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NTSB Report

June 15, 2008 · Cessna P337H · N15EM

Cape Elizabeth, ME

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
June 15, 2008
Injury Outcomes
2 injuries (2 fatalities)
Location
Cape Elizabeth, ME
Aircraft
Cessna P337H
Tail Number
N15EM
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
NYC08FA215

Prior to departing on a cross-country flight, the pilot contacted a flight service station. The pilot was informed that visual flight rules (VFR) flight was not recommended, and after obtaining a weather briefing he filed an instrument-flight-rules (IFR) flight plan. The airplane departed in visual meteorological conditions and the pilot subsequently informed air traffic control that he was experiencing a problem with the airplane's artificial horizon, and that he wanted to try to conduct the flight under VFR. Approximately 15 minutes later, the pilot requested activation of his IFR flight plan. The airplane was flying in instrument meteorological conditions with light to moderate precipitation when radar and radio communications were lost. Radar data indicated that the airplane's heading varied from southwest to northwest, with a turn to the southeast immediately prior to the loss of radar contact. The airplane maintained an altitude between 7,900 and 8,200 feet, except for the last recorded altitude reading, which was at 7,200 feet. The airplane impacted the Atlantic Ocean at a high rate of speed and was not recovered. Review of the airplane's maintenance records revealed that its most recent annual inspection was conducted about 6 months prior to the accident.

NTSB Probable Cause

The pilot's improper decision to continue the flight in instrument meteorological conditions after experiencing an attitude indicator malfunction.

Full Narrative

HISTORY OF FLIGHT On June 15, 2008, about 1310 eastern daylight time, a Cessna P337H, N15EM, was presumed destroyed when it descended from cruise flight, and impacted the Atlantic Ocean, about 18 miles east of Cape Elizabeth, Maine. The certificated private pilot and a passenger were killed. Instrument conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the flight that departed the Millinocket Municipal Airport (MLT), Millinocket, Maine, destined for the Essex County Airport (CDW), Caldwell, New Jersey. The personal flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The pilot owned the airplane, which was based at CDW. According the MLT airport supervisor, the pilot and his wife arrived on June 12, 2008. The airplane was refueled with 64 gallons of 100-low-lead aviation gasoline and placed inside a hanger until the morning of the accident. According to information obtained from Lockheed Martin, at 0916 on the day of the accident, the pilot contacted the Kankakee automated flight service station. The pilot was informed that flight under visual flight rules (VFR) was "not recommended," and after obtaining a weather briefing, he filed an IFR flight plan from MLT to CDW, with a proposed departure time of 1100. According to information obtained from the Federal Aviation Administration (FAA), the airplane departed MLT under VFR and contacted the Boston Air Route Traffic Control Center at 1228. The pilot informed the controller that he had previously filed an IFR flight plan to CDW, "...but we gotta go vfr, i'm having a little trouble with the uh artificial horizon so we're going to try and make it vfr..." At 1244, the pilot indicated that he wanted to obtain an IFR clearance to CDW, which was provided by air traffic control. The airplane was at an altitude of about 8,000 feet mean sea level (msl), when the pilot contacted Naval Air Station (NAS) Brunswick Approach Control about 1250. The pilot did not report any problems and the flight progressed under IFR until radar and radio communications were lost at about 1310. Radar data obtained from NAS Brunswick revealed that the airplane's track consisted of several alternating turns to the southwest and northwest, with a turn to the southeast immediately prior to the loss of radar contact. The airplane maintained an altitude between 7,900 and 8,200 feet, except for the last recorded altitude reading, which was at 7,200 feet. The United States Coast Guard responded to the area in the vicinity of the airplane's last radar target, and observed an oil/fuel slick on the Atlantic Ocean. In addition, small portions consistent with airplane's interior were recovered from the surface of the water. The water depth in the vicinity of the accident site was estimated to be about 250 feet. As of the date of this report, no additional portions of the airplane had been recovered. PERSONNEL INFORMATION The pilot, age 72, held a private pilot certificate with ratings for airplane single-engine land and airplane multiengine land, limited to center thrust. He also held an instrument airplane rating. The pilot's most current logbook was not located. According to a logbook provided by the pilot's son, as of January 29, 2005, the pilot had logged about 2,145 hours of total flight experience, which included about 1,620 hours in multiengine engine airplanes. In addition, at that time the pilot had logged about 250 hours of flight experience in actual instrument conditions and about 215 hours in simulated instrument flight conditions. The pilot reported 2,500 hours of total flight experience on his most recent application for an FAA third-class medical certificate, which was dated March 26, 2007. AIRCRAFT INFORMATION The airplane, serial number P3370317, was manufactured in 1978 as a pressurized, all-metal, high-wing, multiengine airplane. It was powered by two Teledyne Continental Motors TSIO-360-C5 series engines, which were installed in tandem, one in front of the cabin and one behind it. Each engine was equipped with a McCauley propeller assembly. In addition, each engine was equipped with an engine-driven vacuum pump. According to a bill of sale, the pilot purchased the accident airplane on March 22, 1980. Review of the airplane's maintenance records revealed that its most recent annual inspection was conducted on December 20, 2007, at a total airframe time of 2,072 hours. At that time, the front engine had accumulated about 270 hours since new, and the rear engine had accumulated about 900 hours since it was overhauled. The only logbook entry since the annual inspection was dated April 8, 2008, for work associated with the rear engine, which was performed at a total airframe time of about 2,085 hours. The airplane's most recent pitot-static system check was performed on December 13, 2006. METEOROLOGICAL INFORMATION A weather observation taken at 1306, at an airport located about 25 miles west-northwest of the accident site, reported: wind from 110 degrees at 6 knots; visibility 7 miles; few clouds at 500 feet, scattered clouds at 1,000 feet, overcast clouds at 1,500 feet; temperature 14 degrees Celsius (C), dew point 12 degrees C; altimeter 29.84 inches of mercury. Weather radar imagery depicted the airplane flying through an area of 15 to 30 dBZ echoes or light intensity echoes, at the time of the accident. In addition, the Portland WSR-88D (NEXRAD) image, which covered the accident airplane's altitude, revealed instrument meteorological conditions, with light to moderate intensity precipitation. MEDICAL AND PATHOLOGICAL INFORMATION Autopsies were performed on the pilot and passenger on June 16, 2008, by Office of the Chief Medical Examiner, Augusta, Maine. The indicated cause of death for both occupants included "blunt force trauma" and the stated manner of death was an "accident." Toxicological testing was conducted on the pilot by the FAA Forensic Toxicology Research Team, Civil Aerospace Medical Institute, Oklahoma City, Oklahoma.

Flight

Event TypeAccident
Event Time13:10 EDT
Nearest Airport0nm
Flight Plan FiledIFR
Flight Plan ActivatedYes
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftCessna P337H
Tail NumberN15EM
Aircraft CategoryAir
DamageDestroyed
Operating RulePart 91
Engines2
Engine TypeReciprocating
Engine DetailsContinental · TSIO-360 SER · Reciprocating · 225 | Continental · TSIO-360 SER · Reciprocating · 225
Seats6

People & Injuries

Injury Summary2 injuries (2 fatalities)
Fatal2
Serious0
Minor0
Uninjured0
Total2
Crew 1Age 72 · Third Class · Fatal

Conditions

ConditionsIMC
LightDaylight
Wind110° @ 6 kt
Visibility7 sm
CeilingOvercast 1500 ft
Temperature / Dew Point57 / 54
Altimeter30.00 inHg
Observation Time17:06
Weather SourceWFAC

Appendix: Source Data