409&FileExtension=.PDF&FileName=Photo%2015%20%20Turn%20and%20Bank%20Indicator%20Opened-Master.PDF - Photo 16 Turn and Bank Indicator Gyro (item 21, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224410&FileExtension=.PDF&FileName=Photo%2016%20%20Turn%20and%20Bank%20Indicator%20Gyro-Master.PDF - Photo 17 Directional Gyro (item 22, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224411&FileExtension=.PDF&FileName=Photo%2017%20%20Directional%20Gyro-Master.PDF - Photo 18 Directional Gyro Opened (item 23, .PDF, 685 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224412&FileExtension=.PDF&FileName=Photo%2018%20%20Directional%20Gyro%20Opened-Master.PDF - Photo 19 Directional Gyro Housing Opened (item 24, .PDF, 698 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224413&FileExtension=.PDF&FileName=Photo%2019%20%20Directional%20Gyro%20Housing%20Opened-Master.PDF - Photo 20 Directional Gyro Removed from Housing (item 25, .PDF, 709 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224414&FileExtension=.PDF&FileName=Photo%2020%20%20Directional%20Gyro%20Removed%20from%20Housing-Master.PDF - Photo 21 Layout of Cockpit Instruments (item 26, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224416&FileExtension=.PDF&FileName=Photo%2021%20%20Layout%20of%20Cockpit%20Instruments-Master.PDF From the NTSB's public API. 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