# NTSB MIA01FA140: Cessna 404, N404BA, Pena Pobre, PR, May 13, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 13, 2001, 19:33 local (23:33 UTC) - Place: Pena Pobre, PR - Coordinates: 18.221744, -66.589157 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=18.2217&lon=-66.5892&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report May 13, 2003 - Report: Approved by Office Director - Parties: Cessna Aircraft, Continental Motors, FAA - NTSB case key (mKey): 52256 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA01FA140 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/52256/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=52256 - Page: https://openairdocs.org/ntsb/MIA01FA140 ## Probable cause failure of the pilot-in-command to maintain altitude/clearance, resulting in an in-flight collision with rising terrain. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, descent - normal - light condition - dark night - weather condition - fog - use of inappropriate medication/drug, pilot in command - altitude/clearance - not obtained/maintained, pilot in command (cause) - terrain condition - rising ## Analysis The flight was being handled as a VFR aircraft by air traffic control, was given a discreet transponder code, and was radar contact at an altitude of 4,500 feet. The pilot requested a VFR decent from 4,500 feet, and was cleared to "…descend unrestricted west bound." Radar and radio contact were lost at an altitude of 2,700 feet. The controller tried to re-establish radio contact with the airplane's pilot 10 times before initiating search and rescue efforts. A U.S. Coast Guard helicopter found the wreckage, using the aircraft's emergency locator transmitter. The next day a ground search for the aircraft was halted because of hazardous terrain. Search and rescue personnel had to be air lifted into the crash site to remove the victim. A police helicopter was vectored to the crash site by ATC about an 1 1/2 hours after contact was lost with the flight, and the pilot reported that he could not fly near the crash site because of fog. He reported the ceiling about 2,400 feet. The aircraft impacted in heavily wooded, mountainous terrain at the 2,700-foot level of a 3,524-foot mountain. Toxicology test showed that venlafaxine and desmethylvenlafaxine drugs were found in the pilot's blood, and the levels found were consistent with the recent ingestion of more than 10 times a normal dose of venlafaxine. ## Factual narrative HISTORY 0F Flight On May 13, 2001, about 1933 Atlantic daylight time, a Cessna 404, N404BA, registered to Air Cargo Systems International Inc., and operated by City Wings Inc., as a Title 14 CFR Part 91 positioning flight, impacted with rising terrain, at night, in the Caribbean National Forest, near Pena Pobre, Puerto Rico (PR). Visual meteorological conditions prevailed. No flight plan was filed. The airplane was destroyed. The commercial rated-pilot was fatally injured. The flight had departed from St. Croix, U.S. Virgin Islands at 1900. The flight was en route to Aguadilla, PR (TJBQ), with a stopover at Luis Munoz Marin International Airport, San Juan, PR (SJU). According to the air traffic control tapes, the pilot was in radio contact with San Juan approach control and was being handled as a VFR aircraft. The pilot was given a discreet transponder code of 0411, and was in radar contact at about 1910, 12 miles west of St. Croix, at an altitude of 4,500 feet. The pilot requested a VFR descent from 4,500 feet. The controller coordinated with Roosevelt Roads Naval Station, the sector that the flight was in, and subsequently cleared the flight at 1923:59, to "…descend unrestricted west bound." The flight appeared to follow the 160 degree radial, inbound to the San Juan VORTAC (Very High Frequency Omni-Directional Radio Range Tactical Air Navigation Aid). According to ATC controllers at SJU approach control, the minimum-vectoring altitude for all aircraft flying in the same area as N404BA, on instrument flight rule (IFR) flight plans was 6,000 feet. At 1924:10, radar showed that the flight started to descend out of 4,500 feet, and at 1928:33, had stopped its descent at 2,700 feet. Radio and radar contact were lost at 1930:26, and the last radar hit on the flight showed it at an altitude of 2,700 feet. The controller tried to re-establish radio contact with the airplane's pilot 10 times before initiating search and rescue efforts. About 2020, a U.S. Coast Guard helicopter located the wreckage, with the aid of the aircraft's emergency locator transmitter, and rescue workers got within 2 to 3 nautical miles of the wreckage, but due to night darkness, and the steep-rugged terrain elected to wait until day light before continuing the search and rescue operations, postponing their efforts for several hours. The next day a ground search for the aircraft was halted because of hazardous terrain, and the air rescue continued. Search and rescue personnel were air lifted into the crash site to remove the victim. PERSONNEL INFORMATION The pilot, held an FAA commercial pilot certificate, with airplane single and multi-engine land, airplane instrument, last issued on June 6, 1998. The pilot held an FAA class 2 medical certificate issued on August 24, 2000, with no limitations. The pilot received a biennial flight review, as required by 14 CFR Part 61, on August 6, 1999. As per the entries in his company flight records, he had accumulated a total of 550 total flight hours, 166 total single engine flight hours, and 384 hours muti-engine aircraft when he was hired by City Wing Inc; on May 24, 2000. In addition, the records showed that he had a total of 80 night flight hours, 50 simulated instrument flight hours, and 20 actual instrument flight hours. In the last 90 days before the accident the pilot flew a total 90 hours all in this make and model aircraft. In the last 30 days before the accident the pilot flew a total of 67 hours all in this make and model aircraft. According to the company flight records the pilot had not logged any instrument flight hours in the three months before the accident. In addition, the company records showed that the pilot had logged 6.5 of night flight hours in the 90 days before the accident. As of the pilot's last flight physical on August 24, 2000, at the time of the accident, the pilot had logged a total of about 1,000 flight hours in all aircraft. AIRCRAFT INFORMATION The airplane was a Cessna, model 404, serial number 404-0237, manufactured in 1978. At the time of the last annual the airplane had accumulated 11,953.1 total flight hours. The airplane received an annual inspection on April 29, 2001, 50 hours before the accident. The airplane was equipped with two Continental Motors GTSIO-520-M, 375 horsepower engines. According to the engine logbooks, the left engine was put in service March 4, 1997, and the right engine was put in service on November 11, 2000. At the time of the accident it was estimated that the left engine had a total time of 1,363.1 hours since major overhaul (SMOH) and the right engine had 165.7 hours SMOH (See the copies of the engine and airframe logbooks, an attachment to this report). METEOROLOGICAL INFORMATION The reported weather at Roosevelt Roads Naval Air Station (JNR) at 1955, about 12 miles east of the crash site was; 2,500 feet broken, 25,000 feet overcast, visibility 10 sm, winds 140 degrees at 6 knots, temperature 79 degrees F, dew point 75 degrees F, and the altimeter was 30.00 inches Hg. The reported weather at San Juan at 1954, 30 miles northeast of the crash site was; clear, visibility 10 sm, winds 160 degrees at 5 knots, temperature 82 degrees F, dew point 75 degrees F, and the altimeter was 29.99 inches Hg. A police helicopter was vectored to the area of the crash site by ATC at 2045, and the pilot reported that he could not fly near the crash site because of fog. He reported the ceiling about 2,400 feet. The San Juan weather was VMC. However, according too FAA personnel from the area, it is common for rain clouds to move in and out of the Caribbean Forrest, and mountain regions in the area of the crash site, and not always picked up on automated surface observation (ASOS) weather. WRECKAGE AND IMPACT INFORMATION The aircraft impacted in heavily wooded, mountainous terrain about 30 miles southeast of San Juan, Puerto Rico, on the property of the Caribbean National Forest. The wreckage was located at the 2,700-foot level of a 3,524-foot mountain. The accident occurred during the hours of darkness about 18 degrees, 15 minutes north, and 065 degrees, 49 minutes west. Due to the terrain difficulty, and the National Park Service restrictions, access to the wreckage by foot or road was impossible. Rescue personnel had to be lowered into the crash site by helicopter and with their assistance only the two engines were removed from the crash site. The airframe could only be viewed overhead from a helicopter. The airplane appeared to have impacted the trees on a heading of 340 degrees, and parts of the airplane separated as the airplane impacted trees. It was noted that the fuselage, wings and tail had sustained post-impact fire damage. Both engines had separated from the airframe, and both propellers had separated from their respective engines. The fuel system was not recovered, and was not observed. Company records had indicated that 200 gallons of fuel had been added to the airplane's fuel tanks before departure from Saint Croix. After removal of the engines from the crash site they were examined at the facilities of the Puerto Rico State Police, San Juan, Puerto Rico, in the presence of the NTSB IIC, the FAA, representatives of Continental Motors, and Cessna Aircraft, on May 17, 2001. The initial inspection of the left engine revealed the following damage: The number 6 cylinder valves were found broken out of the cylinder head; the propeller was broken off at the hub; the propeller governor was broken off and missing; the magnetos were broken off the engine; the number 5 intake pipe was broken off; the starter was broken off and missing; the alternator was broken; and the hydraulic pump was broken off and missing. The oil pan was found crushed. Most of the exhaust system was missing. Examination of the left engine revealed the presences of fuel in the fuel manifold, and the fuel pump. The fuel p ## Aircraft - Registration: [N404BA](https://openairdocs.org/deregistered/N404BA-2002-05-21), registration cancelled 2002-05-21, S/N 404-0237, built 1978 (OpenAirDocs) - Reported make and model: Cessna 404 - Registry model: [Cessna 404](https://openairdocs.org/model/cessna-404) (registry code 2075901) (OpenAirDocs) - Registry engine: [Continental GTSIO-520 series](https://openairdocs.org/engine/continental-gtsio-520-series) (registry code 17046, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 404-0237 - Airframe hours: 12000 - Engines: Continental GTSIO-520 M 375 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Operator: City Wings Inc, doing business as Prinair/City Wings - Registered owner: Air Cargo Systems International Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 29, 2001, 50 hours before - Departed: STX, ST CROIX - Destination: SJU, San Juan, PR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 22; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; last flight review July 6, 2000; seat: left; toxicology performed; flight hours: 1,000 total, 103 in this make and model, 90 in the last 90 days, 67 in the last 30 days ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 140° at 6 knots - Visibility: 3 statute miles - Lowest ceiling: 2,500 ft broken - Temperature: 79 °F, dew point 75 °F - Altimeter: 30.00 inHg - Observed at: TJNR, 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 (OpenAirDocs). - [Accident 20010513010939A](https://openairdocs.org/incident/20010513010939A), May 13, 2001: Cessna 404, San Juan, Puerto Rico, No damage. (-23)The aircraft was on a VFR flight from st. croix U.S. Virgin islands to San Juan Puerto Rico. Aircraft cruising altitude was 4,500 feet MSL until descend… ## Docket (29 files) The files NTSB released with the investigation on March 18, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=52256. 12.4 MB in all. - Supplement A (item 1, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176329&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176330&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 3, .PDF, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176331&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Reports from Federal Agencies (item 4, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456113&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies-Master.PDF - Reports from Parties to the Investigation (item 5, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456114&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation-Master.PDF - Toxicological Report (item 6, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456115&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456116&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Other Pertinent Forms and Reports (item 8, .PDF, 363 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456117&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Master.PDF - Maintenance Records (item 9, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456118&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Fuel Slips (item 10, .PDF, 600 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456119&FileExtension=.PDF&FileName=Fuel%20Slips-Master.PDF - Photo 1. General view of the wreckage. [Photo taken and provided by Commonwealth of Puerto Rico Emergency Management Agency. No Negative.] (item 11, .PDF, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176343&FileExtension=.PDF&FileName=Photo%201.%20%20General%20view%20of%20the%20wreckage.%20%20%5BPhoto%20taken%20and%20provided%20by%20Commonwealth%20of%20Puerto%20Rico%20Emergency%20Management%20Agency.%20%20No%20Negative.%5D-Master.PDF - Photo 2. Cabin area. [Photo taken and provided by Commonwealth of Puerto Rico Emergency Management Agency. No Negative.] (item 12, .PDF, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176346&FileExtension=.PDF&FileName=Photo%202.%20%20Cabin%20area.%20%20%5BPhoto%20taken%20and%20provided%20by%20Commonwealth%20of%20Puerto%20Rico%20Emergency%20Management%20Agency.%20%20No%20Negative.%5D-Master.PDF - Photo 3. Main wreckage. [Photo taken and provided by Commonwealth of Puerto Rico Emergency Management Agency. No Negative.] (item 13, .PDF, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176347&FileExtension=.PDF&FileName=Photo%203.%20%20Main%20wreckage.%20%20%5BPhoto%20taken%20and%20provided%20by%20Commonwealth%20of%20Puerto%20Rico%20Emergency%20Management%20Agency.%20%20No%20Negative.%5D-Master.PDF - Photo 4. Left side view of the tail section. [Photo taken by Commonwealth of Puerto Rico Emergency Management Agency.] (item 14, .PDF, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176348&FileExtension=.PDF&FileName=Photo%204.%20%20Left%20side%20view%20of%20the%20tail%20section.%20%20%5BPhoto%20taken%20by%20Commonwealth%20of%20Puerto%20Rico%20Emergency%20Management%20Agency.%5D-Master.PDF - Photo 5. Right side view of the tail. [Photo taken by Commonwealth of Puerto Rico Emergency Management Agency.] (item 15, .PDF, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176349&FileExtension=.PDF&FileName=Photo%205.%20%20Right%20side%20view%20of%20the%20tail.%20%20%5BPhoto%20taken%20by%20Commonwealth%20of%20Puerto%20Rico%20Emergency%20Management%20Agency.%5D-Master.PDF - Photo 6. View of the wreckage and the surrounding terrain. [Photo taken by Commonwealth of Puerto Rico Emergency Management Agency.] (item 16, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176350&FileExtension=.PDF&FileName=Photo%206.%20%20View%20of%20the%20wreckage%20and%20the%20surrounding%20terrain.%20%20%5BPhoto%20taken%20by%20Commonwealth%20of%20Puerto%20Rico%20Emergency%20Management%20Agency.%5D-Master.PDF - Photo 7. Broken trees. [Photo taken by Commonwealth of Puerto Rico Emergency Management Agency.] (item 17, .PDF, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176351&FileExtension=.PDF&FileName=Photo%207.%20%20Broken%20trees.%20%20%5BPhoto%20taken%20by%20Commonwealth%20of%20Puerto%20Rico%20Emergency%20Management%20Agency.%5D-Master.PDF - Photo 8. Left engine after removal from the crash site. [Photo taken and provided by Continental Motors. No Negative.] (item 18, .PDF, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176352&FileExtension=.PDF&FileName=Photo%208.%20%20Left%20engine%20after%20removal%20from%20the%20crash%20site.%20%20%5BPhoto%20taken%20and%20provided%20by%20Continental%20Motors.%20%20No%20Negative.%5D-Master.PDF - Photo 9. Accessory section left engine. [Photo taken and provided by Continental Motors. No Negative.] (item 19, .PDF, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176353&FileExtension=.PDF&FileName=Photo%209.%20%20Accessory%20section%20left%20engine.%20%20%5BPhoto%20taken%20and%20provided%20by%20Continental%20Motors.%20%20No%20Negative.%5D-Master.PDF - Photo 10. Left engine fuel pump. [Photo taken and provided by Continental Motors. No Negative.] (item 20, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176354&FileExtension=.PDF&FileName=Photo%2010.%20Left%20engine%20fuel%20pump.%20%20%5BPhoto%20taken%20and%20provided%20by%20Continental%20Motors.%20%20No%20Negative.%5D-Master.PDF - Photo 11. Left engine vacuum pump. [Photo taken and provided by Continental Motors. No Negative.] (item 21, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176355&FileExtension=.PDF&FileName=Photo%2011.%20Left%20engine%20vacuum%20pump.%20%20%5BPhoto%20taken%20and%20provided%20by%20Continental%20Motors.%20%20No%20Negative.%5D-Master.PDF - Photo 12. Same as photo #11. [Photo taken and provided by Continental Motors. No Negative.] (item 22, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176356&FileExtension=.PDF&FileName=Photo%2012.%20Same%20as%20photo%20%2311.%20%20%5BPhoto%20taken%20and%20provided%20by%20Continental%20Motors.%20%20No%20Negative.%5D-Master.PDF - Photo 13. Right engine after it was removed from the crash site. [Photo taken and provided by Continental Motors. No Negative.] (item 23, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176357&FileExtension=.PDF&FileName=Photo%2013.%20Right%20engine%20after%20it%20was%20removed%20from%20the%20crash%20site.%20%20%5BPhoto%20taken%20and%20provided%20by%20Continental%20Motors.%20%20No%20Negative.%5D-Master.PDF - Photo 14. Accessory section right engine. [Photo taken and provided by Continental Motors. No Negative.] (item 24, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176358&FileExtension=.PDF&FileName=Photo%2014.%20Accessory%20section%20right%20engine.%20%20%5BPhoto%20taken%20and%20provided%20by%20Continental%20Motors.%20%20No%20Negative.%5D-Master.PDF - Photo 15. Right engine fuel pump. [Photo taken and provided by Continental Motors. No Negative.] (item 25, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176359&FileExtension=.PDF&FileName=Photo%2015.%20Right%20engine%20fuel%20pump.%20%20%5BPhoto%20taken%20and%20provided%20by%20Continental%20Motors.%20%20No%20Negative.%5D-Master.PDF - Photo 16. Aerial view of the crash site. [Photo taken by Commonwealth of Puerto Rico Emergency Management Agency.] (item 26, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176360&FileExtension=.PDF&FileName=Photo%2016.%20Aerial%20view%20of%20the%20crash%20site.%20%20%5BPhoto%20taken%20by%20Commonwealth%20of%20Puerto%20Rico%20Emergency%20Management%20Agency.%5D-Master.PDF - Photo 17. Aerial view of the crash site. [Photo taken by Commonwealth of Puerto Rico Emergency Management Agency.] (item 27, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176361&FileExtension=.PDF&FileName=Photo%2017.%20Aerial%20view%20of%20the%20crash%20site.%20%20%5BPhoto%20taken%20by%20Commonwealth%20of%20Puerto%20Rico%20Emergency%20Management%20Agency.%5D-Master.PDF - Medical Records Information (item 28, .PDF, 6 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176508&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 29, .PDF, 390 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456120&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF From the NTSB's public API. 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