Accident Details
Probable Cause and Findings
The pilot's failure to maintain control of the airplane while being vectored to intercept the localizer during night instrument meteorological conditions (IMC). Contributing to the accident was the operator's inadequate dispatch procedures, which did not prevent the pilot from flying beyond his duty day, flying at night for which he was not current, or flying in IMC for which he was not qualified by the company.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn February 14, 2014, about 2221 Central Standard Time, a Cessna 210L, N732EJ, crashed in a heavily wooded area near Clay, Alabama. The commercial pilot and one passenger were fatally injured. The airplane was destroyed. The airplane was registered to and operated by Southern Seaplane, Inc., under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as a non-scheduled, domestic, cargo flight. Instrument meteorological conditions prevailed in the area at the time and an instrument flight rules (IFR) clearance had been obtained by the pilot from air traffic control. The flight originated from Jackson-Medgar Wiley Evars International Airport (JAN), Jackson, Mississippi, about 2106 CST, and was destined for Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama.
Earlier that day, an individual with Mississippi Organ Recovery Agency (MORA) contacted Southern Seaplane, Inc., located in Belle Chasse, LA, and spoke with the accident pilot about a request to transport specimens from Stennis International Airport (HSA), Bay St Louis, Mississippi, to BHM and then to JAN. The trip was to depart HSA at 1800 CST, and arrive at BHM before 2000 CST. The pilot in turn contacted the company Director of Operations (DO) and discussed the trip.
According to the company DO, the accident pilot expressed an interest to fly the trip, and the DO indicated he would have been within his duty day at the estimated landing time at Birmingham, and he had experience flying blood and organs for MORA in the past. The DO also indicated that the accident pilot asked him if he could take his wife along, which he agreed to because of the significance of the day. The DO reported that the accident pilot called him about 5 minutes later and said he had checked the weather and determined weather would be moving into BHM, so it was decided to fly to JAN first. He informed the pilot to ask the representative of MORA if it was acceptable to fly into JAN first instead of BHM. He also instructed the pilot to call him when he was on the ground at JAN to discuss the weather and reportedly told him if the weather was bad to have the MORA representative drive the blood samples to BHM.
According to company records, the flight departed Southern Seaplane Airport (65LA), Belle Chasse, LA, on a 14 CFR Part 91 positioning flight between 1730 and 1736 CST, and proceeded to HSA where the pilot landed uneventfully about 1804 (end of civil twilight was later determined to occur in that area at 1810). After landing he was provided with specimens and the pilot informed the individual that provided the specimens of the estimated time of arrival at both airports but that the times were depending on the weather conditions. The person on the ground at HSA who provided the specimens to the pilot reported observing him spend 5 to 7 minutes in a room with computers that provided weather information.
The flight departed HSA about 1835 (approximately 25 minutes after the end of civil twilight), but landed at Magee Municipal Airport (17M), Magee, Mississippi. The company DO reported that the pilot texted him at 1914, and informed him that he had landed there to wait out the storm at JAN, and at 1925, the pilot communicated with an individual with MORA and advised him that he was unable to proceed to JAN because of adverse weather in the Jackson, Mississippi, area. Also while at 17M, at 1944 CST, the pilot called a friend of his who is a certified flight instructor (CFI) and whom had given him an instrument proficiency check (IPC) flight several months earlier. During that call the pilot stated that he was flying a Cessna 210 for a blood run, and was waiting at 17M for thunderstorms to clear. The CFI reported he checked the weather and saw why the pilot had landed. During the phone call the CFI checked the METARS at JAN and also at BHM, noting at that time that the METARS for BHM indicated the ceiling was between 3,500 or 4,000 feet. He also checked the terminal area forecast (TAF) for BHM which indicated the ceiling would be dropping to 1,500 feet and wind gusts to 29 or 30 knots possibly higher were expected. The CFI told the pilot to expect a rough trip based on the winds, and to expect an ILS Runway 24 Approach at BHM based on the wind. The accident pilot did not mention any health issues, and the CFI reported he (accident pilot) seemed upbeat during the phone call. There was no further conversation between the CFI and the accident pilot. The DO reported the flight was delayed longer than expected; the flight departed 17M between 2008 and 2010.
The pilot proceeded to JAN and landed uneventfully about 2050. After landing, a toxicology box of specimens was offloaded, and the individual who received them asked the pilot if he was going to BHM, to which he replied that he was if the weather cooperated. The company DO reported the pilot did not contact him as instructed. The individual who was given the specimens reported that although she had never met the pilot before, to her he appeared anxious. She also reported that the pilot repeatedly apologized for being late and attributed his anxiousness to being tardy, rather than being due to the weather.
According to a chronological summary of flight communications with JAN Air Traffic Control Tower, at 2103, the pilot contacted ground control requesting visual flight rules (VFR) flight following to BHM, to be flown at either 3,500 or 5,500 feet mean sea level (msl). The pilot was advised to maintain VFR at or below 5,000 feet msl, and was assigned a discrete transponder code of 1546. At 2106, the flight was cleared for takeoff, and after takeoff air traffic control (ATC) communications were transferred several facilities while proceeding towards BHM.
At 2145, the pilot established contact with the R14 sector of the Memphis Air Route Traffic Control Center and advised the controller that he was at 5,500 feet. The controller provided the pilot the altimeter setting for BHM, which he acknowledged, but the controller did not communicate with the pilot after that time. The controller did coordinate with the next facility, which was the Atlanta Air Route Traffic Control Center (ARTCC); however, the controller did not instruct the pilot to establish contact with that facility. The Atlanta ARTCC also did not establish contact with the pilot, but the controller did coordinate with the next facility, which was the BHM ATCT.
There was no record of any contact by the pilot with any ATC facility between about 2145, and 2208:04; between 2154 and 2206, radar data from Birmingham ATCT indicates that the flight proceeded in a northeasterly direction while flying about 5,600 feet msl (slight altitude deviations were noted). The radar data indicates that between 2206 and 2208, the flight descended from 5,800 to 4,300 feet msl while continuing in a northeasterly direction.
The transcription of communications from Birmingham ATCT indicates that at 2208:04, the pilot established contact with the facility. The controller immediately provided the altimeter setting and informed the pilot that the airport was IFR, and asked him to advise he had automated terminal information service (ATIS) Golf. The controller also asked the pilot to state his intentions. The pilot stated that he had ATIS information Golf, and requested local IFR clearance for an ILS approach to runway 24. The controller asked the pilot, "just uh for the tapes just need to make sure are you capable and qualified of IFR flight" to which he replied, "affirmative." At 2208:32, the controller cleared the flight to BHM via radar vectors on a 55-degree heading, and to maintain 4,000 feet. Radar data indicates the flight continued in an east-northeasterly flight track with altitude deviations minus 200 feet to plus 200 feet from the assigned altitude noted, although between 2213:28 and 2218:26, with the exception of 1 radar return, the airplane maintained a constant altitude of 4,000 feet msl.
At 2217:57, the controller instructed the pilot to turn right to heading 090 degrees and to descend to and maintain 3,000 feet, which he acknowledged. The radar data indicates the groundspeed at that time was approximately 160 knots. About 2218:16, the radar data indicates a turn to an easterly direction occurred and the airplane began descending. About 2219:18, while at 3,400 feet msl, the controller instructed the pilot to turn to right to heading 150 degrees, which he responded, "one five zero echo Juliet." At 2219:30, a position relief briefing occurred. During this briefing the controller being relieved informed the relieving controller in part, of the active runways, aircraft that were on approach were breaking out about 100 feet above minimums, and there was no icing.
Between 2219:18, and 2220:13, the airplane continued on a flight track of approximately 103 degrees magnetic and descended from 3,400 to approximately 3,000 feet, then about 2220:13, a change to a flight track of approximately 149 degrees was noted and the groundspeed increased to 190 knots.
At 2220:38, the controller instructed the pilot to turn right to heading 210 degrees, and advised him that the flight was 3.5 miles from HUKEV and to maintain 2,800 feet until established on the localizer, cleared for the ILS runway 24 approach. The radar data indicated that at the completion of the controller's approach clearance instruction at approximately 2220:46, the airplane was at 2,700 feet msl, and then turned left flying in a northeasterly flight track. According to the NTSB Radar Study, plotting of the radar targets onto an instrument approach plate indicated the airplane turned left flying nearly over the outbound course of the procedure turn. At 2220:54, the airplane was lost from radar at 2,400 feet msl; the airplane at that time was located at 33 degrees 42.166 minutes North latitude and 086 degrees 33.533 minutes West longitude. About 2 seconds after the last radar target, the pilo...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA14FA120