IAD00FA024

NTSB accident investigation · Cessna 337 · Prnce Frederick, MD · February 28, 2000

Accident · FatalField investigationFinal report
Date
February 28, 2000, 14:55 local (19:55 UTC)
Place
Prnce Frederick, MD
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N53HSCessna 337
Weather
Visual (VMC) · Day
Status
Completed · report May 8, 2001
Report
Approved by Office Director
FAA report
20000228013249A
Case key
48724

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 NTSB’s determination of the probable cause, and any contributing factors.

was the pilot's failure to maintain control of the airplane after a loss of engine power on one engine. Factors in the accident were the pilot/owner's failure to follow the published emergency procedure, his inadequate fuel management, and his intentional flight with known deficiencies which included an inoperative fuel quantity system.

Analysis

The multi-engine centerline-thrust airplane was in cruise at 2,500 feet and 110 knots ground speed, when radar data depicted altitude excursions from 2,500 feet down to 1,300 feet, and witnesses described a steep bank angle, high airspeed, and an increase in power prior to contact with the trees. There was no odor of fuel or evidence of fire at the scene. Examination of the aircraft logbooks revealed that in the 5 years prior to the accident, only 4 entries were made in the maintenance logbooks. Each reflected completion of an annual inspection with no discrepancies noted. No entries were made to reflect compliance with Airworthiness Directives, nor the performance or completion of any scheduled or unscheduled maintenance. The logbook entries were signed by mechanics that were either unlicensed, or whose privileges had been revoked. An FAA Airworthiness condition notice placed on the airplane 3 years prior to the accident was closed without action because the pilot/owner said he would no longer fly the airplane. The pilot's wife reported that the fuel quantity system was inoperative for approximately 6 months prior to the accident. The pilot received his multi-engine rating 3 years after he purchased the airplane. Flight instruction and evaluation for the multi-engine rating were received in an airplane completely different in make, model, and configuration. The pilot noted only 3 hours of instruction in the accident airplane but logged 17 hours of solo time prior to training for his multi-engine exam. His last known biennial flight review was 6 years prior to the accident. The single-engine service ceiling for the airplane at maximum gross weight with the aft engine operating was 10,200 feet. Maximum single-engine rate of climb in the same configuration was 450 feet per minute.

Factual narrative

The factual narrative1,275 words

History of flight

On February 28, 2000, at 1455 Eastern Standard Time, a Cessna 337, N53HS, was destroyed during collision with trees and terrain following an uncontrolled descent from cruise flight in Prince Frederick, Maryland. The certificated private pilot/owner was fatally injured. Visual meteorological conditions prevailed for the personal flight that originated at Eagle Neck, Georgia (1GA0), approximately 1100, destined for Edgewater, Maryland (ANP). No flight plan was filed for the flight conducted under 14 CFR Part 91.

On January 21, 2000, the pilot/owner flew the airplane from Edgewater, Maryland, to Hinesville, Georgia, purchased fuel, and then continued to Eagle Neck, Georgia. The pilot owned homes in Edgewater and Eagle Neck. Examination of the pilot's records did not reveal any subsequent flights until the day of the accident.

A Safety Board Investigator interviewed witnesses at a construction site approximately 1/4 mile east of the crash site. According to one interview summary:

"[The witness] used a model airplane to demonstrate what he saw. He held the airplane model up to the sky in the position of where he first saw the accident airplane. He situated the model so it was in an approximate 90 degree left bank. He then moved the model from his left to right (southeast to northwest) across the skyline in a descent. He described the accident airplane as "moving really, really fast" and continued to emphasize throughout the interview at how fast the airplane was moving.

"[The witness] said he saw the aircraft descend beyond the tree line and said he knew the airplane was going to crash. He heard the aircraft hit the trees and waited to see smoke, which he stated never happened. [The witness] also stated he never heard any engine noise and his impression was that "the aircraft ran out of gas." [The witness] thought the airplane was headed toward one of the two local airstrips. [The witness] explained there were two airstrips located northwest of his position."

A second witness at the same site stated:

"[The witness] stated the wind was blowing 'hard'. He was working at a home site when he saw the airplane flying low approximately 50-100 feet above the trees towards the northwest. He noticed the aircraft's wings were rocking and, 'the aircraft was moving really fast and was out of control.'

"With an aircraft model, [the witness] demonstrated that the aircraft was in an approximate 90 degree left bank as it descended. He said he did not think the pilot was flying the aircraft. [The witness] drove to the location of the accident and arrived approximately 15 minutes later. On-site he noticed no smoke, no odor of fuel, and said the aircraft was 'a pile of rubble'.

"When questioned about the engine noise, [The witness] stated it was smooth and without interruption."

According to an interview summary prepared by a Federal Aviation Administration (FAA) inspector, several witnesses provided similar accounts of the airplane's flight prior to the crash. They each described a steep bank angle, high airspeed, and two witnesses described an increase in power prior to contact with the trees. One witness said the airplane "sounded like it was missing."

In a telephone interview, a Chief Petty Officer, the radar chief at the Patuxent Naval Air Station, described the movement of a radar target that matched the time and course of the accident airplane. The target disappeared from the scope at the time and place the accident was reported.

According to the Petty Officer, the target crossed the Tappahannock Municipal Airport, Tappahannock, Virginia, at 2,500 feet and 110 knots ground speed, on an approximate heading of 025 degrees. According to the Chief:

"Approximately 10 minutes later, the airplane target exhibits altitude excursions down to 1600 [feet], up to 17-18 [hundred feet], down to 1,500, and back up to 23-2,400 [feet]. Then, the target started descending in a right turn to the east. The right turn continued and the target dropped off about 1,300 [feet]."

The accident occurred during the hours of daylight approximately 38 degrees, 29 minutes north latitude, and 76 degrees, 36 minutes west longitude.

Personnel information

The pilot held a private pilot's certificate with ratings for airplane single engine land and multi-engine land. The pilot was issued an FAA third class medical certificate on March 30, 1998.

An examination of two pilot logbooks revealed the books were labeled #1 and #3. No book #2 was located. The pilot's total flight experience could not be determined. Total flight experience was not carried forward to book #3; neither were the times totaled at the bottom of each page. The last entry in book #3 was dated April 17, 1994.

Examination of book #3 revealed that entries for flights in N53HS began April 30, 1993. The pilot logged receipt of 1.5 hours of dual instruction on that date, and 2 hours of dual instruction in the airplane on May 5, 1993. The pilot logged no other instruction in N53HS. He logged 17.2 hours of solo time in N53HS before he was issued a multi-engine rating.

The pilot logged 6.4 hours of dual instruction in a Piper PA-23-160 beginning March 26, 1994. He completed his multi-engine examination in a Piper PA-23-160 on April 6, 1994.

The pilot's last known biennial flight review was completed April 6, 1994.

In a telephone conversation, the pilot's daughter said that the pilot reported to his insurance company 2,265 hours of flight experience, 600 hours of which were in multi-engine airplanes. She said the report to the insurance company was made in 1998.

Aircraft information

Examination of aircraft records revealed the pilot/owner purchased the airplane on July 8, 1991.

Examination of maintenance records revealed the airplane was on an annual inspection program. The most recent annual inspection was performed October 16, 1998. The mechanic who recorded the inspection in the logbook did not record compliance with mandatory inspections, maintenance procedures, and Airworthiness Directives (AD). The same mechanic recorded the previous annual inspection 16 months prior on June 16, 1997. Again, no compliance with mandatory inspections, maintenance procedures, or ADs was noted.

The last documented compliance with any Airworthiness Directives was dated March 17, 1989.

A review of FAA records revealed the mechanic who performed the most recent annual inspection could not exercise the privileges of an IA (Inspection Authority) after March 31, 1998, and that he was the subject of an investigation for releasing an airplane for flight without complying with mandatory Ads. According to the mechanic's FAA records:

"[The FAA] never received response to letter of investigation, which was received by [mechanic] on 2/18/98. On 3/26/98, checked with [FAA inspector], of the IAD (EA27) FSDO office, to which [mechanic] is assigned, and verified that he did not renew his IA. They will notify this office if he does attempt to renew after March 31. [Mechanic's] mental faculties have been confirmed to be less than perfect, by people who know him within the industry, due to advanced age and Alzheimer's. Closed out the investigation with a warning letter mailed out 4/10/98."

According to a letter from an FAA inspector who examined the airplane's maintenance records:

"[The mechanic] did the last few annual inspections. He showed no compliance of any AD's that were due. Also a Mr. Douglas Brown did two annual inspections in 1995 and 1996, again no compliance with any AD's. We have looked into the FAA record system and have found that Brown's certificate number does not exist at all. This information is based on the information found in the aircraft's log books."

According to FAA records, an airworthiness condition notice was issued to N53HS on April 30, 1997. In a telephone interview, an FAA airworthiness insp

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - nonmechanicalCruise - normal
Fluid,fuel - starvation
Operation with known deficiencies in equipment - intentionalPilot in commandFactor
Engine instruments,fuel quantity gage - inoperativeFactor
Fuel management - inadequatePilot in commandFactor
1 engine
Loss of control - in flightEmergency descent/landing
Emergency procedure - not complied withPilot in commandFactor
Aircraft control - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Aircraft

Registration
N53HS
Reported as
Cessna 337
Category
Airplane
Serial number
337-0411
Airframe hours
3,337
Engine
Continental IO-360-C/D, 210 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Robert L. Poetzman
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 16, 1998 · 79 hours before
Departed
1GA0 · Eagle Neck, GA
Destination
ANP · Edgewater, MD

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
66
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
2,265 total · 200 in this make and model · 9 in the last 90 days · 9 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 15 knots, gusting 20
Visibility
7 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 34 °F
Altimeter
30.00 inHg
Observed at
NHK, 15 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.