Air traffic controllers’ lack of training and experience dealing with aircraft in distress were causes or contributing factors in the five fatal crashes covered by the report, the NTSB said.
“The NTSB concludes that, based on the accidents discussed above, the current training provided to air traffic controllers is not effective in preparing them to provide appropriate assistance to aircraft in distress,” the report said.
The report cited a Jan. 13, 2015, fatal crash in New Smyrna Beach as part of the NTSB investigation.
The crash involved a single-engine Cessna that went down after the pilot told air traffic control she was having difficulty flying by sight.
Instead of instructing the pilot to an airport with better visibility, air traffic controllers instructed her to turn to land at New Smyrna Beach Airport.
Conditions at New Smyrna Beach Airport at the time required pilots to maneuver mainly via their instrument panel, the report said.
Not providing the pilot with assistance flying by instruments was a contributing factor in the crash, the NTSB said.
The other fatal Florida crash cited in the report was a fiery crash on Jan. 4, 2013, when a pilot crashed into a home while trying to land at Flagler County Airport in Palm Coast.
The pilot had contacted air traffic controllers saying he was having engine trouble, but had in fact lost all power, the report said.
Although the plane was almost directly over the airport, the air traffic controller directed the plane away and it crashed a mile short of the runway, the report said.
The controllers were operating under the assumption that the plane had at least partial power, it said.
While the pilot did not say the plane had lost all power, the air traffic controllers should have recognized a potential emergency and obtained more specific information from the pilot, the NTSB said.
The pilot and two passengers died in the crash.
Other crashes cited in the report included an April 11, 2014, crash in Hugheston, West Virginia, that killed two; a Dec. 16, 2012, crash in Parkton, North Carolina, that killed the pilot; and an Aug. 11, 2012, crash in Effingham, South Carolina, that left the pilot and a passenger uninjured but seriously damaged their aircraft.
The report recommended two steps for the Federal Aviation Administration to take that would potentially remedy the training deficiencies of air traffic controllers.
The first was for the FAA to require ongoing national scenario-based training for air traffic controllers that would teach them how to identify and respond to emergency situations.
The second recommendation called for the FAA to revise required air traffic controller training with reference to “current and relevant” emergency scenarios from recent events.
The recommendations are not binding and it is up to the FAA to decide if they will be implemented completely or in part.
Tabata’s Facebook page contains a post from January 11, 2015 that appears to show a navigational map of New Smyrna Beach.
NTSB Docket and Docket Items: http://dms.ntsb.gov
NTSB Identification: ERA15FA099
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 13, 2015 in New Smyrna Beach, FL
Probable Cause Approval Date: 04/14/2016
Aircraft: CESSNA 152, registration: N757ZM
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 commercial pilot was in the process of purchasing a block of flight time with the intent of building time toward an additional rating. According to the operator, the pilot did not complete the mandatory checkout. However, she possessed the keys to the airplane since she had flown the previous day with an instructor, but he did not approve her for solo flight because he believed she required additional practice landing the airplane with an instructor onboard. On the day of the accident, she flew an undetermined number of local, solo flights without the knowledge of the operator. The accident flight was initiated at night, presumably with the intent of operating in the local airport traffic pattern. About 7 minutes into the flight, the pilot likely encountered instrument meteorological conditions (IMC) and requested assistance from air traffic control. An air traffic controller attempted to provide the pilot with radar vectors to a nearby airport; however, the pilot was unable to visually acquire that airport. The controller then observed the airplane on radar at 600 ft and descending and directed the pilot to climb and turn. A short time later, radar and radio contact were lost; the airplane had crashed. The level of damage and fragmentation of the wreckage was consistent with ground impact at a high velocity. The flight was conducted on a dark, moonless night, under an overcast ceiling, and the final portion of the flight was over the ocean. These factors would have reduced the pilot’s ability to perceive the natural horizon and increased her risk of spatial disorientation.
Although the pilot held an instrument rating and had recently completed an instrument proficiency check, on the night of the accident, she did not demonstrate the skills necessary to control an airplane in IMC. She also did not display the ability to adequately communicate her situation to the controller, nor did she seem to understand or comply with the assistance offered to her. Review of autopsy results and postaccident toxicological testing showed no evidence of any physiologically induced incapacitation or other impairment. During the sequence of events leading up to the accident, the pilot communicated with two air traffic controllers. The pilot described that she was operating in conditions that limited her ability to navigate and potentially affected her ability to control the airplane under visual flight rules (VFR).
Although the actions of the controllers did not directly contribute to the pilot’s loss of control while attempting to fly under VFR in IMC, the controllers did not act in accordance with Federal Aviation Administration (FAA) guidance that dictates how to assist pilots experiencing this type of emergency. Specifically, the controllers did not ascertain if the pilot was qualified and capable of IFR flight nor did they attempt to locate and direct the pilot toward the nearest areas reporting visual meteorological conditions. Further, a controller assisting the accident controller had the opportunity to solicit a pilot report from another pilot in a nearby airplane to ascertain if that airplane was operating above the reported IMC but did not do so. During postaccident interviews, the air traffic controllers indicated that they had not received FAA-required evidence-based simulation training on emergencies and described the computer-based emergency training that they received as poor quality.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to maintain control of the airplane while operating under visual flight rules (VFR) in night, instrument meteorological conditions, likely due to spatial disorientation. Contributing to the outcome was the radar controller's failure to follow published guidance for providing assistance to VFR pilots having difficulty flying in instrument conditions.
HISTORY OF FLIGHT
On January 13, 2015, about 2058 eastern standard time, a Cessna 152, N757ZM, collided with a public beach at New Smyrna Beach, Florida. The commercial pilot was fatally injured and the airplane was substantially damaged by impact forces. The airplane was registered to a private company and was operated by the pilot under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Night, instrument meteorological conditions (IMC) prevailed for the flight, and no flight plan was filed. The local flight originated from Massey Ranch Airpark (X50), Edgewater, Florida, about 2040.
Prior to the accident flight, the pilot, who was a Japanese citizen, contacted Flight Time Building LLC to purchase a block of flight time in a Cessna 152. According to the company's website, the company sold "blocks" of flight time to licensed pilots, with 50 hours being the minimum-sized block. The company normally dispatched an airplane to the pilot upon completion of a ground and flight "checkout." According to the owner of Flight Time Building, on the day prior to the accident, the pilot flew a local flight with an instructor, followed by a cross country flight with a safety pilot, who was an instructor-in-training. The owner reported that the pilot was not "signed off" for solo flight after the flights on January 12. The flight instructor stated that he needed to see "improved landings" before he could approve her for solo flight.
On the day of the accident, she flew an undetermined number of local, solo flights without the knowledge of Flight Time Building personnel. She possessed the keys to the accident airplane since she had flown it on the previous day with the safety pilot. She refueled the airplane at her own expense and initiated the accident flight, which was a local, night flight in the traffic pattern at X50.
At 2042:03, a radar target correlated to be the accident airplane was about 1 nautical mile (nm) south of X50. Radar data indicated the aircraft was in a left, 360-degree turn.
At 2047:22, the accident pilot pilot transmitted on the emergency frequency, 121.5 MHz, "hello," followed by two more transmissions of the her saying "hello." This coincided with radar data that depicted the accident aircraft emitting a transponder code of, or "squawking," 7700 (emergency) about 3.5 nm south of X50, or about 8.4 nm south of New Smyrna Beach airport (EVB).
At 2047:42, the pilot stated "uh I don't know where I am I want to land." At 2047:52, the Daytona Beach (DAB) Radar South controller transmitted, "The aircraft that doesn't know where they are at; are they at 1,700 feet squawking emergency and 1200?" At 2048:21, the pilot transmitted "I want to land."
The EVB local controller heard the pilot asking for assistance on 121.5 MHz. Because the aircraft was close to EVB, he was able to establish communications. Between 2048 and 2053, the EVB local controller provided assistance to the pilot. The pilot advised the EVB air traffic controller that she could see the ground but could not maintain visual flight conditions. When the EVB local controller turned the pilot toward EVB, the pilot reported that she could see the airport, but a short time later said she could no longer see it. The EVB local controller then attempted to transfer communications to DAB approach control on 125.35 MHz.
At 2053:52, the EVB local controller advised DAB ATC that the aircraft was proceeding towards DAB, and that EVB would have the lights set on high intensity if they needed the airport. The DAB Radar South controller replied, "thanks, we are going to try it." At 2054:35, the pilot of N757ZM transmitted "hello" on the emergency frequency 121.5, and at 2054:41 continued, "on 125.25 no ah contact." The pilot had been instructed by EVB to contact DAB on 125.35 MHz. The DAB Radar South controller responded on 121.5 by asking the pilot if she could hear DAB.
At 2054:49, the pilot again transmitted that she was unable to reach anybody on 125.25. The DAB air traffic controller replied "ok just stay on this frequency you are all right, maintain your present altitude." The EVB local controller informed the DAB air traffic controller that the pilot could not hear DAB on 125.35. DAB advised the EVB local controller that the pilot was on the wrong frequency, and that the DAB controller would assist the pilot on the emergency frequency.
At 2055:15, the pilot transmitted "hello." The DAB air traffic controller established communications with the pilot on 121.5 and asked the pilot if she could hear DAB; the pilot responded, "I can hear you."
At 2055:22, the DAB controller instructed the pilot to "remain calm and to maintain present altitude." The DAB controller told the pilot to continue the right turn northbound towards EVB, and that the airport would be off the right side. The DAB controller added that EVB would have all the runway lights turned on to high and instructed the pilot to advise when she saw the lights.
At 2055:40, the pilot transmitted on 121.5 that she was heading 100 degrees, and asked the DAB air traffic controller what heading she needed to fly. The DAB air traffic controller told the pilot that if she were able, to turn left heading 360 and that EVB would be at the pilot's 12 o'clock position and one and a half nautical miles. After an unintelligible transmission from the pilot, the DAB controller told the pilot she was not required to read back any further transmissions, and to make the turn. The DAB controller instructed the pilot to advise when she saw the lights at EVB. The pilot verified the heading and asked if she needed a left turn, heading 300. The DAB air traffic controller instructed the pilot to continue a left turn, heading 360 and reiterated the EVB position relative to the aircraft. The pilot acknowledged the turn.
At 2056:57, the DAB air traffic controller told the pilot to land any runway at EVB if she saw the runway lights. At 2057:06, the pilot stated she was at 600 feet and the DAB air traffic controller instructed the pilot to maintain her altitude until she saw the airport. The pilot replied that she was in the clouds. The DAB controller told the pilot, "okay don't worry, don't worry, don't worry, don't worry ma'am, just calm down, calm down; make a left turn." The DAB air traffic controller then instructed the pilot to make a left turn to climb because she had been in a descent. The DAB air traffic controller advised the pilot it was okay to be in the clouds but that she needed to climb.
At 2057:48, the DAB controller asked the pilot if she was climbing, and told her that she needed to maintain at least 1,000 feet. The pilot acknowledged the climb to 1,000 feet, followed by an unintelligible transmission. The DAB air traffic controller reiterated the climb to 1,000 feet and for the pilot to advise DAB when she was comfortable. There were no further transmissions from the pilot.
A short time later, radar and radio contact was lost and the airplane crashed onto New Smyrna Beach, in shallow water. Radar data indicated a descending, right turn prior to impact. The altitude of the last observed radar target was 500 feet above mean sea level. Emergency responders arrived at the accident site shortly thereafter in an attempt to provide assistance.
The pilot, age 38, held a commercial pilot certificate with ratings for airplane single engine land, airplane multi-engine land, and instrument airplane. She was issued a Federal Aviation Administration (FAA) third-class medical certificate on August 18, 2014, with a restriction to wear corrective lenses.
Pilot records recovered from the wreckage indicated that the pilot had logged about 416 total hours of flight experience as of January 7, 2015. She had logged about 1.3 hours of night time and about 6.1 hours of actual instrument time prior to the accident flight. Logbook entries showed that she completed a 14 CFR Part 61.55 flight review and a 14 CFR 61.57(d) instrument proficiency check (IPC), in a Cessna 152, at Torrance, California on November 19, 2014. The flight review and IPC were performed with different flight instructors. Her pilot logbook indicated she flew about 2.4 hours on June 30, 2014, in a Beech BE-58 and did not log another flight prior to her flight review and IPC of November 19, 2014.
FAA inspectors interviewed the flight instructors who performed the flight review and IPC. Both flight instructors reported that the accident pilot showed no weaknesses, handled the radios during the flight, was familiar with the local area, and was a "good pilot."
The airplane was a Cessna model 152 that was manufactured in 1977. The high-wing, fixed tricycle landing gear airplane was powered by a Lycoming O-235-L2C engine, rated at 110 horsepower at 2,550 rpm and was equipped with a Sensenich 72CK56-0-54 metal, fixed-pitch propeller.
According to the maintenance logbooks provided by the owner, the most recent annual inspection of the airframe and engine was completed on October 27, 2014, at 502.1 hours tachometer time. The observed tachometer time at the time of the accident was 525.8 hours. The aircraft total time was not recorded in on the logbook entries, and the owner estimated that the total time of the airframe was about 12,000 hours.
The National Weather Service (NWS) Surface Analysis Charts for 1900 and 2200 on January 13, 2015 depicted a cold front moving across central into southern Florida with cold air stratus clouds behind the front. Numerous station models behind the front depicted visibilities restricted in mist or fog, with temperature-dew point spreads of less than 5° F, and in the vicinity of the accident site less than 3° F.
The NWS Weather Depiction Chart for 2000 depicted an extensive area of IMC extending from the accident site and across most of all of central and northern Florida, Georgia, South Carolina, portions of southern and eastern North Carolina, and portions of Tennessee, Alabama, Mississippi, and Louisiana. A second area of IMC was also identified over southern Florida ahead of the front in the vicinity of West Palm Beach with marginal visual meteorological conditions extending through most of central and into southern Florida. The closest visual meteorological conditions with ceilings above 3,000 feet and visibility greater than 5 miles were over southwestern Florida, and extreme south Florida. The chart indicated that fog and low ceilings were not a localized event over the New Smyrna Beach area, but extended over most of the area.
The National Center for Atmospheric Research regional radar mosaic for 2100 depicted no significant weather echoes associated with rain showers or thunderstorms in the vicinity of the accident site during the period.
The NWS 12-hour Low-Level Significant Weather Prognostic Chart valid for 0100 and available for briefing prior to the accident depicted the cold front moving across southern Florida with an extensive area of IMC expected over most of all of Florida, Georgia, South Carolina, Alabama, and into sections of Mississippi, and Tennessee. The chart depicted no significant turbulence outside of convective activity was expected, and depicted the freezing level near 12,000 feet over the region.
No weather reporting capability was present at X50. A review of the observations surrounding the area indicated that at the time the accident airplane departed from X50, IMC were already being reported surrounding the area at EVB, DAB, and to the south at the NASA Shuttle Landing Facility (TTS), Titusville, Florida.
EVB was located approximately 5 nm north of the departure airport at an elevation of 10 feet, and less than 3 miles west of the accident site. The airport had an Automated Weather Observation System. The weather conditions reported at 2055, or about 3 minutes prior the accident, included wind from 350° at 8 knots, visibility 8 statute miles, ceiling overcast at 500 feet, temperature 17° Celsius (C), dew point 16° C, altimeter 30.14 inches of mercury (Hg).
The next closest weather reporting station was DAB, located approximately 14 nm northwest of the departure airport at an elevation of 34 feet. The airport had a control tower and a federally installed and maintained Automated Surface Observation System (ASOS). The weather conditions reported at 2053, or about 5 minutes prior the accident, included wind from 020° at 9 knots, visibility 10 statute miles, ceiling overcast at 700 feet, temperature 18° C, dew point 16° C, and altimeter 30.14 inches of Hg.
The DAB special weather report at 2131 included wind from 360° at 11 knots gusting to 17 knots, visibility 1 statute mile, ceiling overcast at 400 feet, temperature 16° C, dew point 15° C, and altimeter 30.15 inches of Hg.
The DAB special weather report at 2146 included wind from 360° at 8 knots, visibility ½ statute mile in fog, ceiling overcast at 300 feet, temperature 16° C, dew point 15° C, and altimeter 30.15 inches of mercury. Remarks: automated observation system, tower visibility 1-mile, temperature 15.6° C, dew point 15.0° C.
Orlando Sanford International Airport (SFB), Orlando, Florida, was located 20 nm southwest of the departure airport at an elevation of 55 feet, and was equipped with an ASOS. The weather conditions reported at SFB, at 2100, included wind from 360° at 9 knots, visibility 10 statute miles, ceiling broken at 1,000 feet, overcast at 3,900 feet, temperature 19° C, dew point 17° C, altimeter 30.14 inches of Hg.
On the day of the accident, sunset occurred about 1745 and evening civil twilight occurred about 1811. Moonrise occurred at 0029, and moonset occurred at 1212.
The DAB North Controller, who assisted the accident controller, solicited pilot reports (PIREPS) for the DAB local area earlier in her shift, but could not recall their specific content. During the accident sequence, she had been working a Cirrus SR22, whose pilot requested the RNAV runway 29 approach into EVB. The SR22 was at 3,000 feet holding at RISRE, about 10 NM east of EVB and near the accident aircraft, but she did not solicit a PIREP from the pilot or ask about cloud tops.
Paragraphs 10-2-8 and 10-2-9 of FAA order 7110.65 address how air traffic controllers should provide radar assistance to aircraft operating under visual flight rules (VFR) in weather difficulty, including techniques that should be used to the extent possible when providing assistance. They state [in part]:
10-2-8. RADAR ASSISTANCE TO VFR AIRCRAFT IN WEATHER DIFFICULTY
a. If a VFR aircraft requests radar assistance when it encounters or is about to encounter IFR weather conditions, ask the pilot if he/she is qualified for and capable of conducting IFR flight.
b. If the pilot states he/she is qualified for and capable of IFR flight, request him/her to file an IFR flight plan and then issue clearance to destination airport, as appropriate.
c. If the pilot states he/she is not qualified for or not capable of conducting IFR flight, or if he/she refuses to file an IFR flight plan, take whichever of the following actions is appropriate:
1. Inform the pilot of airports where VFR conditions are reported, provide other available pertinent weather information, and ask if he/she will elect to conduct VFR flight to such an airport.
2. If the action in subparagraph 1 above is not feasible or the pilot declines to conduct VFR flight to another airport, provide radar assistance if the pilot:
(a) Declares an emergency.
(b) Refuses to declare an emergency and you have determined the exact nature of the radar services the pilot desires.
3. If the aircraft has already encountered IFR conditions, inform the pilot of the appropriate terrain/obstacle clearance minimum altitude. If the aircraft is below appropriate terrain/obstacle clearance minimum altitude and sufficiently accurate position information has been received or radar identification is established, furnish a heading or radial on which to climb to reach appropriate terrain/obstacle clearance minimum altitude.
10-2-9. RADAR ASSISTANCE TECHNIQUES
Use the following techniques to the extent possible when you provide radar assistance to a pilot not qualified to operate in IFR conditions:
a. Avoid radio frequency changes except when necessary to provide a clear communications channel.
b. Make turns while the aircraft is in VFR conditions so it will be in a position to fly a straight course while in IFR conditions.
c. Have pilot lower gear and slow aircraft to approach speed while in VFR conditions.
d. Avoid requiring a climb or descent while in a turn if in IFR conditions.
e. Avoid abrupt maneuvers.
f. Vector aircraft to VFR conditions.
g. The following must be accomplished on a Mode C equipped VFR aircraft which is in emergency but no longer requires the assignment of Code 7700:
1. TERMINAL. Assign a beacon code that will permit terminal minimum safe altitude warning (MSAW) alarm processing.
WRECKAGE AND IMPACT INFORMATION
The wreckage was located in shallow water at approximate coordinates 29 02 22.68N, 080 53 52.69W. The wreckage was pulled onto the beach by local authorities after coordination with the NTSB investigator-in-charge to prevent further damage and loss of parts.
The left and right wings separated from the fuselage during the impact sequence. The outboard 4 feet of the left wing was separated from the remainder of the wing. The right wing exhibited diagonal and aft crush deformation, beginning 2 feet from the wing root to the aft spar at the wing tip. Aileron control cable continuity was established through multiple recovery cuts and fractures consistent with overstress. A majority of the left aileron was not located. The wing flap actuator was found in the retracted (flaps up) position.
The fuselage was separated into multiple sections, including a section consisting of the engine firewall and instrument panel, the landing gear and cabin floor, and an 8-foot section of aft fuselage. The right main landing gear was not recovered. The nose landing gear was separated and located with the main wreckage.
The empennage separated aft of station 173. The horizontal and vertical stabilizers remained attached. The outboard half of the right horizontal stabilizer leading edge was crushed in an up and aft direction. Rudder and elevator control cable continuity was established through multiple recovery cuts and fractures consistent with overstress.
Both wing fuel tanks were breached during the impact sequence and no residual fuel of found. The fuel selector handle was found in the "on" position and the unit operated normally in the "on" and "off" positions when forced air was introduced into the selector valve. Sand was found in the fuel strainer bowl and screen. The odor of fuel was observed in the strainer bowl.
The propeller separated from the crankshaft flange and was found partially buried in sand at the location of the main wreckage. The blades exhibited twisting deformation, leading edge gouges, and surface polishing.
The engine was separated from the firewall. The carburetor, carburetor air box, and alternator were missing and were not located. All engine components were subjected to salt water and sand immersion. The carburetor flange was fractured from impact and was still attached to the oil sump. The carburetor data plate was lodged into the induction tube at the oil sump.
The valve covers, magnetos, vacuum pump, and exhaust were removed by investigators. Mechanical internal continuity was established by rotating the rear accessory gears at the vacuum pump drive with a mechanical device. All valve action was confirmed through 720 degrees of crankshaft rotation and thumb suction and compression was observed at all cylinders. A digital video boresope examination of the interior of the cylinders and the piston surfaces revealed normal operating signatures. The magnetos were turned with a hand drill and by hand rotation; no spark could be produced. The spark plug electrodes were normal in appearance except for salt water, oil, and sand contamination.
The inspection of the engine did not reveal any abnormalities that would have prevented normal operation or production of rated horsepower.
MEDICAL AND PATHOLOGICAL INFORMATION
A postmortem examination of the pilot was performed at the offices of the District 7 Medical Examiner, Daytona Beach, Florida, on January 14, 2015. The autopsy report noted the cause of death as "Multiple Blunt Traumatic Injuries" and the manner of death was "Accident."
Forensic toxicology testing of the pilot was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The CAMI toxicology report indicated negative for carbon monoxide, ethanol, and drugs. Testing for cyanide was not performed.
FAA Guidance to Pilots
In April 2003, the FAA published Advisory Circular 61-134, General Aviation Controlled Flight into Terrain Awareness. The circular stated in part:
"Operating in marginal VFR /IMC conditions is more commonly known as scud running. According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC. As defined in 14 CFR part 91, ceiling, cloud, or visibility conditions less than that specified for VFR or Special VFR is IMC and IFR [instrument flight rules] applies. However, some pilots, including some with instrument ratings, continue to fly VFR in conditions less than that specified for VFR. The result is often a CFIT [controlled flight into terrain] accident when the pilot tries to continue flying or maneuvering beneath a lowering ceiling and hits an obstacle or terrain or impacts water. The accident may or may not be a result of a loss of control before the aircraft impacts the obstacle or surface. The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot's skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough."
According to FAA Advisory Circular AC 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further states that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions.
According to the FAA Airplane Flying Handbook (FAA-H-8083-3), "Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree.… Generally, at night it is difficult to see clouds and restrictions to visibility, particularly on dark nights or under overcast. The pilot flying under VFR must exercise caution to avoid flying into clouds or a layer of fog." The handbook described some hazards associated with flying in airplanes under VFR when visual references, such as the ground or horizon, are obscured. "The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."
Air Traffic Controller Training
As part of the investigation into this accident, air traffic controllers were asked about their preparedness to provide assistance to a pilot in an emergency situation. FAA air traffic controllers were required to undergo proficiency training that "maintains and upgrades the knowledge and skills necessary to apply air traffic procedures in a safe and efficient manner." This training included recurrent training and refresher training. Chapter 1 paragraph 5, (a) and (b), of FAA JO 3120.4N, Air Traffic Technical Training, addressed the requirements of recurrent and refresher training and stated [in part]:
JO 3120.4N Air Traffic Technical Training
a. Recurrent Training. Recurrent training is collaboratively-developed national safety training delivered via electronic means, instructor-led presentations, or any combination thereof. Recurrent training is intended to increase air traffic controller proficiency, enhance awareness of human factors affecting aviation, and promote behaviors essential for the identification, mitigation, and/or management of risk. Topics are derived from data collected through internal and external safety reporting systems and stakeholder input. Recurrent training is conducted via an 8-hour block of training, two rounds delivered yearly. Each round is comprised of approximately 4 hours of training selected from the topics listed below, and 4 hours of training on relevant and timely safety topics, such as but not limited to: Human Factors, Safety Culture, Threat and Error Management, Crew Resource Management, Event Recovery, and learning that promotes the maturity of the Safety Management System. Recurrent training requirements are identified annually NLT October 1st to be delivered the following calendar year. Recurrent training on the following items need not be duplicated in local refresher training:
(1) Safety alerts and traffic advisories, to include Minimum Safe Altitude Warning (MSAW) procedures and the relationship between charted minimum altitudes and underlying topography.
(2) Weather and other conditions that affect flight (e.g., icing, thunderstorms, windshear, and VFR aircraft that encounter instrument flight rules (IFR) conditions).
(3) Bird activity information and dissemination.
(4) Wake turbulence information and application.
(5) Line up and wait (LUAW).
(6) Runway Safety.
(7) Recovery in ATC Operations.
(8) Fatigue awareness.
b. Refresher Training. Each facility must maintain, in writing, an annual (calendar year) refresher training plan. Annual refresher training contains two elements: nationally and/or facility-developed curriculum and simulation training. Facilities are encouraged to review their quality control data (e.g., Quality Control Monitoring, Service Reviews, and Compliance Verification and data available in the Partnership for Safety Portal) to identify additional topics for annual refresher training in order to meet each facility's changing needs. The following topics must be included unless designated by the TA as not applicable.
(1) Unusual situations, lost aircraft orientation, aviation security procedures (including interceptor procedures and communications), hijacking, and other topics identified by the TA. (Training on emergency situations should be based on real-life incidents and aircraft accidents, stressing a lessons-learned approach.)
(15) Facilities with simulation capabilities such as AT Coach, ETG, TTG, DYSIM, TSS,TTL, SIMFAST, O21 lab, etc., must complete locally identified, evidence-based simulation training on the topics identified in paragraph 5.b., Refresher Training, deemed appropriate by the TA, as follows:
(a) A minimum of one hour of evidence-based simulation training in calendar year 2014.
(b) A minimum of two hours of evidence-based simulation training in calendar year
Appendix (J) of the JO 3120.4N Air Traffic Technical Training identified the definitions and state [in part]:
Appendix J. Definitions
17. Evidence-based Training: Training based on an analysis of safety data.
All of the air traffic controllers indicated the recurrent training required by the FAA was lacking, and they couldn't remember any substance of the topics. All of the recurrent training they could remember was via computer-based instruction or by slide-based presentation. Both of the air traffic controllers on duty the night of the accident could not recall any refresher training utilizing the simulator as required, and the supervisor indicated most controllers viewed the training as an annoyance.
Michael R. Anders, a 58-year-old Kentucky high school teacher, was killed when the plane he was piloting crashed into a Palm Coast home, killing two others.
14 CFR Part 91: General Aviation
Accident occurred Friday, January 04, 2013 in Palm Coast, FL
Probable Cause Approval Date: 05/08/2014
Aircraft: BEECH H35, registration: N375B
Injuries: 3 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 departed under visual flight rules and was at an altitude of about 7,500 feet when the pilot reported vibrations and an “oil pressure problem.” Airports in the area were under instrument meteorological conditions with cloud ceilings of 900 to 1,000 feet above ground level (agl). An air traffic controller provided the pilot with radar vectors for an airport surveillance radar (ASR) approach to a nearby airport that did not have a published ASR procedure. The airplane was about 2.5 miles northwest of the airport, at an altitude of about 5,300 feet agl, when the pilot reported that the engine oil pressure was “zero” with “cool cylinders.” The controller did not obtain nor did the pilot provide any additional information about the engine’s power status. During the next approximately 7 minutes, the airplane continued past the airport to a point about 6.5 miles northeast before the controller vectored the airplane to the south and then west to the final approach course. The airplane subsequently struck trees and a residence about 3/4 mile from the approach end of the runway. A postcrash fire destroyed the airframe and engine.
Postaccident examination of the airplane revealed that the engine sustained a fractured No. 4 connecting rod due to oil starvation. The connecting rod punctured the crankcase, which resulted in a total loss of engine power. The crankshaft oil transfer passage at the No. 4 journal sustained mechanical damage during the accident sequence and contained displaced journal material. All other oil passages were unrestricted. The airplane’s maintenance logbooks were destroyed during the accident. Maintenance performed on the airplane about 1 month before the accident included the replacement of the Nos. 1 and 4 cylinders; however, it could not be determined if this maintenance played a role in the accident. The reason for the oil starvation could not be determined.
Review of the air traffic control transcripts and interviews with the controllers revealed that they vectored the airplane such that it was unable to reach the airport. This was likely due to the weather conditions and the controllers’ incomplete understanding of the airplane’s mechanical condition (complete loss of power), which the pilot did not provide.
At the time of the accident, the pilot was using medication for hypertension and had well-controlled diabetes. It was unlikely that either condition significantly affected the pilot’s performance at the time of the accident.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
A total loss of engine power after the failure of the No. 4 connecting rod due to oil starvation, which resulted in a subsequent forced landing. Contributing to the accident was the pilot’s failure to clearly state that the aircraft had lost all power and the air traffic controllers’ incomplete understanding of the emergency, which resulted in the controllers vectoring the airplane too far from the airport to reach the runway.
HISTORY OF FLIGHT
On January 4, 2013, about 1419 eastern standard time, a Beechcraft H35, N375B, owned and operated by a private individual, experienced a loss of engine power while in cruise flight and was destroyed when it impacted a house, while on approach to the Flagler County Airport (XFL), Palm Coast, Florida. The private pilot and two passengers were fatally injured. Instrument meteorological conditions prevailed and an en route instrument flight rules (IFR) clearance was obtained for the flight, which departed Saint Lucie County International Airport (FPR), Fort Pierce, Florida, and was destined for Knoxville Downtown Island Airport (DKX), Knoxville, Tennessee. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
The airplane arrived at FPR after flying from Stella Maris, Bahamas. The passengers cleared U.S. Customs about 1145. The airplane was subsequently refueled and departed for DKX under visual flight rules.
According to air traffic control information provided by the Federal Aviation Administration (FAA), the pilot contacted Daytona Approach control about 1407, and reported vibrations and an "oil pressure problem." The controller advised the pilot that the airports in the area were IFR with cloud ceilings of 900 to 1,000 feet above ground level. The pilot received radar vectors for an airport surveillance radar approach to runway 29 at XFL, which was about 8 miles north of the airplane's position. At 1411:06, the pilot reported that the engine oil pressure was "zero" with "cool cylinders." At that time, the airplane was flying at an altitude of 5,300 feet mean seal level (msl), and was located about 2.5 miles from the approach end of runway 11, at XFL. The airplane continued to be vectored to a point about 6.5 miles northeast of the airport and was provided headings to the south and then west, to the final approach course for runway 29. The airplane was subsequently cleared to land about 1416. Radar contact with the airplane was lost when the airplane was about 2 miles from the runway, at an altitude of 200 feet msl. At 1418:27, the pilot transmitted "…we need help; we're coming in with smoke." There were no further communications from the airplane.
The XFL airport director observed the airplane as it approached runway 29. He described the weather conditions as instrument meteorological conditions with a low ceiling and mist. He observed the airplane "break out" of the cloud layer, very low, just above the tree line. The airplane's wings were level as it descended and disappeared in the tree line.
Another witness, who was an airline transport pilot and flight instructor, reported that the airplane looked "slow" as it exited clouds, was in a nose high attitude, and appeared to "stall" prior to descending below the tree line, which was followed by smoke about 10 seconds later.
The pilot, age 58, held a private pilot certificate, with ratings for airplane single-engine land and instrument airplane. The pilot's logbooks were not recovered. His most recent FAA third class medical certificate was issued on December 31, 2012. At that time, he reported a total flight experience of 1,300 hours, which included 30 hours during the previous 6 months. The pilot reported 1,100 hours of total flight experience, with 50 hours during the previous 6 months, on an FAA medical certificate application dated February 4, 2010.
The four-seat, all-metal, low-wing, retractable-gear airplane, serial number D-5121, was manufactured in 1957. It was powered by a Continental Motors IO-470-C1, 250-horsepower engine and equipped with a Beech 278 propeller assembly. According to Beechcraft, the airplane was originally manufactured with a Continental Motors O-470-G series engine, which could be modified post manufacturer with a fuel injected engine per Beech Kit 35-648, "Engine Conversion to Fuel Injection on the Beech Model H35 Bonanza." No documentation for the engine that was installed on the accident airplane was found.
The airplane was found to have been modified with the addition of 15-gallon fiberglass wingtip fuel tanks, which would have included a wingtip tank fuel transfer pump mounted in each respective wing's wheel-well, to allow fuel to be transferred from each wingtip fuel tank, to its respective wing. There was no record of a supplemental type certificate for the installation of wingtip fuel tanks found in the airplane's FAA airworthiness file.
According to FAA records, the pilot purchased the airplane on May 30, 2008.
The airplane's maintenance records were not located. According to an FAA inspector, it was reported that the pilot traveled with his personal logbook and the airplane's maintenance records onboard the airplane. Additional information obtained by the FAA inspector revealed that the engine's No. 1 and No. 4 cylinders were replaced due to low compression during early December 2012; however, no work orders or other associated documentation could be located.
A friend of the pilot reported that he believed that the airplane's last annual inspection was performed around September-October 2012. He stated that he was not aware of any previous engine issues with the airplane, except for a small oil leak.
In a written statement, the lineman who refueled the airplane at FPR reported that he noticed "visible oil leaks" on the airplane's nose gear strut. In addition, after he informed the pilot of a fuel imbalance prior to refueling, the pilot informed the lineman that the airplane's right fuel pump was not working.
The weather reported at XFL at 1350 was: wind 360 degrees at 7 knots, visibility 3 statute miles, ceiling 900 feet broken, 1,400 feet overcast, temperature 15 degrees Celsius (C), dew point 13 degrees C, and altimeter 30.22 in/hg.
The following information, which contains excerpts of recorded communications, was obtained by an NTSB air traffic control specialist through interviews and review of communications and radar information obtained from the FAA:
At 1349:34, the pilot contacted Daytona Beach approach control and reported that he was at 4,500 feet. Eight minutes later, the pilot requested a climb to 6,500 feet. The approach controller informed the pilot that they had received a pilot report (PIREP) reporting that the cloud tops were at 7,000 feet. The controller advised the pilot to maintain at or above 7,000 feet, and remain in VFR conditions. The pilot complied and climbed to 7,500 feet.
At 1407:01, the pilot reported, "…we got a vibration in the prop, I need some help here." The approach controller informed the pilot that the closest airport was at his 12 to 1 o'clock position and 5 miles, and asked him if he was instrument flight rules (IFR) capable and equipped. The pilot stated, "I'm IFR, we're just getting a little vibration. We've got an oil pressure problem; we're going to have to drop quickly here." When asked to clarify the nature of the problem, the pilot stated, "…we got a propeller or something going, I'm backing it up here to see."
According to the approach controller, Ormond Beach Airport, which was located approximately 6 miles to the southeast of the airplane's position, was considered briefly, however, because runway 8/26 was closed for construction and there had been a strong tailwind for runway 17, that airport was not an option. The approach controller subsequently cleared the flight to XFL, instructed the pilot to descend and maintain 2,000 feet.
About 1408, the approach controller instructed the pilot to continue his present heading, and informed him that he would get him as close as he could to the Flagler airport for a runway 29 approach. He advised the pilot that the weather ceiling at XFL was 900 feet, and that an instrument approach was necessary. The controller subsequently asked the pilot if he could accept an airport surveillance approach (ASR) into XFL and the pilot replied that he was "…lovely with that" (An ASR approach was a type of instrument approach wherein the air traffic controller issued instructions, for pilot compliance, based on an aircraft's position in relation to the final approach course, and the distance from the end of the runway as displayed on the controller's radar scope).
Flagler County Airport did not have a published ASR approach. The controllers determined that to best handle the emergency it was necessary to offer the pilot an unpublished ASR approach to runway 29 at XFL using area navigation (RNAV) approach minimums. This determination was based on the information obtained from the pilot, and the need for the pilot to conduct an instrument approach into the airport due to the IFR weather conditions.
At 1409, the pilot checked in with the arrival controller and reported he was at 7,000 feet descending to 2,000 feet. The arrival controller instructed the pilot to descend and maintain 3,000 feet, and to turn right to a heading of 060 degrees. According to the arrival controller, he assigned the airplane 3,000 feet because he wanted to ensure the airplane was high enough to remain clear of an antenna that was located northwest of XFL.
About 1410, the controller advised the pilot to expect an ASR approach to runway 29 at XFL.
At 1411:06, the pilot reported, "…we got zero oil pressure, but we've got cool cylinder head temperature." The controller acknowledged the pilot's transmission and instructed the pilot to turn right to a heading of 090 degrees and to descend and maintain 2,000 feet.
At 1411:47, the controller informed the pilot that he would provide guidance along the RNAV runway 29 approach and that the straight in minimum descent altitude (MDA) was 560 feet.
At 1413:46, the controller instructed the pilot to turn right to a heading of 180 degrees and advised that the airplane was about 6 miles east-northeast of XFL on " a base leg for about a four and one-half to five mile final." The pilot acknowledged the turn and said "…we're starting to see some ground here."
At 1414:27, the controller instructed the pilot to descend to 1,600 feet and to turn right, to a heading of 200 degrees.
At 1415:01, the controller informed the pilot that the airplane 5 miles southeast of XFL. About 35 seconds later, the controller provided the pilot turns to intercept the final approach course and informed the pilot that he was 4 miles straight in for runway 29, which the pilot acknowledged.
About 1416, the controller informed the pilot that the airplane was three miles from the runway, asked him to advise when he had the airport in sight, and cleared the airplane to land on runway 29.
At 1417:25, the controller told the pilot that the airplane was below radar coverage, instructed him to contact the XFL tower, and provided missed approach instructions, "if you don't have the airport in sight, climb straight ahead to 2,000 [feet]."
At 1417:59, the pilot transmitted, "…do you read me?" The controller immediately responded that he had him loud and clear and asked the pilot if he had the airport in sight at his 12 o'clock and a mile. The pilot did not respond.
At 1418:27, the pilot transmitted, "…we need help; we're coming in with smoke." The arrival controller informed the pilot that Flagler Tower was waiting for him, and that he was cleared to land.
At 1418:55, the XFL tower controller called the arrival controller and informed him that the airplane did not make it to the airport.
Federal Aviation Administration order 7110.65, "Air Traffic Control," provides guidance and instruction to air traffic controllers when an emergency situation exist or is imminent. Paragraphs 10-1-1, 10-1-2, and 10-2-5 stated in part:
10-1-1: Emergency Determinations...Because of the infinite variety of possible emergency situations, specific procedures cannot be prescribed. However, when you believe an emergency exists or is imminent, select and pursue a course of action which appears to be most appropriate under the circumstances and which most nearly conforms to the instructions in this manual.
10-1-2: Obtaining Information…Obtain enough information to handle the emergency intelligently. Base your decision as to what type of assistance is needed on information and requests received from the pilot because he/she is authorized by 14 CFR Part 91 to determine a course of action.
10-2-5: Emergency Situations…Consider that an aircraft emergency exists…when any of the following exist:
a. An emergency is declared by either:
1. The pilot.
2. Facility personnel.
3. Officials responsible for the operation of the aircraft.
[For additional information, please see the NTSB Air Traffic Control Group Factual Report located in the Public Docket.]
The airplane impacted trees and a residence about 3/4 mile from the approach end of runway 29, slightly left of the extended centerline. The initial impact point (IIP) was identified as a pine tree that was about 60 feet tall and contained broken limbs about 30 to 35 feet above ground level. Various components of wreckage extended from the IIP, on a heading of 288 degrees magnetic for 50 feet. The remainder of the airplane impacted the roof of a detached single family home and a large fire ensued, which destroyed most of the airplane and dwelling.
The airplane's left outboard wing, with about one-half of the corresponding aileron attached, displayed evidence of a tree strike and was found at the base of a tree located about 60 feet from the back of the house. The inbound portion of the left aileron was observed near the right wing, which was inverted and located along the back of the house. The empennage came to rest inverted on the backside edge of the roof alongside of a section of the right wing inboard leading edge. Other remains of the fuselage and left wing were found inside the house. Examination of the airplane's flight control cables did not reveal evidence of any preimpact failures. The right flap actuator remained intact and was observed in a flap retracted position. The landing gear actuator was not observed and the preaccident position of the landing gear could not be confirmed.
The engine was found inverted on the floor of the house. It sustained a significant amount of thermal and impact damage, which destroyed all accessories, with the exception of the propeller governor, which was intact, but fired damaged. A large hole was observed in the crankcase, which contained a portion of the No. 4 connecting rod. The engine was forwarded to Continental Motors Inc., Mobile, Alabama, for further examination.
The propeller remained attached to the crankshaft flange. The spinner was dented and did not display spiral dents. Both propeller blades displayed light chordwise scratches. The outboard section of one propeller blade was missing about 4 to 6 inches of its tip. The propeller blade was cut inboard of the missing section and forwarded to the NTSB Materials Laboratory, Washington, DC, for further examination.
Subsequent teardown of the engine under the supervision of the NTSB investigator-in-charge revealed that the crankshaft exhibited lubrication distress, thermal damage, and mechanical damage at the No. 4 connecting rod journal. The crankshaft oil transfer passage at the No. 4 journal sustained mechanical damage and contained displaced journal material. The remaining crankshaft oil transfer passages were unrestricted. Only fragments of the No. 4 connection rod bearing were recovered and they displayed lubrication and thermal distress. In addition, the number No.4 connecting rod was fractured at the base of the I-beam and exhibited extreme thermal and mechanical damage consistent with a loss of lubrication. The oil galleys and passages in the left and right crankcase halves were intact, clear, and unrestricted.
Subsequent examination of sectioned propeller blade by an NTSB metallurgist revealed that it exhibited extensive evidence of exposure to elevated temperatures that approached the melting point of the blade. This included complete removal of the paint, a thick oxide skin, and internal slumping of the blade material. The blade fracture surface exhibited characteristics consistent with separation while at elevated temperatures. The blade also showed a gradual deformation toward the camber side adjacent to the fracture. The deformation was accompanied by transverse cracking and stretching of the oxide layer on the flat side of the blade indicating deformation after or during high temperature exposure.
MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed on the pilot by the Office of the Medical Examiner, District 23, St. Augustine, Florida. The autopsy report noted the cause of death as "multiple blunt force injures."
Toxicological testing performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, was positive for the following:
"Atenolol detected in Liver
Atenolol detected in Blood (Heart)
1949 (mg/dl) Glucose detected in Urine
149 (mg/dl) Glucose detected in Vitreous
7 (%) Hemoglobin A1C detected in Blood"
Review of the pilot's most recent FAA medical examination application (dated December 31, 2012) revealed "No" was selected to the question "Do you currently use any medication (Prescription or Nonprescription)."