MIA98FA047

NTSB accident investigation · Cessna 414A · Guyton, GA · December 29, 1997

Accident · FatalField investigationFinal report
Date
December 29, 1997, 08:45 local (13:45 UTC)
Place
Guyton, GA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N414MTCessna 414A
Weather
Visual (VMC) · Day
Status
Completed · report October 15, 1999
Report
Approved by Office Director
FAA report
19971229039509A
Case key
38384

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 NTSB’s determination of the probable cause, and any contributing factors.

Inadequate maintenance of the cabin pressurization system, which resulted in inadequate pressurization and incapacitation of the pilot due to the hypoxia. Also causal was the pilot's failure to adequately monitor the cabin pressurization system.

Analysis

About 26 minutes after takeoff while at 21500 feet, the pilot requested a non existent route. Seven minutes later, the passenger stated the pilot was light headed and fading then he had passed out. The passenger had once held a student pilot certificate and about 5 years earlier she had accrued 73 hours of flight time in Cessna 150/152 aircraft. The air traffic controller, and other pilots on the radio frequency tried to assist the passenger. The passenger was advised to provide oxygen for herself and the pilot, but she was unable. The airplane climbed to 34,200 feet where the airplane departed controlled flight, recovered, then departed controlled flight several more times before beginning a nose low descent. Witnesses reported hearing the airplane orbiting several times while flying above a cloud layer then observed the airplane orbiting beneath the clouds. While in a descending right wing low attitude, the airplane impacted the ground and came to rest submerged in a pond. Examination of the flight controls, engines, and propellers revealed no evidence of preimpact failure or malfunction. A discrepancy with the regulating valve was noted. Two small holes were noted in the cabin door seal. The left wing pressurization duct had been replaced about 8 years earlier but the right wing pressurization duct, had not been replaced. The ducts are on-condition components. There was no preimpact failure or malfunction noted with the barometric pressure switch, the cabin altitude annunciator bulbs, the safety valve, solenoid valve, or differential pressure/cabin altitude gauge. Testing for carbonmonoxide for both was negative.

Factual narrative

The factual narrative1,320 words

History of flight

On December 29, 1997, about 0845 eastern standard time, a Cessna 414A, N414MT, registered to the Valley Forge Manufacturing Corp., collided with terrain while descending near Guyton, Georgia. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was destroyed and the commercial-rated pilot and passenger were fatally injured. The flight originated about 0723 from the Orlando Executive Airport, Orlando, Florida.

Review of the Air Traffic Control (ATC) communication tapes with the flight revealed that IFR clearance was received, the flight was cleared to taxi, and takeoff, then ATC tower transferred the flight to Orlando Approach Control, followed by Jacksonville Air Route Traffic Control Center, at 0734.39. At that time, a male voice (pilot) verified climbing to 12,000 feet and about 19 seconds later, the flight was cleared to flight level 190, which was acknowledged by the pilot. The flight was cleared to flight level 230 and at 0743.51, the flight was cleared by the controller to climb to flight level 250. The pilot acknowledged this and requested a routing change. The controller advised the pilot to standby, then about 5 minutes 12 seconds later, the controller advised the pilot to go ahead with his request. The pilot advised that after Savannah, the route would be Jet Route 191, Pulaski, as filed. The controller cleared the flight as requested then about 1 minute 25 seconds later, the controller advised the pilot that Jet Route 191 does not come out of Savannah, and there was no direct airway from Savannah to Pulaski. The pilot acknowledged this by stating that he would have to check his routing then at 0753.07, the flight was cleared direct Pulaksi (VORTAC) after Savannah. The pilot did not acknowledge that clearance; there were no further ATC communication with the pilot (male) voice. All subsequent communications are from the passenger (female) voice.

At 0755.44, the passenger stated "we need help", followed by a mayday call 4 seconds later. Another mayday call transmitted at 0755.53, was acknowledged by the controller, followed by another mayday call at 0756.14. The controller again acknowledged this and at 0756.25, the passenger advised "in trouble the pilot is light headed and fading..." The controller acknowledged this then 11 seconds later, the passenger advised "the pilot is four one four mike tango is passing out do you hear me four one four mike tango pilot is passing out." The controller questioned the passenger whether she could fly the airplane but a flight crew member from a US AIRWAYS flight interjected and asked the passenger if oxygen was available to give to the pilot to which she responded, "I don't know how to get it." The US AIRWAYS flight crew questioned the altitude and the passenger responded, then advised "...The pilot is out I don't know what to do." The US AIRWAYS flight crew advised the passenger to put an oxygen mask on the pilot which the passenger acknowledged at 0757.55, by stating, "I'm looking for it I have to get up." There was no radio contact with the passenger from that point until 0801.46, when she stated that the flight was at flight level 268, and trying to level off. The controller advised her to push forward on the yoke and if oxygen was available, to put it on herself. The US AIRWAYS flight crew also advised her to provide oxygen to herself and to descend. The passenger advised that the pilot was still passed out and acknowledged that the flight needed to descend. The controller and flight crew of US AIRWAYS continued to advise the passenger that the flight needed to descend and at 0802.24, the passenger stated "...I'm pushing I am pushing on the uh wheel." At 0804.02, the passenger stated "trims appears to be going up and I don't understand I seriously don't know how to go down appears to still be climbing and tell me how to get down...." The US AIRWAYS flight crew then advised her to push very hard forward on the control column and to put oxygen on herself. At 0805.07, the passenger advised that the flight was out of control. The flight crew of US AIRWAYS advised the passenger to push a button on the yoke to release the autopilot. An absence of attempted contact by the passenger was noted between 0811.12, until 0827.38. At that time an open microphone with no voice was noted. The last evidence of attempted communication occurred about 0827.52.

An F/A-18D (F18) that had departed the Beaufort Marine Corps Air Station at about 0810 for a training mission was vectored to fly near the airplane and at 0825.39, the controller advised the pilot of the F18 that the accident airplane was in a slow climb at flight level 336. The pilot of the F-18 reported visually acquiring the airplane at 0828.08, and at 0832.03, the F-18 pilot advised the controller that the airplane begins a descent right wing low and recovers, which occurs 2 more times. About 0834.40, the F18 pilot reports to the controller that the airplane was "...pointing straight down..." and about 0835.09, the F18 pilot observed the airplane enter clouds at flight level 200 while in a nose low attitude of about 80 degrees nose low. The F18 did not pursue the airplane for safety concerns.

According to a statement from a controller at the Savannah Air Traffic Control Tower, the airplane was observed on radar in a rapid descent. The controller continued to track the airplane via radar and at 0840.44, the airplane was descending through 2,900 feet. Radar contact was lost at 500 feet on the 295 degree radial and 14 nautical miles from the Savannah VORTAC.

Numerous witnesses near the crash reported hearing an airplane orbit two to three times above the clouds. The airplane descended beneath the base of the clouds and was seen by several witnesses to orbit two to three times. The airplane then began a right descending turn and impacted the ground first with the right wing tip. The airplane then rolled right, impacted obstacles on the ground, and came to rest in a small pond about 200 feet from the initial impact point.

Review of the National Track Analysis Program (NTAP) track sort from the Jacksonville Air Route Traffic Control Center revealed that the airplane slowed to 78 knots ground speed with a nearly direct crosswind for the winds aloft at that altitude. The airplane then began a right descending turn, the ground speed increased, and the airplane returned to the north-northwesterly heading while climbing. The airplane continued climbing on about that same heading to flight level 342, and at 0832.14, the airplane began the second right descending turn. According to personnel from the Jacksonville ARTCC, the last radar return with mode C was at 0835.26. A copy of the NTAP track sort is an attachment to this report.

Other damage

Damage to a parked vehicle and the pond where the airplane crashed was noted.

Personnel information

The pilot had received recurrent flight training from January 13-15, 1997, at SIMCOM International, Inc., utilizing a fixed Cessna 421C simulator, with satisfactory results. The training consisted of 11.5 hours of ground instruction which included a total of 3 hours of briefs and debriefs over the 3 days. On the third day, 1.5 hours of ground instruction included training in environmental systems. The ground training was specific to a Cessna 414A airplane. A total of 6.0 hours of simulator instruction was accomplished over the course of five simulator sessions during the 3-day period. On the last simulator lesson of the third day, the loss of pressurization above 10,000 feet was accomplished. The simulator was capable of indicating this by the cabin altitude annunciator light, the cabin altitude gauge, and the cabin rate of climb. Oxygen in the simulator was not available to the pilot, though donning o

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.

Miscellaneous/otherClimb - to cruise
Pneumatic system - leak
Maintenance,annual inspection - inadequateOther maintenance personnelFactor
Air cond/heating/pressurization - undeterminedCause
Caution/warning system/light(s) - not identifiedPilot in commandCause
Loss of control - in flightClimb
Aircraft control - not maintainedPilot in commandCause
Incapacitation(anoxia/hypoxia)Pilot in command
Aircraft handling - not possibleUnqualified personCause
Incapacitation(anoxia/hypoxia)PassengerCause
In flight collision with terrain/waterDescent
Terrain condition - ground

Aircraft

Registration
N414MT
Reported as
Cessna 414A
Category
Airplane
Serial number
414A-0205
Airframe hours
3,872
Engine
Continental TSIO-520-NB, 335 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Joseph E. Black
Registered owner
Valley Forge Manufacturing Crp
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 19, 1997 · 6 hours before
Departed
ORL · Orlando, FL
Destination
SSU · White Sulphur, WV
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
67
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,545 in this make and model · 3,996 as pilot in command · 11 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 7 knots
Visibility
8 statute miles
Lowest ceiling
3,900 ft broken
Temperature
109 °F, dew point 106 °F
Altimeter
29.00 inHg
Observed at
SAV, 12 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.