Accident Details
Probable Cause and Findings
The intentional low altitude flight/maneuver by the pilot-in-command and his disregard of the altitude clearance with terrain resulting in the inflight collision with water during the dark night. Contributing to the accident was the lack of U.S. Customs procedures regarding the establishing of floors during training exercises at night. Findings in the accident were the pilot's intentional operation of the airplane at night during a training flight without operating the position lights contrary to U.S. Customs Service procedures, and the failure of the flightcrews tracking the airplane to notify the pilot before impact with the water.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On January 6, 1999, about 2236 eastern standard time, a Cessna U206G, N756XQ, registered to U.S. Customs Service, crashed into the Biscayne Bay, about 7 nautical miles east-southeast of the Homestead Air Reserve Base, Homestead, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the public-use flight. The airplane was destroyed and the commercial-rated pilot, the sole occupant, sustained serious injuries. The flight originated about 2121 local, from the Homestead Air Reserve Base, Homestead, Florida.
The pilot stated that he had attended a mission briefing for two training exercises/flights in which he was to fly the accident airplane acting as a "target" for two different U.S. Customs Service aircraft. He later reported that he did not intend on descending below 500 feet during the training exercise except for takeoff and landing. During the mission plan for the accident flight, there was no mention of established floors during the training exercise or the mention that the accident flight would be operated near a barge. The first flight departed with full fuel tanks and lasted approximately 1 hour 15 minutes as determined by times from air traffic control (ATC). The pilot reported that he noted a discrepancy during the flight with the alternator which was surging as evidenced by a hum in the radio with each surge, and he also noticed that the panel lights would dim and brighten with each surge of the alternator. After landing, he ate and exercised. Before takeoff on the second flight, he performed a walkaround, and when he applied power to take off, he noticed that the foot needle of the altimeter was swinging 400 feet either side of the altimeter indication. The altimeter indication became steady prior to rotating for takeoff and he elected to continue the flight. He climbed to 9,000 feet where he orbited waiting for the tracking airplane (Cessna Citation) to depart from Homestead Air Reserve Base (HARB). The Cessna Citation departed at approximately 2140 as determined by ATC, and after departure, he heard the flightcrew of the Citation contact the Domestic Air Interdiction Coordination Center (DAICC), located in Riverside, California. The flightcrew of the Citation requested and performed two head-on intercepts; the final intercept consisted of a "stern" intercept. The DAICC facility vectored his aircraft for the final intercept. Following that intercept, the flightcrew of a U.S. Customs Blackhawk helicopter which departed HARB at approximately 2146 as determined by ATC, for the purpose of night vision goggle training, joined in along with the Cessna Citation. One of the flightcrew members of the Blackhawk asked the accident pilot if he was "freezing up there" to which he responded, "No, I have all the vents closed and the heater on full hot and I'm toasty warm." He further stated that prior to the inception of the apprehension portion of the training exercise, the flightcrew of the Cessna Citation advised him and the flightcrew of the Blackhawk that the apprehension would be performed at HARB. He reported hearing communications between the crew of the Blackhawk and the DAICC facility.
According to a transcription of communications from the HARB Air Traffic Control Tower (ATCT), at 2225.26, the accident pilot contacted HARB ATCT and advised the controller that his aircraft along with the Blackhawk helicopter and the Cessna Citation were going to perform a practice "buzz" scenario and that after landing, the Blackhawk would be landing to perform an enforcement type stop. The accident pilot later reported that he set his altimeter to the barometric setting provided by the controller and while flying at 500-800 feet on a northerly heading, he transited over Elliott Key. He then made a west-southwesterly turn towards a fuel barge that was departing out of the Turkey Point Power Plant (TPPP). He maneuvered his airplane towards a nearly head-on convergence with the barge; the barge was located off his left wing. After passing the fuel barge, he heard communications between the flightcrews of the Blackhawk and the Citation aircraft; the crew of the Blackhawk advised that it appeared that the accident airplane was maneuvering to simulate an air drop to a vessel. He initiated a turn to the northwest, then turned towards the southwest; the last altitude he recalled was 570 feet. He next recalled being underwater, and struggled to free himself. He swam to the surface, then towards the lights of the TPPP, and recalled being in the rotor wash of a helicopter. He held on to a partially inflated life raft that was later determined to have been dropped by a flight crewmember of the Blackhawk helicopter, was pulled into a boat, then lifted by a basket into a helicopter. He later stated that he intended to writeup the discrepancies pertaining to the alternator and altimeter following the second flight. He reported when interviewed in the hospital 4 days after the accident that there was no engine or flight control preimpact failure or malfunction.
The pilot of the Cessna Citation reported that they were tracking the 206 aircraft using Forward Looking Infra Red (FLIR) radar, and on board radar, and noted that the accident airplane appeared to fly over a barge and noted that his radar indicated that the accident airplane was flying between 200 to 300 feet. The airplane then while in a turn to the left, impacted the water first with the left wing, causing it to separate. The airplane then cartwheeled and after coming to rest, began sinking. The Citation flightcrew advised the DAICC facility that the airplane had crashed. There was no communications made by the flight crew of the Cessna Citation to the pilot of the accident airplane immediately before the accident, pertaining to the altitude flown. The on-board radar of the Cessna Citation was not recording at the time of the accident.
Review of a transcription of communications from a voice tape provided by DAICC revealed that the individual in DAICC stated that the accident airplane's altitude was 100 feet. The time of the transmission was not determined. The transcription also indicates that a flightcrew member of the Cessna Citation responded that the accident airplane was flying at 400 feet; time undetermined. There was no communications attempted by personnel from DAICC with the accident pilot immediately before the accident, pertaining to the altitude flown.
The Blackhawk helicopter was vectored to the area by the flightcrew of the Citation and after visually acquiring the debris and pilot in the water, a flightcrew member dropped a life raft from a height estimated to be greater than 35 feet. A park ranger from the United States Department of the Interior National Park Service reported that after he was notified of the airplane accident, he requested additional Park Service employees to respond, and he immediately proceeded via boat to the area or the last known point. Additionally, a U.S. Coast Guard helicopter responded to the accident site, dropped a swimmer in the water, and the Park Service employee who responded via boat, arrived in time to see the pilot being assisted by the swimmer. The pilot was lifted into the Park Service rangers' boat then hoisted into the Coast Guard helicopter where he was transported to the Jackson Memorial Hospital for treatment of his injuries.
PERSONNEL INFORMATION
The pilot's training file indicates that he was designated on October 7, 1994, to act as pilot-in-command of Cessna 206 aircraft. His last check-flight with Customs in a Cessna 206 type airplane was on December 10, 1997, which lasted a total of 4.8 hours. That flight was performed in conjunction with a surveillance flight that lasted 3.5 hours; the remainder of the flight was used for the completion of the evaluation. Additionally, the flight time that the pilot listed on page 2 of the NTSB Pilot/Operator Aircraft Accident Report form only included flight time information obtained from Customs from January 1989 to present. His personal pilot logbook was lost in 1992. He had previously flown the same make and model airplane for the Drug Enforcement Administration for a period of about 2 years; that flight time is not included in the report. The pilot estimated that he had a total of about 1,500 additional flight hours. Additional information pertaining to the pilot is contained on page 2 of the Factual Report-Aviation.
AIRCRAFT INFORMATION
The airplane was removed from government seizure, inspected, and approved for return to service on October 9, 1992. A replacement standard airworthiness certificate was issued on November 13, 1992. An engine that was rebuilt by the manufacturer was installed on June 28, 1994. Review of the aircraft logbook revealed that an entry dated June 17, 1997, indicated that a muffler assembly was replaced. Review of the accompanying work order indicates that the right muffler assembly was replaced. Review of the discrepancy sheets for the annual inspection that was signed off on January 8, 1998, indicates that the left muffler heater shroud was cracked. The muffler was removed, the muffler and shroud were repaired by a FAA certificated mechanic at a non FAA certified repair station, and the muffler and shroud were reinstalled on January 2, 1998. The airplane was not equipped with a radar altimeter.
Further review of the maintenance records revealed that on June 4, 1998, an aircraft maintenance record/work order indicates the discrepancy "altimeter fluctuates in a climb." The altimeter was replaced with an altimeter that had been checked to manufacturers specifications by United Instruments, on November 18, 1997. The altimeter and pitot static system was checked in accordance with 14 CFR Part 91.411(a)(1), on June 4, 1998. There was no written discrepancies prior to the acciden...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# MIA99GA064