NTSB Factual Report

HISTORY OF FLIGHT

On April 7, 2015, about 0006 central daylight time, a Cessna 414A twin-engine airplane, N789UP, collided with terrain following a loss of control during an instrument approach to Central Illinois Regional Airport (BMI), Bloomington, Illinois. The airline transport pilot and six passengers were fatally injured, and the airplane was substantially damaged. The airplane was registered to Make It Happen Aviation, LLC, and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 on an instrument flight rules (IFR) flight plan. Night instrument meteorological conditions (IMC) prevailed for the cross-country flight that departed Indianapolis International Airport (IND), Indianapolis, Indiana, at 2307.

According to Federal Aviation Administration (FAA) air traffic control (ATC) data, after departure, the flight climbed to a cruise altitude of 8,000 ft mean sea level (msl) and proceeded direct to BMI. At 2344:38, the flight was about 42 nautical miles (nm) south-southeast of BMI and entered a cruise descent to 4,000 ft msl. At 2352:06, the pilot established contact with a controller at the Peoria Terminal Radar Approach Control facility, reported being level at 4,000 ft msl, and requested the instrument landing system (ILS) runway 20 instrument approach to BMI. According to radar data, at the time of the request, the flight was located about 21 nm south-southeast of BMI and was established on a direct course to BMI at 4,000 ft msl. The controller told the pilot to expect radar vectors for the ILS runway 20 approach. At 2354:18, the controller told the pilot to make a right turn to a 330° heading. The pilot acknowledged the heading change. At 2359:16, the controller cleared the flight to descend to and maintain 2,500 ft msl. At 2359:20, the pilot acknowledged the descent clearance.

At 0000:01, the controller told the pilot to turn left to a 290° heading, and the pilot acknowledged the heading change. At 0000:39, the controller told the pilot that the flight was 5 nm from EGROW, the final approach fix, cleared the flight for the ILS runway 20 approach, issued a heading change to 230° to intercept the final approach course, and told the pilot to maintain 2,500 ft msl until established on the inbound course. The pilot correctly read back the instrument approach clearance, the heading to intercept the localizer, and the altitude restriction.

At 0001:26, the flight crossed through the final approach course while on the assigned 230° heading before turning to a south heading. The plotted radar data showed the flight made course corrections on both sides of the localizer centerline as it proceeded inbound toward EGROW. At 0001:47, the controller told the pilot to cancel his IFR flight plan on the approach control radio frequency, said that radar services were terminated, and authorized a change to the airport's common traffic advisory frequency (CTAF). At that time, the flight was 3.4 nm outside of EGROW and established inbound on the localizer, at 2,400 ft msl. At 0002:00, the pilot transmitted over the unmonitored airport CTAF, "twin Cessna seven eight nine uniform pop is coming up on EGROW, ILS runway 20, full stop." No additional transmissions from the pilot were recorded on the airport CTAF or by Peoria Approach Control.

At 0003:12, the flight crossed EGROW at 2,100 ft msl, continued to descend, and was right of the localizer centerline. At 0003:46, the flight was about 3.5 nm north of the runway 20 threshold when it descended below available radar coverage at 1,500 ft msl. Subsequently, at 0004:34, radar coverage was reestablished with the flight about 1.7 nm north of the runway 20 threshold at 1,400 ft msl. The plotted radar data showed that, between 0004:34 and 0005:08, the flight climbed from 1,400 ft msl to 2,000 ft msl while maintaining a south course. At 0005:08, the flight began a descending left turn to an east course. The airplane continued to descend on the east course until reaching 1,500 ft msl at 0005:27. The airplane then began a climb while maintaining an east course. At 0005:42, the airplane was 0.75 nm east of the localizer centerline at 2,000 ft msl. At 0005:47, the flight descended below available radar coverage at 1,800 ft msl. Subsequently, at 0006:11, radar coverage was reestablished at 1,600 ft msl about 0.7 nm southeast of the previous radar return. The next two radar returns, recorded at 0006:16 and 0006:20, were at 1,900 ft msl and were consistent with the airplane on an east course. The final radar return was recorded at 0006:25 at 1,600 ft msl about 2.2 nm east-northeast of the runway 20 threshold and was coincident with the accident site location.

Numerous individuals reported being awoken shortly after midnight by the sound of a low-flying airplane over their respective residences. Additionally, several of these witnesses saw dense fog and/or rain after the airplane had overflown their positions.

PERSONNEL INFORMATION

According to FAA records, the 51-year-old pilot held an airline transport pilot certificate with single-engine land, multi-engine land, and instrument airplane ratings. The single-engine land rating was limited to commercial privileges. The pilot was type-rated for the Cessna Citation, Learjet 35, Rockwell Sabreliner, Dassault Falcon 10, and Embraer Phenom business jets. He also held a flight instructor certificate with single-engine, multi-engine, and instrument airplane ratings. His most recent FAA second-class medical certificate was issued on February 2, 2015, with a limitation for corrective lenses. On the application for his current medical certificate, the pilot reported having accumulated 12,000 hours of total flight experience, of which 500 hours were flown within the previous 6 months. A search of FAA records showed no previous accidents, incidents, or enforcement proceedings.

A current pilot logbook was not located during the investigation; the pilot's most recent logbook entry was dated February 15, 2005. A portfolio was found in the airplane wreckage that contained numerous pilot training certificates, fleet management documents, and airplane insurance applications. According to an insurance application that was submitted for the operation of the airplane, dated May 12, 2014, the pilot reported having a total flight experience of 12,100 hours with 9,850 hours in multiengine airplanes, 8,575 hours in turbine-powered airplanes, and 1,150 hours in Cessna 414A airplanes. The portfolio also contained documentation for simulator-based proficiency training in the Cessna 414A that was completed on August 14, 2013, at Recurrent Training Center, Inc., Savoy, Illinois. According to available information, the pilot's last flight review and instrument proficiency check were completed on March 11, 2015, in conjunction with simulator-based recurrent training for a Dassault Falcon 10 business jet at FlightSafety International, Dallas, Texas.

AIRCRAFT INFORMATION

The airplane was a 1980 Cessna 414A (Chancellor), serial number 414A0495. Two turbo-charged Continental TSIO-520-NB reciprocating engines provided thrust through constant-speed, full-feathering, three-blade, Hartzell PHC-C3YF-2UF/FC7663DB-2Q propellers. The low-wing airplane was of conventional aluminum construction, was equipped with a retractable tricycle landing gear, and had a pressurized cabin that was configured to seat seven people. The airplane was equipped for night operations in IMC conditions. The airplane had been modified by supplemental type certificates (STCs) to include winglets, vortex generators, and wing spoilers. Additionally, the maximum continuous horsepower of each engine had been increased to 325-horsepower by an STC modification. The airplane had a total fuel capacity of 213.4 gallons (206 gallons usable) distributed between two wing fuel tanks.

The airplane was originally issued an FAA export certificate of airworthiness on May 22, 1980. The airplane was issued a Canadian registration number, C-GFJT, and was based in Canada until September 1986 when it was imported back into the United States and issued a standard airworthiness certificate and a new registration number (N144PC) on October 1, 1986. On April 12, 1993, the registration number was changed to N789UP.

According to an airplane utilization log found in the wreckage, the airplane's hour meter indicated 2,109.7 hours before the previous flight leg (BMI to IND). The airplane's hour meter was not located during the accident investigation. Calculations indicated that the airplane had accumulated about 1.9 hours during the final two flights (the previous flight from BMI to IND and the accident flight from IND to BMI).

According to available maintenance documentation, at the time of the accident, the airframe had accumulated a total service time of 8,390.2 hours since new. The last annual inspection of the airplane was completed on October 1, 2014, at 8,346.9 total airframe hours. The airplane had accumulated 43.3 hours since the annual inspection. The static system, altimeter system, automatic pressure altitude reporting system, and transponder were last tested on December 2, 2013. A postaccident review of the maintenance records found no history of unresolved airworthiness issues. Additionally, there was no record of recent maintenance to the airplane's glideslope antenna.

At the time of the accident, the left engine, serial number 503140, had accumulated a total service time of 4,881.5 hours since new and 556.7 hours since being overhauled on March 20, 2008. The left propeller, serial number EB1994, had accumulated a total service time of 6,936.4 hours since new and 165.3 hours since being overhauled on November 23, 2010.

At the time of the accident, the right engine, serial number 519303, had accumulated a total service time of 5,591 hours since new and 1,699.9 hours since being overhauled on June 13, 2000. The right propeller, serial number EB1993, had accumulated a total service time of 6,936.4 hours since new and 691.3 hours since being overhauled on February 10, 2006.

Weight and Balance

The airplane's weight and balance for the accident flight and the preceding flight (BMI to IND) were calculated using the reported weights and seat positions for the pilot and the six passengers, maintenance records that established the airplane's basic empty weight and moment, fueling receipts/invoices, and recent flight tracking data.

According to the current weight-and-balance record, dated November 27, 2013, the airplane had an empty weight of 5,226.6 pounds (lbs) and a useful load of 1,860.4 lbs. The empty weight center-of-gravity (CG) was 156.52 inches aft of the datum. At maximum takeoff weight, 7,087 lbs, the forward and aft CG limits were 152.2 inches and 159.04 inches, respectively. At maximum landing weight, 6,750 lbs, the forward and aft CG limits were 151.2 inches and 160.04 inches, respectively.

The average fuel consumption rate was estimated to be 47.36 gallons per hour based on the accumulated flight time between known fuel tank top-offs. Based on this estimated fuel consumption rate and fuel receipts/invoices, the airplane departed BMI for IND with about 114.5 gallons of usable fuel. After landing at IND, the airplane was fueled with 60 gallons of fuel and subsequently departed on the accident flight with an estimated 133.4 gallons of usable fuel.

Weight and balance calculations estimated that the preceding flight (BMI to IND) departed 160 lbs over the maximum takeoff weight and with a CG aft of the permitted envelope. The calculations estimated that airplane landed 287 lbs over the maximum landing weight and with a CG aft of the permitted envelope.

Weight and balance calculations estimated that the accident flight departed 271 lbs over the maximum takeoff weight and with a CG about 4.37 inches aft of the permitted envelope. The calculations estimated that, at the time of the accident, the airplane was 366 lbs over the maximum landing weight and had a CG that was about 3.71 inches aft of the permitted envelope.

According to the FAA's Aircraft Weight and Balance Handbook, if the CG is maintained within the allowable limits for its weight, an airplane has adequate longitudinal stability and control. However, if the loaded airplane results in a CG that is aft of the allowable limits, the airplane can become unstable and difficult to recover from an aerodynamic stall. Additionally, if the unstable airplane should enter an aerodynamic spin, the spin could become flat making recovery difficult or impossible.

METEOROLOGICAL INFORMATION

A National Weather Service (NWS) Surface Analysis Chart issued at 0100 depicted a stationary front extending across central Iowa, northern Illinois, and Indiana; the front was immediately north of Bloomington, Illinois. A second stationary front was depicted extending over Kansas, into Missouri, and turning southeastward into Tennessee and Alabama. The station models on the chart indicated northeast winds at 10 to 15 knots north of the stationary front located across Illinois and east-southeast winds at 5 knots or less south of the front. The station models also depicted an extensive area of overcast clouds over the region with most stations along and south of the front reporting light continuous rain, drizzle, and/or mist. The station model for Bloomington indicated wind from the east-southeast at about 5 knots, surface visibility restricted in mist, overcast cloud cover, temperature and dew point at 13°C, and a sea level pressure of 29.98 inches of mercury. The station models surrounding Bloomington indicated similar conditions with overcast clouds, light continuous rain, and/or mist.

A review of weather radar data recorded at 0004 revealed no significant radar echoes greater than 15 dBZ over the greater Bloomington-Normal area. The observed radar echoes were consistent with light rain. The observed radar echoes along the recorded flight track were consistent with the airplane operating in IMC during the approach and at the time of the accident.

At 2156, about an hour before the flight departed, the BMI automated surface observing system (ASOS) reported: wind 150° at 4 knots, an overcast ceiling at 1,200 ft above ground level (agl), 10 mile surface visibility, temperature 14°C, dew point 12°C, and an altimeter setting of 29.98 inches of mercury.

At 2303, about 4 minutes before the flight departed, the BMI ASOS reported: wind 140° at 6 knots, scattered clouds at 100 ft agl and an overcast ceiling at 800 ft agl, 2 mile surface visibility with light rain and mist, temperature and dewpoint 13°C, and an altimeter setting of 29.99 inches of mercury.

At 0005, about a minute before the accident, the BMI ASOS reported: wind 060° at 6 knots, an overcast ceiling at 200 ft agl, 1/2 mile surface visibility with light rain and fog, runway visibility range (RVR) for runway 29 variable 4,000-6,000 ft, temperature and dewpoint 13°C, and an altimeter setting of 29.98 inches of mercury.

The terminal aerodrome forecast (TAF) issued at 1826 for BMI expected marginal visual flight rules (MVFR) conditions to prevail during the forecast period with a surface visibility greater than 6 miles, an overcast ceiling at 2,500 ft agl, and rain showers in the vicinity after 0100. The terminal forecast was amended at 2048, lowering the overcast ceiling to 1,200 ft agl. At 0038, an updated terminal forecast indicated that low instrument flight rules (LIFR) conditions were expected, including an overcast ceiling at 200 ft agl, and a 1/2 mile surface visibility with light drizzle and fog.

According to available information, the pilot used a commercial weather vendor (FlightPlan.com) to obtain his preflight weather briefing. The vendor logged weather briefings at 1614, 1957, 2117, and 2228. The briefings included weather reports, forecasts, and notices to airmen for the departure, destination, alternate, and selected nearby airports and pilot reports. The final weather briefing, obtained at 2228, included the TAF for Bloomington that had been issued at 2048, which forecasted MVFR conditions. The final briefing also provided weather conditions for nearby airports that were reporting LIFR conditions with overcast ceilings ranging between 200 and 300 ft agl. The

NTSB Probable Cause

The pilot's failure to maintain control of the airplane during the instrument approach in night instrument meteorological conditions, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall/spin. Contributing to the accident were pilot fatigue, the pilot's increased workload during the instrument approach resulting from the lack of glideslope guidance due to an inadequately connected/secured glideslope antenna cable, and the airplane being loaded aft of its balance limit.