Andrew Demos
Andrew W. Demos of Waterford, Michigan, passed away suddenly January 10, 2014 at 32 years of age.
Andy experienced an extraordinary life, having lived and flown as a pilot in Alaska, Australia, Wisconsin, Illinois, and Michigan. He earned a bachelor's degree from Northern Illinois University in Acoustical Physics and New Media Technologies and a masters degree from Embry-Riddle Aeronautical University in Aviation and Aerospace Operations. He was an Eagle Scout and member of the Phi Mu Alpha fraternity.
Federal Aviation Administration / Flight Standards District Office; Belleville, Michigan
Cessna Aircraft; Wichita, Kansas
Continental Motors; Mobile, Alabama
McCauley Propeller Systems; Wichita, Kansas
Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
http://registry.faa.gov/N3829G
Accident Number: CEN14FA110
Date & Time: 01/10/2014, 1948 EST
Registration: N3829G
Aircraft: CESSNA 310R
Aircraft Damage: Destroyed
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Positioning
Analysis
The airplane, operated by an on-demand cargo carrier and flown by a newly hired pilot, was on a positioning flight when it impacted trees and terrain about 1,500 ft short of the runway during a straight-in instrument landing system (ILS) approach. Night instrument flight rules (IFR) conditions prevailed with recorded weather observations that were below the minimum visibility specified for the approach. Radar data showed that while on the final segment of the ILS approach, the airplane's approach was unstabilized in speed and position along the glidepath. The shallow angle of the wreckage path and its length were consistent with controlled flight into terrain. Examination of the wreckage revealed no anomalies that would have precluded normal aircraft operation.
The pilot had undergone company training provided by the company's president, who was also the director of operations, and the chief pilot; these two individuals were the only company instructors approved by the Federal Aviation Administration (FAA) to provide Part 135 training in accordance with the company training manual. However, the majority of the pilot's flight training in the accident airplane make and model was during a flight with a company pilot who was not approved by the FAA to provide Part 135 instruction. Further, although company records stated that the pilot met the training requirements for ground and flight training in accordance with the company training manual, the minimum flight times in the accident airplane make and model were not met and the method of ground instruction was not followed in accordance with the company training manual.
A review of the weather for the pilot's previous company flights showed that he had not flown in actual conditions that were at approach minimums at night, similar to those at the time of the accident. The chief pilot stated that higher approach weather minimum limitations were placed upon the pilot and that company dispatchers watched most new pilots' minimums until they got more experience with the company. However, although the dispatch manager indicated he was aware of weather limitations for the pilot, he stated that the dispatchers had no means of routinely communicating with the pilots inflight, and he could not recall when there had been any other pilots with weather limitations. Furthermore, there was no FAA-approved program or policy within the company operations specifications or other manual for higher approach minimum limitations based upon experience for company pilots of piston engine powered airplanes such as the accident airplane.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's controlled flight into terrain during an instrument landing system approach at night in instrument flight rules conditions. Contributing to the accident were the operator's inadequate training of the pilot, the operator's failure to provide a level of oversight commensurate to the pilot's experience, and the pilot's lack of operational experience in actual night instrument conditions in the make and model of the airplane.
Findings
Aircraft
Descent/approach/glide path - Not attained/maintained (Cause)
Altitude - Not attained/maintained (Cause)
Personnel issues
Use of equip/info - Pilot (Cause)
Total experience w/ equipment - Pilot (Factor)
Environmental issues
Low visibility - Effect on personnel (Cause)
Organizational issues
Training - Operator (Factor)
Oversight of personnel - Operator (Factor)
Factual Information
History of Flight
Approach-IFR final approach
Altitude deviation
Controlled flight into terr/obj (CFIT) (Defining event)
On January 10, 2014, about 1948 eastern standard time, a Cessna 310R, N3829G, impacted trees and terrain about 1,500 feet west of the approach end of runway 9R (6,521 feet by 150 feet, asphalt) at Oakland County International Airport (PTK), Pontiac, Michigan, during a straight-in instrument landing system (ILS) approach to runway 9R. Night instrument meteorological conditions (IMC) prevailed at the time of the accident. The commercial pilot sustained fatal injuries. The airplane was destroyed by impact forces and a post impact fire. The airplane was registered to and operated by Royal Air Freight, Inc. as flight RAX907 under the provisions of 14 Code of Federal Regulations Part 91. The positioning flight was operating on an instrument rules flight plan and departed from Fulton County Airport-Brown Field (FTY), Atlanta, Georgia, about 1701, and was destined to PTK.
During an interview with the National Transportation Safety Board (NTSB) Investigator-In-Charge (IIC), the pilot's wife stated that on the afternoon of January 6, 2014, her husband received a phone call from Royal Air Freight, Inc. to fly a flight to either Fargo, North Dakota or Atlanta, Georgia. After his departure for the trip on January 6, 2014, she had not seen him, and they communicated solely by text messages since that time. He was to return via a flight to Ohio. She said that a January 8, 2014 text message from her husband said that Royal Air Freight, Inc. dispatch told him to get a hotel room. A January 9, 2014 text message stated that he was to fly from Ohio to Minneapolis and that he would arrive in Pontiac, Michigan at 1800. At 1945, her husband sent a text message that described his frustration with Royal Air Freight, Inc.'s scheduling and that "there was a major lack of communication" from Royal Air Freight, Inc. About an hour later, he sent a text message saying that the airplane he was to fly, N3829G, was broken.
The pilot's wife said that they had planned a trip to Florida, which they were to depart for on January 11, 2014. They had planned to pick up a car rental in Detroit, Michigan on January 11, 2014 at 0900 and were to drive to Florida. They had purchased airline tickets for their return trip from Florida. She stated that she requested time off from her employment about two months before the trip.
A maintenance facility in Atlanta, Georgia, issued a maintenance work order dated January 10, 2014 for N3829G, which stated the right engine starter was inoperative, and the left tire pressure was low. The right engine starter was removed and replaced with an overhauled starter, and the subsequent operational check of the starter was "good". The left tire was filled with nitrogen.
On January 10, 2014, a filed instrument flight plan was activated for RAX907 for a flight from FTY to PTK with a proposed departure time of 1650 and a cruise altitude of 7,000 feet mean sea level (msl). The filed alternate airport for the flight was Bishop International Airport (FNT), Flint, Michigan, which was about 22.9 nautical miles (nm) northwest of PTK. The estimated time en route was 2 hours 28 minutes. On January 12, 2014, the NTSB IIC and the Federal Aviation Administration (FAA) Coordinator met with the Royal Air Freight, Inc. chief pilot and the director of operations. During that meeting, the chief pilot stated that they did not know how much fuel was on board when N3829G departed for PTK, and they did not know the alternate airport for the flight. The chief pilot said that "the pilots file their own flight plans."
According to the Royal Air Freight, Inc. General Operations Specifications and Operations Specifications, Royal Air Freight, Inc. retains all responsibility for the operational control of aircraft operations, and thus the safety of each flight conducted under its certificate and operations specification, including the actions or inactions of all its direct employees and agents. Flight locating procedures required that the pilot-in-command of a flight give the dispatcher or a responsible person within Royal Air Freight, Inc. all information in a visual flight rules flight plan. (FAA Form 7233-1, "Flight Plan," contains an entry block for fuel on board and for alternate airport(s)).
On January 10, 2014, at 1658, RAX907 departed FTY and was provided initial air traffic control (ATC) radar service by Atlanta Terminal Radar Approach Control. RAX907 was provided ATC services by numerous TRACONs and air route traffic control centers (ARTCC) en route before being transferred to Detroit TRACON at 1922. According to FAA transcripts, the flight was uneventful.
Prior to RAX907's approach to PTK, another Royal Air Freight, Inc. flight, which was a Learjet 35A, RAX131, had flown the ILS runway 9R approach without incident. A written statement from the captain of RAX131, stated in part:
"Received PTK ATIS as [vertical visibility] 200 [feet], ½ mile visibility, wind [from] 160 [degrees at] 10 [knots]. After check-on with Detroit approach we heard an aircraft being vectored for the approach at PTK, so we listened to the PTK tower [frequency] on [the] secondary radio. He was given [runway visual range (RVR)] of 2,200 [feet] for 9R by the tower. We were vectored for the approach and when we checked on was given [RVR] of 2,000 [feet] for [runway] 9R and wind from 180 [degrees at] 10 [knots].
During the initial part of the approach the winds were strong out of the south. It was smooth, but took a 20 degree angle to maintain the localizer. At approximately 1,800 feet we encountered light to moderate chop and started losing the crosswind. No noticeable changes in airspeed but took out almost all of the crab angle to maintain the localizer.
At approximately 1,250 feet, [the second-in-command] called approach lights in sight. I responded with continue, and almost immediately Alex called green lights, runway in sight 12 o'clock. We continued and landed normally. Crosswind correction was minimal, no major airspeed/power changes noticed.
As we were exiting the runway at the end, left on "U", we heard RAX907 call the tower. Do not remember if the tower issued any weather, did hear them tell RAX907 that he was following a Challenger on a 2 mile final."
At 1922, RAX907 checked in with Detroit TRACON while descending out of 4,900 feet for 4,000 feet. RAX907 was provided radar vectors for the ILS runway 9R approach. After being given a descent to 3,000 feet and a final radar vector to a heading of 060 degrees, the Detroit TRACON controller cleared RAX907 for the ILS runway 9R approach at 1940, and two minutes later directed the pilot to contact PTK tower.
At 1942, RAX907 checked in with the PTK air traffic control tower and was issued a landing clearance to runway 9R following a Challenger on a 2-mile final. RAX907 was issued an RVR of 2,000 feet for runway 9R. RAX907 acknowledged the landing clearance and advised they were looking for the traffic. The controller issued the surface wind. There were no further communications between RAX907 and ATC.
The captain of the Challenger stated in part:
"Weather was reported 2,000 [feet] RVR and vertical visibility 200 [feet]. There was no icing, turbulence or wind shear during the approach only light rain. Intercepting the localizer we had a 42 knot wind out of the south that required at least a 20 degree crab angle. Proceeding down the glide slope the winds diminished gradually and our crab angle was approximately 5 degrees at 300 feet. I called approach lights (MALSR) in sight at 100 feet above minimums and observed them at the 1130 position relative to our nose. At minimums I called runway in sight and we landed. The approach was flown with the autopilot on until minimums. I did not know of the accident until ground control announced the airport was closed while we were exiting the taxiway…"
Pilot Information
Certificate: Commercial
Age: 32
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 10/01/2013
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: 1908 hours (Total, all aircraft), 41 hours (Total, this make and model)
The pilot, age 32, held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. Prior to November 26, 2013, he accumulated a total flight time of approximately 1,907.8 hours, of which 422.3 hours were in multiengine airplanes, 74.7 hours were in actual meteorological conditions, and 109.4 hours were at night.
He was employed by Royal Air Freight, Inc., as a Cessna 310 pilot after passing his Part 135 airman checkride on December 19, 2014. After the checkride, all of the flights he had flown were in Royal Air Freight, Inc. Cessna 310R airplanes, over four trips/days, which had 11 flights totaling about 40.5 hours.
The pilot's logbook showed that during his pilot training for a pilot-in-command position in Cessna 310 airplanes at Royal Air Freight, Inc. he accumulated 7.2 hours of flight time in night conditions, of which 5.4 hours were accumulated in a Cessna 310R during a December 10, 2014 flight that was flown by a Royal Air Freight, Inc. company pilot who was not a company instructor. The remaining 1.8 hours of night flight time was in a Falcon 20 airplane while in the right seat of the airplane. The amount of flight time in actual IMC during his pilot training (0.2 hours were during the checkride) was 6.0 hours, of which 4.3 hours were in Cessna 310R airplanes. Of the 4.3 hours, 3.4 hours were accumulated during the December 10, 2013 trip flown by the company pilot.
There was no record showing that the pilot had flown an instrument approach in a Cessna 310 airplane, in actual night IMC to precision approach weather minimums during his training, checkride, or subsequent flights.
The pilot did not have an FAA record of any previous accidents, incidents, or enforcement actions.
Certificate and Ratings of the Pilot
On March 15, 2005, the pilot was issued a private pilot certificate with a single-engine land rating after passing the examination for the certificate/rating on his first attempt. The total flight time that was reported at the time of examination was 59 hours. He passed the private pilot airplane airman knowledge test, private pilot, on his second attempt and received a score of 88.
On November 11, 2005, the pilot was issued an airplane single-engine instrument rating after passing the examination for the rating on his first attempt. The total flight time that was reported at the time of examination was 155 hours. He passed the instrument airplane rating airman knowledge test, private pilot, on his first attempt and received a score of 87.
On March 29, 2006, the pilot was issued a commercial pilot certificate with a single-engine land rating after passing the examination on his first attempt. The total flight time that was reported at the time of examination for the certificate/rating was 288 hours. He passed the commercial pilot airplane airman knowledge test on his first attempt and received a score of 88.
Pre-employment Interview of the Pilot
The pilot's wife stated that her husband sent resumes in order to apply for a pilot position in late October 2013 and/or early November 2013. One operator that received a resume was contacted by the NTSB IIC and that operator stated that the pilot was not offered employment because there were no positions available at the time of the pilot's application. A second operator that was contacted by the NTSB IIC stated they wanted the pilot to have more experience and therefore did not offer him employment after interviewing the pilot.
The pilot's wife stated that Royal Air Freight, Inc. called her husband in November 2013. She said that her husband's interview with Royal Air Freight, Inc. was a "working flying" interview, which was on November 25 or November 26, 2014. She said the interview started about 1100 or 1200. She said that she received a text from her husband at 1827 that he finished the interview. She believed that the interview was with the chief pilot. She said that her husband told her that the interview with Royal Air Freight, Inc. was "informal", "laid back," and there was "no dress code." She said that the second operator with whom he interviewed had a uniform requirement and that it was "more formal" and "corporate." She said that she believed that her husband met with the Royal Air Freight, Inc. director of operations during the interview at Royal Air Freight, Inc.
During a post-accident interview of the Royal Air Freight, Inc. director of operations with the NTSB IIC, the FAA Coordinator/Safety Inspector, and an FAA Safety Inspector, the director of operations stated they there were trying to fill the position occupied by the pilot because they have always been short of Cessna 310 pilots. When asked if the pilot was the only pilot that was interviewed for a Cessna 310 pilot position, the director of operations said that he did not recall and that the chief pilot was "kind of handing that." The director of operations stated that he believed he talked to the pilot when he was at Royal Air Freight, Inc. for the interview after the chief pilot had talked to him. The director of operations was asked by the NTSB IIC if he recalled what was discussed with the pilot when he met with him; the director of operations responded "not really." The director of operations stated that he knew the chief pilot flew with the pilot during the interview and that he (the director of operations) talked to the chief pilot about how the flight went when they returned, and the chief pilot "just mentioned [the pilot] did a really good job." The director of operations said that they normally conduct pilot interviews in which they fly with applicants on the same day to determine if the applicant can "fly or not." The director of operations said that the interview lasted "quite a while," and only he and the chief pilot talked to the pilot. The director of operations said the decision to hire the pilot was made on the day after his interview.
Training and Checking of the Pilot
According to the pilot's wife, the training that her husband received from Royal Air Freight, Inc. was "relaxed," because they would train him when they "felt like it" or he would "come along for a ride" She felt that the training was not standardized. It took longer for her husband to complete his [training] for his checkride. She said that he would get "critiqued" during his training at Royal Air Freight, Inc. and he was accepting of these critiques and was not defensive about them.
The director of operations and chief pilot were the only company personnel authorized by the FAA to provide Part 135 airman training and checks in accordance with the Royal Air Freight, Inc. "Aircraft Training Manual" that was approved by the FAA Detroit Flight Standards District Office. Training and checking of a pilot to fly a specific aircraft make and model was to be conducted in that make and model of aircraft. The approved general training areas and facilities for ground instruction were company buildings, ramps, hangers, maintenance areas and aircraft. Ground instruction curriculum segments were not to be conducted in flight. The Aircraft Training Manual stated that a "hood" was to be used for instrument flight maneuvers. The chief pilot stated during a post-accident interview that during the pilot's training, a hood was not used, but instead, the pilot's baseball cap was used as the view limiting device to simulate IMC.
During the January 12, 2014 meeting with the director of operations and the chief pilot, the chief pilot was asked by the NTSB IIC if they had training records for the accident pilot that would show the date, the flight time, the aircraft used, the instructor that provided instruction, and the description of training for each of the pilot's training flights. The chief pilot stated that they did not have such a record, were not required to keep records of individual training flights, and were only required to provide a certificate of training. The NTSB IIC then requested that such a record be provided.
The Royal Air Freight, Inc. "New Hire Training" record for the pilot stated that he completed the curriculum segments for Cessna 310/402 aircraft. This record's entries stated that he met the minimum times for "turbine/piston" aircraft cited in the FAA approved training manual (there were higher minimum times for pilot training for "jet" aircraft). The minimum flight times were specific to the make and model of aircraft and could not be substituted by use of another aircraft make and model. Entries from the pilot's New Hire Training record, which are the minimum times cited in the training manual, are cited in Figure 1 (All figures in this report are available in the public docket for this accident, which can be found at: http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=88665.)
Figure 1. Chart showing 7 training modules, the date of instruction and instructor.
The remarks section of FAA Form 8410-3 had the following entries: "route check", "lower than std. takeoff demo", "low mins. demo", "oral included 310/402". The Royal Air Freight, Inc. chief pilot was the check airman for the check.
Higher Approach Minimums for the Pilot
During the January 12, 2014 meeting with the NTSB IIC, the FAA Coordinator, and the director of operations present, the chief pilot stated that the Cessna 310 does not have high approach minimums like the jets.
During a March 12, 2014 post-accident interview of the chief pilot, the chief pilot stated that the pilot and "usually" new hires have higher than standard approach minimums. The chief pilot said that not all new hires have higher than standard approach minimums due to their experience, He said that the pilot "seemed proficient" and the approach minimums limit that were set by him (chief pilot) and dispatch were 400 feet and 1 statue mile (sm) visibility.
During the March 12, 2014 post-accident interview and subsequent the chief pilot's interview, the dispatcher stated that they were told that the pilot was limited to higher approach minimums of 400 feet and 1 sm visibility, and that they watch most new pilots' minimums until they get more experience with the company. The dispatcher was then asked if there were recent pilots with higher approach minimums, to which the dispatcher responded "not that I can remember." The dispatcher was asked if he remembered the last time higher approach minimums were placed upon a pilot and he said "no." The dispatcher was then asked if he had an estimate of when the last time a pilot had higher approach minimums to which he said "no." The dispatcher was asked if there were higher approach minimums placed upon pilots beyond the past year; he said "no, I don't think so."
The only Royal Air Freight, Inc. FAA approved/required pilot-in-command higher weather minimums were cited in the Royal Air Freight, Inc. Operation Specifications, which referenced Part 135.225(e). These limitations were applicable to only a pilot-in-command of turbojet airplanes and not reciprocating airplanes. The limitation would be removed once the pilot-in-command served at least 100 hours as pilot-in-command of that turbojet airplane.
Review of the Pilot's Logbook and Flight Daily Record Sheets
The pilot's logbook included entries for a period dated from November 26, 2013 to January 6, 2014; there were no logbook entries following January 6, 2014. All of the entries during this period were in Royal Air Freight, Inc. aircraft. There were no entries prior to the November 26, 2013 entry showing flight in Royal Air Freight, Inc. aircraft. The entries are cited in Figure 2.
Figure 2. Table showing entries in pilot's logbook, which includes 11 entries between November 26, 2013, and January 5, 2014.
Royal Air Freight, Inc. recorded flights conducted under Parts 91 and 135 on either "Piston Daily Record Sheets" or "Jet Daily Record Sheets". These sheets did not make use of a sequentially ordered numbering system that would identify each sheet by a unique number printed on the respective sheet. These sheets included entries for identifying the pilot and copilot for each flight and a remarks section. Flights in piston aircraft were authorized to be conducted by a single pilot whereas jet aircraft such as the Falcon 20 and Learjet 35A would have two flight crewmembers, a pilot and copilot.
A December 13, 2013, Jet Daily Record Sheet, showed two flights from PTK to Westchester County Airport (HPN), White Plains, New York and HPN to PTK in Learjet N731RA with the Royal Air Freight, Inc. director of operations as pilot and the pilot as copilot. Both flights were recorded as being conducted under Part 91, and the remarks section of the sheet stated: "FLT TRAINING."
During the March 12, 2014 post-accident interview of the director of operations, the director of operations was asked the purpose of a flight to HPN; the director of operations responded "to go to White Plains." After further questioning, the director of operations said that the purpose of the flight was to drop off the chief pilot and a company pilot to fly a Falcon 20 to PTK. The director of operations said that he would have performed the takeoff and landing for the flight to HPN, and the pilot did not perform any maneuvers during the flight; "it was a normal enroute flight." The director of operations said he did not remember how much of the flight was flown by the pilot and if the pilot had flown any approaches during the flight to HPN. He said the pilot was seated in the right pilot seat for the entire flight.
There was no record indicating the pilot met the requirements cited in Part 61.55 prior to the Learjet flight on December 13, 2013. Part 61.55 Second-in-command qualifications, states in part:
(a) A person may serve as a second-in-command of an aircraft type certificated for more than one required pilot flight crewmember or in operations requiring a second-in-command pilot flight crewmember only if that person holds:
(1) At least a private pilot certificate with the appropriate category and class rating; and
(2) An instrument rating or privilege that applies to the aircraft being flown if the flight is under IFR; and
(3) The appropriate pilot type rating for the aircraft unless the flight will be conducted as domestic flight operations within United States airspace.
(b) Except as provided in paragraph (e) of this section, no person may serve as a second-in-command of an aircraft type certificated for more than one required pilot flight crewmember or in operations requiring a second-in-command unless that person has within the previous 12 calendar months:
(1) Become familiar with the following information for the specific type aircraft for which second-in-command privileges are requested—
(i) Operational procedures applicable to the powerplant, equipment, and systems.
(ii) Performance specifications and limitations.
(iii) Normal, abnormal, and emergency operating procedures.
(iv) Flight manual.
(v) Placards and markings.
(2) Except as provided in paragraph (g) of this section, performed and logged pilot time in the type of aircraft or in a flight simulator that represents the type of aircraft for which second-in-command privileges are requested, which includes—
(i) Three takeoffs and three landings to a full stop as the sole manipulator of the flight controls;
(ii) Engine-out procedures and maneuvering with an engine out while executing the duties of pilot in command; and
(iii) Crew resource management training
A December 10, 2013, Piston Daily Record Sheet, showed four flights from PTK to CYHM, CYHM to YIP, YIP to MSN, and MSN to PTK with a Royal Air Freight, Inc. company pilot as pilot and the pilot as copilot. The company pilot was not a Part 135 instructor for Royal Air Freight, Inc. The total block and flight times listed on the Piston Daily Record Sheet were 6.6 hours and 5.7 hours, respectively. During a March 12, 2014 post-accident interview of the company pilot, the company pilot stated that when he was called for the December 10, 2013 trip, he was told by a Royal Air Freight, Inc. dispatcher that he had a "ride-along," which the company pilot said meant it was an "observation pilot pretty much." The company pilot stated that the pilot was seated in the right seat on Part 91 legs and was the flying pilot. The company pilot said the Royal Air Freight, Inc. chief pilot asked him (the company pilot) to "make sure" the pilot was "good" with normal takeoffs and landings. The company pilot stated it was "clear" for the flights, and the pilot did not fly any instrument approaches nor did they simulate IMC. The company pilot said he discussed with the pilot, company procedures, processing freight paperwork, flight in icing conditions in the lower 48 states, Cessna 310 fuel system, fuel consumption, and fuel management.
Aircraft and Owner/Operator Information
Aircraft Manufacturer: CESSNA
Registration: N3829G
Model/Series: 310R
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 924
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 08/23/2013, Continuous Airworthiness
Certified Max Gross Wt.: 5680 lbs
Time Since Last Inspection: 221 Hours
Engines: 2 Reciprocating
Airframe Total Time: 4427.9 Hours at time of accident
Engine Manufacturer: Continental Motors
ELT: Installed, not activated
Engine Model/Series: IO-520-MB
Registered Owner: Royal Air Freight, Inc
Rated Power:
Operator: Royal Air Freight, Inc
Operating Certificate(s) Held: Commuter Air Carrier (135)
Operator Does Business As:
Operator Designator Code: BUHR
The airplane was a 1977 Cessna 310R, serial number 310R0924, powered by two Continental Motors, IO-520-MB, engines. The left engine serial number was 826016-R, and the right engine serial number was 829137-R. The left engine was equipped with a McCauley 3AF32C87-NR, serial number 970419, propeller. The right engine was equipped with a McCauley 3AF32C504-C, serial number 786981, propeller.
The airplane was maintained by Royal Air Freight, Inc. and was to follow a manufacturer's inspection program. The airplane received its last inspection 200-hour and 50-hour airframe inspections on August 23, 2013 at an aircraft total time (ACTT) of 4,224.1 hours and December 23, 2013 at an ACTT of 4,427.9 hours.
Royal Air Freight, Inc. reported that the ACTT was 4,444.9 hours at the time of the accident. The tachometer/Hobbs meter(s) indication at the time of the accident was not obtained due to their damage by impact forces/post-crash fire.
Wing Flaps System
The wing flap system was electrically driven and actuated with flap settings of: 0, 15, and 35 degrees.
The Cessna 310R flight manual listed the airspeed Indicator and limitation values as:
White Arc: 72 to 139 knots indicated airspeed (KIAS); Operating speed range with 35 degrees wing flaps. Lower limit is maximum weight stalling speed in landing configuration. Upper limit is maximum speed permissible with wing flaps extended 35 degrees.
Green Arc: 79 to 181 KIAS; Normal operating range. Lower limit is maximum weight stalling speed with flaps and landing gear retracted. Upper limit is maximum structural cruising speed.
Blue Radial: 106 KIAS; One engine inoperative best rate-of-climb speed at sea level standard day conditions and 5,500 pounds weight.
Yellow Arc 181 to 223 KIAS; Caution range. Operations must be conduction with caution and only in smooth air. The maximum structural cruising speed (Vno) is 181 KIAS.
Meteorological Information and Flight Plan
Conditions at Accident Site: Instrument Conditions
Condition of Light: Night
Observation Facility, Elevation: PTK, 981 ft msl
Observation Time: 1929 EST
Distance from Accident Site:
Direction from Accident Site:
Lowest Cloud Condition:
Temperature/Dew Point: 2°C / 1°C
Lowest Ceiling: Indefinite (V V) / 200 ft agl
Visibility: 0.25 Miles
Wind Speed/Gusts, Direction: 10 knots, 150°
Visibility (RVR): 2000 ft
Altimeter Setting: 29.86 inches Hg
Visibility (RVV):
Precipitation and Obscuration: Fog
Departure Point: Atlanta, GA (FTY)
Type of Flight Plan Filed: IFR
Destination: Waterford, MI (PTK)
Type of Clearance: IFR
Departure Time: 1701 EST
Type of Airspace:
Destination Airport Weather for PTK
Terminal Aerodrome Forecasts (TAFs)
A TAF issued at 1534 for PTK forecasted for the accident time: a wind from 160 degrees at 14 knots, visibility of 2 sm, light rain, mist, overcast cloud base at 400 feet above ground level (agl), wind shear with wind at 2,000 feet agl from 190 degrees at 45 knots.
A TAF issued at 1822 for PTK forecasted for the accident time: a wind from 150 degrees at 10 knots, visibility of 2 sm, mist, overcast cloud base at 400 feet agl, wind shear with wind at 2,000 feet agl from 190 degrees at 45 knots; temporary conditions between 1900 and 2300: visibility ¾ sm, light rain showers, mist, ceiling broken at 200 feet agl.
Surface Observations
PTK was located within one mile to the east of the accident site at an elevation of 981 feet msl. The following reports were issued from PTK during the time period surrounding the accident time:
At 1929, PTK reported a wind from 150 degrees at 10 knots, visibility of 1/4 sm, RVR on runway 9R variable between 2,000 and 2,800 feet, fog, vertical visibility 200 feet, temperature of 2 degrees Celsius (C) and dew point temperature of 1 degree C, altimeter setting 29.86 inches of mercury (Hg).
One-minute data from the Automated Surface Observing System (ASOS) at PTK was retrieved for the times surrounding the accident. Average wind direction (Avg-W Dir) in degrees, average wind speed (Avg-W Spd) in knots, wind gust direction (W-Gust Dir) in degrees, wind gust magnitude (W-Gust Mag) in knots and RVR for runway 9 are cited in Figure 3.
Figure 3. Table of surface observations for times surrounding the accident.
At 1953, PTK reported a wind from 140 degree at 9 knots, visibility of 1/4 sm, RVR on runway 9R variable between 2,000 and 2,600 feet, fog, vertical visibility 200 feet, temperature of 2 degrees C and dew point temperature of 2 degrees C, altimeter setting 29.85 inches of Hg.
Alternate Airport Weather
Surface Observations for FNT
At 1853, FNT reported a wind from 150 degrees at 12 knots, visibility of 5 sm, mist, broken cloud base at 800 feet agl, overcast cloud base at 2,000 feet agl, temperature of 3 degrees C and dew point temperature of 1 degree C, altimeter setting 29.85 inches of Hg.
At 1953, FNT reported a wind from 170 degrees at 13 knots, visibility of 6 sm, light rain, mist, scattered cloud base at 800 feet agl, broken cloud base at 2,600 feet agl, overcast cloud base at 3,200 feet agl, temperature of 4 degrees C and dew point temperature of 2 degrees C, altimeter setting 29.82 inches of Hg, remarks: rain began 48 minutes past the hour.
At 2009, FNT reported a wind from 160 degrees at 14 knots, visibility of 6 sm, light rain, mist, scattered cloud base at 2,900 feet agl, overcast cloud base of 6,500 feet, temperature of 4 degrees C and dew point temperature of 2 degrees, altimeter setting 29.81 inches of Hg.
At 2027, FNT reported wind from 170 degrees at 15 knots, visibility of 6 sm, light rain, mist, scattered cloud base at 700 feet agl, broken cloud base at 5,500 feet agl, overcast cloud base at 7,000 feet, temperature of 4 degrees C and dew point temperature of 2 degrees C, altimeter setting 29.79 inches of Hg.
At 2038, FNT reported wind from 170 degrees at 12 knots and gusts of 21 knots, visibility of 5 sm, light rain, mist, overcast cloud base at 5,500 feet agl, temperature 4 degrees C and dew point temperature of 2 degrees C, altimeter setting 29.79 inches of Hg.
At 2053, FNT reported wind from 180 degrees at 13 knots, visibility of 5 sm, light rain, mist, overcast cloud base at 700 feet agl, temperature of 4 degrees C and dew point temperature of 3 degrees C, altimeter setting 29.79 inches of Hg.
Airport Information
Airport: Oakland County International A (PTK)
Runway Surface Type: Asphalt
Airport Elevation: 981 ft
Runway Surface Condition:
Runway Used: 9R
IFR Approach: ILS
Runway Length/Width: 6521 ft / 150 ft
VFR Approach/Landing:
Destination Airport
The PTK ILS Runway 9R Instrument Approach is shown in Figure 4.
Figure 4: The figure shows the instrument approach chart profile for ILS runway 9R. The minimum descent altitude (MDA) outside the final approach fix (FAF)/outer marker (OM), which is located 5 miles the runway 9R, is 2,700 feet msl.
Flight plan information indicated that FNT, located about 22.9 nm northwest of PTK, was a filed destination alternate for the accident flight. FNT was served by ILS 9 and 27 approaches in addition to RNAV/GPS and VOR approaches to all runways at FNT.
The ILS 9 and 27 straight-in approach minimums were 200 feet agl and ½ sm mile visibility for all aircraft categories, A through D.
The ILS 9 circling approach minimums were 600 feet agl and 1 sm visibility for categories A and B, 600 feet and 1 ½ sm visibility for category C, and 600 feet agl and 2 sm visibilities for category D.
The ILS 27 circling approach minimums were 500 feet agl and 1 sm visibility for category A, 600 feet agl and 1 sm visibility for category B, 600 feet agl and 1 ½ sm visibility for category C, and 600 feet agl and 2 sm visibility for category D.
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 42.664444, -83.442778
The main wreckage, which consisted of the airplane fuselage, was about 1,500 feet from the approach end to runway 9R and located in a wooded area. The wreckage path extended through trees and was oriented on a magnetic heading of about 85 degrees and was about 225 feet in length. The western edge of the wreckage path exhibited a tree strike about 10 feet below the top of a tree about 60 feet in height; the main wreckage was located about 148 feet from this tree strike. There were additional tree strikes and trees that were fallen over in the direction of the main wreckage.
The main wreckage exhibited post-crash fire damage that destroyed the airplane along with impact forces. Both wing fuel tanks were separated from the airplane and located along the wreckage path. The empennage was separated from the fuselage and located near the fuselage along with both engines and propellers. Both engines were separated from the airplane and east/forward of the main wreckage. The left propeller was separated at the hub from the left engine and consistent with torsional overstress. The right propeller was attached to the right engine. The landing gear was in the extended position. The wing flap extension was not determined due to impact damage.
Examination of the flight controls confirmed flight control continuity.
Medical Information
The accident pilot held a first class medical dated November 1, 2013, with no limitations.
The FAA Final Forensic Toxicology Fatal Accident Report for the pilot stated: no carbon monoxide detected in blood, cyanide not performed, no ethanol detected in vitreous, and no drugs listed detected in urine.
An autopsy of the pilot was conducted by the Office of the Medical Examiner, Oakland County, Michigan, on January 11, 2014. The autopsy report stated the cause of death as multiple injuries, and the manner of death as: accident.
Tests And Research
Engine Examination
Both airplane engines underwent a disassembly examination at Continental Motors, Mobile, Alabama, under the supervision of a FAA Inspector who reported that there were no mechanical anomalies that would have precluded normal engine operation.
Propeller Examination
Both propellers underwent a disassembly examination at McCauley Propeller Systems, Wichita, Kansas under the supervision of a FAA inspector. The examination revealed there were no indications of a propeller malfunction or failure. Neither propeller exhibited witness marks consistent with a blade angle corresponding to a feathered position. Both propeller blade angles were approximately 14-17 degrees, relative to reference, and consistent with a low pitch/latch position.
Stabilized Approaches
There were several references that discussed the concept of stabilized approaches. These references included but were not limited to: FAA Instrument Procedures Handbook (FAA H-8083 16), FAA Advisory Circular (AC) 61-134 - Controlled Flight into Terrain Awareness, Flight Safety Foundation's (FSF's) Approach and Landing Accident Reduction Toolkit (ALAR) Briefing Note 7.1 – Stabilized Approach, AvWeb's Leading Edge #23: Stabilized Approaches in Light Airplanes.
The FAA's Instrument Flying Handbook, Chapter 4, Approaches, Descents, Stabilized Approach, states in part:
"In IMC, you must continuously evaluate instrument information throughout an approach to properly maneuver the aircraft or monitor autopilot performance and to decide on the proper course of action at the decision point [decision altitude (DA), decision height (DH), missed approach point (MAP)]. Significant speed and configuration changes during an approach can seriously degrade situational awareness and complicate the decision of the proper action…
You must begin to form a decision concerning the probable success of an approach before reaching the decision point. Your decision-making process requires you to be able to determine displacements from the course or glidepath centerline, to mentally project the aircraft's three-dimensional flight path by referring to flight instruments, and then apply control inputs as necessary to achieve and maintain the desired approach path. This process is simplified by maintaining a constant approach speed, descent rate, vertical flight path, and configuration during the final stages of an approach. This is referred to as the stabilized approach concept to take at the decision point."
During the March 12, 2014 post-accident interview of the Royal Air Freight, Inc. chief pilot, the chief pilot was asked if he covered and provided the pilot with instruction on stabilized approaches and illusions to flight, to which the chief pilot responded yes. The chief pilot was then asked what the stabilized approach criteria were for a Cessna 310. The chief pilot said that a stabilized approach is one in which the airplane is configured with flaps and landing gear with a target power setting, which is usually set three miles outside of the final approach fix. The airplane speed should be "within a certain range." The chief pilot was then asked what are the limits that would define an unstabilized approach in a Cessna 310. The chief pilot could not provide quantitative deviations that would define an unstabilized approach after being asked several times by the NTSB IIC and the FAA Coordinator.
During the March 12, 2014 post-accident interview of the company pilot that had flown with the pilot on December 10, 2013, the company pilot was asked when an approach would become unstabilized in a Cessna 310. The pilot stated that airplane speed would deviate plus or minus 10 knots from target airspeed, one dot deflection in localizer and glideslope, if the airplane descent rate increased for no apparent reason, if airplane groundspeed increased or decreased dramatically for some reason, or if there was a single-engine power loss.
Transition to a Visual Approach
The FAA's Instrument Flying Handbook, Chapter 4, Transition to a Visual Approach, states in part:
"The transition from instrument flight to visual flight during an instrument approach can be very challenging, especially during low visibility operations. Aircrews should use caution when transitioning to a visual approach at times of shallow fog. Adequate visibility may not exist to allow flaring of the aircraft. Aircrews must always be prepared to execute a missed approach/go-around. Additionally, single-pilot operations make the transition even more challenging. Approaches with vertical guidance add to the safety of the transition to visual because the approach is already stabilized upon visually acquiring the required references for the runway. 100 to 200 feet prior to reaching the DA, DH, or MDA, most of the PM's attention should be outside of the aircraft in order to visually acquire at least one visual reference for the runway, as required by the regulations. The [pilot flying (PF)] should stay focused on the instruments until the PM calls out any visual aids that can be seen, or states "runway in sight." The PF should then begin the transition to visual flight. It is common practice for the [pilot monitoring (PM)] to call out the V/S during the transition to confirm to the PF that the instruments are being monitored, thus allowing more of the PF's attention to be focused on the visual portion of the approach and landing. Any deviations from the stabilized approach criteria should also be announced by the PM.
Single-pilot operations can be much more challenging because the pilot must continue to fly by the instruments while attempting to acquire a visual reference for the runway. While it is important for both pilots of a two-pilot aircraft to divide their attention between the instruments and visual references, it is even more critical for the single- pilot operation. …"
The company pilot, who had flown with the pilot on December 10, 2013, stated that he had flown aircraft under Part 135 and Part 121 for several decades and held four type ratings. He accumulated about 11,000 hours of total flight time, of which 3,000 hours were in Cessna 310 airplanes. He stated that he always flies the airplane following ILS guidance to the runway surface in order to maintain his proficiency because as the airplane gets closer to ground the ILS "gets more sensitive." He said that he follows ILS guidance to the runway surface because he has encountered fog/cloud near the ground. He said that when he is transitioning to a runway visual reference, he references the airplane's instrument indications until airplane flare to ensure that the airplane is not low or too high. He said that he has experienced going below an instrument glideslope "by accident."
Radar Performance Study
The Royal Air Freight, Inc. "Aircraft Training Manual" contained a "Typical ILS Approach" profile for each of the airplanes operated. The airspeeds associated with the segments of the approach for the Cessna 310/402 were: 160 knots during vectors to approach approximately 10-15 miles from the final approach fix, 150 knots during the base turn, 135 knots during the last vector or procedure turn inbound, and 120 knots from the final approach fix inbound.
A radar performance study was performed by a NTSB Airplane Performance Specialist. The performance study describes the accident airplane ground track, altitude, and speed. Estimates of airplane pitch, roll, and heading derived from radar data were also presented. The radar data used in the study was from the short-range Airport Surveillance Radar site at PTK. The PTK radar data were filtered for transponder beacon code 7436, that of N3829G.
Radar Data Plots
Figure 5: The radar ground track of N3829G shows the approach into PTK with time, msl height, speed in knots, and rate of climb in feet per minute.
Figure 6: The plot shows N3829G with a one- to two-dot deviation above the glideslope for the ILS 9R approach from about 0.5 nm inbound of the outer marker and about 2,700 feet msl prior to descending below the glideslope about 0.5 nm from runway 9R.
Figure 7: The plot shows N3829G shows a deviation of about one-dot right of the localizer course about 8 nm from runway 9R. The right deviation increased beyond one-dot about 2 nm miles before enter a left deviation of about one-dot.
Figure 8: The plot of N3829G shows a calibrated airspeed above 200 knots during a descent for the ILS 9R approach. Upon reaching an altitude of about 2,700 feet the airspeed was about 150 knots and slowed during the approach to about 125 knots.
Metallurgical Examination of Airspeed Indicator (AI) Face
An AI face, which was separated from its indicating needle, was recovered from the accident site and sent to the NTSB Materials Laboratory for examination of any witness marks on the face. The needle was not found and therefore was not sent along with the AI face. The NTSB metallurgist stated that the AI face received for examination was bent rearwards, as installed on the instrument, in the upper left quadrant. The face was still loosely attached to a portion of the internal mechanism by a single screw.
Microscopic examination did not reveal any surface marks that could be attributed to the needle impacting the face.
As the needle was not supplied it is unknown whether it would fluoresce under Ultra-Violet light. An Ultra-Violet examination was still performed to reveal no fluorescence to indicate that paint had been transferred from the needle to the face during the impact event.
Examination of the hole in the portion of the mechanism, through which the needle shaft normally protrudes, revealed three distinct impressions where the edge had been impacted and deformed outwards, probably by the needle shaft. The face was positioned on the portion of mechanism in what would be its approximate original location. One impression was found to be centered towards the 200 knot graduation and the other two were found to be centered between the 90 knot and 100 knot graduations. As the orientation of the needle on its shaft is unknown, these impressions do not indicate a needle position.
Apple iPhone 5 Internal Memory Download
An Apple iPhone 5 that belonged to the pilot and recovered from the wreckage was sent the NTSB Vehicle Recorder Laboratory to download its internal memory. Upon arrival, an exterior examination revealed that the unit had sustained prolonged thermal exposure. An interior inspection revealed that the circuit board containing the unit's non-volatile memory sustained excessive thermal damage, and the internal memory was not able to be recovered.
Company Aircraft Accident Rate
The NTSB's Summary of US Civil Aviation Accidents for Calendar Year 2012, included a graph of Part 135 on–demand (non-scheduled) total (fatal and nonfatal) and fatal airplane accidents from 2003-2012, as shown in Figure 9.
Figure 9: Shows the non-scheduled Part 135 accident rates from 2003-2012 as accidents per million flight hours.
Royal Air Freight, Inc. has had two previous fatal aviation accidents, which did not include N3829G, and one reported nonfatal aviation accident since 1990. These NTSB accident identification numbers for these accidents are listed below:
CEN10MA088: Gates Lear Jet Corp., N720RA, near Prospect Heights, Illinois, on January 5, 2010
CHI92LA263: Cessna 402B, N7882Q, near Almont, Michigan, on September 2, 1992
ATL90FA157: Beech E18S; N563W, near Greenwood, South Carolina, on August 9, 1990
According to the Royal Air Freight, Inc. director of operations, Royal Air Freight, Inc., would fly its airplanes about 15,000 - 20,000 hours per year.
During the post-accident interviews of current and former pilots employed by Royal Air Freight, Inc., none of those interviewed indicated that Royal Air Freight, Inc.'s previous accidents and/or incidents were taught to them during their training.
The Royal Air Freight, Inc. "Aircraft Training Manual," section 8, Subject Module No. 19 Previous Aircraft Accidents/Incident stated that crewmembers were to be provided with an awareness of the factors leading to and the common causes of aircraft accidents. The subjects included NTSB accident report reviews, human factors/considerations, NASA reporting system, previous company incidents/accidents, and causal factors and preventative measures. An oral/written examination was to be completed to 100 percent by the instructor to determine adequate knowledge of the factors leading to and the common causes of aircraft accidents.
Company Information and Records Review
The NTSB IIC made a request to the East Michigan (Detroit) Flight Standards District Office (FSDO) to obtain Royal Air Freight, Inc. records for examination. On January 16, 2014, an FAA Inspector arrived at the Royal Air Freight, Inc. office at PTK to obtain the requested records. Royal Air Freight, Inc. refused to provide those records and a letter from the East Michigan (Detroit) FSDO was sent to Royal Air Freight, Inc. stating:
"On January 28, 2014, the NTSB IIC contacted a former Royal Air pilot and requested that the pilot provide his logbook for review to the FAA Coordinator assigned to the accident investigation, which the pilot agreed to. On January 29, 2014, the FAA Coordinator contacted the pilot to set up a time to meet the pilot. The pilot stated to the FAA Coordinator that his logbook[s] were somewhere deep in a storage locker and remembering the recommendation of an old flight instructor, never give your logbooks to the FAA, and therefore not willing to give the FAA Coordinator access at the logbooks. The pilot also stated he did not want to become involved in the investigation."
Following requests to Royal Air Freight, Inc. by the NTSB IIC to conduct interviews of company employees and for pilots to provide their logbooks for copy/review, subpoenas were issued to the Royal Air Freight, Inc.'s director of operations, chief pilot, and current and former pilots to compel them for interview and to provide their logbook for copy/review. These interviews began on March 12, 2014.
Company Pilot Training
The Royal Air Freight, Inc. director of operations and the chief pilot were the only two instructors approved by to the FAA to provide initial training, recurrent training, and Part 135 airman checks to company pilots in accordance with the company's FAA approved training manual. The director of operations stated that they were the only two company instructors for the "last several years."
Section 8 of the training manual included, and was not limited to, 85 subject modules that were to be delivered via "lecture and discussion" to pilots, The training manual listed the training aids and courseware to be used. The subject modules included, and were not limited to: the operations manual, operating certificate, operations specifications, concepts of instrument procedures (stabilized approaches), flight techniques in adverse weather (visual illusions under IFR conditions, low visibility – depth perception, fly the glideslope to the runway, and forward versus downward visibility). There was no subject module for aeronautical decision making.
During a telephone conversation with the NTSB IIC, a former company pilot stated that he was employed as a second-in-command pilot on Falcon 20 airplanes by Royal Air Freight, Inc. He said he held a Falcon 20 type rating and received his training at Flightsafety International Inc. prior to his employment at Royal Air Freight, Inc. When he was asked how much flight training and ground training was provided by Royal Air Freight, Inc. in preparation for his Part 135 check ride, which was conducted by the chief pilot, the former pilot said "zero and zero." When asked to describe the ground training received at Royal Air Freight, Inc., the former company pilot said he was given the company operations manual and operations specifications to read, and "that was it." The former company pilot said that he got a call from Royal Air Freight, Inc. saying, "we got a flight." The former pilot said he then flew as a passenger during the outbound leg of Royal Air Freight, Inc. cargo flight under a Part 135, and during the return under Part 91, he was given a Part 135 check ride by the chief pilot. During the checkride, the former pilot performed a stall, a single-engine ILS approach to Willow Run Airport, Detroit, Michigan, and a nonprecision approach to PTK. The former company pilot said that Royal Air Freight, Inc. told him that he did not receive training because his Flightsafety International, Inc. training was "good enough." The former company pilot said that the "only bad thing" at Royal Air Freight, Inc. was the "lack of training" and the difference in training between Royal Air Freight, Inc. and his current employer was "night and day."
A current company pilot, hired by Royal Air Freight, Inc. in November 2013, stated during a post-accident interview that when he applied for a Learjet 35 second-in-command pilot position he received an informal phone interview, which was followed-up by an in-person interview (second interview) and a final in-person interview at Royal Air Freight, Inc. The company pilot said that he received an offer of employment from Royal Air, Inc. during the in-person (second interview). During the final interview, he flew a Learjet 35 from the right pilot seat with the Royal Air Freight, Inc. chief pilot in the left pilot seat. The company pilot said that they did not perform any maneuvers during the flight, but it "was a ride-along" and/or "familiarization" flight that was an hour in duration. The company pilot said that he did not remember who else was aboard the flight. He said that flights flown during October 2013 were training flights. There were no quizzes regarding the Royal Air Freight, Inc. operations specifications.
A second former company pilot, employed by Royal Air Freight, Inc. for about two years after he was hired about November 2011, stated that his initial ground training was different from what he previously experienced. He previously worked as a first officer at a Part 121 air freight operator and at another air carrier. He stated that during his initial ground training at Royal Air Freight, Inc. he would walk in, go upstairs, and "pretty much" sit in their conference room, and it was more of a self-study type program. He said that he was given but not trained and examined on the company operation specifications and the company general operations manual. He said that Royal Air Freight, Inc. did not discuss with him lessons learned from previous accidents/incidents that the company has had. He said the he always worked in a two flight crew environment and found that flying the Cessna 310 in a "hard" IMC environment was definitely a "wake-up call" for him and that single-pilot IMC flying was difficult. During his flight training and check ride at Royal Air Freight, Inc. he did not use a view limiting device during flight visual meteorological conditions. He said that he also rode along on trips with different captains during his training.
A third former company pilot stated that after he graduated from Purdue University's aviation program, he was hired by Royal Air Freight, Inc. in June 2012 as EMB-110 first officer and left Royal Air Freight, Inc. July 2013. He stated that he had about 355 hours of flight time when he was hired, of which 50-60 hours were in multiengine airplanes, and did not have any Part 135 experience. He stated he was given a manual to study in an upstairs conference room where he studied the manual and took notes on his own. He said that Royal Air Freight, Inc. director of operations would come into the conference room every couple of hours to ask him if he had any questions and to talk about a "couple" of the aircraft systems. The former pilot said that "a lot of it was self-teaching" and estimated his study time in the conference room was 6-8 hours per day. He stated that he received a total of about 10-12 hours of ground instruction from the director of operations. He said that the only manual given to him was the EMB-110 systems manual. He said that he was not given the Part 135 operations manual to study. He said that there was no discussion of meteorology during his ground training. He did not receive any written examination during his training and that questions asked to assess his knowledge were not an oral examination but more of an open discussion while the director of operations was teaching. The former pilot said that the chief pilot was not one of the instructor pilots for the EMB-110 so he did not come to the conference room to provide training; the director of operations was the instructor and check airman for the EMB-110. The former pilot said that on June 27, 2012, he flew on a trip with one of the EMB-110 captains and that trip, he believed, counted as training, which was 7.5 hours in duration. The pilot stated that he received only 3.8 hours of flight instruction (the "Certificate of Aircraft Training" stated that the former pilot received 8.1 hours of flight training) that was provided by the director of operations before the former pilot's Part 135 checkride, which was conducted by the director of operations. The former pilot said that during his Part 135 checkride, the only emergency procedure that was performed was an engine failure. During the post-accident interview, the former pilot was shown his Royal Air Freight, Inc. training records, which had signature lines for the pilot and the instructor that provided his training. One of these documents titled "New Hire Training" stated that the pilot completed the training curriculum for the EMB-110. The former pilot stated that he did not think that he received the required 24 hours of basic indoctrination, the 16 hours of aircraft training, and the 4 hours of emergency training cited on the "New Hire Training" form. The former pilot stated that they did not discuss meteorology nor did they discuss stabilized approaches during his training. The former pilot's "Certificate of Ground Training," "Certificate of Aircraft Training," "Certificate of Emergency Training," and Certificate of Flight Training" had signatures on the instructor's signature line and no signatures on the student's signature line. The former pilot stated during the interview that he had not seen these documents before and that he never signed such documents. He said that he had not seen the Royal Air Freight, Inc. training manual.
Additional Information
Corporate Culture
The director of operations was also the president and vice president of Royal Air Freight, Inc. During the post-accident interview of the director of operations, the director of operations was asked by the NTSB IIC to describe what is done to have a good corporate culture. The director of operation's only response was, "Hard to describe all the details that go into that. Many facets."
The company pilot who had flown with the pilot on December 10, 2014, stated during his interview that relative to other pilot employment he had held, working at Royal Air Freight, Inc. regarding workload and fatigue was "…probably the easiest job… ." He stated that he did not experience pressure by Royal Air Freight, Inc. to complete flights.
The third former company pilot, who flew EMB-110 airplanes, stated that some of the positive things about working at Royal Air Freight, Inc. were that he liked his job because of the people he flew with; they were "nice people, experienced." He said the negative aspects of working at Royal Air Freight, Inc. were the lifestyle and that it was a "very demanding job." He said that being called out on trips at three or four times per week at 0200 or 0300 was "really exhausting".
The last company pilot that was interviewed who was currently employed by Royal Air Freight, Inc. was asked by the IIC what are the positives and negatives of working at Royal Air Freight, Inc. He responded by saying "what relevance does this have to this?" He was then asked what the corporate culture was like at Royal Air Freight, Inc., to which he said "I have no idea what the corporate culture is like; I just drive the airplane."
All figures in this report are available in the public docket for this accident, which can be found at: http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=88665
NTSB Identification: CEN14FA110
14 CFR Part 91: General Aviation
Accident occurred Friday, January 10, 2014 in Waterford, MI
Probable Cause Approval Date: 12/17/2015
Aircraft: CESSNA 310R, registration: N3829G
Injuries: 1 Fatal.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
The airplane, operated by an on-demand cargo carrier and flown by a newly hired pilot, was on a positioning flight when it impacted trees and terrain about 1,500 ft short of the runway during a straight-in instrument landing system (ILS) approach. Night instrument flight rules (IFR) conditions prevailed with recorded weather observations that were below the minimum visibility specified for the approach. Radar data showed that while on the final segment of the ILS approach, the airplane's approach was unstabilized in speed and position along the glidepath. The shallow angle of the wreckage path and its length were consistent with controlled flight into terrain. Examination of the wreckage revealed no anomalies that would have precluded normal aircraft operation.
The pilot had undergone company training provided by the company's president, who was also the director of operations, and the chief pilot; these two individuals were the only company instructors approved by the Federal Aviation Administration (FAA) to provide Part 135 training in accordance with the company training manual. However, the majority of the pilot's flight training in the accident airplane make and model was during a flight with a company pilot who was not approved by the FAA to provide Part 135 instruction. Further, although company records stated that the pilot met the training requirements for ground and flight training in accordance with the company training manual, the minimum flight times in the accident airplane make and model were not met and the method of ground instruction was not followed in accordance with the company training manual.
A review of the weather for the pilot's previous company flights showed that he had not flown in actual conditions that were at approach minimums at night, similar to those at the time of the accident. The chief pilot stated that higher approach weather minimum limitations were placed upon the pilot and that company dispatchers watched most new pilots' minimums until they got more experience with the company. However, although the dispatch manager indicated he was aware of weather limitations for the pilot, he stated that the dispatchers had no means of routinely communicating with the pilots inflight, and he could not recall when there had been any other pilots with weather limitations. Furthermore, there was no FAA-approved program or policy within the company operations specifications or other manual for higher approach minimum limitations based upon experience for company pilots of piston engine powered airplanes such as the accident airplane.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's controlled flight into terrain during an instrument landing system approach at night in instrument flight rules conditions. Contributing to the accident were the operator's inadequate training of the pilot, the operator's failure to provide a level of oversight commensurate to the pilot's experience, and the pilot's lack of operational experience in actual night instrument conditions in the make and model of the airplane.
HISTORY OF FLIGHT
On January 10, 2014, about 1948 eastern standard time, a Cessna 310R, N3829G, impacted trees and terrain about 1,500 feet west of the approach end of runway 9R (6,521 feet by 150 feet, asphalt) at Oakland County International Airport (PTK), Pontiac, Michigan, during a straight-in instrument landing system (ILS) approach to runway 9R. Night instrument meteorological conditions (IMC) prevailed at the time of the accident. The commercial pilot sustained fatal injuries. The airplane was destroyed by impact forces and a post impact fire. The airplane was registered to and operated by Royal Air Freight, Inc. as flight RAX907 under the provisions of 14 Code of Federal Regulations Part 91. The positioning flight was operating on an instrument rules flight plan and departed from Fulton County Airport-Brown Field (FTY), Atlanta, Georgia, about 1701, and was destined to PTK.
During an interview with the National Transportation Safety Board (NTSB) Investigator-In-Charge (IIC), the pilot's wife stated that on the afternoon of January 6, 2014, her husband received a phone call from Royal Air Freight, Inc. to fly a flight to either Fargo, North Dakota or Atlanta, Georgia. After his departure for the trip on January 6, 2014, she had not seen him, and they communicated solely by text messages since that time. He was to return via a flight to Ohio. She said that a January 8, 2014 text message from her husband said that Royal Air Freight, Inc. dispatch told him to get a hotel room. A January 9, 2014 text message stated that he was to fly from Ohio to Minneapolis and that he would arrive in Pontiac, Michigan at 1800. At 1945, her husband sent a text message that described his frustration with Royal Air Freight, Inc.'s scheduling and that "there was a major lack of communication" from Royal Air Freight, Inc. About an hour later, he sent a text message saying that the airplane he was to fly, N3829G, was broken.
The pilot's wife said that they had planned a trip to Florida, which they were to depart for on January 11, 2014. They had planned to pick up a car rental in Detroit, Michigan on January 11, 2014 at 0900 and were to drive to Florida. They had purchased airline tickets for their return trip from Florida. She stated that she requested time off from her employment about two months before the trip.
A maintenance facility in Atlanta, Georgia, issued a maintenance work order dated January 10, 2014 for N3829G, which stated the right engine starter was inoperative, and the left tire pressure was low. The right engine starter was removed and replaced with an overhauled starter, and the subsequent operational check of the starter was "good". The left tire was filled with nitrogen.
On January 10, 2014, a filed instrument flight plan was activated for RAX907 for a flight from FTY to PTK with a proposed departure time of 1650 and a cruise altitude of 7,000 feet mean sea level (msl). The filed alternate airport for the flight was Bishop International Airport (FNT), Flint, Michigan, which was about 22.9 nautical miles (nm) northwest of PTK. The estimated time en route was 2 hours 28 minutes. On January 12, 2014, the NTSB IIC and the Federal Aviation Administration (FAA) Coordinator met with the Royal Air Freight, Inc. chief pilot and the director of operations. During that meeting, the chief pilot stated that they did not know how much fuel was on board when N3829G departed for PTK, and they did not know the alternate airport for the flight. The chief pilot said that "the pilots file their own flight plans."
According to the Royal Air Freight, Inc. General Operations Specifications and Operations Specifications, Royal Air Freight, Inc. retains all responsibility for the operational control of aircraft operations, and thus the safety of each flight conducted under its certificate and operations specification, including the actions or inactions of all its direct employees and agents. Flight locating procedures required that the pilot-in-command of a flight give the dispatcher or a responsible person within Royal Air Freight, Inc. all information in a visual flight rules flight plan. (FAA Form 7233-1, "Flight Plan," contains an entry block for fuel on board and for alternate airport(s)).
On January 10, 2014, at 1658, RAX907 departed FTY and was provided initial air traffic control (ATC) radar service by Atlanta Terminal Radar Approach Control. RAX907 was provided ATC services by numerous TRACONs and air route traffic control centers (ARTCC) en route before being transferred to Detroit TRACON at 1922. According to FAA transcripts, the flight was uneventful.
Prior to RAX907's approach to PTK, another Royal Air Freight, Inc. flight, which was a Learjet 35A, RAX131, had flown the ILS runway 9R approach without incident. A written statement from the captain of RAX131, stated in part:
"Received PTK ATIS as [vertical visibility] 200 [feet], ½ mile visibility, wind [from] 160 [degrees at] 10 [knots]. After check-on with Detroit approach we heard an aircraft being vectored for the approach at PTK, so we listened to the PTK tower [frequency] on [the] secondary radio. He was given [runway visual range (RVR)] of 2,200 [feet] for 9R by the tower. We were vectored for the approach and when we checked on was given [RVR] of 2,000 [feet] for [runway] 9R and wind from 180 [degrees at] 10 [knots].
During the initial part of the approach the winds were strong out of the south. It was smooth, but took a 20 degree angle to maintain the localizer. At approximately 1,800 feet we encountered light to moderate chop and started losing the crosswind. No noticeable changes in airspeed but took out almost all of the crab angle to maintain the localizer.
At approximately 1,250 feet, [the second-in-command] called approach lights in sight. I responded with continue, and almost immediately Alex called green lights, runway in sight 12 o'clock. We continued and landed normally. Crosswind correction was minimal, no major airspeed/power changes noticed.
As we were exiting the runway at the end, left on "U", we heard RAX907 call the tower. Do not remember if the tower issued any weather, did hear them tell RAX907 that he was following a Challenger on a 2 mile final."
At 1922, RAX907 checked in with Detroit TRACON while descending out of 4,900 feet for 4,000 feet. RAX907 was provided radar vectors for the ILS runway 9R approach. After being given a descent to 3,000 feet and a final radar vector to a heading of 060 degrees, the Detroit TRACON controller cleared RAX907 for the ILS runway 9R approach at 1940, and two minutes later directed the pilot to contact PTK tower.
At 1942, RAX907 checked in with the PTK air traffic control tower and was issued a landing clearance to runway 9R following a Challenger on a 2-mile final. RAX907 was issued an RVR of 2,000 feet for runway 9R. RAX907 acknowledged the landing clearance and advised they were looking for the traffic. The controller issued the surface wind. There were no further communications between RAX907 and ATC.
The captain of the Challenger stated in part:
"Weather was reported 2,000 [feet] RVR and vertical visibility 200 [feet]. There was no icing, turbulence or wind shear during the approach only light rain. Intercepting the localizer we had a 42 knot wind out of the south that required at least a 20 degree crab angle. Proceeding down the glide slope the winds diminished gradually and our crab angle was approximately 5 degrees at 300 feet. I called approach lights (MALSR) in sight at 100 feet above minimums and observed them at the 1130 position relative to our nose. At minimums I called runway in sight and we landed. The approach was flown with the autopilot on until minimums. I did not know of the accident until ground control announced the airport was closed while we were exiting the taxiway…"
PERSONNEL INFORMATION
The pilot, age 32, held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. Prior to November 26, 2013, he accumulated a total flight time of approximately 1,907.8 hours, of which 422.3 hours were in multiengine airplanes, 74.7 hours were in actual meteorological conditions, and 109.4 hours were at night.
He was employed by Royal Air Freight, Inc., as a Cessna 310 pilot after passing his Part 135 airman checkride on December 19, 2014. After the checkride, all of the flights he had flown were in Royal Air Freight, Inc. Cessna 310R airplanes, over four trips/days, which had 11 flights totaling about 40.5 hours.
The pilot's logbook showed that during his pilot training for a pilot-in-command position in Cessna 310 airplanes at Royal Air Freight, Inc. he accumulated 7.2 hours of flight time in night conditions, of which 5.4 hours were accumulated in a Cessna 310R during a December 10, 2014 flight that was flown by a Royal Air Freight, Inc. company pilot who was not a company instructor. The remaining 1.8 hours of night flight time was in a Falcon 20 airplane while in the right seat of the airplane. The amount of flight time in actual IMC during his pilot training (0.2 hours were during the checkride) was 6.0 hours, of which 4.3 hours were in Cessna 310R airplanes. Of the 4.3 hours, 3.4 hours were accumulated during the December 10, 2013 trip flown by the company pilot.
There was no record showing that the pilot had flown an instrument approach in a Cessna 310 airplane, in actual night IMC to precision approach weather minimums during his training, checkride, or subsequent flights.
The pilot did not have an FAA record of any previous accidents, incidents, or enforcement actions.
Certificate and Ratings of the Pilot
On March 15, 2005, the pilot was issued a private pilot certificate with a single-engine land rating after passing the examination for the certificate/rating on his first attempt. The total flight time that was reported at the time of examination was 59 hours. He passed the private pilot airplane airman knowledge test, private pilot, on his second attempt and received a score of 88.
On November 11, 2005, the pilot was issued an airplane single-engine instrument rating after passing the examination for the rating on his first attempt. The total flight time that was reported at the time of examination was 155 hours. He passed the instrument airplane rating airman knowledge test, private pilot, on his first attempt and received a score of 87.
On March 29, 2006, the pilot was issued a commercial pilot certificate with a single-engine land rating after passing the examination on his first attempt. The total flight time that was reported at the time of examination for the certificate/rating was 288 hours. He passed the commercial pilot airplane airman knowledge test on his first attempt and received a score of 88.
Pre-employment Interview of the Pilot
The pilot's wife stated that her husband sent resumes in order to apply for a pilot position in late October 2013 and/or early November 2013. One operator that received a resume was contacted by the NTSB IIC and that operator stated that the pilot was not offered employment because there were no positions available at the time of the pilot's application. A second operator that was contacted by the NTSB IIC stated they wanted the pilot to have more experience and therefore did not offer him employment after interviewing the pilot.
The pilot's wife stated that Royal Air Freight, Inc. called her husband in November 2013. She said that her husband's interview with Royal Air Freight, Inc. was a "working flying" interview, which was on November 25 or November 26, 2014. She said the interview started about 1100 or 1200. She said that she received a text from her husband at 1827 that he finished the interview. She believed that the interview was with the chief pilot. She said that her husband told her that the interview with Royal Air Freight, Inc. was "informal", "laid back," and there was "no dress code." She said that the second operator with whom he interviewed had a uniform requirement and that it was "more formal" and "corporate." She said that she believed that her husband met with the Royal Air Freight, Inc. director of operations during the interview at Royal Air Freight, Inc.
During a post-accident interview of the Royal Air Freight, Inc. director of operations with the NTSB IIC, the FAA Coordinator/Safety Inspector, and an FAA Safety Inspector, the director of operations stated they there were trying to fill the position occupied by the pilot because they have always been short of Cessna 310 pilots. When asked if the pilot was the only pilot that was interviewed for a Cessna 310 pilot position, the director of operations said that he did not recall and that the chief pilot was "kind of handing that." The director of operations stated that he believed he talked to the pilot when he was at Royal Air Freight, Inc. for the interview after the chief pilot had talked to him. The director of operations was asked by the NTSB IIC if he recalled what was discussed with the pilot when he met with him; the director of operations responded "not really." The director of operations stated that he knew the chief pilot flew with the pilot during the interview and that he (the director of operations) talked to the chief pilot about how the flight went when they returned, and the chief pilot "just mentioned [the pilot] did a really good job." The director of operations said that they normally conduct pilot interviews in which they fly with applicants on the same day to determine if the applicant can "fly or not." The director of operations said that the interview lasted "quite a while," and only he and the chief pilot talked to the pilot. The director of operations said the decision to hire the pilot was made on the day after his interview.
Training and Checking of the Pilot
According to the pilot's wife, the training that her husband received from Royal Air Freight, Inc. was "relaxed," because they would train him when they "felt like it" or he would "come along for a ride" She felt that the training was not standardized. It took longer for her husband to complete his [training] for his checkride. She said that he would get "critiqued" during his training at Royal Air Freight, Inc. and he was accepting of these critiques and was not defensive about them.
The director of operations and chief pilot were the only company personnel authorized by the FAA to provide Part 135 airman training and checks in accordance with the Royal Air Freight, Inc. "Aircraft Training Manual" that was approved by the FAA Detroit Flight Standards District Office. Training and checking of a pilot to fly a specific aircraft make and model was to be conducted in that make and model of aircraft. The approved general training areas and facilities for ground instruction were company buildings, ramps, hangers, maintenance areas and aircraft. Ground instruction curriculum segments were not to be conducted in flight. The Aircraft Training Manual stated that a "hood" was to be used for instrument flight maneuvers. The chief pilot stated during a post-accident interview that during the pilot's training, a hood was not used, but instead, the pilot's baseball cap was used as the view limiting device to simulate IMC.
During the January 12, 2014 meeting with the director of operations and the chief pilot, the chief pilot was asked by the NTSB IIC if they had training records for the accident pilot that would show the date, the flight time, the aircraft used, the instructor that provided instruction, and the description of training for each of the pilot's training flights. The chief pilot stated that they did not have such a record, were not required to keep records of individual training flights, and were only required to provide a certificate of training. The NTSB IIC then requested that such a record be provided.
The Royal Air Freight, Inc. "New Hire Training" record for the pilot stated that he completed the curriculum segments for Cessna 310/402 aircraft. This record's entries stated that he met the minimum times for "turbine/piston" aircraft cited in the FAA approved training manual (there were higher minimum times for pilot training for "jet" aircraft). The minimum flight times were specific to the make and model of aircraft and could not be substituted by use of another aircraft make and model. Entries from the pilot's New Hire Training record, which are the minimum times cited in the training manual, are cited in Figure 1 (All figures in this report are available in the public docket for this accident, which can be found at: http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=88665.)
Figure 1. Chart showing 7 training modules, the date of instruction and instructor.
On December 19, 2013, the pilot passed a Part 135 Airman Competency/Proficiency Check (FAA Form 8410-3) using a Cessna 310 and flight duration of 1.8 hours and included checks under Parts 135.229, 135.297, and 135.299. According to Form 8410-3, the pilot received a grade of "S" (satisfactory) for all of the listed flight maneuvers, which included inflight maneuvers: steep turns, approaches to stalls, specific flight characteristics, and powerplant(s) failure. The emergency procedures included: normal and abnormal procedures and emergency procedures. The accident pilot's logbook entry for the day of the Part 135 checkride stated that he had flown N3829G and the route of flight was PTK to MBS to LAN to PTK. Plots from FlightAware.com for December 19, 2013 for N3829G, were not consistent with inflight maneuvers.
The remarks section of FAA Form 8410-3 had the following entries: "route check", "lower than std. takeoff demo", "low mins. demo", "oral included 310/402". The Royal Air Freight, Inc. chief pilot was the check airman for the check.
Higher Approach Minimums for the Pilot
During the January 12, 2014 meeting with the NTSB IIC, the FAA Coordinator, and the director of operations present, the chief pilot stated that the Cessna 310 does not have high approach minimums like the jets.
During a March 12, 2014 post-accident interview of the chief pilot, the chief pilot stated that the pilot and "usually" new hires have higher than standard approach minimums. The chief pilot said that not all new hires have higher than standard approach minimums due to their experience, He said that the pilot "seemed proficient" and the approach minimums limit that were set by him (chief pilot) and dispatch were 400 feet and 1 statue mile (sm) visibility.
During the March 12, 2014 post-accident interview and subsequent the chief pilot's interview, the dispatcher stated that they were told that the pilot was limited to higher approach minimums of 400 feet and 1 sm visibility, and that they watch most new pilots' minimums until they get more experience with the company. The dispatcher was then asked if there were recent pilots with higher approach minimums, to which the dispatcher responded "not that I can remember." The dispatcher was asked if he remembered the last time higher approach minimums were placed upon a pilot and he said "no." The dispatcher was then asked if he had an estimate of when the last time a pilot had higher approach minimums to which he said "no." The dispatcher was asked if there were higher approach minimums placed upon pilots beyond the past year; he said "no, I don't think so."
The only Royal Air Freight, Inc. FAA approved/required pilot-in-command higher weather minimums were cited in the Royal Air Freight, Inc. Operation Specifications, which referenced Part 135.225(e). These limitations were applicable to only a pilot-in-command of turbojet airplanes and not reciprocating airplanes. The limitation would be removed once the pilot-in-command served at least 100 hours as pilot-in-command of that turbojet airplane.
Review of the Pilot's Logbook and Flight Daily Record Sheets
The pilot's logbook included entries for a period dated from November 26, 2013 to January 6, 2014; there were no logbook entries following January 6, 2014. All of the entries during this period were in Royal Air Freight, Inc. aircraft. There were no entries prior to the November 26, 2013 entry showing flight in Royal Air Freight, Inc. aircraft. The entries are cited in Figure 2.
Figure 2. Table showing entries in pilot's logbook, which includes 11 entries between November 26, 2013, and January 5, 2014.
Flight Daily Record Sheets
Royal Air Freight, Inc. recorded flights conducted under Parts 91 and 135 on either "Piston Daily Record Sheets" or "Jet Daily Record Sheets". These sheets did not make use of a sequentially ordered numbering system that would identify each sheet by a unique number printed on the respective sheet. These sheets included entries for identifying the pilot and copilot for each flight and a remarks section. Flights in piston aircraft were authorized to be conducted by a single pilot whereas jet aircraft such as the Falcon 20 and Learjet 35A would have two flight crewmembers, a pilot and copilot.
A December 13, 2013, Jet Daily Record Sheet, showed two flights from PTK to Westchester County Airport (HPN), White Plains, New York and HPN to PTK in Learjet N731RA with the Royal Air Freight, Inc. director of operations as pilot and the pilot as copilot. Both flights were recorded as being conducted under Part 91, and the remarks section of the sheet stated: "FLT TRAINING."
During the March 12, 2014 post-accident interview of the director of operations, the director of operations was asked the purpose of a flight to HPN; the director of operations responded "to go to White Plains." After further questioning, the director of operations said that the purpose of the flight was to drop off the chief pilot and a company pilot to fly a Falcon 20 to PTK. The director of operations said that he would have performed the takeoff and landing for the flight to HPN, and the pilot did not perform any maneuvers during the flight; "it was a normal enroute flight." The director of operations said he did not remember how much of the flight was flown by the pilot and if the pilot had flown any approaches during the flight to HPN. He said the pilot was seated in the right pilot seat for the entire flight.
There was no record indicating the pilot met the requirements cited in Part 61.55 prior to the Learjet flight on December 13, 2013. Part 61.55 Second-in-command qualifications, states in part:
(a) A person may serve as a second-in-command of an aircraft type certificated for more than one required pilot flight crewmember or in operations requiring a second-in-command pilot flight crewmember only if that person holds:
(1) At least a private pilot certificate with the appropriate category and class rating; and
(2) An instrument rating or privilege that applies to the aircraft being flown if the flight is under IFR; and
(3) The appropriate pilot type rating for the aircraft unless the flight will be conducted as domestic flight operations within United States airspace.
(b) Except as provided in paragraph (e) of this section, no person may serve as a second-in-command of an aircraft type certificated for more than one required pilot flight crewmember or in operations requiring a second-in-command unless that person has within the previous 12 calendar months:
(1) Become familiar with the following information for the specific type aircraft for which second-in-command privileges are requested—
(i) Operational procedures applicable to the powerplant, equipment, and systems.
(ii) Performance specifications and limitations.
(iii) Normal, abnormal, and emergency operating procedures.
(iv) Flight manual.
(v) Placards and markings.
(2) Except as provided in paragraph (g) of this section, performed and logged pilot time in the type of aircraft or in a flight simulator that represents the type of aircraft for which second-in-command privileges are requested, which includes—
(i) Three takeoffs and three landings to a full stop as the sole manipulator of the flight controls;
(ii) Engine-out procedures and maneuvering with an engine out while executing the duties of pilot in command; and
(iii) Crew resource management training
A December 10, 2013, Piston Daily Record Sheet, showed four flights from PTK to CYHM, CYHM to YIP, YIP to MSN, and MSN to PTK with a Royal Air Freight, Inc. company pilot as pilot and the pilot as copilot. The company pilot was not a Part 135 instructor for Royal Air Freight, Inc. The total block and flight times listed on the Piston Daily Record Sheet were 6.6 hours and 5.7 hours, respectively. During a March 12, 2014 post-accident interview of the company pilot, the company pilot stated that when he was called for the December 10, 2013 trip, he was told by a Royal Air Freight, Inc. dispatcher that he had a "ride-along," which the company pilot said meant it was an "observation pilot pretty much." The company pilot stated that the pilot was seated in the right seat on Part 91 legs and was the flying pilot. The company pilot said the Royal Air Freight, Inc. chief pilot asked him (the company pilot) to "make sure" the pilot was "good" with normal takeoffs and landings. The company pilot stated it was "clear" for the flights, and the pilot did not fly any instrument approaches nor did they simulate IMC. The company pilot said he discussed with the pilot, company procedures, processing freight paperwork, flight in icing conditions in the lower 48 states, Cessna 310 fuel system, fuel consumption, and fuel management.
AIRCRAFT INFORMATION
The airplane was a 1977 Cessna 310R, serial number 310R0924, powered by two Continental Motors, IO-520-MB, engines. The left engine serial number was 826016-R, and the right engine serial number was 829137-R. The left engine was equipped with a McCauley 3AF32C87-NR, serial number 970419, propeller. The right engine was equipped with a McCauley 3AF32C504-C, serial number 786981, propeller.
The airplane was maintained by Royal Air Freight, Inc. and was to follow a manufacturer's inspection program. The airplane received its last inspection 200-hour and 50-hour airframe inspections on August 23, 2013 at an aircraft total time (ACTT) of 4,224.1 hours and December 23, 2013 at an ACTT of 4,427.9 hours.
Royal Air Freight, Inc. reported that the ACTT was 4,444.9 hours at the time of the accident. The tachometer/Hobbs meter(s) indication at the time of the accident was not obtained due to their damage by impact forces/post-crash fire.
Wing Flaps System
The wing flap system was electrically driven and actuated with flap settings of: 0, 15, and 35 degrees.
The Cessna 310R flight manual listed the airspeed Indicator and limitation values as:
White Arc: 72 to 139 knots indicated airspeed (KIAS); Operating speed range with 35 degrees wing flaps. Lower limit is maximum weight stalling speed in landing configuration. Upper limit is maximum speed permissible with wing flaps extended 35 degrees.
Green Arc: 79 to 181 KIAS; Normal operating range. Lower limit is maximum weight stalling speed with flaps and landing gear retracted. Upper limit is maximum structural cruising speed.
Blue Radial: 106 KIAS; One engine inoperative best rate-of-climb speed at sea level standard day conditions and 5,500 pounds weight.
Yellow Arc 181 to 223 KIAS; Caution range. Operations must be conduction with caution and only in smooth air. The maximum structural cruising speed (Vno) is 181 KIAS.
MEDICAL INFORMATION
The accident pilot held a first class medical dated November 1, 2013, with no limitations.
The FAA Final Forensic Toxicology Fatal Accident Report for the pilot stated: no carbon monoxide detected in blood, cyanide not performed, no ethanol detected in vitreous, and no drugs listed detected in urine.
An autopsy of the pilot was conducted by the Office of the Medical Examiner, Oakland Country, Michigan, on January 11, 2014. The autopsy report stated the cause of death as multiple injuries, and the manner of death as: accident.
METEOROLOGICAL INFORMATION
Destination Airport Weather for PTK
Terminal Aerodrome Forecasts (TAFs)
A TAF issued at 1534 for PTK forecasted for the accident time: a wind from 160 degrees at 14 knots, visibility of 2 sm, light rain, mist, overcast cloud base at 400 feet above ground level (agl), wind shear with wind at 2,000 feet agl from 190 degrees at 45 knots.
A TAF issued at 1822 for PTK forecasted for the accident time: a wind from 150 degrees at 10 knots, visibility of 2 sm, mist, overcast cloud base at 400 feet agl, wind shear with wind at 2,000 feet agl from 190 degrees at 45 knots; temporary conditions between 1900 and 2300: visibility ¾ sm, light rain showers, mist, ceiling broken at 200 feet agl.
Surface Observations
PTK was located within one mile to the east of the accident site at an elevation of 981 feet msl. The following reports were issued from PTK during the time period surrounding the accident time:
At 1929, PTK reported a wind from 150 degrees at 10 knots, visibility of 1/4 sm, RVR on runway 9R variable between 2,000 and 2,800 feet, fog, vertical visibility 200 feet, temperature of 2 degrees Celsius (C) and dew point temperature of 1 degree C, altimeter setting 29.86 inches of mercury (Hg).
One-minute data from the Automated Surface Observing System (ASOS) at PTK was retrieved for the times surrounding the accident. Average wind direction (Avg-W Dir) in degrees, average wind speed (Avg-W Spd) in knots, wind gust direction (W-Gust Dir) in degrees, wind gust magnitude (W-Gust Mag) in knots and RVR for runway 9 are cited in Figure 3.
Figure 3. Table of surface observations for times surrounding the accident.
At 1953, PTK reported a wind from 140 degree at 9 knots, visibility of 1/4 sm, RVR on runway 9R variable between 2,000 and 2,600 feet, fog, vertical visibility 200 feet, temperature of 2 degrees C and dew point temperature of 2 degrees C, altimeter setting 29.85 inches of Hg.
Alternate Airport Weather
Surface Observations for FNT
At 1853, FNT reported a wind from 150 degrees at 12 knots, visibility of 5 sm, mist, broken cloud base at 800 feet agl, overcast cloud base at 2,000 feet agl, temperature of 3 degrees C and dew point temperature of 1 degree C, altimeter setting 29.85 inches of Hg.
At 1953, FNT reported a wind from 170 degrees at 13 knots, visibility of 6 sm, light rain, mist, scattered cloud base at 800 feet agl, broken cloud base at 2,600 feet agl, overcast cloud base at 3,200 feet agl, temperature of 4 degrees C and dew point temperature of 2 degrees C, altimeter setting 29.82 inches of Hg, remarks: rain began 48 minutes past the hour.
At 2009, FNT reported a wind from 160 degrees at 14 knots, visibility of 6 sm, light rain, mist, scattered cloud base at 2,900 feet agl, overcast cloud base of 6,500 feet, temperature of 4 degrees C and dew point temperature of 2 degrees, altimeter setting 29.81 inches of Hg.
At 2027, FNT reported wind from 170 degrees at 15 knots, visibility of 6 sm, light rain, mist, scattered cloud base at 700 feet agl, broken cloud base at 5,500 feet agl, overcast cloud base at 7,000 feet, temperature of 4 degrees C and dew point temperature of 2 degrees C, altimeter setting 29.79 inches of Hg.
At 2038, FNT reported wind from 170 degrees at 12 knots and gusts of 21 knots, visibility of 5 sm, light rain, mist, overcast cloud base at 5,500 feet agl, temperature 4 degrees C and dew point temperature of 2 degrees C, altimeter setting 29.79 inches of Hg.
At 2053, FNT reported wind from 180 degrees at 13 knots, visibility of 5 sm, light rain, mist, overcast cloud base at 700 feet agl, temperature of 4 degrees C and dew point temperature of 3 degrees C, altimeter setting 29.79 inches of Hg.
AIRPORT INFORMATION
Destination Airport
The PTK ILS Runway 9R Instrument Approach is shown in Figure 4.
Figure 4: The figure shows the instrument approach chart profile for ILS runway 9R. The minimum descent altitude (MDA) outside the final approach fix (FAF)/outer marker (OM), which is located 5 miles the runway 9R, is 2,700 feet msl.
Alternate Airport
Flight plan information indicated that FNT, located about 22.9 nm northwest of PTK, was a filed destination alternate for the accident flight. FNT was served by ILS 9 and 27 approaches in addition to RNAV/GPS and VOR approaches to all runways at FNT.
The ILS 9 and 27 straight-in approach minimums were 200 feet agl and ½ sm mile visibility for all aircraft categories, A through D.
The ILS 9 circling approach minimums were 600 feet agl and 1 sm visibility for categories A and B, 600 feet and 1 ½ sm visibility for category C, and 600 feet agl and 2 sm visibilities for category D.
The ILS 27 circling approach minimums were 500 feet agl and 1 sm visibility for category A, 600 feet agl and 1 sm visibility for category B, 600 feet agl and 1 ½ sm visibility for category C, and 600 feet agl and 2 sm visibility for category D.
WRECKAGE AND IMPACT INFORMATION
The main wreckage, which consisted of the airplane fuselage, was about 1,500 feet from the approach end to runway 9R and located in a wooded area. The wreckage path extended through trees and was oriented on a magnetic heading of about 85 degrees and was about 225 feet in length. The western edge of the wreckage path exhibited a tree strike about 10 feet below the top of a tree about 60 feet in height; the main wreckage was located about 148 feet from this tree strike. There were additional tree strikes and trees that were fallen over in the direction of the main wreckage.
The main wreckage exhibited post-crash fire damage that destroyed the airplane along with impact forces. Both wing fuel tanks were separated from the airplane and located along the wreckage path. The empennage was separated from the fuselage and located near the fuselage along with both engines and propellers. Both engines were separated from the airplane and east/forward of the main wreckage. The left propeller was separated at the hub from the left engine and consistent with torsional overstress. The right propeller was attached to the right engine. The landing gear was in the extended position. The wing flap extension was not determined due to impact damage.
Examination of the flight controls confirmed flight control continuity.
TESTS AND RESEARCH
Engine Examination
Both airplane engines underwent a disassembly examination at Continental Motors, Mobile, Alabama, under the supervision of a FAA Inspector who reported that there were no mechanical anomalies that would have precluded normal engine operation.
Propeller Examination
Both propellers underwent a disassembly examination at McCauley Propeller Systems, Wichita, Kansas under the supervision of a FAA inspector. The examination revealed there were no indications of a propeller malfunction or failure. Neither propeller exhibited witness marks consistent with a blade angle corresponding to a feathered position. Both propeller blade angles were approximately 14-17 degrees, relative to reference, and consistent with a low pitch/latch position.
Stabilized Approaches
There were several references that discussed the concept of stabilized approaches. These references included but were not limited to: FAA Instrument Procedures Handbook (FAA H-8083 16), FAA Advisory Circular (AC) 61-134 - Controlled Flight into Terrain Awareness, Flight Safety Foundation's (FSF's) Approach and Landing Accident Reduction Toolkit (ALAR) Briefing Note 7.1 – Stabilized Approach, AvWeb's Leading Edge #23: Stabilized Approaches in Light Airplanes.
The FAA's Instrument Flying Handbook, Chapter 4, Approaches, Descents, Stabilized Approach, states in part:
"In IMC, you must continuously evaluate instrument information throughout an approach to properly maneuver the aircraft or monitor autopilot performance and to decide on the proper course of action at the decision point [decision altitude (DA), decision height (DH), missed approach point (MAP)]. Significant speed and configuration changes during an approach can seriously degrade situational awareness and complicate the decision of the proper action…
You must begin to form a decision concerning the probable success of an approach before reaching the decision point. Your decision-making process requires you to be able to determine displacements from the course or glidepath centerline, to mentally project the aircraft's three-dimensional flight path by referring to flight instruments, and then apply control inputs as necessary to achieve and maintain the desired approach path. This process is simplified by maintaining a constant approach speed, descent rate, vertical flight path, and configuration during the final stages of an approach. This is referred to as the stabilized approach concept to take at the decision point."
During the March 12, 2014 post-accident interview of the Royal Air Freight, Inc. chief pilot, the chief pilot was asked if he covered and provided the pilot with instruction on stabilized approaches and illusions to flight, to which the chief pilot responded yes. The chief pilot was then asked what the stabilized approach criteria were for a Cessna 310. The chief pilot said that a stabilized approach is one in which the airplane is configured with flaps and landing gear with a target power setting, which is usually set three miles outside of the final approach fix. The airplane speed should be "within a certain range." The chief pilot was then asked what are the limits that would define an unstabilized approach in a Cessna 310. The chief pilot could not provide quantitative deviations that would define an unstabilized approach after being asked several times by the NTSB IIC and the FAA Coordinator.
During the March 12, 2014 post-accident interview of the company pilot that had flown with the pilot on December 10, 2013, the company pilot was asked when an approach would become unstabilized in a Cessna 310. The pilot stated that airplane speed would deviate plus or minus 10 knots from target airspeed, one dot deflection in localizer and glideslope, if the airplane descent rate increased for no apparent reason, if airplane groundspeed increased or decreased dramatically for some reason, or if there was a single-engine power loss.
Transition to a Visual Approach
The FAA's Instrument Flying Handbook, Chapter 4, Transition to a Visual Approach, states in part:
"The transition from instrument flight to visual flight during an instrument approach can be very challenging, especially during low visibility operations. Aircrews should use caution when transitioning to a visual approach at times of shallow fog. Adequate visibility may not exist to allow flaring of the aircraft. Aircrews must always be prepared to execute a missed approach/go-around. Additionally, single-pilot operations make the transition even more challenging. Approaches with vertical guidance add to the safety of the transition to visual because the approach is already stabilized upon visually acquiring the required references for the runway. 100 to 200 feet prior to reaching the DA, DH, or MDA, most of the PM's attention should be outside of the aircraft in order to visually acquire at least one visual reference for the runway, as required by the regulations. The [pilot flying (PF)] should stay focused on the instruments until the PM calls out any visual aids that can be seen, or states "runway in sight." The PF should then begin the transition to visual flight. It is common practice for the [pilot monitoring (PM)] to call out the V/S during the transition to confirm to the PF that the instruments are being monitored, thus allowing more of the PF's attention to be focused on the visual portion of the approach and landing. Any deviations from the stabilized approach criteria should also be announced by the PM.
Single-pilot operations can be much more challenging because the pilot must continue to fly by the instruments while attempting to acquire a visual reference for the runway. While it is important for both pilots of a two-pilot aircraft to divide their attention between the instruments and visual references, it is even more critical for the single- pilot operation. …"
The company pilot, who had flown with the pilot on December 10, 2013, stated that he had flown aircraft under Part 135 and Part 121 for several decades and held four type ratings. He accumulated about 11,000 hours of total flight time, of which 3,000 hours were in Cessna 310 airplanes. He stated that he always flies the airplane following ILS guidance to the runway surface in order to maintain his proficiency because as the airplane gets closer to ground the ILS "gets more sensitive." He said that he follows ILS guidance to the runway surface because he has encountered fog/cloud near the ground. He said that when he is transitioning to a runway visual reference, he references the airplane's instrument indications until airplane flare to ensure that the airplane is not low or too high. He said that he has experienced going below an instrument glideslope "by accident."
Radar Performance Study
The Royal Air Freight, Inc. "Aircraft Training Manual" contained a "Typical ILS Approach" profile for each of the airplanes operated. The airspeeds associated with the segments of the approach for the Cessna 310/402 were: 160 knots during vectors to approach approximately 10-15 miles from the final approach fix, 150 knots during the base turn, 135 knots during the last vector or procedure turn inbound, and 120 knots from the final approach fix inbound.
A radar performance study was performed by a NTSB Airplane Performance Specialist. The performance study describes the accident airplane ground track, altitude, and speed. Estimates of airplane pitch, roll, and heading derived from radar data were also presented. The radar data used in the study was from the short-range Airport Surveillance Radar site at PTK. The PTK radar data were filtered for transponder beacon code 7436, that of N3829G.
Radar Data Plots
Figure 5: The radar ground track of N3829G shows the approach into PTK with time, msl height, speed in knots, and rate of climb in feet per minute.
Figure 6: The plot shows N3829G with a one- to two-dot deviation above the glideslope for the ILS 9R approach from about 0.5 nm inbound of the outer marker and about 2,700 feet msl prior to descending below the glideslope about 0.5 nm from runway 9R.
Figure 7: The plot shows N3829G shows a deviation of about one-dot right of the localizer course about 8 nm from runway 9R. The right deviation increased beyond one-dot about 2 nm miles before enter a left deviation of about one-dot.
Figure 8: The plot of N3829G shows a calibrated airspeed above 200 knots during a descent for the ILS 9R approach. Upon reaching an altitude of about 2,700 feet the airspeed was about 150 knots and slowed during the approach to about 125 knots.
Metallurgical Examination of Airspeed Indicator (AI) Face
An AI face, which was separated from its indicating needle, was recovered from the accident site and sent to the NTSB Materials Laboratory for examination of any witness marks on the face. The needle was not found and therefore was not sent along with the AI face. The NTSB metallurgist stated that the AI face received for examination was bent rearwards, as installed on the instrument, in the upper left quadrant. The face was still loosely attached to a portion of the internal mechanism by a single screw.
Microscopic examination did not reveal any surface marks that could be attributed to the needle impacting the face.
As the needle was not supplied it is unknown whether it would fluoresce under Ultra-Violet light. An Ultra-Violet examination was still performed to reveal no fluorescence to indicate that paint had been transferred from the needle to the face during the impact event.
Examination of the hole in the portion of the mechanism, through which the needle shaft normally protrudes, revealed three distinct impressions where the edge had been impacted and deformed outwards, probably by the needle shaft. The face was positioned on the portion of mechanism in what would be its approximate original location. One impression was found to be centered towards the 200 knot graduation and the other two were found to be centered between the 90 knot and 100 knot graduations. As the orientation of the needle on its shaft is unknown, these impressions do not indicate a needle position.
Apple iPhone 5 Internal Memory Download
An Apple iPhone 5 that belonged to the pilot and recovered from the wreckage was sent the NTSB Vehicle Recorder Laboratory to download its internal memory. Upon arrival, an exterior examination revealed that the unit had sustained prolonged thermal exposure. An interior inspection revealed that the circuit board containing the unit's non-volatile memory sustained excessive thermal damage, and the internal memory was not able to be recovered.
Company Aircraft Accident Rate
The NTSB's Summary of US Civil Aviation Accidents for Calendar Year 2012, included a graph of Part 135 on–demand (non-scheduled) total (fatal and nonfatal) and fatal airplane accidents from 2003-2012, as shown in Figure 9.
Figure 9: Shows the non-scheduled Part 135 accident rates from 2003-2012 as accidents per million flight hours.
Royal Air Freight, Inc. has had two previous fatal aviation accidents, which did not include N3829G, and one reported nonfatal aviation accident since 1990. These NTSB accident identification numbers for these accidents are listed below:
CEN10MA088: Gates Lear Jet Corp., N720RA, near Prospect Heights, Illinois, on January 5, 2010
CHI92LA263: Cessna 402B, N7882Q, near Almont, Michigan, on September 2, 1992
ATL90FA157: Beech E18S; N563W, near Greenwood, South Carolina, on August 9, 1990
According to the Royal Air Freight, Inc. director of operations, Royal Air Freight, Inc., would fly its airplanes about 15,000 - 20,000 hours per year.
During the post-accident interviews of current and former pilots employed by Royal Air Freight, Inc., none of those interviewed indicated that Royal Air Freight, Inc.'s previous accidents and/or incidents were taught to them during their training.
The Royal Air Freight, Inc. "Aircraft Training Manual," section 8, Subject Module No. 19 Previous Aircraft Accidents/Incident stated that crewmembers were to be provided with an awareness of the factors leading to and the common causes of aircraft accidents. The subjects included NTSB accident report reviews, human factors/considerations, NASA reporting system, previous company incidents/accidents, and causal factors and preventative measures. An oral/written examination was to be completed to 100 percent by the instructor to determine adequate knowledge of the factors leading to and the common causes of aircraft accidents.
Company Information and Records Review
The NTSB IIC made a request to the East Michigan (Detroit) Flight Standards District Office (FSDO) to obtain Royal Air Freight, Inc. records for examination. On January 16, 2014, an FAA Inspector arrived at the Royal Air Freight, Inc. office at PTK to obtain the requested records. Royal Air Freight, Inc. refused to provide those records and a letter from the East Michigan (Detroit) FSDO was sent to Royal Air Freight, Inc. stating:
"On January 28, 2014, the NTSB IIC contacted a former Royal Air pilot and requested that the pilot provide his logbook for review to the FAA Coordinator assigned to the accident investigation, which the pilot agreed to. On January 29, 2014, the FAA Coordinator contacted the pilot to set up a time to meet the pilot. The pilot stated to the FAA Coordinator that his logbook[s] were somewhere deep in a storage locker and remembering the recommendation of an old flight instructor, never give your logbooks to the FAA, and therefore not willing to give the FAA Coordinator access at the logbooks. The pilot also stated he did not want to become involved in the investigation."
Following requests to Royal Air Freight, Inc. by the NTSB IIC to conduct interviews of company employees and for pilots to provide their logbooks for copy/review, subpoenas were issued to the Royal Air Freight, Inc.'s director of operations, chief pilot, and current and former pilots to compel them for interview and to provide their logbook for copy/review. These interviews began on March 12, 2014.
Company Pilot Training
The Royal Air Freight, Inc. director of operations and the chief pilot were the only two instructors approved by to the FAA to provide initial training, recurrent training, and Part 135 airman checks to company pilots in accordance with the company's FAA approved training manual. The director of operations stated that they were the only two company instructors for the "last several years."
Section 8 of the training manual included, and was not limited to, 85 subject modules that were to be delivered via "lecture and discussion" to pilots, The training manual listed the training aids and courseware to be used. The subject modules included, and were not limited to: the operations manual, operating certificate, operations specifications, concepts of instrument procedures (stabilized approaches), flight techniques in adverse weather (visual illusions under IFR conditions, low visibility – depth perception, fly the glideslope to the runway, and forward versus downward visibility). There was no subject module for aeronautical decision making.
During a telephone conversation with the NTSB IIC, a former company pilot stated that he was employed as a second-in-command pilot on Falcon 20 airplanes by Royal Air Freight, Inc. He said he held a Falcon 20 type rating and received his training at Flightsafety International Inc. prior to his employment at Royal Air Freight, Inc. When he was asked how much flight training and ground training was provided by Royal Air Freight, Inc. in preparation for his Part 135 check ride, which was conducted by the chief pilot, the former pilot said "zero and zero." When asked to describe the ground training received at Royal Air Freight, Inc., the former company pilot said he was given the company operations manual and operations specifications to read, and "that was it." The former company pilot said that he got a call from Royal Air Freight, Inc. saying, "we got a flight." The former pilot said he then flew as a passenger during the outbound leg of Royal Air Freight, Inc. cargo flight under a Part 135, and during the return under Part 91, he was given a Part 135 check ride by the chief pilot. During the checkride, the former pilot performed a stall, a single-engine ILS approach to Willow Run Airport, Detroit, Michigan, and a nonprecision approach to PTK. The former company pilot said that Royal Air Freight, Inc. told him that he did not receive training because his Flightsafety International, Inc. training was "good enough." The former company pilot said that the "only bad thing" at Royal Air Freight, Inc. was the "lack of training" and the difference in training between Royal Air Freight, Inc. and his current employer was "night and day."
A current company pilot, hired by Royal Air Freight, Inc. in November 2013, stated during a post-accident interview that when he applied for a Learjet 35 second-in-command pilot position he received an informal phone interview, which was followed-up by an in-person interview (second interview) and a final in-person interview at Royal Air Freight, Inc. The company pilot said that he received an offer of employment from Royal Air, Inc. during the in-person (second interview). During the final interview, he flew a Learjet 35 from the right pilot seat with the Royal Air Freight, Inc. chief pilot in the left pilot seat. The company pilot said that they did not perform any maneuvers during the flight, but it "was a ride-along" and/or "familiarization" flight that was an hour in duration. The company pilot said that he did not remember who else was aboard the flight. He said that flights flown during October 2013 were training flights. There were no quizzes regarding the Royal Air Freight, Inc. operations specifications.
A second former company pilot, employed by Royal Air Freight, Inc. for about two years after he was hired about November 2011, stated that his initial ground training was different from what he previously experienced. He previously worked as a first officer at a Part 121 air freight operator and at another air carrier. He stated that during his initial ground training at Royal Air Freight, Inc. he would walk in, go upstairs, and "pretty much" sit in their conference room, and it was more of a self-study type program. He said that he was given but not trained and examined on the company operation specifications and the company general operations manual. He said that Royal Air Freight, Inc. did not discuss with him lessons learned from previous accidents/incidents that the company has had. He said the he always worked in a two flight crew environment and found that flying the Cessna 310 in a "hard" IMC environment was definitely a "wake-up call" for him and that single-pilot IMC flying was difficult. During his flight training and check ride at Royal Air Freight, Inc. he did not use a view limiting device during flight visual meteorological conditions. He said that he also rode along on trips with different captains during his training.
A third former company pilot stated that after he graduated from Purdue University's aviation program, he was hired by Royal Air Freight, Inc. in June 2012 as EMB-110 first officer and left Royal Air Freight, Inc. July 2013. He stated that he had about 355 hours of flight time when he was hired, of which 50-60 hours were in multiengine airplanes, and did not have any Part 135 experience. He stated he was given a manual to study in an upstairs conference room where he studied the manual and took notes on his own. He said that Royal Air Freight, Inc. director of operations would come into the conference room every couple of hours to ask him if he had any questions and to talk about a "couple" of the aircraft systems. The former pilot said that "a lot of it was self-teaching" and estimated his study time in the conference room was 6-8 hours per day. He stated that he received a total of about 10-12 hours of ground instruction from the director of operations. He said that the only manual given to him was the EMB-110 systems manual. He said that he was not given the Part 135 operations manual to study. He said that there was no discussion of meteorology during his ground training. He did not receive any written examination during his training and that questions asked to assess his knowledge were not an oral examination but more of an open discussion while the director of operations was teaching. The former pilot said that the chief pilot was not one of the instructor pilots for the EMB-110 so he did not come to the conference room to provide training; the director of operations was the instructor and check airman for the EMB-110. The former pilot said that on June 27, 2012, he flew on a trip with one of the EMB-110 captains and that trip, he believed, counted as training, which was 7.5 hours in duration. The pilot stated that he received only 3.8 hours of flight instruction (the "Certificate of Aircraft Training" stated that the former pilot received 8.1 hours of flight training) that was provided by the director of operations before the former pilot's Part 135 checkride, which was conducted by the director of operations. The former pilot said that during his Part 135 checkride, the only emergency procedure that was performed was an engine failure. During the post-accident interview, the former pilot was shown his Royal Air Freight, Inc. training records, which had signature lines for the pilot and the instructor that provided his training. One of these documents titled "New Hire Training" stated that the pilot completed the training curriculum for the EMB-110. The former pilot stated that he did not think that he received the required 24 hours of basic indoctrination, the 16 hours of aircraft training, and the 4 hours of emergency training cited on the "New Hire Training" form. The former pilot stated that they did not discuss meteorology nor did they discuss stabilized approaches during his training. The former pilot's "Certificate of Ground Training," "Certificate of Aircraft Training," "Certificate of Emergency Training," and Certificate of Flight Training" had signatures on the instructor's signature line and no signatures on the student's signature line. The former pilot stated during the interview that he had not seen these documents before and that he never signed such documents. He said that he had not seen the Royal Air Freight, Inc. training manual.
ADDITIONAL INFORMATION
Corporate Culture
The director of operations was also the president and vice president of Royal Air Freight, Inc. During the post-accident interview of the director of operations, the director of operations was asked by the NTSB IIC to describe what is done to have a good corporate culture. The director of operation's only response was, "Hard to describe all the details that go into that. Many facets."
The company pilot who had flown with the pilot on December 10, 2014, stated during his interview that relative to other pilot employment he had held, working at Royal Air Freight, Inc. regarding workload and fatigue was "…probably the easiest job… ." He stated that he did not experience pressure by Royal Air Freight, Inc. to complete flights.
The third former company pilot, who flew EMB-110 airplanes, stated that some of the positive things about working at Royal Air Freight, Inc. were that he liked his job because of the people he flew with; they were "nice people, experienced." He said the negative aspects of working at Royal Air Freight, Inc. were the lifestyle and that it was a "very demanding job." He said that being called out on trips at three or four times per week at 0200 or 0300 was "really exhausting".
The last company pilot that was interviewed who was currently employed by Royal Air Freight, Inc. was asked by the IIC what are the positives and negatives of working at Royal Air Freight, Inc. He responded by saying "what relevance does this have to this?" He was then asked what the corporate culture was like at Royal Air Freight, Inc., to which he said "I have no idea what the corporate culture is like; I just drive the airplane."
All figures in this report are available in the public docket for this accident, which can be found at: http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=88665
NTSB Identification: CEN14FA110
14 CFR Part 91: General Aviation
Accident occurred Friday, January 10, 2014 in Waterford, MI
Aircraft: CESSNA 310R, registration: N3829G
Injuries: 1 Fatal.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
On January 10, 2014, about 1948 eastern standard time, a Cessna 310R, N3829G, impacted trees and terrain about 1,500 feet west of the approach end of runway 9R (6,521 feet by 150 feet, asphalt) at Oakland County International Airport (PTK), Pontiac, Michigan, during an instrument landing system approach to the runway. Night instrument meteorological conditions prevailed at the time of the accident. The airplane was destroyed by impact forces and post impact fire. The commercial pilot sustained fatal injuries. The airplane was registered to and operated by Royal Air Freight, Inc. as Flight 907 under 14 Code of Federal Regulations Part 91. The positioning flight was operating on an instrument rules flight plan and departed from Fulton County Airport-Brown Field (FTY), Atlanta, Georgia, about 1701, and was destined to PTK.
Andrew Demos, the pilot in a twin-engine Cessna 310 on its way back from Atlanta, Ga., crashed at 7:48 p.m. Friday in the Pontiac Lake State Recreation Area just on its approach to the Oakland International Airport, near Williams Lake and Gale roads. Visibility was low Friday night with rainy conditions.
The plane was owned by Royal Air, an air freight and charter company based out of the Waterford airport, and Demos has been a charter pilot for the company for about a year, his LinkedIn profile states.
As the Federal Aviation Administration, along with the National Transportation Safety Board, continues what is expected by Oakland officials to be a prolonged investigation into the crash, Demos has not been formally identified at the Oakland County Medical Examiner’s Office.
However, records with the state and online begin to paint a picture of the pilot, whose online resume indicates that he made stops in Australia, Alaska and was certified in his craft at the Illinois Aviation Academy.
He also received a master’s in aerospace operations from Embry-Riddle Aeronautical University and an undergraduate degree in electrical engineering and acoustical physics from Northern Illinois University, according to the profile.
LinkedIn.com also shows that Demos was accredited with just less than 10 aviation classifications, such as certification in emergency control organization operation and certified pilot’s licenses in two countries.
State licensing records indicate that Demos’ wife, Lauren, is also an accomplished professional who specializes in veterinary medicine in Waterford. She is listed as a practicing feline medicine resident at Exclusively Cats, which is located at 6650 Highland Road.
Lauren’s biography lists that she made stops at the same places her late husband did throughout his career — she earned a bachelor’s degree in veterinary medicine at Murdoch University in Perth, Australia and also graduated from Northern Illinois University with a focus in acoustical physics, jazz performance, and computer music, it states.
She was not at the office Monday — on leave due to her husband’s death, said a receptionist at the practice — and was not immediately available for comment.
It is unknown whether the couple had children, officials have said.
WATERFORD TWP. >> Federal aviation investigators were at the scene of a plane crash Saturday in the Pontiac Lake State Recreation Area that left a 32-year-old Waterford resident dead Friday night.
The pilot, Andrew Demos, was flying a twin-engine Cessna 310 back from Atlanta, said J. David VanderVeen, director of Oakland County Central Services, which oversees the Oakland County International Airport. The plane crashed during its final approach at 7:48 p.m. Friday night, killing Demos, the only one aboard.
VanderVeen said Demos has “all the appropriate licenses” and carried multiple degrees in aviation.
“He was real qualified,” he said of Demos, adding, “It’s always tragic when the aviation community loses one of our members and our heartfelt sympathies go out to the family.”
Demos received a master’s in aerospace operations from Embry-Riddle Aeronautical University and earned his certification from the Illinois Aviation Academy, according to his LinkedIn profile.
VanderVeen said the 32-year-old’s next of kin had been contacted. Demos was married, he said, but it’s unknown if the couple had children.
The plane was owned by Royal Air, an air freight and charter company based at the airport. The company declined to comment Saturday.
Royal Air flies private charters and cargo delivery planes, according to the company’s website, with a fleet that consists of seven types of aircraft. It was founded in 1962 at the Oakland airport.
It’s unclear what caused the crash. Visibility was low Friday night with rainy conditions.
“It’s way too early to speculate,” VanderVeen said. Investigators will turn information over to the National Transportation Safety Board, which will “take some time” to conduct an investigation and deliver a final report, he said.
“These things typically take a matter of weeks or months before they make the final determination.”
A jet landed 15 minutes at the airport before the crash and two planes were en route, VanderVeen said, “so, the airport was operational.”
But, on Friday, the airport was under instrument flight rules, meaning visibility was limited and pilots had to use aircraft instruments to take-off and land.
The airport closed for about two hours after the crash, he said. It reopened at 9:55 p.m. Friday.
A spokesperson for the Federal Aviation Administration could not be reached Saturday.
Waterford Regional Fire Department Capt. John Lyman spotted the plane as he was headed toward home Friday. He said he witnessed a glowing light in the sky, followed by a fireball, which shot above 50-foot trees.
Lyman said he headed to the crash and located the plane about 150 yards from the park boat launch off a snowmobile trail.
Waterford Regional Fire crews who responded had to climb through deep snow to get to the crash, he said.
Waterford police, which had no additional comment Saturday, also responded. “He just missed the lake,” Lyman said.
About two hours after the crash, Bill Clink and his family heard helicopters hovering near the crash site, which sat just about a mile from his home in the 9100 block of Gale Road — near Williams Lake Road — which overlooks Pontiac Lake.
“We didn’t even know what it was until my wife looked at her phone and saw the news,” said Clink, who has been worried in the past about the size of the planes that fly over his home to the airport.
An investigator at the Oakland County Medical Examiner’s Office could not confirm the identity of the pilot Saturday, saying the body was badly burned in the incident.
“He’s beyond recognition,” the investigator said. “We cannot say who he is ... we’re going to have to do dentals.”
Crews had to use fire extinguishers on the flames.
This is the second fatal plane crash within seven months at or near the airport.
On June 21, a rented Cessna 172 private, single-engine plane crashed at 1:40 p.m. in a field at the airport’s north end. The crash killed four people — three men and one woman.
Story and video: http://www.wxyz.com
Andrew W. Demos of Waterford, MI, passed away suddenly January 10, 2014 at 32 years of age. Loving husband of Lauren (nee Schuster) for 5 years; adored son of Patricia (Arthur) Frerichs and the late Vasilios Demopoulos; treasured brother of Jennifer (Eric) Papenhagen; grandson of Jean Leech; son in law of Marcia and Edward Schuster, II. Preceded in death by grandparents, Helen and Ernest Gager, Gilbert Leech, and Earl and Jane Reese. Andy experienced an extraordinary life, having lived and flown as a pilot in Alaska, Australia, Wisconsin, Illinois, and Michigan. He earned a bachelors degree from Northern Illinois University in Acoustical Physics and New Media Technologies and a masters degree from Embry-Riddle Aeronautical University in Aviation and Aerospace Operations. He was an Eagle Scout and member of the Phi Mu Alpha fraternity. Family will receive friends and loved ones Sunday, January 19, 2014 from 2 to 8 p.m. at Brust Funeral Home, 135 S. Main St., Lombard, IL with a service at 4 p.m. In lieu of flowers, donations may be given to establish a memorial scholarship in Andy’s name. Contributions may be mailed to: Office of Development, Embry-Riddle Aeronautical University, 600 S. Clyde Morris Blvd, Daytona Beach, FL 32114-3900. Checks should be made out to Embry-Riddle Aeronautical University, and note “In Memory of Andrew Demos” on the memo line. For additional information, contact Steve Bobinsky, Executive Director of Development 928-777-4210.
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