CEN14FA110

The pilot's controlled flight into terrain during an instrument landing system approach at night in instrument flight rules conditions. Contributing to the accident were the operator's inadequate training of the pilot, the operator's failure to provide a level of oversight commensurate to the pilot's experience, and the pilot's lack of operational experience in actual night instrument conditions in the make and model of the airplane.

The airplane, operated by an on-demand cargo carrier and flown by a newly hired pilot, was on a positioning flight when it impacted trees and terrain about 1,500 ft short of the runway during a straight-in instrument landing system (ILS) approach. Night instrument flight rules (IFR) conditions prevailed with recorded weather observations that were below the minimum visibility specified for the approach. Radar data showed that while on the final segment of the ILS approach, the airplane's approach was unstabilized in speed and position along the glidepath. The shallow angle of the wreckage path and its length were consistent with controlled flight into terrain. Examination of the wreckage revealed no anomalies that would have precluded normal aircraft operation. The pilot had undergone company training provided by the company's president, who was also the director of operations, and the chief pilot; these two individuals were the only company instructors approved by the Federal Aviation Administration (FAA) to provide Part 135 training in accordance with the company training manual. However, the majority of the pilot's flight training in the accident airplane make and model was during a flight with a company pilot who was not approved by the FAA to provide Part 135 instruction. Further, although company records stated that the pilot met the training requirements for ground and flight training in accordance with the company training manual, the minimum flight times in the accident airplane make and model were not met and the method of ground instruction was not followed in accordance with the company training manual. A review of the weather for the pilot's previous company flights showed that he had not flown in actual conditions that were at approach minimums at night, similar to those at the time of the accident. The chief pilot stated that higher approach weather minimum limitations were placed upon the pilot and that company dispatchers watched most new pilots' minimums until they got more experience with the company. However, although the dispatch manager indicated he was aware of weather limitations for the pilot, he stated that the dispatchers had no means of routinely communicating with the pilots inflight, and he could not recall when there had been any other pilots with weather limitations. Furthermore, there was no FAA-approved program or policy within the company operations specifications or other manual for higher approach minimum limitations based upon experience for company pilots of piston engine powered airplanes such as the accident airplane.

Destination Airport The PTK ILS Runway 9R Instrument Approach is shown in Figure 4. Figure 4: The figure shows the instrument approach chart profile for ILS runway 9R. The minimum descent altitude (MDA) outside the final approach fix (FAF)/outer marker (OM), which is located 5 miles the runway 9R, is 2,700 feet msl. Figure 4: The figure shows the instrument approach chart profile for ILS runway 9R. The minimum descent altitude (MDA) outside the final approach fix (FAF)/outer marker (OM), which is located 5 miles the runway 9R, is 2,700 feet msl. Alternate Airport Flight plan information indicated that FNT, located about 22.9 nm northwest of PTK, was a filed destination alternate for the accident flight. FNT was served by ILS 9 and 27 approaches in addition to RNAV/GPS and VOR approaches to all runways at FNT. The ILS 9 and 27 straight-in approach minimums were 200 feet agl and ½ sm mile visibility for all aircraft categories, A through D. The ILS 9 circling approach minimums were 600 feet agl and 1 sm visibility for categories A and B, 600 feet and 1 ½ sm visibility for category C, and 600 feet agl and 2 sm visibilities for category D. The ILS 27 circling approach minimums were 500 feet agl and 1 sm visibility for category A, 600 feet agl and 1 sm visibility for category B, 600 feet agl and 1 ½ sm visibility for category C, and 600 feet agl and 2 sm visibility for category D. Engine Examination Both airplane engines underwent a disassembly examination at Continental Motors, Mobile, Alabama, under the supervision of a FAA Inspector who reported that there were no mechanical anomalies that would have precluded normal engine operation. Propeller Examination Both propellers underwent a disassembly examination at McCauley Propeller Systems, Wichita, Kansas under the supervision of a FAA inspector. The examination revealed there were no indications of a propeller malfunction or failure. Neither propeller exhibited witness marks consistent with a blade angle corresponding to a feathered position. Both propeller blade angles were approximately 14-17 degrees, relative to reference, and consistent with a low pitch/latch position. Stabilized Approaches There were several references that discussed the concept of stabilized approaches. These references included but were not limited to: FAA Instrument Procedures Handbook (FAA H-8083 16), FAA Advisory Circular (AC) 61-134 - Controlled Flight into Terrain Awareness, Flight Safety Foundation's (FSF's) Approach and Landing Accident Reduction Toolkit (ALAR) Briefing Note 7.1 – Stabilized Approach, AvWeb's Leading Edge #23: Stabilized Approaches in Light Airplanes. The FAA's Instrument Flying Handbook, Chapter 4, Approaches, Descents, Stabilized Approach, states in part: "In IMC, you must continuously evaluate instrument information throughout an approach to properly maneuver the aircraft or monitor autopilot performance and to decide on the proper course of action at the decision point [decision altitude (DA), decision height (DH), missed approach point (MAP)]. Significant speed and configuration changes during an approach can seriously degrade situational awareness and complicate the decision of the proper action… You must begin to form a decision concerning the probable success of an approach before reaching the decision point. Your decision-making process requires you to be able to determine displacements from the course or glidepath centerline, to mentally project the aircraft's three-dimensional flight path by referring to flight instruments, and then apply control inputs as necessary to achieve and maintain the desired approach path. This process is simplified by maintaining a constant approach speed, descent rate, vertical flight path, and configuration during the final stages of an approach. This is referred to as the stabilized approach concept to take at the decision point." During the March 12, 2014 post-accident interview of the Royal Air Freight, Inc. chief pilot, the chief pilot was asked if he covered and provided the pilot with instruction on stabilized approaches and illusions to flight, to which the chief pilot responded yes. The chief pilot was then asked what the stabilized approach criteria were for a Cessna 310. The chief pilot said that a stabilized approach is one in which the airplane is configured with flaps and landing gear with a target power setting, which is usually set three miles outside of the final approach fix. The airplane speed should be "within a certain range." The chief pilot was then asked what are the limits that would define an unstabilized approach in a Cessna 310. The chief pilot could not provide quantitative deviations that would define an unstabilized approach after being asked several times by the NTSB IIC and the FAA Coordinator. During the March 12, 2014 post-accident interview of the company pilot that had flown with the pilot on December 10, 2013, the company pilot was asked when an approach would become unstabilized in a Cessna 310. The pilot stated that airplane speed would deviate plus or minus 10 knots from target airspeed, one dot deflection in localizer and glideslope, if the airplane descent rate increased for no apparent reason, if airplane groundspeed increased or decreased dramatically for some reason, or if there was a single-engine power loss. Transition to a Visual Approach The FAA's Instrument Flying Handbook, Chapter 4, Transition to a Visual Approach, states in part: "The transition from instrument flight to visual flight during an instrument approach can be very challenging, especially during low visibility operations. Aircrews should use caution when transitioning to a visual approach at times of shallow fog. Adequate visibility may not exist to allow flaring of the aircraft. Aircrews must always be prepared to execute a missed approach/go-around. Additionally, single-pilot operations make the transition even more challenging. Approaches with vertical guidance add to the safety of the transition to visual because the approach is already stabilized upon visually acquiring the required references for the runway. 100 to 200 feet prior to reaching the DA, DH, or MDA, most of the PM's attention should be outside of the aircraft in order to visually acquire at least one visual reference for the runway, as required by the regulations. The [pilot flying (PF)] should stay focused on the instruments until the PM calls out any visual aids that can be seen, or states "runway in sight." The PF should then begin the transition to visual flight. It is common practice for the [pilot monitoring (PM)] to call out the V/S during the transition to confirm to the PF that the instruments are being monitored, thus allowing more of the PF's attention to be focused on the visual portion of the approach and landing. Any deviations from the stabilized approach criteria should also be announced by the PM. Single-pilot operations can be much more challenging because the pilot must continue to fly by the instruments while attempting to acquire a visual reference for the runway. While it is important for both pilots of a two-pilot aircraft to divide their attention between the instruments and visual references, it is even more critical for the single- pilot operation. …" The company pilot, who had flown with the pilot on December 10, 2013, stated that he had flown aircraft under Part 135 and Part 121 for several decades and held four type ratings. He accumulated about 11,000 hours of total flight time, of which 3,000 hours were in Cessna 310 airplanes. He stated that he always flies the airplane following ILS guidance to the runway surface in order to maintain his proficiency because as the airplane gets closer to ground the ILS "gets more sensitive." He said that he follows ILS guidance to the runway surface because he has encountered fog/cloud near the ground. He said that when he is transi