After The Accident: A Single Pilot Was Not Enough

When it investigated the March 24, 2017, crash of a Cessna 500 in a residential area of Marietta, Georgia, one of the things the NTSB wanted to determine was whether the pilot, who was the only occupant, was properly qualified to fly the airplane by himself. After all, Citations are flown single-pilot all the time without incident.

Investigators heard from a friend of the pilot who reported that he had repeatedly told the pilot that he needed a co-pilot on board. He reported that the pilot's response was that he preferred to fly alone. The friend also said that the pilot claimed no single-pilot exemption was needed for him because the airplane had one as a result of having received a single-pilot conformity certificate relating to some modifications that had been made for the previous owner. The friend was interviewed by both the FAA and the NTSB.

The friend happened to have more than 23,000 hours of flight time logged and was a flight instructor and airplane mechanic with inspection authorization. He said that he had known the pilot for about 17 years but had not flown with him in the last eight months before the accident. He said that while he had never given the pilot a check ride or biennial flight review, he did instruct him in the airplane, including instruction on a GPS/navigation/communication touchscreen multi-function display system that had been installed about three years before the accident. Investigators contacted several training facilities that provided single-pilot training for Citations, but none could find a record of having trained the pilot or granted him single-pilot authority.

The friend told them that the pilot was dependent on the autopilot and seemingly averse to hand flying the plane. He said that after takeoff, the pilot would activate the autopilot and use it until on short final for landing at the destination. The friend said that when trying to operate the upgraded avionics, the pilot would become confused and would struggle "pulling up pages" and "correlating all the data." The friend said that the pilot typically flew to only four places, which were preloaded into the system: Savannah, Georgia; Fort Lauderdale, Florida; Opa Locka, Florida; and Cincinnati, Ohio. He said that the pilot could get confused and did not know how to amend the existing flight plan.

The friend said that the pilot would never trim the airplane before turning on the autopilot. He said that he was constantly "fighting" the autopilot and complaining that the airplane was "uncontrollable." The friend told an anecdote of once having been called to fly to Savannah to repair the airplane after the pilot said it was uncontrollable. After arriving, he flew the airplane and found that it just was not trimmed properly.

The pilot, age 78, held a private pilot certificate rated for single-engine land and sea airplanes, multiengine land airplanes and instruments. His logbooks were not available for review by investigators. When he was examined for his last third-class FAA medical on Sept. 27, 2016, he did not report his flight times. His previous medical application on Sept. 18, 2013, showed 6,000 total hours.

The accident flight ended at about 7:24 p.m. when the airplane crashed in the front yard of a home about 15 miles north of Fulton County Airport-Brown Field (KFTY) in Atlanta. The wreckage indicated that the airplane impacted in a nose-level, wings-level attitude with little to no forward movement. A fire broke out. Investigation failed to find problems with the engines or airplane systems.

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The airplane had taken off from Cincinnati Municipal Airport-Lunken Field in Cincinnati at about 6:12 p.m. The pilot was returning home from a business trip. He had filed an IFR flight plan. The airplane was equipped with a cockpit voice recorder (CVR). There wasn't much on it in the way of the pilot's voice, but numerous clicks and the sounds of knobs being turned were picked up.

The friend's statement about the pilot having trouble amending flight plans becomes noteworthy in reviewing the flight because at about 6:51:36, while the airplane was level at FL 230, the Atlanta Center controller who was handling it advised the pilot that there was "an amendment to your routing. Advise ready to copy." The pilot told the controller to standby and a few seconds later said he was ready to copy. The controller radioed, "Now cleared to Fulton County Airport via direct HAVVE intersection, that's hotel alpha victor victor echo and then direct highlands intersection, hotel lima november delta sierra for the buckhead one arrival bravo uniform kilo hotel delta one and maintain flight level two three zero." The pilot's response was unintelligible, according to the transcript of radio communications.

At 6:52:30, the controller asked whether the pilot copied the revised clearance, and, without waiting for an answer, repeated the clearance. The pilot responded, "Okay, I've got to, ah, the buckhead one arrival (unintelligible) set up (unintelligible) have it on board." About 30 seconds later, the pilot added, "and center, eight delta xray, over." The controller said, "Yes, sir, go ahead." The pilot replied, "I have the buckhead one arrival and, uh, after choo choo, I was to go to have---h a v v e---then highlands---h l n d s and then f t y." The controller's response was, "Cleared direct have at this time and then direct highlands for the buckhead one." The pilot correctly confirmed the amended clearance.

At 6:56:26, the controller alerted the pilot to traffic at 11 o'clock and 10 miles, a northbound regional jet at FL 240. The pilot radioed that he did not have the traffic.

At 6:58:57, the controller cleared the flight to descend to FL 220. The pilot acknowledged and then, at 6:59:04, radioed, "I'm having difficulty with my GPS. It's not picking up this arrival, and I was wondering if you can give me, uh, direct routing then instead of going to the arrival." The controller advised that he had the pilot's request and for the pilot to standby. At 6:59:46, the controller cleared the pilot direct to the Fulton County Airport. At 7:00:10, the controller cleared the pilot to descend to 11,000 feet. The pilot acknowledged.

At 7:01:50, the controller advised the pilot to switch to him on a new frequency, 133.1. The pilot acknowledged 123.1, the wrong frequency. At about 7:03, the CVR picked up the pilot saying to himself, "I have no idea what's going on here." At 7:04:35, the pilot radioed the controller asking, "Did you give me one two three point one?" The controller replied that the frequency was 133.1, and the pilot acknowledged.

The pilot was subsequently cleared down to 6,000 feet. At 7:11:02, the pilot radioed, "Hey center, delta xray, we're down to eight thousand, going down to six, and we're having a steering problem, um, can't steer the aircraft very well." The controller replied with a heading of 175 degrees for the pilot to fly direct to the airport, but there was no response. The controller repeated the heading, and the pilot responded, "I'm doing the best I can. What is the ceiling in this area? I'm at seventy three hundred in the clouds."

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The controller cleared the pilot down to 5,800 feet, then down to 5,000 feet. The pilot responded that he was in the clouds at 6,800 feet. At 7:14:29, the controller cleared the flight down to 4,100 feet. The pilot said, "Four thousand one hundred, but I'm not sure I'm (sic) can maintain that." The controller radioed that he needed the pilot to maintain 4,100 because that was the minimum IFR vectoring altitude in the area. The pilot repeated the clearance to 4,100 feet and asked if his heading was okay. The controller responded by advising him to fly a heading of 185 degrees.

At 7:15:44, the controller radioed the pilot that he was at 3,600 feet and needed the pilot to climb back up because he was 500 feet below the minimum IFR vectoring altitude. The pilot radioed, "Yeah, I understand, I'm going back up but, ah, I have, I have very little steering on here and I have mountains (around me). Atlanta doesn't have mountains." The controller responded that he now showed the airplane had sunk to 3,400 feet and the pilot needed to go up to 4,100 feet when able.

At 7:16:44, the pilot advised center, "Apparently, it looks like I have my autopilot back for some reason so it gives me stability." The controller responded that he showed the airplane at 3,500 and "if you're able, climb and maintain four thousand one hundred for terrain." At 7:17:40, the controller advised that he showed the flight back at 4,100 feet and handed it off to Atlanta Approach on frequency 121.0. The pilot did not respond, and the controller repeated the transmission.

At 7:18:21, the pilot came back up on the Atlanta Center frequency and advised, "I can't get to one two one point zero," followed by, "I'm having a problem with my, ah, Garmin, so evidently the whole thing is..." That was followed by the pilot asking, "Can you take me in?" The controller told the pilot to standby and then said, "You're physically unable to switch to one two one point zero." The pilot replied, "Negative, I cannot switch to one two one point zero." The controller told him to "maintain this frequency."

At 7:19:32, the pilot radioed, "Okay, let me tell you a problem I'm having. I'm having. I'm just barely able to keep straight on this and wings level. I cannot get to two one, twenty one point zero, and I don't know if I can make a right turn into the airport." The controller asked if he was able to change to any other radio frequencies, and the pilot said, "I can go on thirty three six or one thirty three seven." The controller asked if he was VFR or still in the clouds and the pilot said he was VFR, but it was hazy. The controller then gave him a left turn to a heading of 177 degrees and advised he was being vectored to the airport.

At 7:21:02, the controller asked the pilot to "report the Fulton County Airport in sight." The pilot said he "should have it in sight now," and the controller advised that the airport was about his 11 o'clock position and about 23 miles away. The pilot said he did not have the airport in sight. At 7:22:09, the controller asked the pilot if he needed to declare an emergency. "I'm not sure, and I think I oughta declare an emergency just in case," the pilot radioed at 7:22:14. He then asked the controller to have the "landing lights" turned up full at the airport.

At 7:22:59, the controller asked the pilot if he had the NOTAMs for the airport. "I don't have anything at this point and time for Fulton County," was the pilot's reply, followed by, "What runway am I running into? Is the runway going sideways?" The controller advised that it looked as if Runway 8 was in use. At 7:23:44, the pilot radioed, "Well, I've got my landing gear down, but I don't know." At 7:23:55, the CVR picked up the sounds of the pilot making straining noises, followed by the sound of the autopilot disconnect alert, followed by the Terrain Awareness and Warning System (TAWS) issuing a warning "sink rate, sink rate" followed by the warning "pull up, pull up." Data recovered from the TAWS unit indicated that the airplane was flying level at about 4,000 feet when it went into a descent of about 8,500 feet per minute. The "pull up" warning went off when the airplane was down to 2,900 feet. Within 7 seconds, the airplane's descent rate increased to almost 12,000 feet per minute and the data ended.

A witness said he saw the airplane flying level about 1,000 feet below the cloud deck when it suddenly made a complete 360-degree roll to the left, then entered a steep 90-degree bank to the left and the nose dropped. The witness was a professional pilot. Another witness also saw the airplane roll.

The autopilot equipment was examined by the manufacturer, and the Safety Board concluded that no preimpact deficiencies were noted that would have precluded normal operation.

The NTSB said that the probable cause of the accident was the pilot's failure to maintain adequate airspeed while manually flying the airplane, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall. Contributing to the accident was the pilot's inability to control the airplane without the aid of the autopilot.

These days, monitoring aircraft systems as they do their thing can constitute a significant part of a pilot's workload. What this NTSB report can teach us is that the monitoring we do needs to be backed up by flying skills, experience and a thorough understanding of how systems work and should be operated. PP

Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.