MIA00FA017

NTSB accident investigation · Cessna T310R · Atlantic Ocean (Atlantic Ocean) · October 31, 1999

Accident · FatalField investigationFinal report
Date
October 30, 1999, 22:10 local (Oct 31, 1999, 02:10 UTC)
Place
Atlantic Ocean (Atlantic Ocean)
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N4XZCessna T310R
Weather
Visual (VMC) · Night/dark
Status
Completed · report July 10, 2001
Report
Approved by Office Director
FAA report
19991030045669A
Case key
47659

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 impact with rough water. A factor in this accident was a dark night, which resulted in no visual cues.

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.

In flight collision with terrain/waterManeuvering
Light condition - dark nightFactor
Diverted attentionPilot in command
Spatial disorientationPilot in command
Aircraft control - not maintainedPilot in commandCause
Terrain condition - water,rough

Analysis

The pilot made radio contact with Air Traffic Control, and was issued an IFR clearance. The controller at the center observed the airplane in a turn and losing altitude. The controller radioed the pilot and asked if he needed assistance. The pilot answered 'standby.' Radar and radio contact was lost. About 4 hours later, a United States Coast Guard aircraft found debris in the water. Radar data showed that the flight was about to intersect the assigned airway, and was at an altitude of 5,800 feet. The flight started drifting left of the airway and climbed from 5,800 feet to 7,400 feet, in 2 minutes and 01 second. The airplane turned about 180 degrees to the left, and then descended 1,500 feet to an altitude of 5,900 feet, in 47 seconds. The flight continued to descend from 5,900 feet to 1,700 feet and reached that altitude in 2 minutes and 36 seconds. The last radar return was at 2209:40 and no altitude was recorded. In addition, the transcript of radio communication indicated that the pilot was receiving his IFR clearance about the same time, and he read back the clearance incorrectly. Due to the ocean conditions and high winds the search for the airplane and victims took several weeks. The airplane was not recovered from the ocean until November 15, 16, 1999. Examination of the recovered wreckage did not reveal any discrepancies. The pilot's personal logbook listing his flight hours was not recovered. Based on his last application for insurance, dated April 20, 1999, it was estimated that the pilot had about 1,207 hours of total flight time in all aircraft, and 36 hours in this make and model airplane, at the time of the application. In addition, at the time of the application the pilot listed 48 hours of night flight time. The weather for Key West, Florida, about 10 miles south of the crash site at 2153 was; wind 040 at 9 knots; visibility 10 sm, lowest ceiling 15,000 broken; temperature 79 degrees F; dew point 73 degrees F; altimeter 30.08 in Hg. The reported condition of the ocean, according to the United States Coast Guard station, Key West, Florida, about the time of the accident was; ocean swells (6 to 8 feet), and the winds were from the northeast at 15 to 20 knots.

Factual narrative

History of flight

On October 30, 1999, about 2210 eastern daylight time, a Cessna T310R, N4XZ, registered to Southern Aerial Photography Inc., impacted with the water about 10 miles north of Key West, Florida. Visual meteorological conditions prevailed at the time, and an IFR flight plan was filed for the 14 CFR Part 91 personal flight. The airplane sunk in about 20 feet of water, and was destroyed. The commercial-rated pilot and three passengers received fatal injuries. The flight had departed from the Key West, Florida Airport, en route to Fort Lauderdale, Florida, at 2200.

According to air traffic control (ATC) at Miami Center, at the time the airplane departed from Key West, the ATC tower was closed. The pilot made radio contact with Miami Center and was advised that he was in radar contact leaving an altitude of 5,500 feet msl. The controller at Miami Center observed the airplane in a turn and losing altitude. The controller radioed the pilot and asked if he needed assistance. The pilot answered "standby." Radar and radio contact were lost at 2210.

About 0200, a United States Coast Guard aircraft found debris in the water at 081.46 West and 24.41 North.

It was reported, by line personnel at Key West, that the airplane arrived about noon on October 30, 1999, and was topped off with fuel.

Radar data showed that the flight was about to intersect the V157 airway, and was at an altitude of 5,800 feet. The flight started drifting left of the airway and climbed from 5,800 feet to 7,400 feet, reaching 7,400 feet in 2 minutes and 01 second. The airplane turned about 180 degrees to the left, and descended 1,500 feet to an altitude of 5,900 feet, in 47 seconds. The flight continued to descend 4,200 feet, from 5,900 feet to 1,700 feet, in 2 minutes and 36 seconds. The last radar return was at 2209:40, and no altitude was recorded. In addition, the transcript of radio communication indicated that between 2203:04 and 2203:41, the pilot was receiving his IFR clearance. At 2203:41, the pilot read back the clearance incorrectly.

The calculated rate of climb from 5,800 feet to 7,400 feet was about 995 feet per minute. The calculated rate of descent from 7,400 feet to 5,900 feet was about 1,915 feet per minute. The calculated rate of descent from 5,900 feet to 1,700 feet was about 1,615 feet per minute.

Due to the ocean conditions and high winds the search for the airplane and victims took several weeks. The airplane was not recovered from the ocean until November 15-16, 1999.

The accident occurred during the hours of darkness about 24 degrees, 41 minutes north, and 081 degrees, 46 minutes west.

Personnel information

The pilot's personal logbook listing his flight hours was not recovered. Based on his last application for insurance, dated April 20, 1999, it was estimated that the pilot had about 1,207 hours of total flight time in all aircraft, and 36 hours in this make and model airplane, at the time of the application. In addition, at the time of the application the pilot listed 48 hours of night flight time.

Aircraft information

The airplane's maintenance records showed that the last entry dated October 28, 1999, was, "Lubed waste gates, inspected left and right exhaust...CAV-AIR Inc."

Meteorological information

The weather for Key West, Florida, about 10 miles south of the crash site at 2153 was; wind 040 at 9 knots; visibility 10 sm, lowest ceiling 15,000 broken; temperature 79 degrees F; dew point 73 degrees F; altimeter 30.08 in Hg.

The reported condition of the ocean, according to the United States Coast Guard station, Key West, Florida, about the time of the accident was; ocean swells (6 to 8 feet), and the winds were from the northeast at 15 to 20 knots.

Computerized sun and moon information revealed that about the time of the accident the altitude of the sun was minus 46.2 degrees below the horizon. The altitude of the moon was minus 28.5 degrees below the horizon. (See sun and moon information, an attachment to this report).

Medical and pathological information

Dr. Robert J. Nelms performed an autopsy on the pilot, on November 15, 1999, at the Monroe County Medical Examiner's Office, Marathon, Florida. According to the autopsy report, "...Cause of Death...blunt impact trauma caused by aircraft crash into water."

Toxicological tests were conducted at the Federal Aviation Administration, Research Laboratory, Oklahoma City, Oklahoma, and revealed, "No ethanol detected in Kidney... no drugs detected in Kidney...15 (mg/dl, mg/hg) Ethanol detected in muscle...Notes...the ethanol found in this case is from postmortem ethanol formation and not from the ingestion of ethanol."

Communications

At 2158:22, the pilot made radio contact with the Miami ARTCC (air route traffic control center), Fort Myers Low Sector Radar Position (R24), and said, "...departing Key West." The controller gave the pilot a transponder code of "four seven zero four."

The pilot called center several times because he did not get the transponder code, and made four attempts to reestablish radio contact.

At 2159:33, the pilot said, "...Miami Center this is uh twin Cessna 4XZ do you copy." The R24 controller answered, "...loud and clear, how me." The pilot of N4XZ said, "...loud and clear sir do you have our uh squawk uh four seven zero four." The controller said, "No sir I do not."

At 2203:04, the R24 controller said, "...radar contact one zero miles north of Key West leaving five thousand five hundred you're cleared to Fort Lauderdale Executive via join victor one fifty seven [V157 airway], Famin [intersection], radar vectors Executive, climb and maintain one one thousand, Key West altimeter zero zero eight."

At 2203:21, the pilot said, "roger uh did you say." The R24 answered at 2203:28, and repeated, "...you're radar contact cleared to the Fort Lauderdale Executive via join victor one five seven to Famin intersection expect radar vectors to Fort Lauderdale climb and maintain one one thousand."

At 2203:41, the pilot of N4XZ said, "roger cleared to Fort Lauderdale Executive via join victor one fifty seven uh maintain one one thousand...." [Note: The piloted omitted the Famin Intersection, and radar vectors on the read back of the clearance.]

At 2203:48, the R24 controller said, "...verify leaving five thousand uh seven hundred." The pilot said, "five thousand seven hundred leaving."

The R24 controller called the pilot 2 minutes 46 seconds later at 2206:38, and said, "...[N4XZ] Miami say heading...N4XZ Miami."

At 2206:50, the pilot of N4XZ said, "Miami stand by." The R24 controller said, "...are you having a problem." There was no response; radio and radar contact was lost.

The R24 controller had several other aircraft on the frequency attempt to make contact with N4XZ without successes.

Wreckage and impact information

After the airplane was recovered from the water it was taken to Air and Sea Recovery Inc., Fort Lauderdale, Florida, where the recovered parts were examined.

Examination of the airframe revealed that the components that were recovered included the wing main spar carry-through from the left engine to the right engine, the left aileron, the horizontal and vertical tail section, three seats, the cockpit area to include the power quadrant, center console, the left and right engines, right propeller including all three blades with the hub, two of the left propeller blades and a portion of the left propeller hub.

The fuselage and wing carry through area, out to the wing, displayed extensive impact damage. The leading edges of the wings were missing back to the main spar. The top surfaces of the airplane displayed more impact damage then did the bottom surfaces. Due to the destruction of the fuselage very little recoverable information was available.

The landing gear drive gearbox located on the floor of the fu

Aircraft

Registration
N4XZ
Reported as
Cessna T310R
Category
Airplane
Serial number
310R1538
Engine
Continental TSIO-520-BB, 285 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Haim Israeli
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 17, 1999 · 16 hours before
Departed
EYW · Key West, FL
Destination
FXE · Fort Lauderdale, FL
Flight plan
IFR
Airport
EYW · Key West International

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
54
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,207 total · 336 in this make and model

Weather

Conditions
Visual (VMC) · Night/dark
Wind
40° at 9 knots
Visibility
10 statute miles
Lowest ceiling
15,000 ft broken
Temperature
79 °F, dew point 73 °F
Altimeter
30.00 inHg
Observed at
EYW, 10 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.