Accident Details
Probable Cause and Findings
The design of the cabin pressurization system, which made it prone to unnecessary shutdown, combined with a checklist design that prioritized troubleshooting over ensuring that the pilot was sufficiently protected from hypoxia. This resulted in a loss of cabin pressure that rendered the pilot and passenger unconscious during cruise flight and eventually led to an in-flight loss of power due to fuel exhaustion over the open ocean.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On September 5, 2014, about 1410 eastern daylight time (EDT), a Daher-Socata TBM700 (marketed as a TBM900 model), N900KN, was destroyed when it impacted open water in the Caribbean Sea near the northeast coast of Jamaica. The commercial pilot and the passenger were fatally injured. An instrument flight rules flight plan was filed for the cross-county flight that originated from Greater Rochester International Airport (ROC), Rochester, New York, at 0826 and was destined for Naples Municipal Airport (APF), Naples, Florida. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91.
The pilot used a fixed based operator (FBO) at ROC, his home airport, to hangar the airplane. On the day of the accident, FBO personnel towed the airplane to the ramp in advance of the pilot's arrival. The pilot arrived at the airport before the passenger, who was his wife, and briefly spoke with two of the FBO employees, who described his demeanor as relaxed. Once his wife arrived, they loaded their bags and then boarded the airplane. An FBO employee pulled the chocks and marshalled the airplane off the FBO ramp.
Surveillance video retrieved from the ROC airport showed that the airplane departed at 0826. According to recorded Federal Aviation Administration (FAA) air traffic control (ATC) information, a controller instructed the pilot to climb to 9,000 ft mean sea level (msl) and fly direct to a waypoint on the pilot's flight plan. Several minutes later, the controller instructed the pilot to climb to Flight Level (FL) 280, and the pilot complied. The flight proceeded without incident for about 45 minutes.
About 0912, ATC lost communications with the airplane for a few minutes. The airplane was operating in Cleveland Center's airspace at FL280 when the pilot was instructed to contact the controller of the next sector; however, he did not acknowledge the handoff or attempt to contact the handoff controller on the provided frequency. The controllers made multiple attempts to contact the pilot, but the pilot did not respond until about 4 minutes 30 seconds after the controller's initial handoff instruction. The pilot reported to the controller that "ah something happened I don't know what happened to you but we're back." The controller subsequently issued a new frequency, which the pilot acknowledged.
About 0917, the passenger contacted the new sector as previously instructed. The sector controller instructed the flight to contact Washington Center and provided a new frequency. The passenger acknowledged the instruction and checked in with the controller at Washington Center. All further radio communications from the airplane were made by the pilot.
At 1003:11, the pilot checked in with an Atlanta Center controller as instructed and confirmed that the flight was level at FL280. About 1 minute later, the pilot radioed "nine hundred kilo november we need to descend ah down to about one eight zero we ah have an indication that's not correct in the plane." The controller cleared the flight to FL250, and the pilot acknowledged, "two five zero and we need to get lower nine hundred kilo november." The controller asked whether the pilot was declaring an emergency, and at 1004:50, the pilot replied, "ah not yet but we'll let you know;" radar data indicated that the airplane had started to descend from FL280 and was at FL277 when this transmission occurred. The controller instructed the flight to turn left 30°, and at 1005:02, the pilot acknowledged, "thirty left nine hundred kilo November." The pilot's speech during this period did not display any anomalies.
About 1005, the controller contacted another ATC facility to coordinate the airplane's clearance to a lower altitude. Although the pilot had not declared an emergency and had not specified the nature of his problem, the second facility agreed to redirect another airplane after the controller reported that the pilot had "a pressurization issue." By 1006, the controller had coordinated efforts to descend the airplane to FL200 and then to FL180.
At 1006:35, while the airplane was at FL250, the controller cleared the flight to descend and maintain FL200. After receiving no acknowledgement, the controller repeated his instruction at 1006:43, and the pilot quickly acknowledged, "two zero zero nine hundred kilo november." A continuation of the carrier signal on the audio recording indicated that the airplane transmit switch remained keyed (activated) for about 4 seconds after the pilot concluded his statement. Radar data showed that the airplane remained at FL250 instead of descending as cleared by ATC and acknowledged by the pilot.
At 1007:17, the controller cleared the flight direct to the Taylor VOR. No verbal response from the flight occurred, but the audio recording contained about 2 seconds of carrier signal, indicating that the airplane's radio transmit switch was keyed. The controller repeated his clearance, and at 1007:36, the pilot immediately responded, "direct taylor nine hundred kilo november." Radar data shows the airplane did not alter its course toward the Taylor VOR.
At 1008:10, the controller asked the flight to confirm that it had received the descent clearance to FL200. At 1008:15, the pilot replied, "two zero zero kilo November." Review of the audio recording indicated that the pilot's voice was faint during this transmission.
At 1008:40, the controller stated, "November zero kilo November descend and maintain flight level two zero zero and you are cleared direct taylor." The pilot responded immediately with, "direct kilo November nine hundred kilo November." Review of the audio recording indicated that the faintness in the pilot's voice associated with the previous call was gone. Subsequently, the controller made numerous attempts to contact the pilot, but no further radio transmissions (either verbal or carrier signal) from the flight were received.
About 1039, two Air National Guard (ANG) F-16s from McEntire Joint National Guard Base (MMT), Eastover, South Carolina, were vectored to intercept N900KN about 40 miles southeast of MMT. Minutes later, the F-16s intercepted the airplane on a 165° magnetic heading at FL250 and 175 knots indicated airspeed. One of the ANG pilots made several radio calls to the accident airplane but did not receive a response. The F-16s completed a visual inspection of the airplane, which did not reveal any visible damage to the airplane or an accumulation of ice; however, there was a small line of condensation noted along the bottom of the right cockpit window. The engine was running, and the anti-collision lights were operating normally. According to a statement from one of the ANG pilots, he observed two occupants in the cockpit. The left seat was occupied by a male seated with his back straight, while the right seat occupant's torso and head were slouched against the fuselage aft of the right cockpit window. The ANG pilot also observed headsets on both occupants and noted that the left seat occupant's boom mic was pointed straight up. About 1 hour 20 minutes after the airplane was first intercepted, the left seat occupant's head slumped forward, which enabled the ANG pilots to see his chest rising and falling. Neither occupant was wearing an oxygen mask.
Two F-15s from Homestead Air Reserve Base (HST), Homestead, Florida, relieved the F-16s about 70 miles east of Daytona Beach, Florida about 1 hour after the initial intercept. According to one of the F-15 pilots, the airplane maintained the same heading, airspeed, and altitude as noted by the F-16 intercept from MMT. According to one of the F-15 pilot's statement, he did not observe any signs of smoke or fluids coming from the engine, which continued to function normally. The exterior lights and instrument panel were illuminated; however, the distance between the airplanes prevented the intercept pilots from reading the indications on the glass panel display. According to one of the F-15 pilots, the intercept group disengaged from the airplane before the flight reached Cuba.
The intercept from HST captured several digital camera photographs of the airplane that were forwarded to the NTSB. Review of the photographs confirmed that neither occupant was wearing an oxygen mask. Magnification of the photographs showed that the bottom corners of the emergency exit door on the right side of the cabin appeared to be recessed into the fuselage frame. A postaccident demonstration by the manufacturer revealed that the airplane's emergency exit door protruded out from the fuselage frame when the airplane was pressurized.
According to a review of FAA radar data, about 1409, the airplane entered a high rate of descent from FL250. The last radar target was recorded over open water about 10,000 ft msl, about 20 nautical miles north of Port Antonio, Jamaica.
Search aircraft and watercraft from the Jamaican Defense Authority and the United States Coast Guard observed an oil slick and small pieces of debris scattered over 1/4 mile near the last radar target. The airplane was subsequently located by an autonomous underwater vehicle and recovered by a salvage effort about 4 months after the accident.
PERSONNEL INFORMATION
Pilot
The pilot, age 68, held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued on August 6, 2013, with the limitation "must wear glasses for distant [vision], [and] have glasses for near vision." A pilot data information sheet provided by SIMCOM Aviation Training showed that, at the time of his most recent training, which took place 1 week before the accident, the pilot reported a total of 7,100 flight hours with 240 hours within the preceding 12 months. The pilot's personal logbook(s) were not located after the accident. According to a friend of the pilot, the pilot had...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA14LA424