Ferry Flight Conducted In Night IFR Conditions

A veteran Cape Air pilot whose Cessna 402 went down shortly after takeoff from Martha's Vineyard on September 26th, 2008, suffered from spatial disorientation causing him to lose control of the aircraft, according to the NTSB Probable Cause report. The pilot was fatally injured in the accident.

According to the report, the pilot of the multiengine airplane, operated by a regional airline, was conducting a positioning flight in night instrument meteorological conditions. The flight was to have been from Martha's Vineyard (KMVY) to Boston Logan International (KBOS). An instrument flight plan had been filed for the flight. After takeoff, the airplane made a slight left turn before making a right turn that continued until radar contact was lost. The airplane reached a maximum altitude of 700 feet before impacting terrain about 3 miles northwest of the departure airport. Postaccident examination of the wreckage did not reveal any preimpact failures. The weather reported at the airport, about the time of the accident, included a visibility of 5 statute miles in light rain and mist and an overcast ceiling at 400 feet. Analysis of the radar and weather data indicated that, with the flight accelerating and turning just after having entered clouds, the pilot likely experienced spatial disorientation.

Pilot Information
The pilot, age 61, held an airline transport pilot certificate, with a rating for airplane multiengine land. He also held a commercial pilot certificate, with ratings for airplane single-engine land and instrument airplane. In addition, the pilot held a type rating for Boeing 747, Douglas DC-8, and Lockheed L-382 airplanes.  At the time of the accident, the pilot had accumulated approximately 16,746 hours of total flight experience, which included 2,330 hours in the same make and model as the accident airplane. His most recent regulatory checkride was conducted on August 2, 2008.

The pilot's logbooks which were provided by his family were not current. Company flight records revealed that the pilot had not logged any instrument meteorological flight experience during the 12 months, and 0.2 hours during the 24 months that preceded the accident; respectively. He had logged 168 instrument approaches during the 12 months preceding the accident. The pilot had flown about 200 hours, and 35 instrument approaches during the 90 days that preceded the accident.

A Cape Air representative stated that it was likely that the pilot had accumulated more instrument flight experience than was indicated in his flight records. He believed that due to the pilot's age and experience, the pilot might have only logged the minimum experience necessary to meet currency requirements. Company records pertaining to another pilot, who was based at MVY, revealed that pilot had logged about 130 hours of instrument flight experience during the 12 months preceding the accident.

Cape Air Cessna 402 File Photo

The pilot's most recent FAA first-class medical certificate was issued on September 16, 2008. He had been off-duty during the 3 days preceding the accident. He was scheduled to report for duty at 1200, and he had completed a round trip flight from MVY to BOS prior to the accident flight.

Meteorological Information
A weather observation taken at MVY at 1953, reported: wind from 110 degrees at 6 knots; visibility 5 statute miles with light rain and mist; overcast ceiling at 400 feet; temperature 19 degrees Celsius (C); dew point 18 degrees C; altimeter 30.17 inches of mercury.

Review of a National Weather Service "rawinsonde" sounding from the Chatham, Massachusetts, site number 74494, indicated a surface wind from 125 degrees true at 9 knots, veering to the south with height. A low-level wind maximum was noted immediately above a low-level temperature inversion with winds from 135 degrees at 39 knots at 1,300 feet mean sea level. The sounding further indicated a greater than 90 percent chance of severe turbulence below 2,000 feet, to the surface.

A Cessna 402 operated by Cape Air, destined for Providence, Rhode Island, departed from runway 24 at MVY, approximately 1 minute after the accident flight. The pilot of that flight did not report any unusual weather during his initial climb and described the turbulence below 1,000 feet as "light."

Medical and Pathological Information
An autopsy was performed on the pilot, on September 28, 2008, by the Commonwealth of Massachusetts, Office of the Chief Medical Examiner, Boston, Massachusetts. The autopsy report indicated the cause of death as blunt trauma, and listed multiple traumatic injuries. Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. The reported noted the presence of "Quinine" detected in the pilot's blood. Quinine could be found in tonic water, used to treat severe malaria, and used to reduce the frequency of nocturnal leg cramps. The pilot's wife reported that he was not taking any medications. The pilot began taking a multivitamin about one month prior to the accident; however, it did not contain Quinine.

Tests and Research
On January 13-14, 2009, both engines and their respective turbochargers were disassembled and examined at Teledyne Continental Motors, Mobile, Alabama, under the supervision of an NTSB investigator. The examinations did not reveal any abnormalities, which would have precluded normal engine operation.

Disassembly of both propellers at McCauley Propeller Systems, Wichita, Kansas, under the supervision of an FAA inspector, did not reveal any preimpact failures. All propeller blades displayed evidence of rotation and operation under conditions of power at the time of impact. According to a representative from McCauley, the exact blade angle for both propellers could not be determined; however, the propeller piston rod damage location along each respective rod's length was in the same lateral position, which indicated that both propellers were operating at approximately the same blade angle at impact.

The gyros from the pilot's attitude indicator, horizontal situation indicator (HSI), and the copilot's attitude indicator and directional gyro where forwarded to the NTSB Material's Laboratory, Washington, DC, for further examination. The examination did not reveal any evidence of rotational scoring on any of the gyro housings, and on the rotors associated with the pilot's gyros. Some minor circumferential scratches were noted on the rotors associated with the copilot's gyros. It was noted that the gyros were not severely damaged; and it was not possible to determine if they were operating at the time of the accident.

FMI: www.ntsb.gov