NTSB Factual Report

HISTORY OF FLIGHT

On July 5, 2009, about 1256 eastern daylight time, a Cessna 400 (Columbia Aircraft Manufacturing LC41-550FG), N207JB, registered to and operated by an individual, crashed in a wooded area, in Huntington, West Virginia, during an instrument flight rules (IFR) flight from the Tri-State Airport (HTS), Huntington, West Virginia, to Kalamazoo / Battle Creek International Airport (AZO), Kalamazoo, Michigan. Instrument meteorological conditions prevailed at the time and an IFR flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight. The pilot and passenger were killed, and the airplane was destroyed. The flight departed HTS at 1254.

Information obtained from family members and local authorities reveal that the pilot was on a return IFR flight to AZO, the pilot's home base. The pilot was in the HTS area visiting family members. The pilot filed an IFR flight plan the night before and obtained a weather briefing on the morning of the accident at about 1041. The flight plan was filed for one person onboard. The decision to add a passenger was made later that morning.

An airport representative stated that the pilot called at 1100 to have the airplane pulled out of the hanger and fueled. The pilot requested to have a total of 10 gallons of Avgas added to the tanks; 5 gallons in each wing fuel tank. At 1210, the pilot arrived to the ramp, paid for the fuel, and started his preflight inspection. The representative noted that the pilot's preflight was about 25 minutes in duration. The airplane was started and taxied out of the area with no discrepancies observed.

The pilot received his IFR clearance and contacted the ground controller for taxi instructions to runway 12. The tower controller cleared the pilot for takeoff with an instruction to turn right for a heading of 210 degrees. A witness working near the departure end of runway 12 stated he heard and observed the airplane's engine rev up before departing from runway 12. He "watched the plane ascend and noted no abnormal functions and watched him turn in the distant". Once airborne, the pilot was then told by the tower controller to contact departure.

Radar data provided by the HTS airport surveillance radar (ASR) showed the airplane climbing to an altitude of 1, 500 feet (ft) means sea level (msl) , before turning right. The pilot contacted the departure controller and advised he was at 1,900 and climbing to 4,000. The radar data showed the airplane continue to climb to 2, 200 ft msl. The controller advised the pilot he had radar contact and asked the pilot what was his on course heading. The pilot responded 337 degrees. The departure controller asked the pilot if he was in a right turn and the pilot confirmed that he was. The departure controller instructed the pilot to continue the right turn to the on course heading and to maintain 5,000 ft msl. The pilot never acknowledged those instructions. The highest radar contact indicated the airplane was at 2,300 ft msl. About that time the radar showed the airplane turned left and started to descend. The last radar contact indicated the airplane was at 2,200 ft msl. The airplane was lost from radar immediately after that. The wreckage was located in close proximity and to the east southeast of the last radar contact.

A witness sitting on the back porch of his residence heard what sounded like a single engine airplane flying low near his home. A few moments later, he heard a loud crash sound resembling metal hitting trees, immediately after, the sound of the flying airplane stopped. The witness heard no sound of engine failure or other obvious malfunctions prior to the cessation of engine noise. He traveled to the ridge top behind his home and did not see anything that represented a plane crash. He called 911 to report the occurrence. The HTS Aircraft Rescue and Fire Fighting immediately responded to the notifications and shortly there after located the wreckage 3.5 miles south of the airport.

PERSONNEL INFORMATION

The pilot, age 54, seated in the front left seat, held a private pilot certificate with ratings for airplane single engine land and instrument airplane. He was issued a Federal Aviation Administration (FAA) third-class medical certificate on May 19, 2008, with limitations of must wear corrective lenses. He had documented 575 total hours at that time. The pilot had documented in his pilot's flight logbook a total of 642 flight hours as of June 28, 2009. Of those hours, 39 hours were in actual instrument flight, 1.3 hours within the prior 30 days of the accident, and 118 hours were simulated instrument time. The pilot documented a total of 184 hours in the accident airplane.

The passenger, seated in the right front seat, held no FAA certificates.

AIRCRAFT INFORMATION

The Cessna 400 (Columbia Aircraft Manufacturer LC41-550FG) was built in 2005 with serial number 41564. On June 7, 2006 the airplane was issued a standard airworthiness certificate and registered in the utility category. The four place, composite built, fixed landing gear airplane was power by a Teledyne Continental Motors, TSIO-550-C, 310 horse power engine, which was equipped with a three bladed, Hartzell, variable pitch, propeller. The airplane was equipped with a Garmin 1000 avionic system and had a two axis autopilot system. The architecture of the Garmin-1000 avionic suite consists of multiple line replaceable units (LRUs) that perform the various functions and are connected together to form the general cockpit display. The airplane was maintained in accordance with the manufacturer's recommended maintenance program. A review of the airplane's maintenance records revealed the airplane had an annual inspection on the airframe, propeller, and engine on March 9, 2009, at which time the airplane had accumulated a total of 583 hours. The airplane had maintenance performed on June 9, 2009, when airworthiness directive 2009-9-9, dated May 11, 2009, was complied with at which time the airplane had accumulated a total of 602 hours.

METEOROLOGICAL INFORMATION

The closest official weather observation was at HTS, 3.5 miles north of the accident site. The HTS 1251, METAR was winds from 090 degrees at 4 knots; visibility, 10 statute miles; clouds overcast at 800 ft above ground level (agl); temperature 19 degrees Celsius (C); dew point 18 degrees C; altimeter 29.87 inches of mercury.

The National Weather Services (NWS) Surface Analysis Chart for 1100 on July 5, 2009, depicted a warm front south of the accident site with an extensive area of low clouds along and north of the frontal system associated with overrunning conditions. The Huntington station model depicted easterly winds at 5 knots, visibility restricted in mist, overcast skies, a temperature of 66° F, with a 2° dew point spread. The Weather Depiction Charts for 1200 depicted the Huntington area in an area of IFR conditions due to low overcast ceilings at 600 ft agl with visibility restricted in light rain and mist. The Radar Summary Chart for 1219 depicted a large area of precipitation extending along and north of the frontal system.

The HTS special report at 1322, wind variable at 6 knots, visibility 10 miles in light rain, ceiling overcast at 1,000 ft agl , temperature 20° C, dew point 18° C, altimeter 29.85 inches of mercury. Remarks: automated observation system, peak wind from 200° at 28 knots at 1321, ceiling 700 ft variable 1,400 ft agl, hourly precipitation less than 0.01 inches.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in a heavily wooded area on a hill ridge side at an elevation of 850 ft msl, from the departing runway. The initial impact was with 50 ft tall trees. The second impact was with the ground at the top edge of the ridge. The airplane was in a left wing low and about 50 degrees nose down pitch attitude during the impact sequence. The energy path of the wreckage was on an approximate course of 60 degrees along the descending ridge side. The debris field fanned outward from the initial tree impact point to 440 ft in distant by 75 ft in width. The cockpit, fuselage, wings, control surfaces were fragmented. The vertical stabilizer and rudder were recognizable. The engine, metal firewall, and propeller were crushed together and compacted with soil and wood. It was located 228 ft from the initial tree impact point behind a damaged tree trunk from the impact. The propeller separated from the engine crankshaft. The three propeller blades were twisted from mid point toward the tips with nicks and gouges throughout the length. One of the blades was bent 90 degrees aft. Another blade was missing a tip section.

A post recovery examination of the wreckage conducted by the airplane's manufacturer representative with Safety Board oversight established flight control continuity. All separations were consistent with overstress separation. All flight control surfaces were recovered. The right main landing gear strut, backup altimeter, and the left aileron control (balance) weight, were not located. The left aileron control weight attaching point damage was consistent with overstress separation. The flap actuator was observed in the full up position (retracted). The fuel selector valve was on the left fuel tank. The engine, propeller, and three avionic components (two flight computers, and one attitude reference unit) from the Garmin 1000 system were retained by the Safety Board for further examination.

TEST AND RESEARCH

A teardown examination of the propeller and engine were conducted by their respective manufacturer with Safety Board oversight. The propeller incurred damaged consistent with impact while operating at high power. All three blades had multiple bends with significant twisting. The blade preload plates had multiple impact marks at different blade angles indicative of the blades had multiple strikes and were changing pitch during the crash sequence. There were no discrepancies noted that would preclude normal operation of the propeller. The examination of the engine revealed all damages were consistent with impact damage. The engine examination did not reveal any abnormalities that would have prevented normal operation and production of rated horsepower.

The Safety Board Vehicle Recorder Division obtained information from the manufacturer, the various Garmin 1000 LRU boxes do store fault codes in non-volatile memory within each separate unit. These fault codes typically get triggered when there is a sensed error within the various LRU functions. Recorded fault codes are typically not continuously recorded but are rather event driven whenever a fault is detected and are stored for assistance in troubleshooting problems by maintenance personnel. The 3 units were physically damaged as a result of the accident. The damage was such that the units were not able to be powered up. According to the manufacturer the units recovered are capable storing fault data in onboard memory devices. The manufacturer was contacted to obtain assistance in reading out the individual memory chips located within the various units. Due to the fact that the units could not be re-powered, the normal maintenance extraction of the fault codes could not be accomplished. The manufacturer was unwilling to provide the laboratory the necessary detailed programming data structure information necessary to decode the memory in order to recover the fault codes from the individual memory devices.

Digital audio transmissions from the radar approach facility and the local control facility were sent to the Safety Board Vehicle Recorder Division's Audio Laboratory for a noise spectrum analysis. The transmissions indicated evidence of the engine/propeller operating at approximately 2540 rpm and indicated no evidence of aural cockpit warnings.

According to FAA advisory circular (AC) 60-4A, "Pilot's Spatial Disorientation," spatial orientation in flight is difficult to achieve especially in instrument meteorological conditions. It makes reference to an effective perception, integration and interpretation of visual,

vestibular, and proprioceptive sensory information must be maintained. Any discrepancies between the person's sensory inputs will result in a sensory mismatch that can produce illusions and lead to the pilot's spatial disorientation. It may take as much as 35 seconds to establish full control after loss of visual reference by qualified pilots. The spatial disoriented pilot may place the aircraft in a dangerous attitude, which can lead to a rapid, uncontrollable, near-vertical, descent.

MEDICAL AND PATHOLOGICAL INFORMATION

The Department of Health and Human Services, Chief Medical Examiner Office in Charleston, West Virginia, conducted a postmortem examination. The cause of death for the pilot and passenger was blunt force trauma.

The FAA Civil Aeromedical Institute (CAMI) conducted toxicology testing on specimens from the pilot and passenger. No ethanol was detected in the pilot's urine; ethanol was detected in the in the muscle and liver, and putrefaction was noted. No ethanol was detected in the passenger's heart; ethanol was detected in the liver, muscle, lung, and kidney, and putrefaction was noted.

NTSB Probable Cause

The pilot's failure to maintain control of the airplane due to spatial disorientation.