Aviation Accident Summaries

Aviation Accident Summary ERA09MA157

Quebradillas, PR, USA

Aircraft #1




The airplane was over water, operating on an instrument flight rules (IFR) flight plan at 7,000 feet, and approaching the middle of the western shore of Puerto Rico, when the pilot canceled the flight plan to “clear this weather.” The airplane subsequently turned northeast and descended to 5,500 feet. After proceeding over land for about 28 miles, and as it approached the island’s northern coast, the airplane disappeared from radar in the vicinity of a well-defined cumulus congestus cloud, containing level 5 “intense” activity, typically associated with severe turbulence. Witnesses reported seeing the airplane “spiral” and “spin straight down” from clouds before it impacted the ocean. The accident occurred 14 minutes after sunset, and the airplane did not have onboard weather radar or downloadable satellite weather, but did have a lightning detector. There were no weather advisories or pilot reports of adverse weather at the time of the accident, and no “mayday” calls from the pilot. Some smaller, less-aerodynamic items, including windshield material, were recovered on land; however, the majority of the wreckage was located 300 to 800 yards offshore. Missing items included the right horizontal stabilizer, the right elevator, the vertical stabilizer and the rudder, which could have been swept away by ocean currents. No preaccident mechanical anomalies were noted with the airplane, but weight and balance calculations indicated that it was about 300 pounds overweight at the time of the accident. The airplane’s ground speed at the end of the flight was calculated to be 189 knots; however, the in-flight airspeed during the encounter with intense weather was unknown. The airplane’s “never exceed speed” was 180 knots calibrated airspeed (KCAS), the “maximum structural cruising speed” was 147 KCAS, and the “maneuvering speed” was 123 KCAS at maximum gross weight. Observed downward bending of wing components, missing tail components, and witness reports of a “pop” or “boom” when the airplane was still at altitude indicate that portions of the tail likely separated in flight from the airplane due to overstress.

Factual Information

HISTORY OF FLIGHT On February 8, 2009, at 1836 Atlantic standard time, a Cessna 206H, N118ME, was destroyed when it impacted offshore waters near Quebradillas, Puerto Rico (PR). The certificated commercial pilot and five passengers were killed. Visual meteorological conditions prevailed near the surface, while instrument meteorological conditions prevailed at higher altitudes. An instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 flight. The flight originated at Casa De Campo International Airport (MDLR), La Romana, Dominican Republic about 1720, destined for Fernando Luis Dominicci Airport (TJIG) in San Juan, Puerto Rico. According to the owner of the accident airplane, the accident pilot had been scheduled to fly five passengers to MDLR in a Piper PA-31 on February 6, 2009, but since the airplane was grounded, the flight was conducted in the accident airplane. The flight departed TJIG and arrived at MDLR uneventfully, and the pilot returned to TJIG later the same day. No flights were conducted in the accident airplane on Saturday, February 7. On Sunday, February 8, 2009, Federal Aviation Administration (FAA) inspectors conducted a ramp check of the airplane while it was parked at TJIG. No serious discrepancies were noted. The airplane later departed TJIG and arrived at MDLR to pick up five passengers, four of whom the pilot had flown to MDLR on Friday, to return them to San Juan. The accident flight departed MDLR with a planned route of flight of airway W9 to the MELLA intersection, airway G633 to the Dorado (DDP) non-directional beacon, then direct to TJIG. At 1811, the San Juan en route radar approach (ZSU) controller identified the airplane on radar 29 miles west of Mayaguez (MAZ), Puerto Rico at 7,000 feet mean sea level (msl). At 1819, the controller cleared the pilot to proceed direct to the destination airport. When the airplane was between MELLA intersection and the MAZ very high frequency omnidirectional range (VOR), about 28 miles southwest of the accident site, the pilot cancelled the IFR flight plan and requested to continue under visual flight rules (VFR) “so we can clear this weather.” The controller approved the pilot’s request, and also requested that the airplane remain on the last assigned discreet transponder code. The airplane subsequently turned to the northeast, over land, toward the northern coastline of Puerto Rico. At 1830, after a query by the controller, the pilot reported that he was descending to 5,500 feet. At 1838, just after the last radar return of the airplane was observed, the controller again queried the pilot about his altitude, but received no response. The controller then solicited assistance from another pilot in the area, who also attempted radio contact, but without success. There were no mayday or other distress calls, nor were there any low altitude alerts heard or observed. The last radar return was observed over Quebradillas at 5,000 feet, and at a calculated ground speed of 189 knots. Shortly thereafter, the local police received telephone calls reporting an airplane crash, and subsequently, the U.S. Coast Guard confirmed that the airplane was in the water, less than 0.25 miles offshore. A witness who was at a restaurant overlooking the accident site reported that she heard a “pop” or “boom” sound, then observed the airplane descend out of the clouds. She heard another loud boom as the airplane hit the water. The witness also noted that the engine was running between the booms, and that it was raining, with big heavy drops, and windy at the time. Another witness reported that while he was closing some windows, he heard an “aircraft engine” that was “making strange noise followed by some silence.” Suddenly, a “backfire” was heard, followed by silence, and he then saw the airplane descending until it disappeared behind a house. A third witness was outside when he heard an airplane that seemed to be having a problem with its engine, and compared the sound to “a lawn mower getting out of fuel.” He subsequently watched the airplane in a “spiral nose down attitude going into the sea.” A fourth witness stated that she was outside when she heard an airplane that “sounded like it was misfiring and suddenly the engine sound stopped.” She looked in the direction of the sound, and saw the airplane spinning without a wing, and later heard the sound of an impact. A witness who was at MDLR at the time of the airplane’s takeoff called the NTSB Investigator-in-Charge (IIC) to report his observations of the airplane before it departed. He reported that he was at his partner’s fixed base operator (FBO) picking up a passenger, and observed the airplane taxiing out for departure in a “very tail low condition.” He also stated that the “nose wheel was barely on the taxiway.” He took a picture of the airplane with his cell phone camera because he thought the airplane was “overloaded and out of aft CG.” He also reported that the airplane required about 3,000 feet of runway to get airborne, with a 10-knot headwind. A friend of the passengers provided an additional photo taken of the airplane while on the ramp at MDLR prior to departure. Although no occupants appeared to be in the front seats at the time, the airplane was in a tail-low, nose-high attitude. PERSONNEL INFORMATION Pilot The pilot, age 28, held a commercial pilot certificate with single- and multi-engine land ratings and an instrument airplane rating. The following is a chronological summary of the pilot’s qualifications, based on FAA records: On July 16, 2005, the pilot received a private pilot, single-engine land rating. The airman file indicated he had a total of 78.0 flight hours at the time. On September 28, 2007, the pilot received an instrument airplane rating. The airman file indicated he had a total of 181.7 flight hours at the time. On July 21, 2008, the pilot received his commercial pilot certificate with airplane single-engine land and instrument airplane ratings. The airman file indicated he had a total of 381.2 flight hours at the time. On August 18, 2008, the pilot received his commercial certificate with a multi-engine land rating. The airman file indicated he had a total of 428.4 flight hours at the time. The pilot held an FAA first class medical certificate that was issued on October 10, 2008. The medical certificate indicated that the pilot had reported a total flight time of 1,100 hours at the time of the medical examination. The pilot's logbook indicated that he had a total of about 622 flight hours total time, of which, approximately 235 hours were in the accident airplane. The pilot's logbook indicated that he had a total of 47 hours of flight in actual instrument conditions, but had not logged any hours in instrument conditions within 90 days of the accident. An inspector from the FAA Flight Standards District Office (FSDO) in San Juan conducted an interview with the girlfriend of the pilot to determine the pilot's 72-hour history prior to the accident. The 72-hour history revealed no factors that precluded the pilot from performing his flying duties in a normal manner. Passengers The owner of the airplane reported that the five passengers on the accident flight were friends and business associates of his father and himself, and that the flight was a personal flight. He further noted that the passengers routinely traveled to La Romana because they owned property there, and that there was no financial remuneration for the flight. AIRCRAFT INFORMATION The airplane, manufactured in 2000, was equipped with a Lycoming IO-540-AC1A5 six-cylinder engine and a McCauley three-bladed constant-speed propeller. The airplane did not have onboard weather radar or downloadable satellite weather, but did have a “Strikefinder” lightning detector. There was no cockpit voice recorder or flight data recorder on the airplane. The airplane was registered to ATIS Corporation of Carolina, Puerto Rico. ATIS Corporation was formed in May, 2008, to operate the airplane under CFR Part 135. ATIS Corporation had submitted a pre-application Statement of Intent (SOI) to the FAA on June 23, 2008, for an air carrier certificate as a Part 135 single-pilot operation. The accident airplane was identified as the airplane to be operated by ATIS Corporation on the Part 135 certificate. ATIS Corporation was still in the process of applying for the Part 135 certificate and had not begun Part 135 operations. On September 30, 2008, ATIS Corporation sent the FAA another pre-application SOI. The SOI identified the accident pilot as the President of ATIS Corporation. The pilot's resume indicated that the he held a commercial pilot certificate with an instrument rating. It stated that the pilot had accumulated 1,100 hours of total flight time, which included 100 hours of night flight time, 300 hours of cross country flight time, and 90 hours of multi-engine flight time. In a letter to the FAA, dated September 30, 2008, the stated intent of ATIS Corporation was identified as: "We intend to operate an ON DEMAND, Passengers and Cargo operation, Single Pilot Operator, based at Isla Grande Airport, San Juan, P.R. Our company is to be known as ATIS, Corp., will have its operations and maintenance facilities located at the Isla Grand Airport, Tropical Aviation Facilities, South Access Road, San Juan, P.R." On February 4, 2009, the pilot and an aviation consultant hired by ATIS Corporation met with inspectors from the San Juan FAA FSDO for a pre-certification meeting to discuss the requirements of operating as a Part 135 single pilot operation. A conformity inspection of the airplane, as part of the certification process, was scheduled for Thursday, February 12, 2009. A 100-hour inspection of the airplane occurred on February 6, 2009. The airplane total time at the time of the inspection was 1,458.9 hours. The airplane's maximum gross weight limit was 3,600 pounds with a useful load of 1,350 pounds. The airplane's weight and balance was calculated using the available accident flight information for the fuel, pilot and passenger weights, and baggage. Reportedly, the airplane departed TJIG with full fuel tanks on the day of the accident. The amount of fuel burned on the day of the accident was not known; however, assuming a total fuel burn of 30 gallons, the airplane would have weighed approximately 3,943 pounds or 343 pounds over the maximum allowable gross weight of the airplane. The Center of Gravity (CG) Moment Envelope Worksheet indicated that the accident airplane's CG was aft of the aft CG limit. The worksheet does not provide exact CG location when the maximum allowable gross weight is exceeded. Radar data indicated that the airplane’s ground speed was 189 knots during the last several recordings; however, the airplane’s in-flight airspeed at the time could not be determined. The Cessna 206H Information Manual lists the “never exceed speed” (VNE) as 180 knots calibrated airspeed (KCAS), the “maximum structural cruising speed” (VNO), the speed only to be exceed in smooth air, as 147 KCAS, and the “maneuvering speed” (VA), the speed not to be exceeded when making abrupt control movements, as 123 KCAS at an aircraft weight of 3,600 lbs. METEOROLOGICAL INFORMATION The closest weather reporting facility to the accident site was at Rafael Hernandez Airport (TJBQ), Aguadilla, PR, located about 11 nautical miles west of the accident site at an elevation of 237 feet. The airport recorded the following weather conditions surrounding the time of the accident: The TJBQ weather observation, at 1750, included winds from 050 degrees at 17 knots gusting to 22 knots, visibility 10 miles, ceiling broken at 2,000 feet, temperature 24 degrees Celsius (C), dew point temperature 19° C, and an altimeter setting 30.04 inches of mercury. The TJBQ weather observation, at 1850, included winds from 090 degrees at 11 knots gusting to 18 knots, visibility 7 miles in light rain, ceiling broken at 2,000 feet, temperature 23 degrees C, dew point temperature 19 degrees C, and an altimeter setting 30.05 inches of mercury. Weather satellite data revealed a well-defined cumulus congestus cloud over the accident site at 1832, 4 minutes prior to the reported accident time. Superimposing the ground track of the airplane over recorded radar echo areas indicated maximum reflectivity of 50 dBZ, or level 5 “intense” activity that included severe turbulence. At the time of the image, the radar beam was extending from 3,600 to 9,000 feet over the accident site and indicated that the accident airplane was in instrument meteorological conditions (IMC). There was no evidence that the pilot had received a weather briefing before the flight. However, there were also no AIRMET or SIGMET weather alerts, and no pilot reports of any significant weather. According to U.S. Naval Observatory data, sunset at Isabela, Puerto Rico, about 5 miles west of the accident site, occurred at 1822, and the end of civil twilight occurred at 1845. WRECKAGE AND IMPACT INFORMATION The majority of airplane wreckage came to rest in the Atlantic Ocean, approximately 300 to 800 yards off shore, in about 60 to 100 feet of water. Strong ocean currents may have precluded the recovery of all of the major airframe components. Several small pieces of airplane wreckage were found on land, in a residential area. The pieces were scattered approximately 0.6 to 1.1 miles south of the main wreckage area. The pieces recovered on land included a pilot’s aluminum clipboard with leg strap, a section of the right, upper wing strut fairing, a section of the right main landing gear wheel fairing, the right main landing gear wheel fairing service door, a section of right wing stringer material, the right wing tip strobe power supply unit, two sections of right wing tip material, a fragment of clear plastic identified as from the center of the cockpit windshield, and a spiral notebook containing an airplane flight log. The investigation team conducted several on-foot searches and two helicopter searches; however, no additional wreckage was found on land. On February 15, 2009, salvage divers recovered the engine with propeller attached and several small sections of the fuselage. On February 16, divers recovered the left wing, portions of the right wing, including most of the main spar, cockpit and cabin sections, the left horizontal stabilizer, and the left elevator. Salvage divers concluded their efforts on February 16, recovering additional portions of the right wing and fuselage. The right horizontal stabilizer, right elevator, tail cone, vertical stabilizer, and rudder were not recovered. After recovery from the ocean, the wreckage was transported to a local salvage storage facility for examination. Examination of the wreckage revealed no evidence of preexisting mechanical anomalies. The fuselage was fragmented into four main sections and several smaller sections. The larger sections included the engine, the instrument panel and pilots’ seats/floorboard section, the center row seats floorboard/section, and the aft row seats/floorboard and left fuselage section. The empennage aft of the aft row seats was not recovered. The right side of the fuselage was uniformly crushed towards the left. The left wing remained intact except for the leading edge forward of the spar, inboard of the landing light lens. The left wing was found separated from the fuselage at the wing root, with fracture surfaces consistent with overload. The wing tip remained attached to the left wing. The left wing spar was bent aft, inboard of the location of the fuel filler cap. The separations at the end of the root of the spar were bent forward, forming a "Z" shape with the aft bend in the location of the fuel cap. The left wing and spar were bent downward outboard of the wing strut attachment point. The left lift strut was separated approximately 3 feet from the fuselage attachment location; the inboard section remained attached to a portion of the fuselage floor. The separation had signatures consistent with co

Probable Cause and Findings

The pilot exceeded the design limits of the airplane, which resulted in an in-flight break up while maneuvering in adverse weather conditions.


Source: NTSB Aviation Accident Database

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