Primary finding
Probable cause
The pilot's failure to maintain aircraft control and collision avoidance with terrain due to spatial disorientation. Contributing to the accident were the low cloud ceiling and night conditions.
Investigator assessment
Analysis narrative
The cargo flight was departing on its fourth flight leg of a five-leg flight in night instrument conditions, which included a surface observation of light snow and a broken ceiling at 500 feet above ground level (agl). One pilot who departed just prior to the accident flight indicated that moderate snow was falling and that he entered the clouds about 200 feet agl. The accident airplane's wings and tail were de-iced prior to departure. Radar track data indicated the accident flight was about 45 seconds in duration. An aircraft performance radar study indicated that the airplane reached an altitude of about 1,130 feet mean sea level (msl), or about 400 feet above ground level, about 114 knots with a left bank angle of about 29 degrees. The airplane descended and impacted the terrain at an airspeed of about 155 knots, a pitch angle of -16 degrees, a left roll angle of 22 degrees, and a descent rate of 4,600 feet per minute. The study indicated that the engine power produced by the airplane approximately matched the engine power values represented in the pilot's operating handbook. The study indicated that the required elevator deflections were within the available elevator deflection range, and that the center-of-gravity (CG) position did not adversely affect the controllability of the airplane. The study indicated that the load factor vectors, the forces felt by the pilot, could have produced the illusion of a climb, even when the airplane was in a descent. The inspection of the airframe and engine revealed no anomalies that would have precluded normal operation.
Source record
Factual narrative
HISTORY OF FLIGHT On December 5, 2007, at 0651 eastern standard time, a Cessna 208B, N28MG, collided with terrain about one mile east southeast of the Rickenbacker International Airport (LCK), Columbus, Ohio, during takeoff climb from Runway 23R (11,937 feet by 150 feet, asphalt). Ground impact forces destroyed the airplane, which was registered to Avion Capital Corporation and operated by Castle Aviation, Inc. The commercial pilot and a pilot-rated passenger received fatal injuries. The Title 14 Code of Federal Regulations Part 135 cargo flight departed LCK at 0649 en route to the Buffalo Niagara International Airport (BUF), Buffalo, New York. Instrument meteorological conditions prevailed and an instrument flight rules flight (IFR) plan was filed. The night cargo flight was scheduled for a five-leg trip. The airplane departed on its first flight leg from the Akron-Canton Regional Airport for Hamilton, Ontario, Canada, at 2223 on December 4, 2007, and arrived at 2323. The airplane then departed Hamilton at 0054 on December 5, 2007, for BUF and arrived at 0115. The aircraft departed BUF at 0304 and arrived at LCK at 0453. The airplane was topped off with 155 gallons of Jet A fuel and loaded with 714 pounds of cargo. The pilot started the airplane's engine about 0640. The pilot taxied to the de-icing ramp, and the wings and tail were de-iced with about 160 gallons of Type I de-icing fluid at 0644. A witness reported that the propeller did not require de-icing. At 0646, the pilot received the taxi clearance to taxi to runway 23R at Delta taxiway. At 0649, the pilot was cleared for takeoff from runway 23R at Delta taxiway, and then to turn left to a heading of 090 degrees. The pilot acknowledged the takeoff clearance and departed. There were no further radio transmissions from N28MG. Radar track data indicated that 10 radar returns were recorded of the accident flight, which was about 45 seconds in duration. The radar track data indicated that the airplane climbed to about 1,100 feet mean sea level (msl) in a left turn with a ground speed of about 109 knots, prior to descending and impacting the terrain about one mile east southeast of the airport. PESONNEL INFORMATION The 58-year-old pilot held a commercial pilot certificate with single-engine land, multi-engine land, and airplane instrument ratings. He held a second-class medical certificate that was issued in September 2007. The pilot's logbook and duty logs indicated that the pilot's total flight time was about 1,310 hours with about 200 hours flown in the 208B. The pilot's logbook indicated that he had flown about 778 hours in actual instrument conditions. The pilot's logbooks indicated that he started flight training in October 1997. Castle Aviation hired the pilot in August 2007. His resume and flight time breakdown that he provided to Castle Aviation prior to being hired indicated the following flight experience: Total Flight Time in Cessna 172 and Piper Turbo Arrow: 1,050 hours. Instrument Hours: 650 hours. Cross Country Hours: 700 hours. Night Flying Hours: 62 hours. Multi-Engine Hours (Piper Seneca, Cessna 421 and Cessna 425): 60 hours. A review of the pilot's Federal Aviation Administration (FAA) airman file indicated the dates when the pilot had obtained his pilot's ratings. It also indicated that the pilot had initially been disapproved for three ratings. The airman file indicated the following: 1. On June 25, 1998, the pilot was disapproved for the private pilot single-engine land rating. 2. On July 9, 1998, the pilot received the private pilot single-engine land rating. 3. On March 23, 1999, the pilot was disapproved for the instrument airplane rating. 4. On March 27, 1999, the pilot received the instrument airplane rating. 5. On May 21, 2000, the pilot received his commercial pilot certificate with airplane single engine land and airplane instrument ratings. 6. On June 25, 2006, the pilot received his commercial certificate with the multi-engine land rating. 7. On August 10, 2007, the pilot was disapproved for the certified flight instructor (CFI) - airplane single engine land rating. The president of Castle Aviation reported that he was not aware that the accident pilot had not passed the FAA CFI flight test prior to hiring the pilot. Castle Aviation company records indicated that the pilot started his ground school and flight training in August 2007. The pilot completed 34 hours of ground school training on October 1, 2007. The pilot completed the Cessna Aircraft Company's "Caravan Cold Weather Ops On-Site Program" on October 22, 2007. The pilot passed the Pilot-in-Command (PIC) check ride for "VFR Duties Only" on October 22, 2007, and had logged about 63.8 hours of flight time in the 208B. The pilot passed the Part 135 Instrument Proficiency check ride on November 20, 2007, and had logged about 151 hours of flight time in the 208B. As a result of passing the instrument proficiency check ride, the pilot was authorized to perform the duties of PIC in instrument meteorological conditions. He logged about 33.9 additional hours of flight time as PIC prior to the accident, of which 12.5 hours were logged as actual instrument conditions and 32.5 hours were logged as night conditions. AIRCRAFT INFORMATION The single-engine Cessna 208B, serial number 208B0732, was manufactured in 1999. It had seating for two and was configured for cargo operations. The maximum gross takeoff weight of the airplane was 8,750 pounds. The engine was a flat rated 675 shaft horsepower Pratt & Whitney PT6-114A engine. The aircraft was maintained on the factory Cessna Phase Card Inspection Program. The last inspection was performed on November 16, 2007, at 9,896.6 hours and 8,889 airframe cycles and consisted of a Mini Check. The engine had 3,897 hours and 3,412 cycles since overhaul as of November 16, 2007. The aircraft total time at the time of the accident was estimated to be 9,936 hours and 9,033 cycles. A review of the Airworthiness Directives (AD's) was performed. No discrepancies were noted. Particular attention was given to AD's related to operation in icing conditions and all AD's had been complied with. The airplane was fueled with 155 gallons of Jet-A fuel from Truck 7. A fuel sample was taken from Truck 7 and it was clean and clear with no indication of water. The airplane was deiced from truck ICE1 at 0644. The truck supplied heated Type I fluid only. The wings were sprayed with about 100 gallons of fluid and the tail was sprayed with about 60 gallons. A sample was taken and it passed the refractive index test. A FAA inspector examined whether the accident airplane was within weight and balance limitations at takeoff. Post accident, the freight was unloaded and weighed. The manifest weight was 714 pounds. The actual weight on reweigh was observed to be 704 pounds, plus the 10-pound hazardous material package. This would equal the provided weight of 714 pounds at the time of departure. AirNet (the cargo provider) stated that all of the material had been recovered. This was further determined to be true by comparing the air bills recovered to the air bills known to be on board. No manifest was found at the accident site, although a number of documents normally kept on the top of the aluminum clipboard (“the can”) were not located. A weight and balance form for the accident flight was not located. Weight and balance computations were performed using four different scenarios. All four scenarios used the following as a standard: 1. 2,200 pounds of fuel. 2. Aircraft weight of 4,466 pounds. 3. Pilot and Jumpseater – 400 pounds. 4. 25 pounds of baggage in zone 5 5. 100 pounds (pallet rollers, tail stand, straps) in zone 6. 6. 10 pound hazmat package in zone 5. This created a total weight of 7,905 pounds. The Cessna 208B has a maximum allowable gros