# NTSB MIA98FA047: Cessna 414A, N414MT, Guyton, GA, December 29, 1997 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 29, 1997, 08:45 local (13:45 UTC) - Place: Guyton, GA - Coordinates: 32.329566, -81.390686 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.3296&lon=-81.3907&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report October 15, 1999 - Report: Approved by Office Director - NTSB case key (mKey): 38384 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA98FA047 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38384/pdf - Page: https://openairdocs.org/ntsb/MIA98FA047 ## Probable cause 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 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, climb - to cruise - pneumatic system - leak - maintenance,annual inspection - inadequate, other maintenance personnel (contributing factor) - air cond/heating/pressurization - undetermined (cause) - caution/warning system/light(s) - not identified, pilot in command (cause) - Loss of control - in flight, climb - aircraft control - not maintained, pilot in command (cause) - incapacitation(anoxia/hypoxia), pilot in command - aircraft handling - not possible, unqualified person (cause) - incapacitation(anoxia/hypoxia), passenger (cause) - In flight collision with terrain/water, descent - terrain condition - ground ## Aircraft - Registration: [N414MT](https://openairdocs.org/deregistered/N414MT-1998-04-07), registration cancelled 1998-04-07, S/N 414A0205 (OpenAirDocs) - Reported make and model: Cessna 414A - Registry model: [Cessna 414A](https://openairdocs.org/model/cessna-414a) (registry code 2075907) (OpenAirDocs) - Category: Airplane - Serial number: 414A-0205 - Airframe hours: 3872 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; 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 (OpenAirDocs). - [Accident 19971229039509A](https://openairdocs.org/incident/19971229039509A), Dec 29, 1997: Cessna 414A, Guyton, GA, Destroyed, 2 fatal. Climbing to FL250 PIC became ill. Passed out. 414 climbed to FL350. Stalled. Spun in. Wife right seat reported even (.4)about 26 minutes after takeoff while at… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; 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.