Primary finding
Probable cause
The pilot's failure to maintain adequate airspeed, resulting in an inadvertent stall/spin. Contributing factors in this accident were the entanglement of the parachute in the elevator control system, reducing the pilot's ability to regain control.
Investigator assessment
Analysis narrative
Surviving skydivers said that as the airplane was climbing to the jump altitude of 10,500 feet agl, the stall warning horn sounded intermittently several times. They paid no particular attention to it because they had heard it on previous flights. When the airplane reached the jump altitude, the pilot signaled for one of the parachutists to open the door. When she did, she told the pilot that the airplane had overshot the drop zone by approximately 1 mile. As the pilot started a right turn back towards the drop zone, the stall warning horn sounded again, then the airplane "rolled off on its right wing" and entered a spin. The skydivers became disoriented and nauseated. Four skydivers managed to bail out safely, but one of them broke her right leg when she struck the right horizontal stabilizer after exiting the airplane. The reserve parachute on the fifth skydiver deployed and became entangled around the tail of the airplane. She sustained fatal injuries. The sixth skydiver was unable to exit the airplane and was found inside, fatally injured. The pilot was seriously injured. Ground witnesses reported hearing the engine RPMs decrease, then saw the airplane spinning. Somewhere between 1,000 and 5,000 feet, the airplane leveled out for a few seconds and witnesses saw a parachute wrapped around the tail. The airplane then spun or dove to the ground. Downloaded data from the onboard GPS and Automated Activation Devices worn by three of the skydivers corroborated these accounts.
Source record
Factual narrative
HISTORY OF FLIGHT On April 19, 2008, approximately 1615 central daylight time, a Cessna P206, N2537X, registered to and operated by Freefall Express Skydiving, Inc., and piloted by a commercial pilot, was destroyed when it struck trees and impacted terrain following an in-flight loss of control near Mount Vernon, Missouri. Visual meteorological conditions prevailed at the time of the accident. The skydiving flight was being conducted under the provisions of Title 14 CFR Part 91 without a flight plan. The pilot and one parachutist were seriously injured, two parachutists were fatally injured, and three parachutists were not injured. The local flight originated from the Mount Vernon Municipal Airport (2MO) approximately 1530. Written statements were received from all four surviving parachutists, and two of them were interviewed in person. The following is a summary of their accounts. As the airplane was climbing to the jump altitude of 10,500 feet agl (above ground level), the stall warning horn sounded intermittently several times. The parachutists said they paid no particular attention to it because they had heard it on previous flights. When the airplane reached the jump altitude, the pilot signaled for one of the parachutists to open the door. When she did, she told the pilot that the airplane had overshot the drop zone by approximately 1 mile. As the pilot started a right turn back towards the drop zone, the stall warning horn sounded again, then the airplane "rolled off on its right wing" and entered a spin. One parachutist wrote, "We were spinning so fast, it was difficult for me to tell what direction we were facing or in what direction we were spinning. I was holding on to the pilot's seat with my left hand, the door frame with my right hand, my head was touching the ceiling, my feet on the floor, and I was being forced to the back of the plane." A second parachutist wrote, "We were holding on to each other. I felt sick from the spinning." A third parachutist said the force of the spin pushed her against the cabin. The pilot told everyone to move aft, "to transfer our weight to the tail of the airplane." Three parachutists exited the airplane and parachuted to safety. A fourth parachutist broke her right leg when she struck the right horizontal stabilizer after exiting the airplane. Because she was disoriented, she said she activated her reserve parachute and landed safely. The reserve parachute on the fifth parachutist deployed and became entangled around the tail of the airplane. She sustained fatal injuries. The sixth parachutist was unable to exit the airplane and was found inside, fatally injured. The pilot was airlifted to Mercy St. John's Hospital in Springfield, Missouri. Seven ground witnesses submitted written statements. One witness said he heard the engine RPMs decrease, "[an] indication that the [air]plane [was] slowing down for the skydivers to jump." Then he saw the airplane "falling nose down and spinning." He said that approximately 5,000 feet, the airplane seemed to slow or stop spinning and he observed four skydivers in the sky. Approximately 3,000 feet, he noticed "a white parachute on the tail of the plane." Approximately 2,000 feet the airplane leveled out on a westerly heading and appeared to climb. Then it started "spinning and heading nose down again." Another ground witness observed the same sequence of events, but estimated the altitude of the airplane to be between 500 and 1,000 feet when she saw the fifth parachute. "It appeared to inflate and then collapse." She said the airplane made a 90 degree turn to the west and she could see the parachute was attached to the tail. "The plane then angled 45 degrees toward the ground and fell nose first." A third ground witness saw the airplane "spiraling downward, nose first, and out of control. The pilot was able to pull the plane out from the downward spiral" between 2,000 to 3,000 feet, and it appeared to climb, then "it began to spiral nose first again." That is when the witness noticed a "white reserve [para]chute caught on the tail of the plane." Another ground witness saw the airplane "in a head-down spin. The plane leveled out and flew normal for a few seconds, and then a white parachute seemed to come out beside the plane and catch on the tail. The plane then began another series of spins." She said the parachute "appeared to come put of the door and inflate beside the plane." PERSONNEL (CREW) INFORMATION The pilot, age 32, held a commercial pilot certificate with airplane single/multiengine land and instrument ratings, dated September 2, 2007. He also held a first class airman's medical certificate, dated October 24, 2007, with the limitation, "Must wear corrective lenses." A photostatic copy of the pilot's logbook was submitted for examination. It contained entries from July 13, 2000, to April 6, 2008. According to this document, the pilot began his flight training at Elmdale Airpark (6F4), Abilene, Texas. He made his first solo flight on October 19, 2001, and received his private pilot license on August 10, 2002. During this time, the pilot had no less than 18 lessons involving 18.2 hours of various stalls and slow flight. On November 12, 2006, the pilot enrolled in Pan Am Flight Training Academy's instrument and commercial curriculums at Deer Valley Airport (DVT), Phoenix, Arizona. The chief flight instructor failed to respond to this investigator's request for an interview. According to the pilot's logbook, he failed the instrument rating practical test on February 26, 2007, then passed it on March 14, 2007. During this time, the pilot was given no less than 6 lessons involving 7.9 hours of various stalls and slow flight. He failed the commercial multiengine practical test on July 24, 2007, then passed it on July 31, 2007. During this time, the pilot was given no less than 12 lessons involving 17.4 hours of various stalls and slow flight. He failed the commercial single-engine practical test on August 31, 2007, then passed it on September 2, 2007. During this time, the pilot was given no less than 2 lessons involving 1.9 hours of various stalls and slow flight. At no time during his training in either Abilene or Phoenix was the pilot given spin instruction. According to the various FAA practical test guides, only flight instructor applicants are required to have spun an airplane (or had a spin demonstrated). On November 15, 2007, he was given a Freefall Express Skydiving checkout in the Cessna 182. Between that date and April 5, 2008, he logged 66 hours in the Cessna 182, all of which was flying skydivers. On April 6, 2008, he flew skydivers in the Cessna P206 and logged 8.5 hours. This was the last recorded entry in his logbook. As of that date, the pilot had logged the following flight time (in hours): Total Time, 320.5 Single engine, 278.5 Multiengine, 42.0 Pilot-in-command, 222.3 Instruction received, 236.3 Night, 55.0 Actual instruments, 4.0 Simulated instruments, 73.5 Flight simulator, 30.0 Cross-country, 73.6 AIRCRAFT INFORMATION N2537X, a model P206 (s.n. P206-0037), was manufactured by the Cessna Aircraft Company, and received its FAA airworthiness certificate on December 11, 1964. It was equipped with a Continental IO-520-F-9 engine (s.n. 553089), driving a McCauley 3-blade, all-metal, constant speed propeller (m.n. D3A34C402). According to the aircraft's maintenance records, the last annual inspection of the airframe and 100-hour inspections of the engine and propeller were accomplished on May 18, 2007, at a tachometer time of 3,227.9 hours. At the time of the accident, the airframe and engine had accumulated 4,302.7 and 4,394.2 hours, respectively. The engine and propeller had accumulated 1,621.7 and 440.95 hours since major overhaul. According to the FAA principal airworthiness inspector who had been recently assigned to Freefall Express Skydiving, neither the engine nor the propeller were cer