NTSB Factual Report

HISTORY OF FLIGHT

On June 8, 2013, at 1002 eastern daylight time, a Cessna 340A, N217JP, was destroyed when it impacted shallow waters of the Loxahatchee National Wildlife Refuge, near Boynton Beach, Florida. The commercial pilot was fatally injured. Instrument meteorological conditions prevailed in the vicinity, and the airplane was operating on an instrument flight rules (IFR) flight plan from Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, to Leesburg International Airport (LEE), Leesburg, Florida. The business flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to excerpts from the Federal Aviation Administration (FAA) Air Traffic Control Accident Package:

The pilot was cleared to depart FXE utilizing the Fort Lauderdale Three Departure to ARKES intersection, then direct to BAIRN intersection, then as filed [direct to LEE], climb to 2,000 feet, expect 16,000 feet 10 minutes after departure.

At 0945, the pilot was cleared to take off from FXE runway 8, and to then turn left to heading 310 degrees magnetic. After takeoff, the pilot was cleared to contact Miami Departure Control.

At 0947, the pilot advised Miami Departure Control that the airplane was passing 600 feet for 2,000 feet, in a left turn, heading 310 degrees. The departure controller advised radar contact, then cleared the airplane to 4,000 feet, which the pilot acknowledged.

At 0949, the pilot advised that he was having "instrument problems," and that he would like to "head west and stay v-f-r if I can for the climb." The controller confirmed with the pilot that the airplane was on an IFR flight plan, advised him of traffic ahead, told him to fly heading 270, and directed him switch to the next departure frequency, which the pilot acknowledged.

At 0950, the pilot contacted the next departure controller, who directed him to climb the airplane to 8,000 feet. The pilot responded that he would do so once he was clear of a cloud, and reiterated that he had "instrument problems." The controller acknowledged that the pilot would like to keep the airplane at 2,000 feet, and told the pilot to let him know when he could climb the airplane.

About 30 seconds later, the pilot stated that he was climbing the airplane to 8,000 feet, which the controller acknowledged.

Just before 0954, the controller advised the pilot to turn the airplane right to a heading of 350 degrees, which the pilot acknowledged.

Just before 0956, the controller advised the pilot to climb the airplane to 11,000 feet, which the pilot acknowledged, and at 0958, the controller advised the pilot to contact Miami Center, which the pilot also acknowledged.

The pilot then contacted Miami Center, and reported passing 6,800 feet for 11,000 feet. The controller provided the local barometric pressure, and advised the pilot of moderate to heavy precipitation along his route of flight for the next 10 miles. The pilot was given the option of deviating either left or right, and when able, to proceed direct to BAIRN.

The pilot responded "BAIRN direct when able."

At 0959:48, the controller instructed the pilot to climb the airplane to 13,000 feet, which the pilot acknowledged.

At 1001:44, the controller advised the pilot to climb and maintain 15,000 feet, but did not receive a response. After two more queries, the pilot stated that he was trying to maintain v-f-r, "I have an instrument failure here."

The controller then stated, "I'm showing you turning east. That looks like a really bad idea. If you can, turn back to the west to get out of this stuff a lot quicker, going to the west."

There were no further transmissions from the airplane.

Radar data indicated that at 1000:26, the airplane began a turn from a northerly heading approaching 90 degrees, toward the east, completing it about 1001:01. At 1001:11, the airplane reached its maximum altitude of 9,500 feet, still heading eastbound. By 1001:25, the airplane had descended to 8,100 feet, and by 1001:30, it had descended to 7,900 feet. At 1001:35, the altitude indicated 7,500 feet, and at 1001:40, the altitude indicated 0 feet (ground based altitude readouts are indicated in nearest 100-foot increments).

There was no radar indication at 1001:45, but a renewed eastbound track began with a 0-foot altitude at 1001:50, 300 feet at 1001:55, 600 feet at 1002:00, 1,100 feet at 1002:05 and 1,500 feet at 1002:10. The airplane then turned to the northeast, with the last radar contact at 1,400 feet, at 1002:15.

PILOT INFORMATION

The pilot, age 75, held a commercial pilot certificate with airplane single engine land, multi-engine land and instrument airplane ratings. He also held a flight instructor certificate and was previously a U.S. Air Force pilot.

According to the pilot's logbook, as of June 1, 2013, he had 16,560 total hours of flight time, including 11,166 hours in multi-engine airplanes, 2,702 hours of actual instrument flight time and 736 hours of simulated instrument flight time. In the previous 30 days, the pilot logged 4.3 hours of actual instrument flight time and 11.3 hours of simulated instrument flight time.

The pilot's latest FAA Second Class Medical Certificate was issued on August, 21, 2012, and a review of FAA pilot medical records did not reveal any significant issues.

The pilot's wife indicated that the pilot was on a business trip, but did not know his activities the day and night before the accident or who he may have met with. The pilot's wife also stated that that she was unaware of any significant preexisting medical conditions, and that there was no pressing need for the pilot to return home that day.

AIRPLANE INFORMATION

According to the aircraft logbook, the latest annual inspection was completed on September 1, 2012, at an airframe time of 4,209.4 hours. At that time, both engine logbooks indicated that 100-hour inspections were completed, with both engines having 1,392.7 hours of operation since major overhaul.

The aircraft logbook also noted that, as of December 12, 2012, with no airframe hours stated, the flight director was overhauled. Other electronics items were removed for "configuration, interface and alignment with flight director. Autopilot was ground checked and a successful flight check was performed."

On January 25, 2013, at 4,230.2 hours, the left auxiliary fuel pump was removed and replaced with an overhauled pump.

The last logbook entry, on March 18, 2013, at 4,238.6 hours, "complied with visual inspection AD2001-01-16 no defects noted." According to FAA website information, that airworthiness directive applied to exhaust systems on certain Cessna 300 and 400 airplanes.

Photographs of the cockpit, taken in 2009 by a previous pilot when the airplane's registration was N226LD, showed six primary flight instruments forward of the pilot's yoke; an attitude indicator (gyro) over a horizontal situation indicator (gyro) in the center, an airspeed indicator over a turn and slip indicator to the left of those, and an altimeter over a vertical speed indicator to the right. To the right of the altimeter was the autopilot mode selector. To the right of that was a Garmin GNS 530 nav/comm and below that, a Garmin GNS 430 nav/comm. To the right of the GNS 530 was a weather radar, and to the left of the GNS 430, an Insight Strikefinder.

In front of the copilot's yoke, there was another airspeed indicator. To the right of that was another attitude gyro, and the right of that, another altimeter.

According to FAA-H-8083-25, "Pilot's Handbook of Aeronautical Knowledge," an airspeed indicator measures the difference between pitot, or impact air pressure, and static pressure. The altimeter and vertical speed indicator (rate-of-climb indicator) operate with static air only.

According to the airplane model's Pilot's Operating Handbook (POH),

The airplane had two independent pitot pressure systems, one for the pilot-side airspeed indicator, and one for the copilot-side airspeed indicator. Each system had its own pitot tube located on either side of the airplane nose cap. Heat to each pitot tube could applied via a cockpit switch.

Static pressure for the pilot-side airspeed, altimeter and rate-of-climb indicators was obtained via a normal static source aft of the main cabin door. In the event of normal static air blockage, an alternate source from within the airplane's nose compartment could have been selected by the pilot.

Copilot instruments received static pressure from a completely independent source.

The POH also noted that the proper operation of the airspeed, altimeter and rate-of-climb indicators could be determined by cross-checking the copilot instruments. In addition, "when a climb or descent is initiated, these instruments should indicate an appropriate change. If on change is indicated, it would be reasonable to assume that a static source blockage has occurred and that the alternate static source should be selected. If only the airspeed indicator appears to be affected when a climb or descent is initiated, it would be reasonable to assume that a pitot system blockage has occurred."

A vacuum system was installed to provide a source of vacuum for the vacuum instruments. The system included an engine-driven pump on each engine, a pressure relief valve for each pump, a common vacuum manifold with check valves, a vacuum air filter, and one vacuum suction gauge with failure indicator for left and right. Each vacuum pump would create a vacuum on the common manifold, exhausting the air overboard.

The POH further stated that vacuum air powered the pilot-side horizontal and directional gyros, and the copilot-side horizontal and directional gyros. If one vacuum pump failed, the manifold check valves would isolate the failed pump and the suction indication for the respective pump would move to the failed position. No corrective action was required by the pilot, as the system would automatically isolate the failed vacuum source, allowing normal operation via the remaining operative vacuum pump.

METEOROLOGICAL INFORMATION

Surface weather, recorded at West Palm Beach International Airport, West Palm Beach, Florida, located about 060 degrees magnetic, 20 nm from the accident site, at 0953, included wind from 120 degrees true at 7 knots, visibility 2 statute miles, thunderstorm, heavy rain, ceiling 1,500 feet broken, 2,800 feet overcast, temperature 23 degrees C, dew point 23 degrees C, altimeter setting 30.07 inches Hg.

Ground based weather radar indicated that the airplane transitioned from an area of "green" intensity (30-35 dBZ reflectivity- light precipitation) to "yellow" (35-40 dBZ reflectivity – moderate precipitation), then "orange" (40-45 dBZ reflectivity- heavier precipitation) as it was first losing altitude. It then climbed back up into an area of "green" intensity precipitation.

Ground based weather radar also indicated that the airplane's turn to the right was toward heavier precipitation, while a straight course at that time would have initially kept the airplane in lighter precipitation.

There were no convective or non-convective Significant Meteorological Information (SIGMET) advisories active for the accident location at the accident time. There were also no Airmen's Meteorological Information (AIRMET) advisories active for the accident location at the accident time.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in swampy terrain with water depths varying to about 5 feet. The initial impact point located in the vicinity of 26 degrees 30.48 minutes north latitude, 080 degrees, 24.59 minutes west longitude, or about 1,500 feet north of the last radar position. The wreckage was highly fragmented, and was dispersed along an approximately 320-degree magnetic heading. The first recognizable item at the initial impact point was the left tip tank.

The two engines were recovered, but without a propeller attached to either one. A propeller was eventually located, but was initially unrecoverable. Both engine propeller flanges were fractured, with some material missing as were some flange bolts, and other bolts were sheared off. Neither engine exhibited any evidence of pre-impact failure, nor did either vacuum pump. The cockpit vacuum pressure gauge was found frozen at 5.8 psi.

Subsequent to the departure of the investigative team, additional material, including the one propeller, was recovered. Examination of the additional wreckage occurred on November 5, 2013, with representatives from the airplane and engine manufacturers, with FAA oversight. At the time, all flight control surfaces were accounted for, but flight control continuity could only be partially confirmed due to the amount of fragmentation of the wreckage.

Pitot tubes were not observed, but a pitot tube cover was seen in a box that had been in the airplane.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot at the District 15, State of Florida, Office of the District Medical Examiner, West Palm Beach, Florida. The cause of death was determined to be "multiple blunt traumatic injuries." Non-recovery of internal organs precluded complete examination.

Toxicological testing was performed at the FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma. No blood was available for testing. Ethanol was present in muscle and brain tissue with putrefaction (post-mortem decomposition) noted on the report.

ADDITIONAL INFORMATION

Flight Planning

According to Lockheed Martin Flight Services (LMFS) Quality Assurance (QA), no [weather briefing] services were provided for N217JP. LMFS QA also noted that DTC (Data Transformation Corporation) DUATS (Direct User Access Terminal Service) also did not provide any services, but that CSC (Computer Sciences Corporation) did have a flight plan on file.

Air Traffic Control Services

During a recorded conversation following the accident between the "Miami Center Operations Manager in Charge" (OMIC), and an air traffic quality control group (QCG) official, the following was stated:

OMIC: "By the time he's telling him, think it's a bad idea to go to the right, the guy had already been committed going to the right to begin with and got in trouble.

QCG: "All right, so we may have led him down the garden path."

OMIC: "Yeah, by giving him that option and mentioning you can go right or left."

FAA Order JO 7110.65 "Air Traffic Control" states, in part:

"2-6-4. WEATHER…SERVICES

a. Issue pertinent information on observed/reported weather and chaff areas by defining the area of coverage in terms of azimuth (by referring to the 12-hour clock) and distance from the aircraft or by indicating the general width of the area and the area of coverage in terms of fixes or distance and direction from fixes.

Weather significant to the safety of aircraft includes such conditions as funnel cloud activity, lines of thunderstorms, embedded thunderstorms, large hail, wind shear, microbursts, moderate to extreme turbulence (including CAT), and light to severe icing.

c. Use the term 'precipitation' when describing radar-derived weather. Issue the precipitation intensity from the lowest descriptor (LIGHT) to the highest descriptor (EXTREME) when that information is available. Do not use the word 'turbulence' in describing radar-derived weather.

g. When requested by the pilot, provide radar navigational guidance and/or approve deviations around weather or chaff areas. In areas of significant weather, plan ahead and be prepared to suggest, upon pilot request, the use of alternative routes/altitudes."

NTSB Probable Cause

The pilot’s loss of situational awareness, which resulted in an inadvertent aerodynamic stall/spin after he climbed the airplane back into instrument meteorological conditions (IMC). Contributing to the accident was the pilot’s improper decision to continue flight into IMC with malfunctioning flight instrument(s).