N247AT

Destroyed
Fatal

CESSNA 340S/N: 3400214

Accident Details

Date
Sunday, December 24, 2017
NTSB Number
CEN18FA061
Location
Bartow, FL
Event ID
20171224X03602
Coordinates
27.946388, -81.773887
Aircraft Damage
Destroyed
Highest Injury
Fatal
Fatalities
5
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
5

Probable Cause and Findings

The pilot's loss of control due to spatial disorientation during takeoff in instrument meteorological conditions.

Aircraft Information

Registration
N247AT
Make
CESSNA
Serial Number
3400214
Engine Type
Reciprocating
Year Built
1973
Model / ICAO
340C340
Aircraft Type
Fixed Wing Multi Engine
No. of Engines
2

Registered Owner (Historical)

Name
AVIATION TRANSPORTATION LLC
Address
5115 S LAKELAND DR STE 1
Status
Deregistered
City
LAKELAND
State / Zip Code
FL 33813-2565
Country
United States

Analysis

HISTORY OF FLIGHTOn December 24, 2017, at 0717 eastern standard time, a Cessna 340 airplane, N247AT, impacted terrain after departure from Bartow Municipal Airport (BOW), Bartow, Florida. The private pilot and four passengers were fatally injured, and the airplane was destroyed. The airplane was registered to Aviation Transportation LLC and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Instrument meteorological conditions prevailed at the time of the accident and an instrument flight rules (IFR) flight plan was filed. The flight was originating at the time of the accident with a planned destination of Key West International Airport (EYW), Key West, Florida.

The pilot filed an IFR flight plan on a Garmin GPS device and received an IFR clearance from the Tampa air traffic control tower. The BOW air traffic control tower was closed at the time of the accident.

According to two fixed base operator (FBO) employees at BOW, the pilot requested that the airplane be towed from the hangar to the ramp. The pilot stated that he wanted a tow so that he did not have to taxi next to the other hangars because of reduced visibility and dense fog. About 0645, the five occupants boarded the airplane and the FBO employees towed it to the ramp.

The FBO employees stated that the pilot started the engines and that they watched as the airplane very slowly taxied toward the end of runway 9L. The fog limited their visibility to about 400 ft. They could no longer see the airplane in the dense fog, so they moved to an area on the ramp closer to the runway. The pilot contacted Tampa Approach at 0710 for his IFR clearance. The FBO employees heard an increase in engine noise consistent with an engine run-up, and about 0715, they heard the airplane take off but they could not see the airplane because of the dense fog. The engines "sounded strong and [were] operating at full power" during the takeoff. They heard two tire "chirps" on the runway, then the sound of the airplane was consistent with a climb. They then heard an explosion on the east side of the airport and drove toward the explosion to find the airplane on fire. One of the FBO employees recorded a video of the airplane taxiing on the ramp toward the runway and another video of the takeoff.

The video captured by the FBO employee was 46 seconds long. While recording the video, the employee was located near the middle of the ramp and about 1/2 mile from the end of runway 9L. The accident airplane is not visible due to the dense fog. The sound of the engines is audible. The video pans from right to left and appears to follow the sounds of the airplane during the takeoff roll. At 26 and 28 seconds, two distinct chirps are heard. The video ends while the engines are still audible.

A helicopter pilot based at BOW observed the airplane taxiing on the ramp toward the runway. He recorded a video of the airplane taxiing on the ramp in the dense fog. He heard the airplane take off about 12 minutes later. During the takeoff, he heard a 'pop' similar to an engine backfire and about 3 seconds later, heard the explosion near the end of runway 9L. He and a colleague drove to the accident site, where they found the airplane engulfed in flames and saw the FBO employees nearby. He estimated that the runway visual range at the time was 600 to 800 ft due to the fog. PERSONNEL INFORMATIONThe pilot's logbooks were not located, and the pilot's instrument currency or proficiency could not be determined.

The mechanic who maintained the airplane stated that the pilot always flew with his feet flat on the floor and not on the rudder pedals. He also stated that the pilot never flew dangerously or recklessly. He added that the pilot's personal logbooks were always kept on the back shelf in the airplane.

The pilot's personal assistant stated that he always flew the airplane a couple of days before a flight with passengers. She stated that everyone she talked to described him as a good pilot and diligent with his pilot duties.

An acquaintance of the pilot, who also was the pilot's flight instructor in 2002, recounted flying the accident airplane with the pilot. He stated that the pilot mentioned an in-flight engine failure he experienced in the accident airplane. The pilot told him that he continued to his destination rather than making a precautionary single-engine landing because the logistics of diverting were too difficult. The acquaintance also stated that he and the pilot were supposed to fly the accident airplane together in early 2017. On the morning of the planned flight, he checked the weather conditions, which were about 1/4 mile visibility and 100 ft ceilings with dense fog. He told the pilot that they could not complete the flight because of the weather, and the pilot responded that, legally, they were allowed to fly under Part 91. The acquaintance had not talked to the accident pilot since that canceled flight.

A local airplane mechanic, who was a business acquaintance of the pilot, stated that he flew with the pilot one time and then refused to fly with him again. The acquaintance stated that he was not a safe pilot and took unnecessary risks. AIRCRAFT INFORMATIONThe mechanic who maintained the airplane stated that, 2 days before the accident, at the request of the pilot, he moved the co-pilot seat aft and adjusted the rear seats forward. He also stated that the accident airplane had a known autopilot issue; if the autopilot was engaged on the ground, it would command the elevator trim full nose-down. He understood this issue was a result of the autopilot's gyros not being level on the ground, which caused the autopilot to sense and attempt to compensate for a high pitch attitude. He stated that the accident pilot was aware of this autopilot issue.

The airplane logbooks did not reveal any past maintenance discrepancies or write-ups related to the autopilot or elevator trim.

One of the aforementioned BOW FBO employees reported that, on December 22, 2017, he received a fuel order from the pilot. He filled the airplane's tip tanks and auxiliary tanks with 100LL fuel; the nacelle tanks were already full. Later that day, he removed the airplane from the hangar; the pilot flew the airplane for about 30 minutes, then the employee towed the airplane back to the hangar.

A review of the left and right engine maintenance logbooks revealed entries for annual inspections that included an oil change and oil filter inspection and replacement on January 2, 2017, at 1,582.9 hours tachometer time. The previous two entries, dated December 20, 2015, and November 17, 2014, at 1,558.4 hours and 1,543 hours, respectively, noted an annual inspection was completed with oil and oil filter changes.

The oil filter found on the left engine at the accident site was marked with 1,543 hours tachometer time and dated January 6, 2014. When questioned about the discrepancy, the mechanic stated that the oil was actually not changed on either engine during the two previous inspections as noted in the logbooks and that the entries were not accurate. The mechanic stated that he planned to change the oil and replace the filters during the next annual inspection, which was due in January 2018.

The logbooks also revealed that the most recent IFR certification for the transponder and pitot static system was completed on June 20, 2014. To fly in IFR conditions the system must be inspected and certified every 24 calendar months. METEOROLOGICAL INFORMATIONThe automated weather observation station at BOW reported consistent weather conditions from 0635 to 0715, which included visibility less than 1/4 mile, fog, an overcast cloud layer at 300 ft, temperature 56°F, and an altimeter setting of 30.18 inches of mercury.

An area forecast discussion was issued for the region by the National Weather Service (NWS) that identified widespread shallow fog. An NWS dense fog advisory was in effect for Polk County, Florida. A center weather advisory was in effect for the accident area and advised of ceilings below 500 ft agl and visibilities below 1 mile in fog and mist. An AIRMET for IFR conditions was in effect for the accident area.

There was no evidence that the pilot obtained a preflight weather briefing from a recorded source. AIRPORT INFORMATIONThe mechanic who maintained the airplane stated that, 2 days before the accident, at the request of the pilot, he moved the co-pilot seat aft and adjusted the rear seats forward. He also stated that the accident airplane had a known autopilot issue; if the autopilot was engaged on the ground, it would command the elevator trim full nose-down. He understood this issue was a result of the autopilot's gyros not being level on the ground, which caused the autopilot to sense and attempt to compensate for a high pitch attitude. He stated that the accident pilot was aware of this autopilot issue.

The airplane logbooks did not reveal any past maintenance discrepancies or write-ups related to the autopilot or elevator trim.

One of the aforementioned BOW FBO employees reported that, on December 22, 2017, he received a fuel order from the pilot. He filled the airplane's tip tanks and auxiliary tanks with 100LL fuel; the nacelle tanks were already full. Later that day, he removed the airplane from the hangar; the pilot flew the airplane for about 30 minutes, then the employee towed the airplane back to the hangar.

A review of the left and right engine maintenance logbooks revealed entries for annual inspections that included an oil change and oil filter inspection and replacement on January 2, 2017, at 1,582.9 hours tachometer time. The previous two entries, dated December 20, 2015, and November 17, 2014, at 1,558.4 hours and 1,543 hours, respectively, noted an annual inspection was completed with oil and oil filter changes.

The oil filter found on the left engine at the accident site was marked with 1,543 hours tachometer time and dated ...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN18FA061