MIA06LA071

NTSB accident investigation · Cessna 402C · Dorado, PR · March 27, 2006

Accident · Serious injuriesLimited investigationFinal report
Date
March 27, 2006, 13:30 local (17:30 UTC)
Place
Dorado, PR
Injuries
1 serious, 2 minor, 5 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N223PBCessna 402C
Weather
Instrument (IMC) · Day
Status
Completed · report July 25, 2007
Report
Approved by Office Director
Parties
FAA Flight Standards District Office
FAA report
20060327004869A
Case key
63400

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 use on-board weather radar equipment for weather avoidance and the pilot's continued operation into known adverse weather conditions, resulting in injury to passengers.

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 weatherCruise - normal
Weather condition - turbulence in clouds
Weather radar - not usedPilot in commandCause
Flight into known adverse weather - continuedPilot in commandCause

Analysis

While flying at 5,000 feet in a broken layer with some light rain and turbulence with the autopilot on, the pilot later reported, encountering severe turbulence, which lasted for 1 second. Several passengers hit their heads on the ceiling as a result. She reported avoiding all clouds after that, requested medical assistance, and landed uneventfully. One passenger who was injured reported that the pilot advised them that the flight would be "bumpy" and they needed to keep their seatbelts fastened, which she complied with. At the time of the event she could hear "...something like small pebbles dropping onto the plane. There was mist on the windshield that streamed from the bottom/middle of the windshield to the top." She further stated that after assessing herself, "maybe a minute or two, the pilot turned on a screen that had been blank up to that point." She also reported seeing "...green blobs that came on and off. It reminded me of the radar screen that I have seen on TV." Weather radar images indicate the airplane was near VIP Level 1 to Level 4 radar returns at the time of the occurrence.

Factual narrative

On March 27, 2006, about 1330 Atlantic standard time, a Cessna 402C, N223PB, registered to and operated by Hyannis Air Service, Inc., dba Cape Air, as flight 36, experienced in-flight clear air turbulence while flying over Dorado, Puerto Rico. Instrument meteorological conditions prevailed in the area and an instrument flight rules flight plan was filed for the 14 CFR Part 135 scheduled domestic passenger flight from Eugenio Maria de Hostos Airport, Mayaguez, Puerto Rico, to Luis Munoz Marin International Airport, San Juan, Puerto Rico. The airplane was not damaged and the pilot and four passengers were not injured. One passenger was seriously injured, and two passengers sustained minor injuries. The flight originated about 1317, from Mayaguez.

The pilot stated that while flying at 5,000 feet in a broken layer with some light rain and turbulence, the flight had, "...just broken out for a few miles. Every one was at ease a few passengers were sleeping, that's when we hit a severe [turbulence]. This only lasted about 1 second, Everyone was thrown in [their] seats. It was so severe that even though I was strapped in I was floating for a few seconds until my seatbelt caught me. I looked down at the altimeter and it was still showing 5,000 [feet] and on course. The autopilot stayed on. Our [weather] radar was not picking up anything ahead." The person in the right front seat and several passengers hit their heads on the ceiling. She looked back and the passengers appeared, "... stunned but otherwise OK." She asked air traffic control for a lower altitude and weather deviation, and was advised to deviate to the north only and to descend to 4,000 feet. She "... avoided all clouds after that and she pulled the power back." She notified operations for medical assistance, and proceeded to the destination airport where she landed uneventfully. The incident occurred a few miles west of the Dorado NDB.

The passenger who sustained the serious injury reported that the pilot advised them that the flight would be "bumpy" and they needed to keep their seatbelts fastened. She further reported that her seatbelt was tightly fastened at the time of the turbulence encounter, and at that time, she could hear "...something like small pebbles dropping onto the plane. There was mist on the windshield that streamed from the bottom/middle of the windshield to the top." She further stated that after assessing herself, "maybe a minute or two, the pilot turned on a screen that had been blank up to that point." She also reported seeing "...green blobs that came on and off. It reminded me of the radar screen that I have seen on TV." The pilot landed without any more incidents.

NTSB review of weather radar images from the reported area and time of occurrence revealed that intensities of approximately 20-45 DBZ were noted west of Dorado, Puerto Rico. These correlate to National Weather Service (NWS) Video Integrated Processor (VIP) Level 1 (Very Light) to Level 4 (very strong) echo intensities.

Aircraft

Registration
N223PB
Reported as
Cessna 402C
Category
Airplane
Serial number
402C0105
Airframe hours
26,840
Engines
Teledyne Continental TSIO-520VB, 325 horsepower, reciprocatingTeledyne Continental TSIO520VB, 325 horsepower, reciprocating
Damage
No damage
Flight
Part 135
Registered owner
Hyannis Air Service, Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · March 1, 2006
Departed
TJMZ · Mayaguez, PR
Destination
TJSJ · San Juan, PR
Flight plan
IFR

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
27
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
February 1, 2006
Seat
Left
Flight hours
2,942 total · 973 in this make and model · 2,585 as pilot in command · 264 in the last 90 days · 76 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
60° at 14 knots
Visibility
10 statute miles
Lowest ceiling
3,000 ft broken
Temperature
82 °F, dew point 73 °F
Altimeter
30.00 inHg
Observed at
TJSJ, 23 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.

Other investigations on N223PB · 1

Matched to the same aircraft by N-number and date.