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Accident analysis: Nonpilot operationsAccident analysis: Nonpilot operations

If you can’t fly it by hand, you’re a passenger

By now, automation has been recognized as a double-edged sword, and those edges only get sharper as the technology becomes more capable. The more the panel can do for you, the easier it becomes to forget that someday you may have to do it yourself. That’s not a good situation. Crucial components have been known to pick inconvenient times to go on strike. And even when all the equipment is working properly, it’s essential to know how to actually make it work.
Turbine Pilot Accident Analysis
Illustration by Alex Williamson

What happened

At 7:24 p.m. on March 24, 2017, a 1976 Cessna 500 Citation CJ1 crashed into the front yard of a home in Marietta, Georgia, igniting a fire that consumed much of the wreckage and left the house uninhabitable. The residents were not home, fortunately; the solo 78-year-old private pilot was the only casualty. According to the NTSB report, the airplane hit the ground “in an approximate nose-level/wings-level attitude with little to no forward momentum.” There was no apparent damage to wires or trees near the initial point of impact, suggesting a near-vertical descent.

The flight departed from Cincinnati Municipal Airport Lunken Field at 6:12 p.m. on an IFR flight plan to Fulton County Airport-Brown Field in Atlanta. At 6:51, with the jet in level cruise at Flight Level 230, the Atlanta ARTCC amended its route. The controller repeated the transmission twice more before the pilot read it back at 6:55. The Citation’s cockpit voice recorder (CVR) captured the sound of him turning knobs on the Garmin GTN 750 GPS installed three years before.

At 6:59, the pilot transmitted that he “was having a little trouble with my…GPS” and requested direct routing to the airport. He was cleared direct with instructions to descend and maintain 11,000 feet. Three minutes later, the CVR caught him saying, “I have no idea what’s going on here.”

At 7:07, he read back the controller’s instruction to descend to 6,000 feet. At 7:10, the CVR picked up “a sound similar to the autopilot disconnecting.” Thirty-six seconds later he radioed that he was descending through 8,000 feet but was “having a steering problem…can’t steer the aircraft very well.” He reported being “in the clouds” and received a series of descents down to the minimum vectoring altitude of 4,100 feet.

At 7:15, the controller warned that radar showed the piliot 500 feet below the sector’s minimum vectoring altitude. The pilot replied, “I’m going back up but…I have very little steering on here and I have mountains around me. Atlanta doesn’t have mountains.” When the Citation reached 3,400 feet, the controller issued a low-altitude alert. The pilot responded that “Apparently it looks like I have my autopilot back for some reason, so it gives me some stability” and climbed back to 4,100...but when handed off to Atlanta Approach, replied “I can’t get to one-two-one-point-zero…I’m having a problem with my, uh, Garmin…Can you take me in?” The center controller agreed to coordinate his approach.

At 7:19, 28 miles from the field in visual conditions, the pilot radioed that “I’m just barely able to keep straight on this and wings level. I cannot get to one-two-one-point-zero and I don’t know if I can make a right turn into the airport.” Three minutes later, he accepted the controller’s invitation to declare an emergency and asked, “What runway am I running into about, is the runway going sideways?” Advised that Runway 8 was in use but Runways 14 and 32 were available, he replied, “Well, I’ve got my landing gear down, but I don’t know.” ATC received no further transmissions. A nearby Atlantic Southeast Airlines flight reported having “heard him transmit to you a couple of times with no response.”

At 7:24 the CVR recorded the pilot saying, “It’s going down, it’s going down.” The tape ended 19 seconds later. Data stored by the jet’s terrain awareness and warning system showed its descent rate increasing from 0 to 8,500 feet per minute, reaching 12,000 fpm just seven seconds later. Nine witnesses saw the Citation spinning toward the ground with its wings almost level and little forward motion.

Four, including a regional airline pilot, described the aircraft going through one or more 360-degree rolls before entering the spin.

The NTSB’s examination of the wreckage found no evidence of any failure of the GPS, autopilot, or flight controls.

What didn’t

The pilot bought the CJ1 in 2001 and obtained a pilot-in-command type rating in 2002. Its previous owner had qualified for single-pilot operation under Sierra Industries’ conformity certificate, but the NTSB could not find any evidence that the accident pilot ever obtained either the initial or recurrent training required to exercise the single-pilot waiver. A 23,000-hour airline transport pilot, CFI, and IA who had flown with him reported that the pilot professed not to need a single-pilot exemption thanks to the one granted to the previous owner. His logbooks weren’t recovered, so neither his currency nor time in type could be determined.

The CFI recalled having tried to teach the pilot to operate the GTN 750 with little success; he struggled “pulling up pages” and “correlating all the data.” He only flew between four different destinations and had preloaded those flight plans. Any en-route amendment confused him, as he could not remember how to change them in flight and consistently forgot to activate approach procedures. He was also “very dependent” on the autopilot, habitually engaging it just after takeoff and leaving it on until short final, the CFI said. Apparently thinking the autopilot controlled the trim, he “never” trimmed the airplane first, leaving the autopilot to fight the trim. The chronic out-of-trim condition provoked frequent complaints that the airplane was “uncontrollable.” The instructor once flew to Savannah to troubleshoot the Citation, only to find it out of trim but otherwise in perfect working order. He characterized the owner/pilot as “brilliant” but “prideful,” unwilling to listen to suggestions or admit to any error.

What should have

Redundancy to minimize the risk of single-point failure is the bedrock of aviation risk management. It’s why corporate and charter operators favor two-pilot crews operating multiengine aircraft with full instrumentation at the co-pilot’s position. Too many accidents in owner-flown aircraft, on the other hand, betray the opposite attitude: the assumption that everything will be all right as long as nothing goes wrong.

ASI Staff

David Jack Kenny

David Jack Kenny is a freelance aviation writer.

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