ERA09MA157
ERA09MA157

HISTORY OF FLIGHT

On February 8, 2009, at 1836 Atlantic standard time, a Cessna 206H, N118ME, was destroyed when it impacted offshore waters near Quebradillas, Puerto Rico (PR). The certificated commercial pilot and five passengers were killed. Visual meteorological conditions prevailed near the surface, while instrument meteorological conditions prevailed at higher altitudes. An instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 flight. The flight originated at Casa De Campo International Airport (MDLR), La Romana, Dominican Republic about 1720, destined for Fernando Luis Dominicci Airport (TJIG) in San Juan, Puerto Rico.

According to the owner of the accident airplane, the accident pilot had been scheduled to fly five passengers to MDLR in a Piper PA-31 on February 6, 2009, but since the airplane was grounded, the flight was conducted in the accident airplane. The flight departed TJIG and arrived at MDLR uneventfully, and the pilot returned to TJIG later the same day. No flights were conducted in the accident airplane on Saturday, February 7.

On Sunday, February 8, 2009, Federal Aviation Administration (FAA) inspectors conducted a ramp check of the airplane while it was parked at TJIG. No serious discrepancies were noted. The airplane later departed TJIG and arrived at MDLR to pick up five passengers, four of whom the pilot had flown to MDLR on Friday, to return them to San Juan.

The accident flight departed MDLR with a planned route of flight of airway W9 to the MELLA intersection, airway G633 to the Dorado (DDP) non-directional beacon, then direct to TJIG.

At 1811, the San Juan en route radar approach (ZSU) controller identified the airplane on radar 29 miles west of Mayaguez (MAZ), Puerto Rico at 7,000 feet mean sea level (msl).

At 1819, the controller cleared the pilot to proceed direct to the destination airport. When the airplane was between MELLA intersection and the MAZ very high frequency omnidirectional range (VOR), about 28 miles southwest of the accident site, the pilot cancelled the IFR flight plan and requested to continue under visual flight rules (VFR) “so we can clear this weather.” The controller approved the pilot’s request, and also requested that the airplane remain on the last assigned discreet transponder code. The airplane subsequently turned to the northeast, over land, toward the northern coastline of Puerto Rico.

At 1830, after a query by the controller, the pilot reported that he was descending to 5,500 feet.

At 1838, just after the last radar return of the airplane was observed, the controller again queried the pilot about his altitude, but received no response. The controller then solicited assistance from another pilot in the area, who also attempted radio contact, but without success.

There were no mayday or other distress calls, nor were there any low altitude alerts heard or observed. The last radar return was observed over Quebradillas at 5,000 feet, and at a calculated ground speed of 189 knots. Shortly thereafter, the local police received telephone calls reporting an airplane crash, and subsequently, the U.S. Coast Guard confirmed that the airplane was in the water, less than 0.25 miles offshore.

A witness who was at a restaurant overlooking the accident site reported that she heard a “pop” or “boom” sound, then observed the airplane descend out of the clouds. She heard another loud boom as the airplane hit the water. The witness also noted that the engine was running between the booms, and that it was raining, with big heavy drops, and windy at the time.

Another witness reported that while he was closing some windows, he heard an “aircraft engine” that was “making strange noise followed by some silence.” Suddenly, a “backfire” was heard, followed by silence, and he then saw the airplane descending until it disappeared behind a house.

A third witness was outside when he heard an airplane that seemed to be having a problem with its engine, and compared the sound to “a lawn mower getting out of fuel.” He subsequently watched the airplane in a “spiral nose down attitude going into the sea.”

A fourth witness stated that she was outside when she heard an airplane that “sounded like it was misfiring and suddenly the engine sound stopped.” She looked in the direction of the sound, and saw the airplane spinning without a wing, and later heard the sound of an impact.

A witness who was at MDLR at the time of the airplane’s takeoff called the NTSB Investigator-in-Charge (IIC) to report his observations of the airplane before it departed. He reported that he was at his partner’s fixed base operator (FBO) picking up a passenger, and observed the airplane taxiing out for departure in a “very tail low condition.” He also stated that the “nose wheel was barely on the taxiway.” He took a picture of the airplane with his cell phone camera because he thought the airplane was “overloaded and out of aft CG.” He also reported that the airplane required about 3,000 feet of runway to get airborne, with a 10-knot headwind.

A friend of the passengers provided an additional photo taken of the airplane while on the ramp at MDLR prior to departure. Although no occupants appeared to be in the front seats at the time, the airplane was in a tail-low, nose-high attitude.

PERSONNEL INFORMATION

Pilot

The pilot, age 28, held a commercial pilot certificate with single- and multi-engine land ratings and an instrument airplane rating. The following is a chronological summary of the pilot’s qualifications, based on FAA records:

On July 16, 2005, the pilot received a private pilot, single-engine land rating. The airman file indicated he had a total of 78.0 flight hours at the time.

On September 28, 2007, the pilot received an instrument airplane rating. The airman file indicated he had a total of 181.7 flight hours at the time.

On July 21, 2008, the pilot received his commercial pilot certificate with airplane single-engine land and instrument airplane ratings. The airman file indicated he had a total of 381.2 flight hours at the time.

On August 18, 2008, the pilot received his commercial certificate with a multi-engine land rating. The airman file indicated he had a total of 428.4 flight hours at the time.

The pilot held an FAA first class medical certificate that was issued on October 10, 2008. The medical certificate indicated that the pilot had reported a total flight time of 1,100 hours at the time of the medical examination. The pilot's logbook indicated that he had a total of about 622 flight hours total time, of which, approximately 235 hours were in the accident airplane.

The pilot's logbook indicated that he had a total of 47 hours of flight in actual instrument conditions, but had not logged any hours in instrument conditions within 90 days of the accident.

An inspector from the FAA Flight Standards District Office (FSDO) in San Juan conducted an interview with the girlfriend of the pilot to determine the pilot's 72-hour history prior to the accident. The 72-hour history revealed no factors that precluded the pilot from performing his flying duties in a normal manner.

Passengers

The owner of the airplane reported that the five passengers on the accident flight were friends and business associates of his father and himself, and that the flight was a personal flight. He further noted that the passengers routinely traveled to La Romana because they owned property there, and that there was no financial remuneration for the flight.

AIRCRAFT INFORMATION

The airplane, manufactured in 2000, was equipped with a Lycoming IO-540-AC1A5 six-cylinder engine and a McCauley three-bladed constant-speed propeller. The airplane did not have onboard weather radar or downloadable satellite weather, but did have a “Strikefinder” lightning detector.

There was no cockpit voice recorder or flight data recorder on the airplane.

The airplane was registered to ATIS Corporation of Carolina, Puerto Rico. ATIS Corporation was formed in May, 2008, to operate the airplane under CFR Part 135. ATIS Corporation had submitted a pre-application Statement of Intent (SOI) to the FAA on June 23, 2008, for an air carrier certificate as a Part 135 single-pilot operation. The accident airplane was identified as the airplane to be operated by ATIS Corporation on the Part 135 certificate. ATIS Corporation was still in the process of applying for the Part 135 certificate and had not begun Part 135 operations.

On September 30, 2008, ATIS Corporation sent the FAA another pre-application SOI. The SOI identified the accident pilot as the President of ATIS Corporation. The pilot's resume indicated that the he held a commercial pilot certificate with an instrument rating. It stated that the pilot had accumulated 1,100 hours of total flight time, which included 100 hours of night flight time, 300 hours of cross country flight time, and 90 hours of multi-engine flight time.

In a letter to the FAA, dated September 30, 2008, the stated intent of ATIS Corporation was identified as:

"We intend to operate an ON DEMAND, Passengers and Cargo operation, Single Pilot Operator, based at Isla Grande Airport, San Juan, P.R. Our company is to be known as ATIS, Corp., will have its operations and maintenance facilities located at the Isla Grand Airport, Tropical Aviation Facilities, South Access Road, San Juan, P.R."

On February 4, 2009, the pilot and an aviation consultant hired by ATIS Corporation met with inspectors from the San Juan FAA FSDO for a pre-certification meeting to discuss the requirements of operating as a Part 135 single pilot operation. A conformity inspection of the airplane, as part of the certification process, was scheduled for Thursday, February 12, 2009.

A 100-hour inspection of the airplane occurred on February 6, 2009. The airplane total time at the time of the inspection was 1,458.9 hours.

The airplane's maximum gross weight limit was 3,600 pounds with a useful load of 1,350 pounds. The airplane's weight and balance was calculated using the available accident flight information for the fuel, pilot and passenger weights, and baggage. Reportedly, the airplane departed TJIG with full fuel tanks on the day of the accident. The amount of fuel burned on the day of the accident was not known; however, assuming a total fuel burn of 30 gallons, the airplane would have weighed approximately 3,943 pounds or 343 pounds over the maximum allowable gross weight of the airplane. The Center of Gravity (CG) Moment Envelope Worksheet indicated that the accident airplane's CG was aft of the aft CG limit. The worksheet does not provide exact CG location when the maximum allowable gross weight is exceeded.

Radar data indicated that the airplane’s ground speed was 189 knots during the last several recordings; however, the airplane’s in-flight airspeed at the time could not be determined. The Cessna 206H Information Manual lists the “never exceed speed” (VNE) as 180 knots calibrated airspeed (KCAS), the “maximum structural cruising speed” (VNO), the speed only to be exceed in smooth air, as 147 KCAS, and the “maneuvering speed” (VA), the speed not to be exceeded when making abrupt control movements, as 123 KCAS at an aircraft weight of 3,600 lbs.

METEOROLOGICAL INFORMATION

The closest weather reporting facility to the accident site was at Rafael Hernandez Airport (TJBQ), Aguadilla, PR, located about 11 nautical miles west of the accident site at an elevation of 237 feet. The airport recorded the following weather conditions surrounding the time of the accident:

The TJBQ weather observation, at 1750, included winds from 050 degrees at 17 knots gusting to 22 knots, visibility 10 miles, ceiling broken at 2,000 feet, temperature 24 degrees Celsius (C), dew point temperature 19° C, and an altimeter setting 30.04 inches of mercury.

The TJBQ weather observation, at 1850, included winds from 090 degrees at 11 knots gusting to 18 knots, visibility 7 miles in light rain, ceiling broken at 2,000 feet, temperature 23 degrees C, dew point temperature 19 degrees C, and an altimeter setting 30.05 inches of mercury.

Weather satellite data revealed a well-defined cumulus congestus cloud over the accident site at 1832, 4 minutes prior to the reported accident time.

Superimposing the ground track of the airplane over recorded radar echo areas indicated maximum reflectivity of 50 dBZ, or level 5 “intense” activity that included severe turbulence. At the time of the image, the radar beam was extending from 3,600 to 9,000 feet over the accident site and indicated that the accident airplane was in instrument meteorological conditions (IMC).

There was no evidence that the pilot had received a weather briefing before the flight. However, there were also no AIRMET or SIGMET weather alerts, and no pilot reports of any significant weather.

According to U.S. Naval Observatory data, sunset at Isabela, Puerto Rico, about 5 miles west of the accident site, occurred at 1822, and the end of civil twilight occurred at 1845.

WRECKAGE AND IMPACT INFORMATION

The majority of airplane wreckage came to rest in the Atlantic Ocean, approximately 300 to 800 yards off shore, in about 60 to 100 feet of water. Strong ocean currents may have precluded the recovery of all of the major airframe components.

Several small pieces of airplane wreckage were found on land, in a residential area. The pieces were scattered approximately 0.6 to 1.1 miles south of the main wreckage area. The pieces recovered on land included a pilot’s aluminum clipboard with leg strap, a section of the right, upper wing strut fairing, a section of the right main landing gear wheel fairing, the right main landing gear wheel fairing service door, a section of right wing stringer material, the right wing tip strobe power supply unit, two sections of right wing tip material, a fragment of clear plastic identified as from the center of the cockpit windshield, and a spiral notebook containing an airplane flight log. The investigation team conducted several on-foot searches and two helicopter searches; however, no additional wreckage was found on land.

On February 15, 2009, salvage divers recovered the engine with propeller attached and several small sections of the fuselage. On February 16, divers recovered the left wing, portions of the right wing, including most of the main spar, cockpit and cabin sections, the left horizontal stabilizer, and the left elevator. Salvage divers concluded their efforts on February 16, recovering additional portions of the right wing and fuselage. The right horizontal stabilizer, right elevator, tail cone, vertical stabilizer, and rudder were not recovered.

After recovery from the ocean, the wreckage was transported to a local salvage storage facility for examination. Examination of the wreckage revealed no evidence of preexisting mechanical anomalies.

The fuselage was fragmented into four main sections and several smaller sections. The larger sections included the engine, the instrument panel and pilots’ seats/floorboard section, the center row seats floorboard/section, and the aft row seats/floorboard and left fuselage section. The empennage aft of the aft row seats was not recovered. The right side of the fuselage was uniformly crushed towards the left.

The left wing remained intact except for the leading edge forward of the spar, inboard of the landing light lens. The left wing was found separated from the fuselage at the wing root, with fracture surfaces consistent with overload. The wing tip remained attached to the left wing. The left wing spar was bent aft, inboard of the location of the fuel filler cap. The separations at the end of the root of the spar were bent forward, forming a "Z" shape with the aft bend in the location of the fuel cap. The left wing and spar were bent downward outboard of the wing strut attachment point.

The left lift strut was separated approximately 3 feet from the fuselage attachment location; the inboard section remained attached to a portion of the fuselage floor. The separation had signatures consistent with compression overload. Two additional bends were noted in the lift strut, a "Z" bend located near the fuselage juncture and a 50-degree bend located approximately 1.25 feet from the wing attachment point. The left aileron and flap remained attached to their respective mounts. Cable cuts were not observed on the upper or lower surfaces of the left wing.

The right wing was fragmented into several small sections consistent with water impact in a right-wing-low attitude. The recovered sections of the right wing leading edge were crushed aft in an accordion pattern. The right wing spar was separated into three sections; approximately 1 foot inboard of the wing strut attachment point and the location where the wing spar stiffeners terminate in the outboard wing. The inboard section of the wing spar was bent downward approximately mid-span, and hydraulic deformation was noted along the forward facing surface. The center section of the wing spar was bent forward and aft along its length resembling an “S” shape. Downward twisting was observed on the outboard end of the center spar section beginning at the location of the outboard end of strut webbing stiffener. The outboard end of the spar was bent down and aft at the location where the spar webbing terminates and the spar continues outboard as stiffeners.

The right wing strut was bent approximately 1 foot from the fuselage attachment point in the opposite direction of the wing strut separation, forming a “Z” shape. A witness mark was found on the right main landing gear tire that was consistent with impact from the fracture surface of the right wing strut. Only portions of the right aileron and the right flap were recovered from the ocean, and they had not remained attached to their mounts.

Elevator flight control cable continuity was confirmed at the cockpit controls and included approximately 12 feet of one cable and approximately 6 feet of the other, each terminated with signatures consistent with overload separations. Rudder flight control cable continuity was confirmed at the cockpit controls and included approximately 12 feet of cables which terminated with signatures consistent with overload separations. Aileron flight control cable continuity was confirmed at the cockpit controls and included approximately 1 to 2 feet of cables that terminated with signatures consistent with overload separations. Left aileron flight control cable continuity was confirmed at the wing mounted aileron bellcrank and no anomalies were noted with its routing. The left aileron cables terminated with signatures consistent with overload separations approximately 6 feet beyond the end of the wing root. The right wing aileron cables and bell crank were not recovered. Normal wear signatures were observed on the left aileron bell crank and there were no indications of flutter. The elevator trim chain was observed on the sprocket; one end of the chain terminated with signatures consistent with overload the other end had approximately 2 feet of cable attached and the cable terminated with signatures consistent with overload.

The left horizontal stabilizer and left elevator were the only sections of the empennage that were recovered. The leading edge of the left horizontal stabilizer was crushed aft to the forward spar. The spar was not deformed and the fracture surfaces at the root of the stabilizer showed signatures consistent with overload.

External examination of the engine revealed surface corrosion on the exterior surfaces, consistent with salt water immersion. The oil filter, oil filter adapter, right magneto, and the lower vacuum pump were separated from the engine and recovered on February 16, 2009. The starter and fuel injector servo were separated from the engine. The right side rocker covers were pushed inboard revealing imprints of the rocker bosses and valve spring retainers on their external surfaces. The cylinder heads of the numbers 2, 4 and 6 cylinders were fractured in the area of the pushrod tubes. Sand and water were found inside the engine.

The propeller remained attached to the engine. One blade was curled aft approximately 90 degrees. Its trailing edge exhibited “S” bending, blade twisting and leading edge gouging. The blade was partially separated from the hub and the hub was fractured near the blade root. A second blade was turned in the hub toward a “feathered” position. A third blade was bent aft approximately 10 degrees and exhibited twisting.

The engine was suspended from a hoist and partially disassembled to facilitate the examination. The remaining accessories, except for the alternator, were removed. The lower sparkplugs were removed and an attempt was made to rotate the engine. The engine could be turned through about 340 degrees of rotation before coming to a "soft" stop. Impact-damaged components were removed to facilitate turning the engine. The engine was rotated by turning the crankshaft flange and continuity of the crankshaft confirmed. Compression and suction were observed from all six cylinders. The interiors of all six cylinders were examined using a lighted borescope and no anomalies noted.

The fuel servo regulator section was disassembled and both diaphragms were found intact. An odor consistent with that of aviation gasoline was detected as the servo was disassembled. The fuel inlet screen was removed and found free of debris. The flow divider top cover was removed. The spring was present and the diaphragm was intact. An odor consistent with that of aviation gasoline was detected as the flow divided was disassembled.

The engine-driven fuel pump remained attached to the engine. It was partially consumed by corrosion and could not be actuated. An odor consistent with that of aviation gasoline was detected inside the pump. Both magnetos exhibited external corrosion and fractured mounting flanges. The left magneto remained attached to the engine. Its rotor could be turned by hand, but produced a sound and feel consistent with sand inside the magneto. It produced no spark. The right magneto impulse coupling could be moved by hand, but the rotor could not be turned.

The spark plugs exhibited dark gray coloration and normal wear. Material consistent in appearance with sand or silt was found in the electrode wells of six of the sparkplugs. The ignition harness was separated in multiple places. The upper vacuum pump remained attached to the engine and its drive coupling remained intact. Impact damage was noted on the side of the pump and its carbon rotor and vanes were fractured. The lower pump was separated from the engine. Its drive spline was fractured, but its drive coupling remained intact. Impact damage was noted on the side of the pump and its carbon rotor and vanes were fractured. Sand was observed inside the pump cavity.

The oil suction screen was full of sand and sand was observed in the oil sump. The oil filter element was examined and no metallic contaminants were observed.

MEDICAL AND PATHOLOGICAL INFORMATION

The remains of the pilot were not recovered.

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