NTSB Factual Report

HISTORY OF FLIGHT

On November 30, 1997, about 1310 eastern standard time, a Commander 114-B, N302RS, registered to "R" Stuff Inc., operating as a 14 CFR Part 91 personal flight crashed while maneuvering in the vicinity of Cross City, Florida. Instrument meteorological conditions prevailed. A VFR flight plan was filed, but was not activated. The airplane was destroyed. The noninstrument rated private pilot and two passengers were fatally injured. The flight originated from Crystal River, Florida, about 36 minutes before the accident. The airplane was reported missing on December 3, 1997. The airplane was located on December 4, 1997, at 1334, at N29.36' W83.15'.

Review of transcribed communication between N302RS, Jacksonville Approach (Vitts radar VR) and Jacksonville Air Route Traffic Control Center (28) revealed N302RS reported off Crystal River, Florida, climbing through 2,300 feet at 1737Z (1237 EST) to VR. The pilot informed VR that he was en route to Tallahassee via Cross City. He was instructed to squawk 0413 and provided with the local altimeter setting. N302RS was informed he was radar contact 10 miles north of Crystal River Airport, to proceed on course to Tallahassee, and asked what his cruising altitude would be. N302RS stated at 1738:31, "ah were going to try for five thousand five hundred but ah we'll just remain below these ah cloud level here." VR informed N302RS at 1738:48, "okay I'll give you a little pilot report from pilots that ah cruised through the area about ah the last fifteen twenty minutes I talked to pilots at ah six or four, six eight and ten and they said there was no available ah vfr altitudes but ah look like this weather may have cleared out a little bit since then." N302RS replied, we are climbing through 3,000 and were on a really nice spot, visibility's probably good 15 to 20 miles. The pilot informed ATC at 1739, that he was going off frequency to activate his VFR flight plan. There is no recorded record that the flight plan was activated with any FAA Flight Service Station. N302RS asked VR at 1742:53, if they could fly along the coast line and that they were going to level off at 3,500 to stay VFR, which was approved. At 1746:26, N302RS informed VR that he had to descend to 3,300 to maintain VFR, and was informed by VR at 1746:35, that radar services were terminated, squawk VFR, and to contact R28 for advisories. N302RS contacted R28 at 1747:36, and requested flight following to Tallahassee. R28 replied at 1748:08, "Commander two Romeo Sierra I'll be unable flight following due to IFR traffic today." The pilot responded at 1748:12, "Roger sir thank you very much we'll just keep you on frequency then until we get close to Tallahassee." There was no other recorded communication with N302RS.

Review of the Discrete Area Radar Tracking System, National Track Analysis Program (NTAP), at 1800:03, indicates that N302RS continued towards the northwest at 3,200 feet. The airplane was observed climbing at 1800:51. At 1802:04, the airplane was at 3,700 feet and started a left descending 270-degree turn. The last radar return was recorded at N29.35' W83.16', 1600 feet at 1803:04.

PERSONNEL INFORMATION

Information on file with the Federal Aviation Administration Airman Certification Branch, Oklahoma City, Oklahoma, revealed the pilot was issued a private pilot certificate with ratings airplane single engine land on June 14, 1997. Review of the pilot's logbook revealed the pilot had recorded as logged 146 total flight hours. Thirty-five hours had been logged in the Commander 114-B, of which 14 were as the pilot-in-command. The pilot had a total of 1.1 hours dual hooded flight and 1.7 hours of dual actual instrument flight. The last recorded hood flight was June 13, 1997, and the last recorded instrument flight was September 8, 1997. Review of initial training records conducted by IFR Flight Training School in Austin, Texas, revealed the pilot had completed 30.7 hours of ground instruction, and 19.6 hours of flight instruction on November 21, 1997, in the Commander 114-B. For additional first pilot information, see page 3 of this report.

AIRCRAFT INFORMATION

Review of airframe maintenance records revealed the altimeter system altitude reporting equipment, and transponder was inspected on November 13, 1997. For additional aircraft information, see page 2 of this report.

METEOROLOGICAL INFORMATION

Instrument meteorological conditions prevailed at the time of the accident. The nearest weather reporting facility at the time of the accident was Gainesville, Florida, located about 40 miles to the east. The 1253 surface weather observation was: 700 broken, 900 broken, 1,800 overcast, 2,500 overcast, visibility 7 miles, temperature 70 degrees Fahrenheit, dewpoint 68 degrees Fahrenheit, wind from 240 degrees at 9 knots, and altimeter 29.63 inHg. Geostationary Operational Environmental Satellite data reviewed by the NTSB meteorologists revealed the cloud bases were near 1,000 feet with the predominant cloud tops about 6,000 to 7,000 feet; some cloud tops were above 10,000 feet, with light rain showers. The flight visibility was 0 miles in the clouds and above 3 miles below the clouds. For additional informational see NTSB Meteorologist's Weather Study.

Review of transcribed communication between N302RS and the Gainesville Automated Flight Service Station revealed the pilot received five weather briefings on November 30, 1997. The pilot was informed on the first, third, and fourth weather briefing that VFR flight was not recommended. He was also informed that Tallahassee was IFR on all weather briefings except for the fifth briefing, and that an airmet was in effect for the whole state stating, "VFR flight not recommended all day long." The last recorded weather briefing began at 1208 and was terminated at 1211. The pilot requested and received the Tallahassee weather. The weather was described by the forecaster as marginal VFR, with an associated airmet for moderate turbulence. The pilot filed a VFR flight plan from X-31 to Tallahassee at 1210.

WRECKAGE AND IMPACT INFORMATION

The wreckage of N302RS was located in the vicinity of Ramsey Bend Hunting Club, Township 10, Range 10, Cross City, Florida.

Examination of the crashsite revealed the airplane collided with the top of a 60 foot tree in a descending, nose-down, left wing low attitude. The airplane continued forward 102 feet before colliding with the terrain/water, separating the left aileron assembly, a section of the left flap assembly, and the right hand elevator tip. The airplane bounced, collided with an embankment and trees 125 feet down the crash debris line on a heading of 040 degrees magnetic. The left wing was compressed aft. The leading edge skin assembly separated outboard of the wingwalk, forward of the auxiliary spar, and aft to the left hand outboard spar. The left hand fuel tank was destroyed and the left wing tip separated. The right wing was accelerated forward. The outboard right leading edge skin and right wing tip were bent around the base of a tree. The leading edge skin assembly separated outboard of the wingwalk, forward of the auxiliary spar, and aft of the right hand outboard spar. The right hand fuel tank was destroyed. The nose gear, and left and right main landing gear were found in the up position. The flaps were in the retracted position. The engine assembly separated from the engine mount, firewall, and rotated around its lateral axis to the left 90 degrees. Torsional twisting, and "s" bending was present on all propeller blades. Two propeller blades were loose in the propeller hub with chordwise scarring. The remaining propeller blade exhibited polishing on the cambered and aft surface. The nose section, center section, and aft section were destroyed.

Examination of the airframe, flight control assembly, engine assembly and accessories revealed no evidence of a precrash mechanical failure or malfunction. Continuity of the flight control system was confirmed for pitch, roll, and yaw. All components necessary for flight were present at the crash site.

Examination of the top Airborne vacuum pump revealed the driveshaft rotated freely and the vanes exhibited normal wear. The bottom Airborne vacuum pump was not recovered.

Examination of the altimeter revealed the screw pivot separated from the altimeter frame and the screw pivot was broken. The dual diaphragm separated from the mounting stud.

Examination of the vertical speed indicator revealed the sector gear disengaged from the pointer hand staff. The hair spring lost tension and the vsi pointer pegged at 2,000' per minute rate of descent. The diaphragm was not damaged.

Examination of the turn and slip indicator revealed the pivot separated from the rotor assembly. Scoring was present on the rotor assembly.

Examination of the airspeed indicator revealed the airspeed pointer had shifted counter clockwise from zero between 15 to 20 knots. The airspeed indicator was connected to a manometer. With applied air of 100 knots supplied to the manometer, the airspeed indicator read 85 knots. MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examination of the pilot was conducted by Dr. Margrarita Arruza, Associate Medical Examiner, District Four, Medical Examiners Office, Jacksonville, Florida, on December 5, 1997. The cause of death was multiple injuries. Postmortem toxicology of specimens from the pilot was performed by the Forensic Toxicology Research section, Federal Aviation Administration, Oklahoma City, Oklahoma. These studies were negative for neutral, acidic, and basic drugs. The studies were positive for ethanol which was attributed to postmortem ethanol production.

Postmortem examination of both passengers was conducted by Dr. Arruza, on December 5, 1997. The cause of death was multiple injuries.

TEST AND RESEARCH

Advisory Circular 60-4A states in part, "The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon or surface reference exist, the attitude of an aircraft must be made by artificial means from the flight instruments. Sight supported by other senses, allow the pilot to maintain orientation. However during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of orientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is "up."...The disoriented pilot may place the aircraft in a dangerous attitude....Therefore, the use of flight instruments is essential to maintain proper attitude when encountering any of the elements which may result in spatial disorientation."

Autopilot components and radio equipment were removed from the airplane and forwarded to the FAA Manufacturing Inspection District Office in Kansas City, Kansas. The components were transported by the FAA for further examination by Allied Signal Aerospace located in Olathe, Kansas. Examination of the KFC 200 autopilot system and radios revealed no evidence of a precrash mechanical failure or malfunction. The autopilot was not in use at the time of the accident. For additional information see Allied Signal Aerospace Examination and testing of KFC Autopilot components and radio equipment. ADDITIONAL INFORMATION

The airplane wreckage was released to Mr. Kevin Twiss, Claims Manager, Phoenix Aviation, Atlanta, Georgia, on December 18, 1997. The pilot logbook was released to Mrs. Jennifer Watkins, daughter of the deceased pilot on December 13, 1997. The altimeter, vertical speed indicator, turn and slip indicator, airspeed indicator, and integrated navigation source selector was released to Mr. Bret T. Poe, Accident Recovery Manager, Atlanta Air Salvage, Griffin, Georgia, on December 24, 1997. Avionics, and autopilot equipment was released to Mr. Bret Poe, on February 11, 1998.

NTSB Probable Cause

VFR flight by the noninstrument-rated pilot into instrument meteorological conditions (IMC), and his failure to maintain control of the aircraft, due to spatial disorientation, which resulted in an uncontrolled descent and collision with the terrain (tree, ground & water). Related factors were: the adverse weather condition (low clouds/ceiling), and the pilot's lack of instrument experience.