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NTSB investigation record

CEN10FA101

Completed

Cessna 172· N8405E

Date
January 17, 2010
Location
Holland, MI
Conditions
IMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's decision to take off in known instrument meteorological conditions without instrument currency or recent instrument experience, which led to spatial disorientation resulting in an inadvertent spin. Contributing to the accident was the pilot's lack of adequate rest prior to the flight.

Investigator assessment

Analysis narrative

The pilot rented the airplane for most of the day to give rides to friends and had fueled it to capacity. He told a lineman that he planned to takeoff and, if necessary, would file an instrument-flight-rules flight plan and return to the airport. Witnesses saw the airplane take off and disappear into the overcast. Shortly thereafter, they heard an airplane make four passes over the airport. The sound became progressively louder but they could not see the airplane. On the fifth pass, the airplane was seen approximately 50 feet above the ground and it barely cleared a stand of trees. Recorded ATC transscripts revealed that the pilot contacted approach control and told the controller that he was caught in heavy fog and wanted vectors back to the airport. The airplane crashed shortly thereafter in a snow-covered field. An examination of the airplane showed impact damage consistent with having descended to the ground in an uncontrolled spin. An examination of the airplane's systems showed no anomalies. Although the pilot was instrument rated, he had not flown with instruments since receiving his rating 2 years ago. He had logged 1.8 hours in actual instrument meteorological conditions, 50.8 in simulated IMC, and 6.7 hours in a flight simulator. Ceiling and visibility at the time of the accident was below landing minimums and was recorded as 200 feet overcast and 3/4-mile in mist. The RNAV (GPS) RWY 8 approach chart was found on the pilot’s lap. Although the airplane was IFR certified, it was not RNAV or GPS equipped. Toxicology results indicated the presence of propoxyphene, a prescription narcotic medication. The concentration present was consistent with use at a time outside of 24 hours prior to the accident and would not have caused impairment. Cellular telephone records showed that the pilot had engaged in calls and text message conversations with the passenger the night before the accident. Starting at 6:00 P.M. the night before the accident, the pilot received or made calls or text messages every hour, through midnight, until 3:12 A.M. In one conversation, the passenger told the pilot that he would be in good flying shape for the next day, and the pilot replied that he needed to get 4 hours of rest before he flew. The final outgoing call to the passenger was placed at 7:59 A.M. on the day of the accident.

Source record

Factual narrative

HISTORY OF FLIGHT On January 17, 2010, at 1004 eastern daylight time, a Cessna 172N, N8405E, registered to and operated by Tulip Air Service and piloted by a commercial pilot, was destroyed when it impacted snow-covered terrain following a loss of control while maneuvering near Holland, Michigan. Instrument meteorological conditions (IMC) prevailed at the time of the accident. The personal flight was being conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91, and no flight plan had been filed. The pilot and passenger on board the airplane were fatally injured. The local flight originated from the Tulip City Airport, Holland, Michigan, approximately 0945. According to the operator, the pilot had rented the airplane for most of the day to give rides to his friends. He and his first passenger arrived at the airport approximately 0800. After checking his file, the front office worker gave the pilot the airplane’s keys. Due to the poor weather conditions, the pilot postponed the flight. While he gave his passenger a tour of the facilities, he had the airplane fueled to capacity. As the lineman fueled the airplane, the pilot told him that he planned to take off and, if necessary, he would file an IFR flight plan with Muskegon Approach Control and return to the airport. He then preflighted the airplane. Approximately 0945, the lineman and the front office worker saw the airplane take off on runway 08 and disappear into the overcast. The front office worker said he was “very concerned” that they took off without filing an instrument flight plan or receiving an instrument clearance. Shortly thereafter, the lineman heard an airplane make five passes over the airport. The first two passes were in a north-south direction and the sound got progressively louder, but he could not see the airplane. On the third pass, he could not determine the direction of flight. The fourth pass was in an east-west direction and he still could not see the airplane. On the fifth pass, he saw the airplane flying from east to west approximately 50 feet above the ground and it “barely cleared the trees.” He then heard the pilot call Muskegon Approach Control. According to the transcript of radio communications, the pilot contacted Muskegon Approach Control at 1000:22 and told the controller that he was “caught in some fog” and wanted “vectors to runway 8 for Tulip City.” When the controller asked the pilot if he was IFR, the pilot replied that he wanted to “file a quick IFR into Tulip City.” Believing the pilot was on the ground there followed a discussion on what frequencies to contact FSS. At 1003:43, when the controller asked the pilot if he wanted to file a flight plan, the pilot replied, “Caught in some heavy fog and would just like vectors to Tulip City Airport.” Asked if he was VFR, the pilot replied that he “was VFR, and now have to go in for an emergency.” The controller assigned him a transponder code of 0-4-3-0, but the pilot never acknowledged, and there were no further communications. The last radar contact position for the airplane placed it 4 miles south of Tulip City at 1,500 feet agl (above ground level). Shortly thereafter, and ELT (emergency locater transmitter) beacon was detected. Authorities were notified and the wreckage was located approximately 1130. PERSONNEL (CREW) INFORMATION The pilot was a 23-year-old foreign exchange student from Nairobi, Kenya, and was a sophomore at nearby Hope College in Holland. He held a U. S. commercial pilot certificate, dated November 13, 2007. In addition to his airplane single engine land rating, he also held an airplane multi engine land rating, dated December 6, 2007, and an instrument airplane rating, dated August 23, 2007. His second class airman medical, dated October 24, 2006, contained no restrictions or limitations. His logbook contained entries from October 26, 2006, to December 22, 2009. As of the last entry in the logbook, the pilot had accumulated the following flight times (in hours): Total time: 321.5 Single engine: 306.1 Multi engine: 15.3 Pilot-in-command: 273.1 Dual instruction: 151.1 Solo: 97.3 Cross-country: 135.1 Actual instrument: 1.8 Simulated instrument: 50.8 Night: 16.7 The pilot’s flight time was accrued in the following airplane types (in hours): Cessna 172: 189.4 Cessna 172RG: 24.9 Cessna 152: 83.9 Cessna 152TW: 7.2 Cessna 205: 1.2 Cessna 550: 8.0 Beech A36: 1.5 Piper PA-20: 1.7 Piper PA-23: 7.3 ATC610 Simulator: 6.7 The last entry in his logbook was dated December 22, 2009, when he took his flight review. It was for one hour and was done in the accident airplane. The last time he logged an instrument flight was on April 8, 2008. It was for 1.0 hours and was done in actual IMC. The passenger was a 20-year old junior and political science major at Hope College. AIRCRAFT INFORMATION The airplane, a Cessna Aircraft Corporation model 172N, serial number 17272195, was manufactured in 1979. It was equipped with a Lycoming O-320-H2AD engine (serial number RL-3557-76T), rated at 160 horsepower, driving a McCauley all-metal 2 bladed, fixed-pitch propeller (model number 1C160/DTM7557), serial number 235928). According to the maintenance records, the last annual inspection of the airframe and engine was done on November 6, 2009, at a tachometer time of 805.7 hours. At that time, the airframe and engine had accumulated 7,337.4 total hours. The engine was last overhauled on December 8, 2008, at a tachometer time of 471.7 hours. At the time of the last inspection, the engine had accrued 334 hours since major overhaul. The ELT battery was replaced on January 26, 2009. The altimeter, encoder, and pitot-static system were certified for IFR on March 31, 2008. METEOROLOGICAL INFORMATION The following Automated Surface Observing Station (ASOS) observations were recorded at Tulip City Airport (KBIV) approximately the time of takeoff and the time of the accident: Takeoff: Wind calm; visibility 1/2 statute mile, freezing fog; ceiling 200 feet overcast; temperature -3 degrees Centigrade (C); dew point -5 degrees C; altimeter 29.89 inches of Mercury. Accident: Wind calm; visibility 3/4 statute mile, mist; ceiling 200 feet overcast; temperature -3 degrees C; dew point – 4 degrees C; altimeter 29.89 inches of Mercury. Weather conditions remained below VMC and landing minimums for the various instrument approach procedures available from early morning to early afternoon (see “Weather Reports and Records,” EXHIBITS). AIDS TO NAVIGATION There were no known difficulties with navigational aids. COMMUNICATIONS There were no communications difficulties. AERODROME INFORMATION Tulip City Airport (KBIV), situated at an elevation of 687 feet msl, is located 2 miles south of Holland, Michigan at N42-44.59 and W086-06.30. An ASOS is located on the field, and Tulip City Air Service, Incorporated, the sole fixed base operator, offers computerized weather services. The nearest Flight Service Station is in Lansing, Michigan, and Muskegon Approach Control handles all IFR arrivals and departures. The airport has a rotating beacon and is served by a single runway, 08-26 (6,001 feet by 100 feet, asphalt). There are four published instrument approaches to the airport. The runway is equipped with high intensity runway lights (HIRL), and both runway ends have runway end identification lights (REIL). Only runway 26 is equipped with a medium intensity approach lighting system (MALSR) with runway alignment indicator lights. According to Tulip City Airport officials, all landing approach aids and lights were functioning at the time of the accident. WRECKAGE AND IMPACT INFORMATION The on-scene investigation was conducted on January 18, 2010. The accident site was located in a corn and soybean field, located one mile northwest of the intersection formed by 58th

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