# NTSB MIA06LA071: Cessna 402C, N223PB, Dorado, PR, March 27, 2006 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 27, 2006, 13:30 local (17:30 UTC) - Place: Dorado, PR - Coordinates: 18.4680555555556, -66.4122222222222 - Nearby events: https://openairdocs.org/map.md?lat=18.4681&lon=-66.4122&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 2 minor, 5 uninjured - Status: Completed, report July 25, 2007 - Report: Approved by Office Director - Parties: FAA Flight Standards District Office - NTSB case key (mKey): 63400 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA06LA071 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63400/pdf - Page: https://openairdocs.org/ntsb/MIA06LA071 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - normal - weather condition - turbulence in clouds - weather radar - not used, pilot in command (cause) - flight into known adverse weather - continued, pilot in command (cause) ## 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](https://openairdocs.org/aircraft/N223PB), registered now, S/N 402C0105, built 1979 (OpenAirDocs) - Reported make and model: Cessna 402C - Registry model: [Cessna 402C](https://openairdocs.org/model/cessna-402c) (registry code 207590R) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 402C0105 - Airframe hours: 26840 - Engines: Teledyne Continental TSIO-520VB 325 horsepower reciprocating; Teledyne 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 27; injuries: none; 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 (OpenAirDocs). - [Accident 20060327004869A](https://openairdocs.org/incident/20060327004869A), Mar 27, 2006: Cessna 402C, Dorado, Puerto Rico. (-23) While flying over Dorado, p.r. NDB, encountered severe turbulence at 5000 ft. for about 1 second. Several passengers hit their heads on aircraft ceiling.… ## Other investigations on N223PB (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB ERA15LA125](https://openairdocs.org/ntsb/ERA15LA125), Feb 10, 2015: Cessna 402C (N223PB), Isla de Vieques, PR, substantial damage. Probable cause: The pilot's failure to maintain directional control during the landing roll with a strong crosswind, which resulted in a runway excursion. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.