NTSB Factual Report

***This report was modified on December 13, 2016. Please see the docket for this accident to view the original report.***

HISTORY OF FLIGHT

On August 26, 2015, about 1620 eastern daylight time, a Cessna 310R, N90PS, was destroyed when it impacted water during a missed approach at Space Coast Regional Airport (TIX), Titusville, Florida. The commercial pilot was fatally injured. The airplane was registered to Gibbs Rentals Inc., Wilmington, Delaware, and privately operated as a 14 Code of Federal Regulations Part 91 personal flight. Instrument meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) flight plan was filed for the planned flight to TIX. The flight originated from Orlando Executive Airport (ORL), Orlando, Florida, at 1556.

Review of radar data obtained from the Federal Aviation Administration revealed that the airplane departed from ORL at 1556. The Orlando Terminal radar departure sector air traffic controller instructed him to climb to 3,000 feet, and the pilot acknowledged the instruction. The controller then advised the pilot of an area of heavy precipitation near TIX. The controller then instructed the pilot to turn left to a heading of 220 degrees. At 1558, the controller instructed the pilot to turn left to a heading of 110 degrees and climb to 4,000 ft. One minute later, the controller instructed the pilot to descend to 3,000 feet. The pilot acknowledged and complied with all of the instructions.

At 1603:31, communications with the pilot were transferred to an Orlando terminal radar approach controller, who informed the pilot that there was moderate precipitation from TIX out to 2 miles south of the airport, light precipitation out to 8 miles, and then extreme precipitation beyond that. He also reported that thunderstorms and rain were in the vicinity of TIX and that the visibility was 3 miles. The controller was subsequently relieved for a break and he told the relief controller about the weather near TIX and his plan to intercept the final approach course about 6 to 7 miles south of the end of the runway.

At 1610, the relief controller instructed the pilot to fly a heading of 080 degrees and instructed him to descend to 2,100 ft. At 1613:11, he instructed the pilot to turn left heading 030 degrees and maintain 2,100 feet and to intercept the localizer course for the instrument landing system approach to runway 36 at TIX. The pilot acknowledged the instruction. The airplane intercepted the final approach course at 1614:55 at 1,900 feet and about 1.6 nautical miles inside of the final approach fix.

At 1614, the relief controller instructed the pilot to contact the TIX control tower. The pilot subsequently made two attempts to contact the TIX tower, and on the second attempt, the TIX controller responded that the airport was operating under IFR. The pilot responded that he was on an IFR flight plan, and the TIX controller cleared the flight to land.

At 1617, the pilot advised the TIX controller that the airport was not in sight and that he was executing a missed approach. The TIX controller transferred communications back to the Orlando approach controller, who then asked the pilot if he wanted to fly the full published missed approach or if he was requesting an alternate missed approach to the south to avoid heavy precipitation. The pilot requested a turn to the south because he was in "heavy" precipitation. Radar data indicated that, while the air traffic controller was asking the pilot about the alternate missed approach, the pilot had begun a right turn. The controller then told the pilot to turn right to 210 degrees when able, and the pilot acknowledged the right turn instruction. During a subsequent interview, the controller stated that he issued a right turn because convective weather was less severe to the airplane's right than to its left.

At 1620, radar data indicated that, after the airplane completed a 180-degree climbing right turn to reverse direction, it made a rapid descent and impacted a river. No further voice communications were received by air traffic control.

PERSONAL INFORMATION

According to FAA records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. His most recent FAA second-class medical certificate was issued August 23, 2013. At the time of the medical examination, the pilot reported 976 total hours of flight experience and 0 hours of flight experience within the previous 6 months. The pilot's logbook was not recovered. Insurance documentation reported that, as of October 24, 2014, the pilot had accumulated 1,000 hours' total flight experience, of which 407 hours were in multiengine airplanes and 300 hours were in the accident airplane make and model. The pilot did not report his instrument experience on the insurance application, nor was it required.

AIRCRAFT INFORMATION

According to FAA and aircraft maintenance records, the airplane was originally issued an airworthiness certificate on February 17, 1975, and registered to the owner on October 24, 2014. It was powered by two Continental IO-550-A2F, 300-horsepower engines and driven by two McCauley propellers, model 3A32C87. According to maintenance records, the most recent annual inspection was conducted on October 16, 2014, with a recorded total time in service of 4259.3 hours. At that time, both engines had accumulated 805.4 hours since major overhaul.

The airplane was equipped with a Bendix RDS-82VP weather radar system and a Garmin 496 handheld GPS receiver with onboard satellite-based weather depiction. The pilot also had access to a tablet computer that had an aviation flight planning application, Fore Flight, and a weather application. The extent to which the pilot might have used any of these devices during the flight could not be determined.

METEOROLOGICAL INFORMATION

At 1545, the pilot called an automated flight service station and requested a weather briefing. A briefer advised the pilot that the planned route of flight was currently clear but that there were thunderstorms moving up from the south that could affect the flight. He added that thunderstorms were in the area to the north and south of TIX. The briefer advised the pilot to call back right before takeoff for an update on the weather movement. The pilot then filed an IFR flight plan and ended the call. The pilot did not call back before takeoff.

The official observation for conditions near the time of the accident, which was reported from TIX at 1555, included wind from 040° at 16 knots gusting to 26 knots, visibility 2 miles in thunderstorm and moderate rain, ceiling broken at 1,000 feet agl, temperature 29° C, dew point 24° C, altimeter 29.94 inches of Hg. Remarks: thunderstorm began at 1445. None of the observations for TIX surrounding the time of the accident were listed as special observations (SPECI), and the only remarks noted were of the beginning and ending of the thunderstorm and a report of showers in the vicinity after the accident. There was no aircraft mishap report noted, and there were no indications of the type and frequency of lightning over the region during the period or of the location and movement of towering cumulus (TCU) or cumulonimbus (CB) clouds.

Infrared satellite imagery for 1615 depicted several defined cumulonimbus clouds over the Titusville area and central and southern Florida. The radiative cloud top temperature over the accident site corresponded to cloud tops near 45,000 feet based on the upper air sounding.

The National Weather Service radar reflectivity mosaic for 1620 depicted scattered echoes across northern, central, and southeast Florida. The echoes were south of the departure area for Orlando with a large area of intense-to-extreme echoes identified over the Titusville area and extended to the southwest.

A review of lightning activity between 1545 and 1630 depicted over 1,100 lightning strikes, of which over 350 were cloud-to-ground type strikes, within a 15-mile radius of TIX. At 1608, the air traffic control tower at TIX was struck by lightning.

Security camera video was obtained for the investigation; the video began at 1551 and ended at 1701. The security camera recorded numerous airplanes parked on the ramp area at TIX and a self-service fuel tank about 30 feet from the security camera. The camera was motion activated and only captured images when motion was detected. At 1551, the video indicated dark cumulonimbus clouds building. The recording taken at 1609 indicated heavy rain, and visibility was reduced to about 1/4 mile. Most of the parked airplanes on the ramp were not visible, and the fuel tank was noticeable but not clearly visible.

The Federal Meteorological Handbook requires that, at a manual observing station such as TIX, if lightning is observed the frequency, type of lightning, and location shall be reported. The handbook also requires that a special observation be issued when a thunderstorm begins or when visibility deceases to 3 miles or less.

WRECKAGE AND IMPACT INFORMATION

The airplane was recovered from a depth of about 6 feet from the Indian River. The debris field was compact, and both engines were located about 40 feet apart from each other. The airplane was fragmented and only a portion of the airplane was recovered due to currents. The recovered pieces were no larger than about 2 feet by 2 feet. Some of the components recovered were sections of the nosecone, seats, left wing spar, empennage, horizontal stabilizer, and both nacelle baggage compartment doors. Flight control continuity could not be verified due to impact damage and the inability to locate the flight controls and associated cables. Measurement of the elevator trim actuator corresponded to an off-scale nose-up trim, consistent with impact damage.

The left engine had separated from the airframe, and the propeller had separated from the engine and was not recovered. Engine powertrain continuity was confirmed from the front of the engine to the rear accessory section by manually rotating the crankshaft and observing movement of the timing gears and valve train. All six cylinders were attached; however, the cooling fins exhibited impact damage. The top sparkplugs were removed, and the electrodes were intact and grey. There was some sea water corrosion present on all of the sparkplugs. Thumb compression was achieved when the crankshaft was manually rotated. The right and left magnetos separated, but were recovered. The magnetos were damaged by corrosion due to sea water immersion. The ignition harness was damaged when the magnetos separated.

The right engine had separated from the airframe, and the propeller separated from the engine and was not recovered. Engine powertrain continuity was confirmed from the front of the engine to the rear accessory section by manually rotating the crankshaft and observing movement of the timing gears; however, rocker arm motion did not occur. The engine case was opened and it was determined that the cam shaft was fractured in two pieces. Subsequent metallurgical examination of the camshaft revealed fracture features consistent with overstress during impact. The top spark plugs were removed and the electrodes were intact and grey in color. There was some sea water corrosion present on all sparkplugs. The magnetos were damaged by corrosion due to sea water immersion. The ignition harness was damaged when the magnetos separated.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was conducted on the pilot on August 31, 2015, by the Office of the Medical Examiner, Rockledge, Florida. The cause of death was determined to be "multiple blunt force injuries."

Forensic toxicology was conducted on lung and muscle specimens from the pilot by the FAA's Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, and the results were negative for ethanol and drugs.

ADDITIONAL INFORMATION

FAA Order 7110.65, "Air Traffic Control," contains a Pilot/Controller Glossary that addresses how air traffic controllers shall describe levels of precipitation based on dBZ levels and states, in part, the following:

PRECIPITATION RADAR WEATHER DESCRIPTIONS –

a. LIGHT (< 30 dBZ)

b. MODERATE (30 to 40 dBZ)

c. HEAVY (> 40 to 50 dBZ)

d. EXTREME (> 50 dBZ)

(Refer to AC 00-45, Aviation Weather Services.)

FAA 7110.65, Paragraph 2-6-4, "Weather and Chaff Services," states, in part, the following:

b. Inform any tower for which you provide approach control services of observed precipitation on radar which is likely to affect their operations.

FAA Order 7110.65, Paragraph 2-6-3, "PIREP Information," and states, in part, the following:

Significant PIREP information includes reports of strong frontal activity, squall lines, thunderstorms, light to severe icing, wind shear and turbulence (including clear air turbulence) of moderate or greater intensity…and other conditions pertinent to flight safety.

a. Solicit PIREPs when requested or when one of the following conditions exists or is forecast for your area of jurisdiction:

1. Ceilings at or below 5,000 feet. These PIREPs must include cloud base/top reports when feasible.

2. Visibility (surface or aloft) at or less than 5 miles.

3. Thunderstorms and related phenomena.

During a postaccident interview, the Orlando terminal radar approach controller who advised the pilot of the precipitation south of the airport provided the following information. He stated that on initial contact with the airplane, the pilot verified that he had the current automated terminal information service (ATIS) for TIX airport. He advised the pilot of the weather shown on his display and issued the airplane a 115 degree heading for the instrument landing system (ILS) runway 36 approach to TIX. He told the pilot to expect a 6 to 8 mile turn to final to keep him out of the precipitation that was south of TIX along the final approach course. He told the pilot that there was heavy to extreme precipitation in the vicinity of the TIX airport and moderate precipitation over the TIX airport. He said that if he had continued to work the airplane, he would have issued the radar-displayed weather again when the airplane was on final approach. After issuing the 115 degree vector, he issued the pilot a 10 degree left turn because it looked like the wind was pushing the airplane south. Soon after the 10 degree left turn was issued, he was relieved by another controller. During the position relief briefing, he told the oncoming controller that the pilot was aware of the weather and still wanted to shoot the ILS runway 36 approach to TIX. Although he never specifically addressed it in the position relief briefing, he believed the oncoming controller understood the plan to take the airplane out to a 6 to 8 mile final. After completing the position relief briefing, he remained for a 2 minute overlap before departing the position.

During a postaccident interview, the relief Orlando terminal radar approach controller provided the following information. He stated that before taking over the position, he received a position relief briefing from the outgoing controller. His plan was to bring the airplane close to the final approach fix (FAF) because there was weather south of the final approach course. He vectored the airplane to the final approach course, issued a 30 degree right turn to intercept, and issued the approach clearance. He noticed that the airplane was further away from the final approach course than he wanted, and he issued the pilot an additional 10 degree turn to the right to establish the airplane on the final approach course. He advised the pilot that he would join the final approach course at the FAF and asked the pilot if that would be okay; the pilot accepted the plan. He then issued the pilot a frequency change to TIX air traffic control tower. He did not recognize that the airplane intercepted the final approach course inside the FAF. TIX tower called him and advised him that the pilot never got the airport in sight and was going to execute the published missed approach procedure. The pilot returned to his frequency, and he advised the pilot that there was heavier weather to the north of T

NTSB Probable Cause

The pilot's continued flight into known convective weather conditions, which resulted in the airplane's encounter with thunderstorms and the pilot's subsequent loss of airplane control during a missed approach. Contributing to the accident was the failure of the approach controllers and the tower controllers to provide timely and accurate weather information to the pilot.