MIA02FA084

NTSB accident investigation · Mitsubishi MU-2B-35 · Carolina, PR · April 15, 2002

Accident · FatalField investigationFinal report
Date
April 15, 2002, 15:03 local (19:03 UTC)
Place
Carolina, PR
Injuries
2 fatal, 2 minor; on the ground: 1 fatal, 2 minor
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N45BSMitsubishi MU-2B-35
Weather
Instrument (IMC) · Day
Status
Completed · report October 28, 2004
Report
Approved by Office Director
Parties
Hartzell Propeller, Inc., Honeywell, FAA, AAI-100, FAA Flight Standards District Office, Mitsubishi Heavy Industries America, Inc.
FAA report
20020415014239A
Case key
54556

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 failure of the pilot to maintain airspeed (Vs) while maneuvering following inadvertent encounter with clouds resulting in an inadvertent stall and uncontrolled descent and subsequent in-flight collision with trees, a wall, and a building.

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 encounter with weatherManeuvering
Weather condition - clouds
Loss of control - in flightManeuvering
Airspeed(vs) - not maintainedPilot in commandCause
Stall - inadvertentPilot in command
In flight collision with objectDescent - uncontrolled
Object - tree(s)
Object - wall/barricade
Object - building(nonresidential)

Analysis

The flight departed VFR, and when near the destination airport, was advised by air traffic control to hold VFR over the "plaza" and to make left 360 degree orbits. Several witnesses reported light rain was occurring at the time of the accident; there was no lightning or thunder. One witness located where the airplane came to rest reported observing the airplane emerge from the base of the clouds in a 45-degree left wing low and 20 degrees nose low attitude. He momentarily lost sight of the airplane but then noted it rolled to a wings level attitude. He also reported hearing the engine(s) "cutting in an out." Another witness located approximately 1/4 mile north of the accident site observed the airplane flying eastbound beneath the clouds in a right wing and nose low attitude, he also reported hearing the engine(s) sounding like they were "cutting in and out." A pilot-rated witness located an estimated 1,000 feet from where the airplane came to rest estimated that the ceiling was at 300 feet and there was light drizzle. He observed the airplane in a 45-degree angle of bank to the right and in a slight nose low attitude. He stated that the airplane continued in that attitude before he lost sight of the airplane at 250 feet. The airplane impacted trees then a concrete wall while in a nose and right wing low attitude. The airplane then traveled through automobile hoists/lifts which were coverered by corrugated metal, and came to rest adjacent to a building of an automobile facility. Impact and a postcrash fire destroyed the airplane, along with a building and several vehicles parked at the facility. Examination of the airplane revealed the flaps were symmetrically retracted and landing gears were retracted. No evidence of preimpact failure or malfunction was noted to the flight controls. Examination of the engines revealed no evidence of preimpact failure or malfunction; impact and fire damage precluded testing of several engine accessories from both engines. Examination of the propellers revealed no evidence of preimpact failure or malfunction. Parallel slash marks were noted in several of the corrugated metal panels that covered the hoists/lifts, the slashes were noted 25 and 21 inches between them. According to the airplane manufacturer, the 25 inch distance between the propeller slashes corresponds to an airspeed of 123 knots. Additionally, the power-off stall speed at the airplanes calculated weight with the flaps retracted and 48 degree angle of bank was calculated to be 122 knots. Review of NTSB plotted radar data revealed that the pilot performed one 360-degree orbit to the left with varying angles of left bank and while flying initially at 1,300 feet, climbing to near 1,500 feet, then descending to approximately 800 feet. The airplane continued in the left turn and between 1502:10 and 1502:27, the calibrated airspeed decreased from 160 to 100 knots. At 1502:27, the bank angle was 48 degrees, and the angle of attack was 26 degrees. Between 1502:30 and 1502:35, the true heading changed indicating a bank to the right. The last plotted altitude was 200 feet, which occurred at 1502:35. A NTSB weather study indicated that at the area and altitude the airplane was operating, NWS VIP level 1 to 2 echoes (light to moderate intensity) were noted. Additionally, the terminal aerodrome forecast (TAF) for the destination airport indicated that temporarily between 1400 and 1800 (the flight departed at approximately 1436 and the accident occurred at approximately 1503), visibility 5 miles with moderate rain showers, scattered clouds at 1,500 feet, and a broken ceiling at 3,000 feet.

Factual narrative

History of flight

On April 15, 2002, about 1503 Atlantic standard time, a Mitsubishi MU-2B-35, N45BS, registered to Maxfly Aviation, Inc., operated by Crucian International Airlines, experienced a loss of control while orbiting and crashed at an automobile parts and service facility near Carolina, Puerto Rico. Instrument meteorological conditions prevailed in the area at the time of the accident and no flight plan was filed for the 14 CFR Part 91 positioning flight from Henry E. Rohlsen Airport (TISX), St. Croix, U.S.V.I., to Luis Munoz Marin International Airport (TJSJ), San Juan, Puerto Rico. The airplane was destroyed by impact and a post crash fire and the airline transport-rated pilot, the sole occupant, was fatally injured. One individual on the ground at the automobile facility was fatally injured and two individuals at the facility sustained minor injuries. The flight originated from St. Croix, about 1436.

On the day of the accident at 1345, the pilot phoned the San Juan Automated Flight Service Station (SJU AFSS), and filed two flight plans, neither of which involve the accident flight. The pilot did not obtain a preflight weather briefing during the phone call. According to a transcription of communications with the San Juan Combined En Route Approach Control facility, at 1437:47, the pilot contacted the facility and advised that the flight had departed from TISX, climbing through 2,500 to 8,500 en route to TJSJ. The pilot was provided a discrete transponder code and the flight was radar identified. The flight continued and at 1454:07, air traffic control communications were transferred to San Juan Approach Control. The pilot established initial contact with that facility and advised the controller that the flight was, "...out a eight point five." The controller acknowledged and provided an altimeter setting, which the pilot acknowledged. At 1459:16, the controller advised the pilot, "...hold [visual flight rules] over plaza please make left [360's]." The pilot responded with the last two letters of the call sign of the airplane and at 1502:31, the controller advised the pilot to hold south of Plaza Carolina, to continue south and hold south of the plaza. There was no response from the pilot. At 1505:02, the controller advised on the frequency that the airplane was lost from radar.

Several witnesses reported that the weather conditions near the crash site at the time of the accident consisted of light rain; there was no lightning or thunder. One witness located where the airplane came to rest reported observing the airplane emerge from the base of the clouds in a 45-degree left wing low and 20 degrees nose low attitude. He momentarily lost sight of the airplane but then noted it rolled to a wings level attitude. He also reported hearing the engine(s) "cutting in an out." Another witness located approximately 1/4 mile north of the accident site observed the airplane flying eastbound beneath the clouds in a right wing and nose low attitude, he also reported hearing the engine(s) sounding like they were "cutting in and out." A pilot-rated witness located an estimated 1,000 feet from where the airplane came to rest estimated that the ceiling was at 300 feet and there was light drizzle. He observed the airplane in a 45-degree angle of bank to the right and in a slight nose low attitude. He stated that the airplane continued in that attitude before he lost sight of the airplane at 250 feet. The pilot-rated individual did not witness the accident but traveled to the accident site and observed a postcrash fire.

Personnel information

The pilot was the holder of an airline transport pilot certificate with ratings airplane multi-engine land and sea. He was also the holder of a commercial pilot certificate with the rating airplane single engine land. He was issued a first class medical certificate on January 3, 2002, with the limitation, "Holder shall carry glasses for near vision while exercising the privileges of his airman certificate."

His last check ride in accordance with 14 CFR Part 135.297 occurred on February 15, 2002, during a 1.5 hour flight in the accident airplane. The result was listed as "approved."

Review of his pilot logbook that begins with an entry dated January 2, 1994, and ends with an entry dated April 8, 2002, revealed he logged a total time of approximately 768 hours in Mitsubishi model MU2 airplanes. Further review of his pilot logbook revealed that between January 28, 2000, and April 8, 2002 (the last logged entry), he logged a total time of 586.3 hours all in the accident airplane. Between January 4, 2002, and April 8, 2002 (the last logged entry), he logged a total time of 117.1 hours; all in the accident airplane. He logged a total time of 10,583.2 hours, of which approximately 9,413 hours were as pilot-in-command. His total logged time for multi-engine land and sea was approximately 10,243 hours.

Aircraft information

The airplane received type certification on May 28, 1971, and was manufactured in 1972, as a Mitsubishi MU-2B-35, serial number 558. The airplane was initially certified and equipped with two Air Research TPE-331-6-251M engines rated at 665 shaft horsepower. The engines were modified in accordance with Service Bulletin TPE331-72-0120, which changed the engine model to TPE331-6-252M; the shaft horsepower remained unchanged. The airplane was also equipped with two hydraulically operated Hartzell model HC-B3TN-5C constant speed propellers which are full manual feathering and reversing.

The airplane was last inspected on February 13, 2002, in accordance with a 50/150 hour inspection using the airline's maintenance manual and checklist. The airplane had accumulated approximately 60 flight hours since the inspection as of the last logged flight in the pilot's pilot logbook (April 8, 2002). Review of the airplane maintenance records revealed that the last recorded altimeter system and transponder checks performed in accordance with Title 14 Code of Federal Regulations (CFR) Part 43, Appendix's E and F, occurred on January 22, 1999. A computerized printout for the airplane dated July 10, 2001, indicates that the "static", "[altimeter]" and "transponder" checks due every 24 months, were due on January 1, 2003.

A review of the aircraft log sheets revealed that between January 16, 2002, and April 5, 2002, the airplane had been operated 71.6 hours on 95 flights; there were only two pilot-reported discrepancies recorded in the log between these dates. Both discrepancies were related to the right engine and were corrected. The first dealt with the starter/generator, and the second dealt with the bleed valve.

Meteorological information

According to an NTSB Meteorological Factual Report (NTSB Weather Report), a special weather observation taken at the Luis Munoz Marin International Airport, San Juan, Puerto Rico, at 1456 (approximately 7 minutes before the accident), indicates the wind was from 080 degrees at 9 knots, the visibility was 10 statute miles, scattered clouds existed at 900 feet, a broken ceiling existed at 2,100 feet, overcast clouds existed at 4,500 feet, the temperature and dew point were 24 and 23 degrees Celsius, respectively, and the altimeter setting was 30.01 inHg. The remarks section indicates the rain ended at 1444, the sea level pressure was 1016.1 mb, and rain showers were noted in the vicinity southeast through south and north through northeast. Another special weather observation taken from the same airport at 1511 (approximately 8 minutes after the accident), indicates the wind was from 070 degrees at 12 knots gusting to 17 knots, the visibility was 10 statute miles, a broken ceiling existed at 800 feet, a second broken layer existed at 1,200 feet, overcast clouds existed at 3,500 feet, the temperature, dew point and altimeter remained the same from the previous special observation.

The NTSB Weather Report further in

Aircraft

Registration
N45BS
Reported as
Mitsubishi MU-2B-35
Category
Airplane
Serial number
558
Airframe hours
7,236
Engine
Airesearch TPE331-6-252M, 665 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Operator
Crucian International Airlines
Registered owner
Maxfly Aviation, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · February 13, 2002 · 60 hours before
Departed
TISX · Christiansted
Destination
TJSJ · San Juan, PR

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
60
Injuries
Fatal
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
February 15, 2002
Seat
Left
Toxicology
Performed
Flight hours
10,583 total · 768 in this make and model · 9,413 as pilot in command · 97 in the last 90 days · 43 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
80° at 9 knots
Visibility
10 statute miles
Lowest ceiling
2,100 ft broken
Temperature
75 °F, dew point 73 °F
Altimeter
30.01 inHg
Observed at
TJSJ

Docket · 52

The files NTSB released with the investigation on August 27, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 90.0 MB in all.

Meteorology 5 - Factual Report of Group ChairmanItem 1 · .PDF · 222 KBMeteorology 5 - Attachment 1 - San Juan Sounding 12ZItem 2 · .PDF · 376 KBMeteorology 5 - Attachment 2 - San Juan Sounding 00ZItem 3 · .PDF · 384 KBMeteorology 5 - Attachment 3 - Radar 1908ZItem 4 · .PDF · 6.8 MBMeteorology 5 - Attachment 4 - Radar 1919ZItem 5 · .PDF · 3.3 MBMeteorology 5 - Attachment 5 - Satellite Image 1902ZItem 6 · .PDF · 3.5 MBMeteorology 5 - Attachment 6 - Visible Satellite Image 1902ZItem 7 · .PDF · 3.5 MBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 8 · .PDF · 414 KBAircraft Performance InformationItem 9 · .PDF · 83 KBSupplement S - Aircraft Occupant and Injured Ground PersonnelItem 10 · .PDF · 338 KBWitness StatementsItem 11 · .PDF · 233 KBFAA Chronological Summary of Flight SheetItem 12 · .PDF · 44 KBTranscript of Radio CommunicationsItem 13 · .PDF · 142 KBPolice ReportItem 14 · .PDF · 1.9 MBReport/Documents from Mitsubishi Heavy Industries America, Inc.Item 15 · .PDF · 1.3 MBReport from Hartzell Propeller, Inc.Item 16 · .PDF · 84 photos · 14.6 MBReport from HoneywellItem 17 · .PDF · 262 photos · 21.0 MBRadar DataItem 18 · .PDF · 148 KBStall Speed ChartItem 19 · .PDF · 45 KBFueling InformationItem 20 · .PDF · 459 KBAir Carrier CertificateItem 21 · .PDF · 51 KBAirframe Maintenance Records (excerpts)Item 22 · .PDF · 666 KBLeft Engine Logbook (excerpts)Item 23 · .PDF · 806 KBRight Engine Logbook (excerpts)Item 24 · .PDF · 908 KBMaintenance Records (excerpts)Item 25 · .PDF · 922 KBTime Life Record SheetsItem 26 · .PDF · 89 KBAirman Competency/Proficiency Check FormItem 27 · .PDF · 128 KBPilot Month End Flight Time Total SheetItem 28 · .PDF · 34 KBPilot Flight/Duty Time Summary sheetsItem 29 · .PDF · 166 KBPilot Logbook (excerpts)Item 30 · .PDF · 17.7 MBAircraft Log SheetsItem 31 · .PDF · 2.7 MBPersonnel StatementsItem 32 · .PDF · 257 KBService Bulletin TPE 331-72-0120Item 33 · .PDF · 411 KBStatement from Jacob BercoviciItem 34 · .PDF · 53 KBToxicological ReportItem 35 · .PDF · 115 KBStatement of Party Representatives to NTSB InvestigationItem 36 · .PDF · 105 KBStatement from Alfreda S. OvesenItem 37 · .PDF · 52 KBStatement from Luis A. IrizarryItem 38 · .PDF · 51 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 39 · .PDF · 134 KBPhoto 1: View of the airplane at the accident site.Item 40 · .PDF · 377 KBPhoto 2: View of the airplane at the accident site.Item 41 · .PDF · 455 KBPhoto 3: View of the accident site.Item 42 · .PDF · 423 KBPhoto 4: View of the airplane, and debris.Item 43 · .PDF · 608 KBPhoto 5: View of the left propeller.Item 44 · .PDF · 606 KBPhoto 6: View of the right propeller.Item 45 · .PDF · 480 KBPhoto 7: View looking from the 2nd floor of the building adjacent to the main wreckage towards the damaged concrete wall showing the route of flight.Item 46 · .PDF · 447 KBPhoto 8: View showing the right fuel tip tank found on the north side of the damaged concrete wall.Item 47 · .PDF · 452 KBPhoto 9: View showing parallel slash marks in corregate panel. The measured distance is approximately 25 inches.Item 48 · .PDF · 340 KBPhoto 10: Close-up view of the measurement of the corregated panel showing the distance between the parallel slash marks.Item 49 · .PDF · 441 KBPhoto 11: View of the separated outer right wing panel.Item 50 · .PDF · 423 KBPhoto 12: View of the left engine assembly.Item 51 · .PDF · 451 KBPhoto 13: View of the right engine assembly.Item 52 · .PDF · 327 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.