MIA08FA026
MIA08FA026

[ This factual report was modified on January 26, 2010 ]


HISTORY OF FLIGHT

On December 7, 2007, at 2117 central standard time (unless otherwise noted, all times are in central standard time based on a 24 hour clock) , a Cessna R182, N2643C, registered to Cherry Tree Aviation LLC and operated by Executive Flight Center, collided with trees and terrain during an uncontrolled descent near Woodland, Alabama. The instructional flight was conducted under visual flight rules (VFR), at night, under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Marginal VFR conditions prevailed at the time of the accident, and no flight plan was filed. The certified flight instructor (CFI) and student pilot were fatally injured, and the airplane was destroyed. The flight originated from Orlando Executive Airport, Orlando, Florida at 1948 eastern standard time (est)

Review of a transcript between the pilot and the Federal Aviation Administration (FAA) Nashville Federal Contract Facility, Automated Flight Service Station (AFSS) revealed that the CFI called the AFSS at 0147 and filed an instrument flight plan to fly from Alabama to Florida (the leg preceding the accident flight). The telephone call was terminated at 0150. The flight departed Madison County Executive/Tom Sharp Jr. Field at 0227 and arrived uneventfully at Orlando Executive Airport, Orlando, Florida, at 0645 est.

According to the line supervisor at Shelt Air, a fixed based operator at the Orlando Executive Airport, the airplane was refueled with 61.2 gallons of 100 low lead aviation fuel after arrival. The CFI requested a courtesy car so she could take the student pilot to a hotel to attend a conference, and that she was going to get some rest after she returned. Both the CFI and the student pilot departed in the courtesy car, and the CFI returned at 0900 est. The line supervisor stated the CFI went to the crew room and appeared to be sleeping in a lounging chair with a blanket for about 2 to 4 hours. The line supervisor then observed the CFI eating pizza that was delivered to Shelt Air as a part of customer appreciation day at about 1230 est, and she also received a courtesy massage.

The CFI asked if she could use the courtesy car later in the afternoon to pick up the student pilot. The courtesy car was not available, so the CFI rented a car at 1715 est. The rental car was returned about 1900 est.

No record of a formal weather briefing, or a filed flight plan, for the accident flight back to Alabama was found.

Recorded radar data from the accident flight was requested, obtained, and analyzed by the NTSB. Two radar data files were used. One was provided by the United States Air Force and contained target records from multiple radar sites in the eastern United States. The FAA supplied a second radar data file containing targets from Atlanta Terminal Radar Approach Control, obtained from a radar sensor located at Columbus, Georgia (CSG).

Radar coverage collectively provided by these sites documented the flight path of the accident flight from departure until loss of data at 2105 (12 minutes before the accident). The radar coverage was virtually continuous, with no indication of erratic transponder operation. Data from radar sensors located at Marietta, Georgia; Haleyville, Alabama; and Montgomery, Alabama, were reviewed but provided no additional target information on the aircraft between loss of contact and the accident site.

Altitude reports in the Air Force radar data file were uncorrected mode C reports (pressure altitude). The local altimeter setting at ORL was 30.28 in.Hg when N2643C departed. The altimeter setting at Valdosta, Georgia, at 2009 (approximately the time that N2643C passed southwest of the Valdosta Airport) was 30.29 in.Hg. The Anniston, Alabama 2100 altimeter setting was 30.23 in.Hg. As mode C altitude reports are quantified in 100-foot increments, these altimeter settings indicate that the pressure altitude reported by the aircraft during the flight would be increased 300 to 400 feet to convert pressure altitude to true altitude (based on the ORL altimeter setting).

N2643C was operating under visual flight rules and did not receive any air traffic control (ATC) services after departure from ORL. The transcript of ATC communications with N2643C shows that the pilot was cleared for takeoff at 1948 est and directed to turn left northwest-bound after departure. At 2005 est, the tower controller instructed the pilot to set the aircraft’s transponder to code 1200. The pilot responded, “Sorry about that,” indicating that he may have forgotten to turn the transponder on when departing. There were no further radar-related exchanges between the pilot and ATC during the accident flight.

Review of recorded data from an Air Force radar site located at Cape Canaveral, Florida shows an aircraft on code 1200 departing ORL at 2050 est and leaving the area to the northwest. There are no other aircraft with those characteristics leaving ORL at that time. The track proceeded northwest toward Gainesville, where the aircraft turned to the west and passed just west of the Gainesville Regional Airport class D airspace. The track then resumed a northwest heading, making another slight turn and passing just west of the Valdosta Regional Airport class D airspace. The aircraft turned toward the north and then back to the northwest, passing through the east side of the Benning Military Operations Area. The last target associated with N2643C was seen at 2105 by the CSG radar, approximately 40 nautical miles southeast of the accident site. The exact route flown from loss of contact to the accident site is unknown; however, the accident site was located along an extended line from the last radar contact.

A witness who lived in the vicinity of the crash site stated he heard an airplane fly over his house between 2115 to 2130, with the power at a high rpm. A short time later, he heard an impact and immediately called the emergency 911 operators to report the accident. No eyewitnesses or other ear witnesses were identified during the investigation. Bethel East Volunteer Fire Department personnel located the wreckage at 2237.


PERSONNEL INFORMATION

The Certified Flight Instructor (CFI)

The CFI, age 28, held an FAA commercial pilot certificate issued on December 18, 2003, with ratings for airplane single and multiengine land, and instrument airplane. She also held a flight instructor certificate issued on December 30, 2006, with ratings for airplane single and multiengine land, and instrument airplane. The CFI held an FAA first class medical certificate issued on February 26, 2007, with no restrictions.

The CFI reported on her application for the medical certificate that she had accumulated 1,600 total flight hours. Review of her logbook revealed the flight time entries were not totaled, and numerous pages had yellow sticky notes with flight time entries. The last recorded entry in the logbook was on December 6, 2007. The CFI's last recorded night flight was on November 29, 2007, and she had logged 1.6 hours of night flight in the last 90 days. The CFI had flown 19.8 hours in the last 30 days, and 89.4 hours in the last 90 days. Her last flight review and total flight time in the Cessna R182 could not be determined. The CFI's last certified flight instructor renewal was conducted on December 30, 2006.

The Student Pilot

The student pilot, age 36, held a third class medical and a student pilot certificate issued on May 25, 2007, with no restrictions. The student pilot's logbook revealed his last recorded flight was on November 9, 2007. No flights were recorded in a Cessna R182. The student pilot had a total of 23.8 hours, of which 30 minutes were in the Cessna 172 and 23.3 hours were an American Champion. The pilot had flown 2.9 hours in the last 30 days and 8.2 hours in the last 90 days.


AIRCRAFT INFORMATION

The four seat, single-engine, high-wing airplane, serial number (S/N) R18200190, was manufactured in 1978. It was powered by a Lycoming O-540-J3C5D, 235 horsepower reciprocating engine, and it was equipped with a McCauley model B2D34C214/90DHB-8 constant speed propeller.

A review of the aircraft logbook revealed the last entry was on November 29, 2007, and the tachometer indicated 3425.9 hours. The last annual inspection was conducted on February 23, 2007, and the tachometer and airframe total time was 3,163.7 hours. The last 100-hour inspection was conducted on October 6, 2007, and the tachometer indicated 3,363.6 hours. As of the last entry in the aircraft logbook, the airplane had flown 62.3 hours since the last inspection. A major engine overhaul was conducted on January 15, 1997, at tachometer time 2056.8 hours, and the total time on the engine was 2,056 hours. The total time on the engine since the major overhaul, as of November 29, 2007, was 1,369.1 hours. The last oil change was conducted on November 7, 2007 and the tachometer indicated 3,420.7 hours.

The last pitot static and transponder test was conducted September 28, 2007, and the tachometer indicated 3,372.1 hours. Work Order 290-11-2007 was submitted on November 29, 2007 for an erratic transponder problem. A pitot static and transponder verification test was completed and the transponder was found to be within limits. The tachometer and Hobbs meter were not located at the crash site and the total airframe and engine times were not determined.


METEOROLOGICAL INFORMATION

Surface Weather Observations.

The surface weather observation at the airport in Columbus, Georgia (KCGS), located between 15-20 nautical miles west of radar targets identified where the accident aircraft altitude was between 2100-2400 feet msl, about 2045, were as follows: broken ceiling at 2,400 feet agl (2,800 feet msl), with another broken layer at 2,900 feet agl, and overcast at 6,000 feet agl. Visibility was reported to be 6 statute miles with haze. MVFR conditions prevailed. Light winds were out of the east at the surface. Ceilings had been varying over the previous hour. The CGS station elevation is 400 feet msl.

The surface weather observation at the airport in Lagrange, Georgia (KLGC), located along the route of flight from the last radar positions and accident site, and about 43 nautical miles southeast of the accident site, were as follows during the time period between 2020 and 2120: Cloud ceiling variable, with deteriorating conditions after 2040. At 2040, the report indicates a few clouds at 1,500 feet agl (2,200 feet msl); scattered clouds at 2,600 feet agl, and broken ceilings at 3,100 feet agl. At 2100, the report indicates scattered clouds at 1,700 feet agl (2,400 msl), broken ceilings at 2,600 feet agl, and overcast ceiling at 5,000 feet agl. At 2120, the reports indicates that the ceiling was broken at 1,700 feet agl (2,400 msl), and overcast at 2,400 agl. The KLGC station elevation is about 700 feet msl.

The 2053 surface weather observation at Anniston Metropolitan Airport, Anniston, Alabama (KANB), located 17 nautical miles west of the crash site was: visibility 8 statute miles with broken ceilings at 1,500 feet agl (2,100 feet msl). By 2153, the visibility had decreased to 5 statute miles, mist was present, and the ceilings had become overcast at 1,500 feet agl (2,100 feet msl). MVFR conditions prevailed. Station elevation is about 600 feet MSL.

AIRMET Information.

AIRMET SIERRA was in effect for Georgia and Florida during accident time, and also for Alabama during the accident time and location. The AIRMET indicated that ceilings were below 1,000 feet agl, visibility was below 3 statute miles, with mist and fog.

Prior to AIRMET SIERRA taking affect, portions of Georgia and Florida were covered by an “outlook” in previous forecasts, including the 1920 AIRMET SIERRA, which forecast instrument flight rules (IFR) conditions.

Also prior to AIRMET SIERRA taking affect, the flight portion near the accident site was covered by an “outlook” in previous forecasts, including the 1737 AIRMET SIERRA, which forecast IFR conditions 2100 to 0300 the following day.

A Terminal Aerodrome Forecast for KANB was produced at 1732 and forecast conditions during the accident time of east winds at 4 knots, visibility greater than 6 statute miles, with a broken ceiling at 6,000 agl.

Rawinsode Information.

A rawinsonde launched from KFFC at 1800, located 50 nautical miles south/south-east of the accident site, identified a cloudy (or mutli-layered cloudy) level between approximately 3,000 -7,000 feet msl, with a ceiling of about 2,000 feet agl. Below the cloud base identified by the rawinsonde, the atmosphere was much drier and did not support the presence of large-scale cloudy areas; however the likelihood of radiation fog forming before sunrise was classified as “moderate”.

Satellite Observations.

At the accident site, a GOES 12 satellite scan at 2115 indicated brightness temperatures of 280 degrees Kelvin, which corresponds to cloud tops of about 6,000 to 7,000 feet msl. A MODIS brightness temperature (limb) retrieval from the TERRA spacecraft at the time/location of the accident is almost identical, and confirms the GOES retrieval.

Darkness Conditions.

Astronomical data obtained from the United States Naval Observatory website revealed sunset was at 1634 and end of twilight was at 1701 near the accident site location. Moonrise was at 0446 and moon set was at 1453. The phase of the moon was waning crescent with four percent of the moon's visible disk illuminated.


WRECKAGE AND IMPACT INFORMATION

The wreckage was located behind a private residence located in the vicinity of Woodland, Alabama. Examination of the crash revealed the airplane collided with the trees about 35 feet above the base of the trees, and then the ground in a descending nose-down attitude.

The direction from the tree strikes to the final resting site was toward the south, nearly opposite the intended route of flight. The airplane came to rest inverted and was aligned on a heading of 305 degrees. The forward portion of the airplane, including the engine, was imbedded about four feet below the surface of the ground. The upper and lower engine cowlings were destroyed.

The inboard portion of the right wing partially separated from the fuselage and was pushed aft. The outboard portion of the right wing was observed wrapped around a tree. The left wing was partially separated from the fuselage. The leading edge of the left wing was crushed aft, and the upper and lower wing skins were fragmented. The fuselage structure was crushed aft all the way to the leading edge of the horizontal stabilizers.

Examination of the airframe and flight controls revealed no evidence of a precrash mechanical failure or malfunction. All flight control surfaces were accounted for at the accident site. The wing flaps and landing gear were found in the retracted position. The instrument panel, and flight instruments were fragmented, and the autopilot was destroyed. The directional gyro was disassembled and examined; the gyro was impact damage and exhibited rotational scoring on the rotor surface, and also on the interior wall of the gyro’s case. The fuel selector valve was found in the “both” position.

Both propeller blades were separated from the propeller hub. The propeller hub was fractured and partially separated from the propeller crankshaft flange. One propeller blade exhibited "s" bending with chordwise scratching on the cambered and non-cambered sides of the propeller blade, and nicks were present on the trailing edge of the propeller blade. The other propeller blade exhibited torsional twisting and "s" bending. Diagonal scratching was present on the cambered side of the propeller blade and a gouge was present on the leading edge four inches inboard of the propeller tip.

Partial disassembly of the engine assembly and recovered accessories revealed no evidence of a pre-impact mechanical malfunction. Compression and suction were observed from all six cylinders. Crankshaft and camshaft continuity was established.

The right side exhaust stack assembly and tailpipe had separated and were crushed. The right side muffler was also separated and crushed. The shroud assembly/heater (which serves as the cabin heat source), was removed and examined in detail. The examination revealed no evidence indicative of a corrosion, cracking, or pre-impact compromise.

The left side exhaust stack from the no. 2 cylinder had separated and was crushed. The left side exhaust stacks from the no. 4 and no. 6 cylinders remained attached and were crushed. The left side muffler was crushed and separated. The left exhaust shroud assembly (which serves as the carburetor heat source), remained attached to the muffler and was crushed. This assembly was removed and examined in detail. The examination revealed no evidence indicative of a corrosion, cracking, or pre-impact compromise.


MEDICAL AND PATHOLOGICAL INFORMATION

The Alabama Department of Forensic Science, Montgomery, Alabama, performed an autopsy on the CFI on December 9, 2007. The reported cause of death was "multiple blunt force injuries." The FAA’s Forensic Toxicology Research Section, Oklahoma City, Oklahoma, performed postmortem toxicology of specimens from the pilot. Carbon monoxide and cyanide testing was not performed, due to the lack of suitable samples that were available for testing. No ethanol was detected in the liver. The testing was negative for basic, acidic, and neutral drugs and putrefaction was present.

The Alabama Department of Forensic Science, Montgomery, Alabama, performed an autopsy on the student pilot on December 9, 2007. The reported cause of death was "multiple blunt force injuries." The FAA’s Forensic Toxicology Research Section, Oklahoma City, Oklahoma, performed postmortem toxicology of specimens from the pilot. Carbon monoxide and cyanide testing was not performed, due to the lack of suitable samples that were available for testing. Ethanol, 107 (mg/dl, mg/hg) was detected in the muscle, and 32 (mg/dl, mg/hg) were detected in the liver. N-propanol, 4 (mg/dl, mg/hg) was detected in the muscle and 5 (mg/dl, mg/hl) were detected in the liver. N-butanol, 2 (mg/dl, mg/hg) was detected in the muscle. No putrefaction was noted.


TESTS AND RESEARCH

CFI Sleep History.

The husband of the CFI stated his wife did not have a sleep disorder or take any medication to help her sleep. Her sleep patterns normally stayed the same during their off days and when they took a trip together. She liked to get about 9 hours of sleep, however she normally averaged 7 to 8 hours of sleep. It normally took his wife between 10 to 15 minutes to get to sleep and she would awake 1 to 2 times a night to get a drink of water or go the bathroom.

He stated that the CFI had been complaining the week before the accident that she was not getting enough sleep and that they needed to start getting to bed earlier, between 2030 to 2100 hours. They started their new schedule on December 2, 2007, and adhered to it on every night except for December 4, 2007. He stated he did not recall what time his wife awoke on December 6, 2007, the day before the accident, and that he met his wife at a retirement center at 1545 that day. They departed the retirement center and went to a local store, their church and back to the retirement center. His wife left the retirement center to go home to have dinner and then to bed between 1930 to 2000, due to an early flight on December 7, 2007, to Orlando, Florida. The husband stated, "He remembered thinking that his wife would only get about 4 hours of sleep because she would be getting up at 0045AM on Friday morning December 7, 2007."

The CFI’s husband said he arrived home at midnight and inadvertently woke his wife up. They exchanged greetings and his wife went back to sleep, and he woke her up at 0045. His wife departed the house about 0100 and drove to the airport, and he called her on her cell phone at 0120 while she was driving. His wife appeared to be alert during their conversation. He went back to sleep, awoke, called his wife on the phone after she arrived in Orlando, and sent her several e-mails through the day. At the time of the accident, the CFI had been awake about 20.5 hours.

Student Pilot Sleep History.

The wife of the deceased student pilot stated her husband did not have a sleep disorder or take any medication to help him sleep, and he would normally eat when he had time to eat. He normally only required 4 to 5 hours of sleep and he would go to sleep between 2200 to 2300 hours. He kept a notepad next to the bed. He was the most hyperactive person that you would ever meet. If he awoke in the night he would lay there and think, write some notes, or get up and go in the other room and do some office work on the computer. His sleep pattern was the same every day, including weekends, holidays, and while on vacation.

The student pilot’s wife stated that the student pilot wanted to attend a conference in Orlando. He did not want to depend on the airlines on getting him to and from Orlando, so he could spend the weekend with his children. In addition, he wanted to build some flight time. She could not remember what time her husband started to work the day before the accident. He went to bed at 2045, awoke at 0130, and went to the airport at 0145 to meet his instructor at 0200. She called her husband at 0630, and her husband stated the other pilot had driven him to the conference and that she was going to return to the airport to get some rest. She talked to her husband again at 1745, and he stated they were on their way back to the airport and that he should be home at 2200. Her husband called her at 1815 and left a message on her cell phone that they had been delayed in traffic, his phone battery was low, and he would be home in 3 to 4 hours. At the time of the accident the student pilot had been awake about 20 hours.

FAA Guidance on Night Flight.

The FAA Airplane Flying Handbook, FAA-H-8083-3, chapter 10, states the following about night flying and its affect on spatial orientation:

"Night flying requires that pilots be aware of, and operate within, their abilities and limitations. Although careful planning of any flight is essential, night flying demands more attention to the details of preflight preparation and planning. Preparation for a night flight should include a thorough review of the available weather reports and forecasts with particular attention given to temperature/dewpoint spread. A narrow temperature/dewpoint spread may indicate the possibility of ground fog. Emphasis should also be placed on wind direction and speed, since its effect on the airplane cannot be as easily detected at night as during the day...Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree in controlling the airplane…”

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