NYC02FA060

NTSB accident investigation · Rockwell 500S · Exeter, RI · February 17, 2002

Accident · FatalField investigationFinal report
Date
February 17, 2002, 17:52 local (22:52 UTC)
Place
Exeter, RI
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N999NRockwell 500S
Weather
Instrument (IMC) · Night
Status
Completed · report January 16, 2003
Report
Approved by Office Director
FAA report
20020217002339A
Case key
54199

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 pilot's failure to maintain control after encountering icing conditions while on approach for landing. Factors in this accident were the night light conditions and pilot's failure to select the airplane's propeller de-icing switches to the "on" position.

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.

Loss of control - in flightApproach
Aircraft control - not maintainedPilot in commandCause
Weather condition - icing conditionsFactor
Anti-ice/deice system - not selectedPilot in commandFactor
Light condition - nightFactor

Analysis

The airplane was in instrument meteorological conditions and the pilot was cleared for an approach. As the airplane neared the final approach fix, the controller observed the airplane diverge from the approach course and change altitude rapidly. Shortly thereafter, the pilot said he had "all sorts of problems." The pilot requested and received vectors to an alternate airport. At 1748:29, the pilot was cleared for an ILS approach and was told to report when "established" on the approach. When asked if he was established on the ILS course, the pilot replied "I sure hope so." The controller observed the airplane descend below the published glide slope intercept altitude and advised the pilot to climb back to 2,000 feet. The pilot reported "I have problems." When asked the nature of the problem, the pilot reported "...I'm all over the place...I think I'm iced up..." Radar data indicated the airplane's radar track began following a left descending turn from 1,900 feet, about 1 minute before radar contact was lost. At 1751:33, the controller advised the pilot that his altitude was 1,000 feet, and requested that he climb to 3,000 feet. The pilot responded, "hey, I'm trying like hell." Radar contact with the airplane was lost about 1752, at 800 feet. A witness near the accident site stated he observed the airplane come out of the clouds, "wobbling" from side to side, make a "hard" left turn and strike the ground. He stated the engine was "loud" and seemed to be at "full throttle." Examination of the airplane did not reveal any pre impact mechanical malfunctions. The pilot purchased the accident airplane about 2 months prior to the accident. His total flight time in make and model was estimated to be about 200 hours. Airman's Meteorological Information (AIRMET) Zulu, Update 4, for Ice and Freezing Level was valid for the accident site area at the time of the accident. The AIRMET advised of occasional moderate rime/mixed icing in cloud in precipitation below 12,000 feet. The AIRMET reported the freezing level was from the surface to 4,000 feet. According to United States Naval Observatory astronomical data obtained for the accident site area, Sunset occurred at 1723, and the end of civil twilight was at 1751. The airplane was equipped with both wing leading edge and empennage de-icing boots. The switches for the de-icing boots were observed in the "Auto" position. The propeller de-ice and windshield anti-ice switches were observed in the "off" position.

Factual narrative

History of flight

On February 17, 2002, at 1752 eastern standard time, a Rockwell 500S (Twin Commander), N999N, was substantially damaged when it impacted terrain in Exeter, Rhode Island. The certificated private pilot was fatally injured. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the flight that departed Wilmington International Airport (ILM), Wilmington, North Carolina, destined for Newport State Airport (UUU), Newport, Rhode Island. The business flight was conducted under 14 CFR Part 91.

According to the pilot's son, the pilot was conducting a regular flight from Naples, Florida, to Rhode Island, in furtherance of his sporting goods business.

According to information obtained from the Federal Aviation Administration (FAA), at 0759:17, the pilot contacted the Saint Petersburg Automated Flight Service Station (AFSS) and requested a weather briefing for a flight between Naples, Florida, and Wilmington, North Carolina and then to Newport, Rhode Island. At 1408:51, the pilot contacted the Raleigh AFSS and requested a weather briefing between Wilmington, North Carolina, and Newport State, Rhode Island.

According to Air Traffic Control (ATC) information provided by the FAA, and interviews of ATC personnel conducted by the Safety Board:

At 1711:51, the pilot made initial contact with Providence Approach Control and advised he had the current weather conditions at UUU. He requested the Localizer Runway 22 Approach, with a circle to land on runway 34. Radar data indicated the airplane was at 11,000 feet approximately over the Hampton, New York, VOR. The controller advised the pilot to proceed direct to UUU, and issued a descent clearance to 3,000 feet.

At 1730:53, air traffic control issued a traffic advisory to the pilot about a Cessna 402 at the "10 o'clock position, 9 miles passing left to right." The pilot responded, "I'll never see it sir my head's so stuck in these clouds."

At 1731:14, the controller observed the airplane on a course more easterly than he intended and asked the pilot to verify his heading. The pilot responded, "I am now gonna move to zero five zero."

At 1735:55, the controller advised the pilot he was cleared for the "localizer runway two two approach" and to report when "established." The pilot acknowledged the clearance.

At 1737:32, the controller advised the pilot that he appeared south of the localizer and asked if he was established on the approach. The pilot responded, "negative sir, I show myself (unintelligible) appears if I've gone through." The controller cancelled the approach clearance and instructed the pilot to turn left heading 090 degrees and maintain 2,000 feet. The pilot acknowledged the instructions.

During an interview, the controller stated that after he canceled the approach clearance, he intended to vector the airplane to the northeast for another Localizer 22 approach at UUU. He then observed the airplane's altitude readout change rapidly. At 1737:58 radar data indicated the airplane's altitude was 2,000 feet, 14 seconds later the altitude was 1,100 feet. Approximately 27 seconds later, the airplane's altitude was 1,700 feet.

The controller stated he questioned the pilot in regards to his altitude and the pilot responded, "hold on, I'm having all sorts of problems here" and then within seconds added, "alright seventeen hundred on my way to two thousand." The controller instructed the pilot to report established on an eastbound heading. The pilot responded, "...give me a break for a minute."

At 1739:59, the controller advised the pilot, "Providence and New Bedford are minimum VFR, Providence overcast one thousand two hundred and New Bedford overcast one thousand one hundred." The pilot requested vectors to PVD.

At 1740:17, the controller instructed the pilot to climb and maintain 3,000 feet and fly a heading of 250 degrees. The controller stated he felt 3,000 feet would be better for the pilot instead of remaining at 2,000 feet because he had difficulties earlier at UUU in maintaining the correct altitude. The controller provided the pilot the weather sequence for PVD, and advised the pilot to expect the ILS Runway 5R approach. The pilot acknowledged.

From 1743:17 to 1747:11, the controller provided a series of vectors to the pilot en route to PVD. Radar data indicated the airplane's altitude and groundspeed remained constant during this time at 3,000 feet and 182 knots.

At 1747:37, the controller instructed the pilot to descend and maintain 2,000 feet and issued a wind shear alert of minus 10 knots at 500 feet on final to PVD. The pilot acknowledged.

At 1748:29, the pilot was cleared for the "ILS runway five right approach" at PVD, and instructed to report when "established." The pilot acknowledged the clearance.

At 1749:57, the pilot reported, "triple niner has the localizer." The controller asked the pilot to verify that he was established on the localizer, and the pilot responded, "I sure hope so." At this point the controller observed the airplane's altitude descend below the published minimum glide slope intercept altitude for the approach, and at 1750:32, advised the pilot, "november nine nine november you're still outside the outer marker, climb, maintain two thousand please unless you show yourself established on the localizer." The pilot acknowledged and then replied, "son of a bitch I got problems." Radar data indicated the airplane's altitude was 1,600 feet. The controller asked the nature of the problem and the pilot replied, "I'm all over the place, I have no idea I (unintelligible) I think I'm iced up."

At 1751:03, the controller advised, "november nine nine november check your altitude immediately climb and maintain three thousand altitude indicates one thousand two hundred." The pilot's response was unintelligible. Radar data indicated the airplane was at 1,200 feet. The controller stated he observed the radar target make a tight 180-degree turn.

Radar data indicated the airplane's radar track began following a left descending turn from 1,900 feet, about 1 minute before radar contact was lost.

At 1751:33, the controller advised, "november nine nine november climb and maintain three thousand altitude indicates one thousand sir." The pilot responded, "hey, I'm trying like hell." Radar data indicated the airplane was at 1,000 feet.

The last radar target with an associated altitude was recorded at 1751:42, and indicated an altitude of 800 feet.

At 1751:48, the controller advised the pilot that Quonset Airport (OQU) was off his right side and about 3 miles away. The pilot replied, "gimme something would ya." The controller instructed the pilot to "fly eastbound" and that OQU would be at his "12 o'clock position and 4 miles."

There were no further communications received from the pilot, and radar contact was lost about 1752.

A witness near the accident site stated he observed the airplane come out of the clouds, "wobbling" from side to side. The airplane then made a "hard" left turn and struck the ground. He stated the engine was "loud" and seemed to be at "full throttle."

Another witness stated the airplane just cleared the tree tops and was descending at a 45-degree angle when he lost sight of the airplane. He described the engine noise as "very loud."

The accident occurred during the hours of night, approximately 41 degrees, 34 minutes north latitude, and 71 degrees, 31 minutes west longitude.

Personnel information

The pilot held a private pilot certificate with ratings for single and multiengine land airplanes, and rotorcraft. He also held an instrument airplane rating. The pilot's logbooks were not recovered. He reported 860 hours of total flight experience, with 47 hours accumulated in the previous 5 months, on his most recent application for a FAA second class medical

Aircraft

Registration
N999N
Reported as
Rockwell 500S
Category
Airplane
Serial number
3277
Airframe hours
2,145
Engines
Lycoming IO-540-E1B5, 290 horsepower, reciprocatingLycoming IO-540-E1B5, 290 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Registered owner
Lewis N. Madeira
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 18, 2001 · 106 hours before
Departed
ILM · Wilmington, NC
Destination
UUU · Newport, RI
Flight plan
IFR
Airport
PVD · Theodore Francis Green State, runway 5R, 7,166 × 150 ft, asphalt

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
58
Injuries
Fatal
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
900 total · 200 in this make and model

Weather

Conditions
Instrument (IMC) · Night
Wind
350° at 10 knots
Visibility
6 statute miles
Lowest ceiling
1,000 ft overcast
Temperature
37 °F, dew point 36 °F
Altimeter
29.69 inHg
Observed at
PVD, 11 nm away

Docket · 55

The files NTSB released with the investigation on November 7, 2002, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Meteorology 5 - Factual Report of Group ChairmanItem 1 · .PDF · 613 KBMeteorology 5 - Attachment 1Item 2 · .PDF · 524 KBMeteorology 5 - Attachment 2Item 3 · .PDF · 263 KBMeteorology-Attachment 3Item 4 · .PDF · 79 KBMeteorology 5 - Attachment 5Item 5 · .PDF · 106 KBMeteorology 5 - Attachment 6Item 6 · .PDF · 85 KBMeteorology 5 - Attachment 7Item 7 · .PDF · 250 KBMeteorology 5 - Attachment 4Item 8 · .PDF · 14 KBATC 3 - Factual Report of Group ChairmanItem 9 · .PDF · 101 KBATC 3 - Attachment 1Item 10 · .PDF · 6 KBATC 3 - Attachment 2aItem 11 · .PDF · 401 KBATC 3 - Attachment 2bItem 12 · .PDF · 620 KBATC 3 - Attachment 2cItem 13 · .PDF · 447 KBATC 3 - Attachment 2dItem 14 · .PDF · 155 KBATC 3 - Attachment 3Item 15 · .PDF · 263 KBATC 3 - Attachment 4Item 16 · .PDF · 39 KBATC 3 - Attachment 5Item 17 · .PDF · 53 KBATC 3 - Attachment 6Item 18 · .PDF · 65 KBATC Attachment 7Item 19 · .PDF · 78 KBATC 3 - Attachment 8Item 20 · .PDF · 902 KBATC 3 - Attachment 9Item 21 · .TXTATC 3 - Attachment 10Item 22 · .PDF · 108 KBATC 3 - Attachment 11aItem 23 · .PDF · 714 KBATC 3 - Attachment 11bItem 24 · .PDF · 1.4 MBATC 3 - Attachment 12Item 25 · .PDF · 412 KBATC 3 - Attachment 13Item 26 · .PDF · 167 KBATC 3 - Attachment 14Item 27 · .PDF · 204 KBATC 3 - Attachment 15Item 28 · .PDF · 2.7 MBATC 3 - Attachment 16Item 29 · .PDF · 55 KBATC 3 - Attachment 17Item 30 · .PDF · 456 KBATC 3 - Attachment 18Item 31 · .PDF · 30 KBATC 3 - Attachment 19aItem 32 · .PDF · 24 KBATC 3 - Attachment 19bItem 33 · .PDF · 25 KBATC 3 - Attachment 19cItem 34 · .PDF · 11 KBATC 3 - Attachment 19dItem 35 · .PDF · 27 KBATC 3 - Attachment 19eItem 36 · .PDF · 11 KBATC 3 - Attachment 19fItem 37 · .PDF · 11 KBATC 3 - Attachment 19gItem 38 · .PDF · 13 KBPhotograph # 2: View of Aircraft from rearItem 39 · .PDF · 82 KBPhotograph # 1: View of Aircraft as it came to rest.Item 40 · .PDF · 105 KBPhotograph # 3: Right EngineItem 41 · .PDF · 82 KBPhotograph # 4: Left EngineItem 42 · .PDF · 81 KBPhotograph # 5: View of the front left portion of the airplaneItem 43 · .PDF · 114 KBWitness StatementsItem 44 · .PDF · 567 KBRadar PlotsItem 45 · .PDF · 1.1 MBGarmin GNS 430 Examination ReportItem 46 · .PDF · 43 KBIcing System Component Examination ReportItem 47 · .PDF · 150 KBDirectional Gyro Examination ReportItem 48 · .PDF · 122 KBMaintenance Records (excerpts)Item 49 · .PDF · 580 KBRefueling ReceiptItem 50 · .PDF · 69 KBRhode Island State Police Site DiagramItem 51 · .PDF · 65 KBU.S. Naval Observatory Astronomical DataItem 52 · .PDF · 45 KBFAA Toxicological ReportItem 53 · .PDF · 68 KBStatement of Party Representatives to NTSB InvestigationItem 54 · .PDF · 82 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 55 · .PDF · 103 KB

FAA reports on this event · 1

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