Aviation Accident Final Report

The surviving passengers stated that before departure the pilot gave a short safety Page 4 of 9 MIA97FA082 briefing, but they did not recall any briefing about life vests. After departure from St. Croix, the pilot was notified that some passengers baggage had been left. They returned to St. Croix and picked up the baggage. They departed St. Croix again and after about 20 minutes they could see St. Thomas. As they approached St. Thomas the pilot was observed to continually lean forward and look out the front windshield as if he was looking for something. One passenger reported seeing a blinking red light on the center pedestal and that it had the word "hydraulic" on it. The engines were operating normally and the pilot did not report any problems or tell them to prepare for a crash. Suddenly the airplane crashed into the water. As the airplane came to a stop the lights went out. The surviving passengers stated three passengers exited through the pilot's door and one passenger stayed in the airplane. The pilot also exited the aircraft. After they got in the water the pilot gave a life vest to one of the passengers. The three passengers that got out along with the pilot started swimming toward the island. One passenger got separated and was not seen again. One surviving passenger stated he was picked up by a helicopter and taken to the St. Thomas Airport where an ambulance took him to the hospital. The other surviving passenger stated he was picked up by a boat and taken to shore where a ambulance took him to the hospital. The pilot and two surviving passengers were rescued by the U.S. Coast Guard about 3 hours after the accident. The body of one passenger was also located about this time but could not be recovered. The fourth passenger is missing. PERSONNEL INFORMATION The pilot, age 43, was hired by Air Sunshine, Inc. in October 1996, as a pilot on the Cessna 402 airplane. He holds an airline transport pilot (ATP) certificate, with airplane single- engine land, multiengine land, single-engine sea, multiengine sea, and rotorcraft helicopter. The pilot's FAA first class medical certificate was issued on December 2, 1996, with no restrictions or limitations. According to company records, the pilot completed ground training on October 31, 1996. The pilot received a competency check required by Title 14 CFR Part 135.293 on November 4, 1996. On November 12, 1996, the pilot received a line check required by Title 14 CFR Part 135.299. On December 6, 1996, the pilot received an instrument proficiency check required by Title 14 CFR Part 135.297. The pilot reported he had flown as pilot on Cessna 402 aircraft for two other commuter airlines. At the time of the accident he had accumulated about 13,000 total flight hours with 11,500 flight hours as pilot-in-command and 9,000 flight hours in the Cessna 402, all as pilot- in-command. The pilot had just entered on flight duty at the beginning of the accident flight. He had accumulated 2 flight hours and 12 duty hours the day before the accident and had been off duty for 23 hours before the accident flight. He had arrived in the Caribbean on February 3, 1997, after being a passenger on N318AB as it was ferried from Fort Lauderdale to San Juan, Puerto Rico. This was his first time flying in the Puerto Rico-Virgin Island area. Records reflected that the pilot had made about 15 approaches, 5 of those at night, to St. Thomas before the accident flight. The pilot had accumulated 13 flight hours and 60 duty hours for the month of February, all within the 5 days before the accident. The pilot had accumulated 118 flight hours in the month of January 1997. (Additional pilot information is contained in this report under Pilot Page 5 of 9 MIA97FA082 Information and in attachments to this report). AIRCRAFT INFORMATION N318AB, a Cessna 402C, was a 1980 model aircraft and had accumulated 16,085 total flight hours at the time of the accident. The aircraft received a no. 3 inspection in accordance with a manufacturer's maintenance program on February 1, 1997, at aircraft total time 16,055. On September 11, 1995, the left and right altimeters, no.1 and no. 2 transponders, no. 1 and no. 2 altitude encoders, and the static system received a 24 month check required by Title 14 CFR Part 91.411 and 91.413 for instrument flight. The autopilot system received a 1 year check on October 31, 1996 and the magnetic compass received a 1 year check on December 27, 1996. (Additional aircraft information is contained in the aircraft section of this report and in attachments to this report). METEOROLOGICAL INFORMATION Visual meteorological conditions prevailed at the time of the accident. Sun and moon calculations showed that at the location and time of the accident the sun was at an altitude of - 18 degrees on a bearing of 271.8 degrees. The moon was at an altitude of .5 degrees on a bearing 274.9 degrees and had a 3% illumination. (Additional meteorological information is contained in this report under weather information and in attachments to this report). AIDS TO NAVIGATION Just before the accident the flight was receiving visual flight rules (VFR) flight following from the FAA San Juan Combined Enroute and Approach Control (CERAP)Facility. After departure from St. Croix, the flight was instructed to squawk transponder code 0473. The pilot complied with this and was identified on CERAP radar. Upon approaching St. Thomas the pilot was instructed to contact the FAA St. Thomas Control Tower. The pilot contacted the tower and was cleared to enter right base leg for the traffic pattern for runway 10. The flight was then cleared to land on runway 10. The FAA reported the San Juan CERAP radar is equipped with a minimum safe altitude warning (MSAW) system. Aircraft that descend below the minimum safe altitude for a sector will trigger an alarm to the controller, who will then issue a warning to the pilot. FAA reported the system was operational on the night of the accident and that the tower controller at St. Thomas also had the capability to receive MSAW alerts from the San Juan CERAP radar and issue warnings to pilots. As the flight approached St. Thomas and descended below the safe altitude for the sector, the MSAW system did not trigger an alert. The FAA stated that the flight was operating under VFR and the transponder code 0473 assigned to the flight was within the 0400 code subset reserved for VFR flights, which is inhibited from triggering MSAW alerts to the controllers. (See attached FAA ATC data). Recorded radar from the San Juan CERAP showed the flight climbed to 3,500 feet after departure from St. Croix. At about 1926, the flight began the descent from 3,500 feet for landing at St. Thomas. The flight continued descending on a northerly heading until crashing into the Caribbean Sea about 3 southwest of the airport. The data showed that at 1930:31, the flight descended through 1,100 feet. At 1931:00, the flight descended through 700 feet and at 1931:56, the flight descends below 100 feet. (See attached radar data). COMMUNICATIONS The pilot and ATC controllers reported there were no problems with communications. Page 6 of 9 MIA97FA082 WRECKAGE AND IMPACT INFORMATION The aircraft wreckage was not located and recovered after the accident. All three landing gear, the right main gear door, and debris from the interior of the aircraft was found floating and recovered from the Caribbean Sea near the crash site by the U.S. Coast Guard. The two main landing gear had separated from the aircraft after failure of the strut housings. The fractures on the strut housings were consistent with overstress separation. The nose landing gear separated when the gear scissors separated and the gear slipped out of the gear strut housing. The right main landing gear door had aft crushing on the lower forward edge. The interior debris which was found contained the aft bulkhead panel which contained the FAA registration and airworthiness certificates. MEDICAL AND PATHOLOGICAL INFORMATION The pilot and two surviving passengers received minor injuries as a result of the accident and postcrash exposure in the sea. Two passengers were not recovered and are presumed to have received fatal injuries. The pilot submitted to a drug screen in accordance with the Air Sunshine, Inc. drug testing program. Specimens taken from the pilot about 18 hours after the accident were negative for opiates, cannabinoids, and cocaine. (Additional medical and pathological information id contained in supplement K to this report). COMPANY/OPERATIONS INFORMATION Air Sunshine, Inc. is the holder of an FAA Air Carrier Certificate issued on September 2, 1982, and is authorized by Operations Specifications to conduct operations under Title 14 CFR Part 135. Air Sunshine is further authorized to use Cessna 402C aircraft in visual flight rules (VFR) and instrument flight rules (IFR) day or night operations. The principal base of operation is Fort Lauderdale, Florida, and the company conducts scheduled flight operations within the State of Florida and between St. Croix, St. Thomas, and San Juan, Puerto Rico. The Caribbean flight operations began in December 1996. The Air Sunshine, Inc. Operations Manual, which is accepted by the FAA, requires that a VFR or IFR flight plan be filed for all revenue flights. The manual does give provisions for the pilot to file a VFR flight plan with the company provided an authorized flight following person follows the flight. According to the pilot, he did not file a VFR or IFR flight plan with the FAA for the accident flight. He did not file a VFR flight plan with the company, but did get flight following services through the company. Additionally, he maintained contact with FAA Air Traffic Control Facilities throughout the flight. Company officials stated the flight was not followed by an authorized flight following person. (See attached flight locating procedures). The Air Sunshine, Inc. Operations Manual requires the pilot-in-command or a delegated crewmember to give a passenger briefing prior to takeoff. The briefing includes use of seat belts, location of emergency exits, life vests, and emergency briefing cards. Passengers stated the pilot did give a briefing prior to takeoff. (See attached passenger briefing procedures and card). ADDITIONAL INFORMATION A passenger reported that he observed a red light with the word "hydraulic" blinking on the center control pedestal prior to the accident. The Cessna 402C handbook shows the hydraulic failure warning light is mounted in the annunciator panel on the left side of the Page 7 of 9 MIA97FA082 pilot's instrument panel. (See page from Cessna 402C Pilot Operating Handbook). The FAA Airmans Information Manual and Instrument Flying Handbook describes a phenomenon called "Featureless Terrain Illusion" in sections titled "Illusions Leading To Landing Errors". The publications state, "an absence of ground features, as when landing over water, darkened areas, and terrain made featureless by snow can create the illusion that the aircraft is at a higher altitude than it actually is. The pilot who does not recognize this illusion will fly a lower approach." Other writers have termed this illusion as black hole conditions and reported that pilots have actually descended early and landed short of the runway and in some cases crashing into the sea while approaching over water. (See attached pages from FAA publications and FAA Civil Aeromedical Institute fax). Aircraft components which were recovered by the U.S. Coast Guard after the accident were released by NTSB on March 12, 1997, to Steve Smalley, Air and Sea Recovery. FAA SURVEILLANCE Federal Aviation Administration records showed that the Air Sunshine, Inc. Air Carrier Certificate is held and managed by inspectors from the FAA Flight Standards District Office in Fort Lauderdale, Florida. The company received a Regional Air Safety Investigation Program (RASIP) inspection between February 12 and February 16, 1996. The Principal Operations Inspector last performed a base inspection on October 24, 1996, and the Principal Maintenance Inspector last performed a base inspection on May 20, 1996. Maintenance Inspectors from the FAA San Juan Flight Standards District Office performed one ramp inspection and two en route inspections of the Air Sunshine, Inc. Caribbean operations in January 1997. Neither the Principal Operations Inspector, Principal Maintenance Inspector, Principal Avionics Inspector, or any FAA Operations Inspectors conducted inspections of the Air Sunshine, Inc. Caribbean operations since service was begun in December 1996. (See attached FAA records). Pilot Information Certificate: Airline Transport Age: 43, Male Airplane Rating(s): Multi-engine Land; Multi-engine Sea; Single-engine Land; Single- engine Sea Seat Occupied: Left Other Aircraft Rating(s): Helicopter Restraint Used: Seatbelt, Shoulder harness Instrument Rating(s): Airplane Second Pilot Present: No Instructor Rating(s): None Toxicology Performed: Yes Medical Certification: Class 1 Valid Medical--no waivers/lim. Last FAA Medical Exam: 12/02/1996 Occupational Pilot: Last Flight Review or Equivalent: Flight Time: 13000 hours (Total, all aircraft), 9000 hours (Total, this make and model), 11500 hours (Pilot In Command, all aircraft), 290 hours (Last 90 days, all aircraft), 103 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft) Page 8 of 9 MIA97FA082 Aircraft and Owner/Operator Information Aircraft Make: Cessna Registration: N318AB Model/Series: 402C 402C Aircraft Category: Airplane Year of Manufacture: Amateur Built: No Airworthiness Certificate: Normal Serial Number: 402C0318 Landing Gear Type: Retractable - Tricycle Seats: 10 Date/Type of Last Inspection: 02/01/1997, AAIP Certified Max Gross Wt.: 7210 lbs Time Since Last Inspection: 30 Hours Engines: 2 Reciprocating Airframe Total Time: 16085 Hours Engine Manufacturer: Continental ELT: Installed, not activated Engine Model/Series: TSIO-520-VB Registered Owner: TROPICAL TRANSPORT SVCS., LTD. Rated Power: 325 hp Operator: AIR SUNSHINE, INC. Operating Certificate(s) Held: Commuter Air Carrier (135) Operator Does Business As: Operator Designator Code: RSHA Meteorological Information and Flight Plan Conditions at Accident Site: Visual Conditions Condition of Light: Night/Dark Observation Facility, Elevation: STT, 24 ft msl Distance from Accident Site: 4 Nautical Miles Observation Time: 1945 AST Direction from Accident Site: 20° Lowest Cloud Condition: Scattered / 2000 ft agl Visibility 20 Miles Lowest Ceiling: None / 0 ft agl Visibility (RVR): 0 ft Wind Speed/Gusts: 8 knots / Turbulence Type Forecast/Actual: / Wind Direction: 40° Turbulence Severity Forecast/Actual: / Altimeter Setting: 30 inches Hg Temperature/Dew Point: 26°C / 22°C Precipitation and Obscuration: Departure Point: ST. CROIX, VI (STX) Type of Flight Plan Filed: None Destination: (STT) Type of Clearance: VFR; VFR on top Departure Time: 1915 AST Type of Airspace: Class D Wreckage and Impact Information Crew Injuries: 1 Minor Aircraft Damage: Destroyed Passenger Injuries: 2 Fatal, 2 Minor Aircraft Fire: None Ground Injuries: N/A Aircraft Explosion: None Total Injuries: 2 Fatal, 3 Minor Latitude, Longitude: Page 9 of 9 Administrative Information Investigator In Charge (IIC): JEFFREY L KENNEDY Report Date: 04/10/1998 Additional Participating Persons: STANLEY SANTIAGO; SAN JUAN, PR HOWARD HOLLIS; FT. LAUDERDALE, FL Publish Date: Investigation Docket: NTSB accident and incident dockets serve as permanent archival information for the NTSB’s investigations. Dockets released prior to June 1, 2009 are publicly available from the NTSB’s Record Management Division at pubinq@ntsb.gov, or at 800-877-6799. Dockets released after this date are available at http://dms.ntsb.gov/pubdms/. The National Transportation Safety Board (NTSB), established in 1967, is an independent federal agency mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of any part of an NTSB report related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. A factual report that may be admissible under 49 U.S.C. § 1154(b) is available here.