Friday, November 26, 2021

Loss of Control in Flight: Cessna 421 Golden Eagle, N731PF; fatal accident occurred September 29, 2019 in DeLand, Volusia County, Florida

Shawna Jo Carbonaro (passenger)
March 1st, 1985 – September 29th, 2019

Armand Girouard (pilot)
December 28th, 1991 - September 29th, 2019

Ernendro Pedro Philippe (pilot-rated passenger)
September 14th, 1987 - September 29th, 2019

Aviation Accident Final Report - National Transportation Safety Board 

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Orlando, Florida
Continental Motors; Mobile, Alabama
Textron Aviation; Wichita, Kansas

Investigation Docket - National Transportation Safety Board:

Location: Deland, Florida 
Accident Number: ERA19FA283
Date and Time: September 29, 2019, 16:00 Local
Registration: N731PF
Aircraft: Cessna 421 
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight 
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General aviation - Personal


The owner of the airplane had purchased the airplane with the intent to resell it after repairs had been made. As part of that process, a mechanic hired by the owner had assessed the airplane’s condition, proposed the necessary repairs to the airplane’s owner, and had identified a pilot who would, once the repairs and required inspection annual inspection had been completed, fly the airplane from where it was located to where the owner resided. While the mechanic had identified a potential pilot for the relocation flight, he had not yet completed the repairs to the airplane, nor had he completed the necessary logbook entries that would have returned the airplane to service.

The pilot-rated passenger onboard the airplane for the accident flight, was the pilot who had been identified by the mechanic for the relocation flight. Review of the pilot-rated passenger’s flight experience revealed that he did not possess the necessary pilot certificate rating, nor did he have the flight experience necessary to act as pilot-in-command of the complex, high-performance, pressurized, multi-engine airplane. Additionally, the owner of the airplane had not given the pilot-rated-passenger, or anyone else, permission to fly the airplane. The reason for, and the circumstances under which the pilot-rated passenger and the commercial pilot (who did hold a multi-engine rating) were flying the airplane on the accident flight could not be definitively determined, although because another passenger was onboard the airplane, it is most likely that the accident flight was personal in nature. Given the commercial pilot’s previous flight experience, it is also likely that he was acting as pilot-in-command for the flight.

One witness said that he heard the airplane’s engines backfiring as it flew overhead, while another witness located about 1 mile from the accident site heard the accident airplane flying overhead. The second witness said that both engines were running, but they seemed to be running at idle and that the flaps and landing gear were retracted. The witness saw the airplane roll to the left three times before descending below the tree line. As the airplane descended toward the ground, the witness heard the engines make “two pop” sounds. 

The airplane impacted a wooded area about 4 miles from the departure airport, and the wreckage path through the trees was only about 75-feet long. While the witnesses described the airplane’s engines backfiring or popping before the accident, the post-accident examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Additionally, examination of both propeller blades showed evidence of low rotational energy at impact, and that neither propeller had been feathered in flight.

Given the witness statement describing the airplane “rolling three times” before it descended from view toward the ground, it is most likely that the pilot lost control of the airplane and while maneuvering. It is also likely that the pilot’s lack of any documented previous training or flight experience in the accident airplane make and model contributed to his inability to maintain control of the airplane.

Toxicology testing was performed on the pilot’s chest cavity blood. The results identified 6.7 ng/ml of delta-9-tetrahydracannabinol (THC, the active compound in marijuana) as well as 2.6 ng/ml of its active metabolite, 11-hydroxy-THC and 41.3 ng/ml of its inactive metabolite delta9-carboxy-THC. Because the measured THC levels were from cavity blood, it was not possible to determine when the pilot last used marijuana or whether he was impaired by it at the time of the flight. As a result, it could not be determined whether effects from the pilot’s use of marijuana contributed to the accident circumstances.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s failure to maintain control of the airplane, which resulted in a collision with terrain. Contributing was the pilot’s lack of training and experience in the accident airplane make and model.


Personnel issues Aircraft control - Pilot
Aircraft (general) - Not attained/maintained
Personnel issues Total experience w/ equipment - Pilot

Factual Information

On September 29, 2019, about 1600 eastern daylight time, a Cessna 421, N731PF, was substantially damaged when it impacted trees and terrain near DeLand Municipal Airport (DED), DeLand, Florida. The commercial pilot, pilot-rated passenger, and aft-seated passenger were fatally injured. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight.

The owner of the airplane stated that he purchased the airplane on June 21, 2019, and that planned to make repairs and resell the airplane. The airplane was based at DED at the time of purchase and had not undergone an annual inspection for several years. The owner hired a mechanic to make the necessary repairs and conduct an annual inspection of the airplane. During the inspection, the mechanic informed the owner that the left tachometer generator and the fuel gauges were inoperative and that other items also needed repair or replacement. Once the work was done and the annual inspection was signed off, the mechanic would find a pilot to transport the airplane to Texas, where the owner resided. The mechanic subsequently found a pilot who he thought would be able to fly the airplane to Texas (the pilot-rated passenger).

The mechanic stated that he had not completed the repairs to the airplane or signed off the airplane’s annual inspection at the time of the accident flight. The airplane owner stated that he did not know the pilot or the passengers and that he was not aware that the airplane was being flown at that time.

A witness in the vicinity of the accident site shortly before the accident stated that he heard the airplane fly overhead at an altitude of about 2,000 ft and described the engines as sounding “rough.” About 10 minutes later, he observed the airplane overhead at an altitude of 1,000 ft and heard the engine “sputtering and backfiring.”

According to another witness who was about 1-mile away from the accident site, he heard the accident airplane flying very low overhead. He then observed the airplane banking to the left and said that both engines seemed to be running at “low idle.” As he continued to watch the airplane, he noticed that the flaps and landing gear were retracted. The witness also observed the airplane roll to the left three times before descending below the tree line. As the airplane descended toward the ground, the engines made “two pop” sounds. The witness saw no smoke coming from the airplane during the descent.

The airplane crashed in a heavily wooded area and a post-impact fire ensued.

The pilot, age 27, held a commercial pilot certificate with ratings for single-engine land, multiengine land, and instrument airplane. The pilot also held a flight instructor certificate with an airplane single-engine rating. His Federal Aviation Administration (FAA) first-class medical certificate was issued June 4, 2018. A review of the pilot’s logbook revealed that the last entry was dated May 29, 2019. The total pilot-in-command time entered was 500 hours, including about 40 hours of multiengine airplane flight time. The logbook did not show that the pilot had received any instruction or had logged any previous flight experience in the Cessna 421. While the pilot did have an endorsement in his logbook for the operation of high-performance airplanes, he did not have an endorsement for the operation of complex airplanes.

The pilot-rated passenger, age 32, held a private pilot certificate with a rating for airplane single-engine land. His FAA third-class medical certificate was issued on April 12, 2019. A review of his pilot logbook revealed a total of 155 flight hours, all in single-engine airplanes.

A review of the airplane’s maintenance records revealed that the airplane received its last annual inspection on February 15, 2014, at a Hobbs meter time of 858 hours. The Hobbs meter reading at the time of the 2019 examination was 862 hours.

The main wreckage was located about 4 nautical miles from DED on a 230° magnetic heading. The wreckage path was about 75 ft in length from the first broken tree branch, which was about 75 ft high, to the location where the airplane came to rest at the base of a tree in an upright position. There were freshly broken branches at the wreckage site.

All flight control surfaces were located at the accident site. The cockpit section of the airplane was crushed, and a tree trunk extended from the bottom of the fuselage to the top of the right side of the cockpit. The fuselage exhibited crush damage to the aft pressure bulkhead. The empennage was broken away from the fuselage at the aft pressure bulkhead and remained partially attached by flight control cables. The vertical and horizontal stabilizers remained attached to the empennage. The vertical stabilizer was buckled, and the rudder was attached at the lower attachment points. The rudder was broken in two parts; the lower section containing the rudder trim was buckled, and the upper section was also buckled and partially attached to the remaining rudder assembly.

Examination of both engines and their components revealed no anomalies that would have prevented normal operation or production of the rated horsepower. Examination of both propellers revealed the presence of witness marks that showed contact between the blade counterweights and the propeller hub, which were consistent with the propellers being at a low pitch position (and not feathered) during impact. Additionally, the damage to the propeller hubs and their assemblies, as well as the twisting, bending, and paint scuffing observed on the propeller blades, were all consistent with relatively low rotational energy at impact.

The Office of the Medical Examiner, Daytona Beach, Florida, performed an autopsy on the pilot and pilot-rated passenger. Their cause of death was blunt force trauma.

For the pilot, toxicology testing performed at the FAA Forensic Sciences Laboratory identified in chest cavity blood samples, 6.7 ng/ml of delta-9-tetrahydracannabinol (THC, the active compound in marijuana), 2.6 ng/ml of its active metabolite 11-hydroxy-THC, and 41.3 ng/ml of its inactive metabolite delta-9-carboxy-THC. In addition, 12.5 ng/ml of THC, 390 ng/ml of 11-hydroxy-THC, and 734.5 ng/ml of delta-9-carboxy-THC were found in urine samples. The tests were negative for carbon monoxide and ethanol.

For the pilot-rated passenger, toxicology testing performed at the FAA Forensic Sciences Laboratory was negative for carbon monoxide, ethanol, and drugs.

History of Flight

Maneuvering Loss of control in flight (Defining event)

Pilot Information

Certificate: Commercial; Flight instructor
Age: 27, Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane 
Second Pilot Present: Yes
Instructor Rating(s): Airplane single-engine 
Toxicology Performed: Yes
Medical Certification: Class 1 Without waivers/limitations
Last FAA Medical Exam: June 4, 2018
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: (Estimated) 500 hours (Total, all aircraft), 0 hours (Total, this make and model), 185 hours (Pilot In Command, all aircraft)

Pilot-rated passenger Information

Certificate: Private 
Age: 32, Male
Airplane Rating(s): Single-engine land 
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None 
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 Without waivers/limitations
Last FAA Medical Exam: April 12, 2019
Occupational Pilot: UNK
Last Flight Review or Equivalent:
Flight Time: (Estimated) 155 hours (Total, all aircraft)

Passenger Information

Age: Female
Airplane Rating(s): 
Seat Occupied: Rear
Other Aircraft Rating(s): 
Restraint Used: Unknown
Instrument Rating(s): 
Second Pilot Present: Yes
Instructor Rating(s): 
Toxicology Performed:
Medical Certification: 
Last FAA Medical Exam:
Occupational Pilot: No 
Last Flight Review or Equivalent:
Flight Time:

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N731PF
Model/Series: 421 Undesignated
Aircraft Category: Airplane
Year of Manufacture: 1968
Amateur Built:
Airworthiness Certificate: Normal
Serial Number: 421-0164
Landing Gear Type: Tricycle 
Seats: 6
Date/Type of Last Inspection: February 15, 2014 Annual
Certified Max Gross Wt.: 6841 lbs
Time Since Last Inspection: 4 Hrs
Engines: 2 Reciprocating
Airframe Total Time: 858 Hrs
Engine Manufacturer: Continental
ELT: C91A installed, not activated 
Engine Model/Series: GTSIO-520-D
Registered Owner: 
Rated Power: 375 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC) 
Condition of Light: Day
Observation Facility, Elevation: DED, 79 ft msl
Distance from Accident Site: 4 Nautical Miles
Observation Time: 15:55 Local 
Direction from Accident Site: 230°
Lowest Cloud Condition: Scattered / 3100 ft AGL 
Visibility 10 miles
Lowest Ceiling: Broken / 4800 ft AGL 
Visibility (RVR):
Wind Speed/Gusts: 7 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 60°
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 30.07 inches Hg 
Temperature/Dew Point: 29°C / 23°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Deland, FL (DED) 
Type of Flight Plan Filed: None
Destination: Deland, FL (DED)
Type of Clearance: VFR
Departure Time: 15:42 Local
Type of Airspace: Class G

Airport Information

Airport: Deland Muni-Sidney H Taylor Fi DED
Runway Surface Type:
Airport Elevation: 79 ft msl
Runway Surface Condition: Unknown
Runway Used: 
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal 
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: On-ground
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 29.024444,-81.344169

An airplane crash that killed three people near DeLand in 2019 was likely caused when the pilot lost control of the aircraft, according to a report from the National Transportation Safety Board.

The NTSB also found that the pilot’s lack of experience and training in flying a Cessna 421, a twin-engine propeller aircraft which can hold six or seven people, contributed to the crash.

Armand Girouard, 27, the pilot, and Shawna Carbonaro, 34, both of DeLand, and Ernendro Philippe, 32, of Kissimmee, were killed when the Cessna crashed about 4 p.m. Sept. 29, 2019 in a wooded area south of State Road 44, according to NTSB records.

Both Girouard and Philippe had pilot licenses, but Philippe did not have the necessary pilot certificate rating or experience to be in command of the complex, multi-engine Cessna 421, according to the NTSB. 

The NTSB report stated it was likely that Girouard, who was a commercial pilot, flight instructor and had a multi-engine rating, was flying the plane when it crashed.  But there was no indication on Girouard’s logbook that he had ever previously flown a Cessna 421, the NTSB stated.

Girouard also did not have a complex airplane endorsement, according to the NTSB. The high-performance and pressurized Cessna 421 was a complex airplane, the NTSB stated.

The NTSB concluded that it is most likely the pilot lost control of the airplane given that a witness described seeing the plane “rolling three times” before losing sight of it as it headed toward the ground.

“It is also likely that the pilot’s lack of any documented previous training or flight experience in the accident airplane make and model contributed to his inability to maintain control of the airplane,” the NTSB report stated.

Volusia Sheriff's Office deputies and bystanders search through burning wreckage in an attempt to rescue any survivors from a plane crash in 2019 in western Volusia County.

Why the plane was in the air in the first place was unclear since neither its owner nor a mechanic making repairs had given permission for it to take off, the NTSB stated. The NTSB report stated the flight was likely “personal in nature,” because of the third person onboard.

A Texas man named Martin Flores bought the plane on June 21, 2019 for $35,000 with plans to resell it at a profit, according to NTSB records. 

Flores said he paid a mechanic named Cristopher De Leon of De Leon Aircraft Maintenance in Weslaco, Texas, to make the repairs. 

Flores said the plane was purchased in an Ebay auction from a James Carter who lived in Tennessee, according to the records. 

Flores said he paid $6,000 for repairs to the plane and another $4,500 for a pilot to fly it to Texas, according to records.

But the plane never made it to Texas. 

The Cessna 421 took off from DeLand Municipal Airport at 3:42 p.m. on September 29, 2019 and flew 17 miles north where it performed some flight maneuvers at 2,500 feet before it turned back and descended to 1,000 feet and headed back toward the DeLand

The airplane crashed into woods about four miles from DeLand Municipal Airport, leaving a path of wreckage 75-feet long through the trees, the NTSB report stated.

A witness told investigators he heard the plane’s engines backfiring. Another witness said both engines were running but they seemed to be running at idle, the NTSB report stated. A check of the plane’s wreckage found no indication of any pre-crash mechanical malfunction that could have affected the plane’s flying ability.

De Leon said he had not completed repairs to the plane, nor had he completed logbook entries required before the plane could return to the sky, according to the NTSB. Fuel gauges and some other items on the plane were among those listed for repair.

Flores had also not given anyone permission to fly the plane, the NTSB stated. He also said he did not know the three people on board the airplane.

Flores said that the mechanic found an instructor to fly the plane. Flores said he did not know the name of the instructor but the name of his contact was a person named "Ernedro." The pilot passenger on the plane was Ernendro Philippe, according to the NTSB.

A toxicology test on the pilot revealed the presence of THC, the active compound in marijuana, the NTSB said. But the test could not determine when the pilot used the marijuana or whether he was impaired by it while flying, the NTSB report stated.

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