The NTSB recently finished its investigation of the October 28, 2013, accident involving a Cessna Citation 500 in which a nationally-known minister and the pilot were killed. Pastor Edward Dufresne, who was 72 years old, led the World Harvest Church in Murrieta, California, and used the twin-engine jet in his travels around the country for preaching engagements. His 49-year-old pilot was properly certificated and experienced for single-pilot operation of the Citation. Dr. Dufresne had made an appearance in Wichita, Kansas, the day before the accident. His next speaking engagement was at a church in Schertz, Texas. The flight had departed Mid-Continent Airport at about 10:07 a.m., and was en route to New Braunfels Regional Airport, New Braunfels, Texas. In the vicinity of Derby, Kansas, the airplane entered an uncontrolled descent and was destroyed in the impact and post crash fire. There was a partial in-flight break-up, since the outer portion of the left wing was found on the ground more than one-half mile from the main wreckage. As investigators probed the events leading up to the accident, they found some things which make one wonder whether the pilot somehow felt he was immune from not only FAA regulations, but also from the hazards we humans face when we knowingly put ourselves in risky situations.
The 1975 jet had accumulated an estimated 7,810 flight hours at the time of the accident. It was originally certificated with seating for two pilots and seven passengers. The original type-certificate data sheet called for a minimum crew of two; a pilot and co-pilot. However, the FAA granted an exemption allowing single-pilot operation for Citation 500 series aircraft provided certain criteria were met by both the pilots and the airplanes. This airplane was purchased by Dufresne, Inc., in 2005, after having been registered to more than a dozen other owners.
To fly single-pilot, the pilot had to have an ATP or commercial certificate, a CE-500 series type rating, at least 1,000 hours total flight time, 50 hours of night flight, 75 hours of instrument time, 500 hours in turbine powered airplanes, and a first- or second-class FAA medical certificate. The pilot met the requirements. He had a commercial ticket for single- and multi-engine airplanes. He had a type rating for CE-500 airplanes, and had completed a proficiency check. He was instrument rated. He had logged 2,605 hours with 1,172 in type and 351 hours of instrument time. His second-class medical certificate was current.
“I don’t see any primary [radar return] nor do I see anything under at all . . .like he disappeared.. . I just turned around and came back and he was gone.” —Kansas City Center controller handling the flight.
To be flown single-pilot, the airplane needed to have a fully functioning autopilot with approach coupling, functioning gyroscopic flight instruments, a boom microphone, a transponder “ident” button on the pilot’s control yoke, and a flight director system. As you’ll see, had the FAA requirements been complied with, this accident might not have happened.
Investigators used FAA radio and radar data to reconstruct what initially appeared to be a totally routine flight. The airplane took off from runway 1R at Wichita. The weather on the ground was VFR, with the wind from 010 degrees at 10 knots, 10 miles visibility in light rain, a broken ceiling at 4,400 feet AGL and a solid overcast at 6,500 feet. Within three minutes after liftoff, the airplane was at 7,000 feet MSL and still climbing. At this point, it would have entered solid instrument conditions. Unfortunately, as an NTSB meteorological study later showed, it also was on the verge of entering icing conditions. Less than 30 seconds later, it was at 8,000 feet and began a turn to the right. In the next four minutes, as it continued to climb, its course line began to wander. At 10:14:49, the pilot radioed the Kansas City Air Route Traffic Control Center’s Sector 62 radar controller, “Kansas City, Citation Six One Zero Echo Delta leveling at one five thousand.” The controller replied, “November Six One Zero Echo Delta, Kansas City Center, climb and maintain flight level two three zero, cleared direct Millsap.” The pilot confirmed, “Millsap direct, uh, zero echo delta.” Radar showed the airplane again entering a right turn. At that point, the Millsap VOR, located in Mineral Wells, Texas, was about 295 nautical miles away on a course of about 184 degrees. As the airplane climbed to 15,200 feet, it remained in the right turn and reached a course of about 240 degrees. It then turned left, going back to about 170 degrees and descended to 14,600 feet. Radar data showed that the airplane then climbed back up to 15,200 feet, while its course continued to wander from what would have been a direct path to Millsap.
Radar data recorded at 19 seconds past 10:16 a.m., showed that the Citation began to descend while entering a left turn which put in on a course of about 90 degrees, due east. Thirty-two seconds later, the airplane had plummeted to 10,100 feet and then dropped off radar. The controller who was handling the flight got on the ATC interphone and asked other controllers if they had seen N610ED on their scopes, or had any radio contact. Wichita Approach Control told the Kansas City Center controller, “...the track stopped. I don’t see any primary [radar return] nor do I see anything under him at all...like he disappeared.” The center controller replied, “...I just turned around [away from the radar screen] and came back and he was gone.”
The airplane crashed in a bean field about 13 miles southeast of the Wichita airport. The impact crater was about 15 feet deep. Small pieces of wreckage were scattered as far as 300 feet away. In addition to the outer portion of the left wing being found in a corn field about 3,100 feet away from the main wreckage, the left aileron was found 1,950 feet away. Pieces of the wing, including the separated parts, were sent to Cessna for examination under government supervision. The examination showed something startling: unacceptable repairs had been made which included improperly installed rivets, double-drilled fastener holes, the use of unapproved materials, internal areas with no protective primer, and excessive and sloppy application of wing tank sealant.
Although it appeared that the left wing held together until the rapid descent was well developed and the crash was a certainty, investigators wanted to find out just what had been going on with the airplane’s maintenance in view of what was discovered during the examination at Cessna. One investigator spoke with a mechanic in Murrieta, California, who had worked on the airplane. He said that in 2010, in order to save money, the owner used inexperienced volunteers to prepare the airplane for painting. They caused quite a bit of damage to the wings, including sanding down rivets. That necessitated extensive repairs to the tops of both wings.
Another investigator spoke with a mechanic in Texas who had received a phone call from the pilot the day before the accident, just after arrival at Wichita. The mechanic reported that pilot told him about problems while inbound to Wichita. The autopilot had disconnected several times, was not usable, and the pilot wound up hand flying the entire flight. The pilot also is reported to have said the horizontal situation indicator and artificial horizon gyros kept showing warning flags, and that the artificial horizon on the co-pilot’s side was “sideways.” The pilot also reportedly said there were changes in engine power which were not commanded and required re-trimming the aircraft. The mechanic said he advised the pilot not to fly the airplane with engine control issues.
A third investigator spoke with a person at an aircraft instrument company in Wichita, who said the pilot contacted him the day before the accident to buy a new attitude indicator for the right side of the panel. The person quoted the pilot as saying that the instrument wasn’t working, but saying nothing about other issues with the airplane. Investigators could not find evidence that the pilot made moves to fix anything else.
Although the co-pilot’s artificial horizon had been replaced, the safety board concluded that what the pilot was seeing on the instrument panel was nothing to bet your life on.
Remember the FAA requirements for single-pilot operation of Cessna Citations? With the malfunctioning autopilot and instrument problems, this airplane should never have been flown single-pilot, and possibly not at all. Even if the pilot had somehow forgotten the FAA’s requirements, at the very least he might have anticipated a very heavy workload for just one person because of the problems he experienced on the way into Wichita. The aviation weather forecast would have increased the pilot’s concerns about a heavy workload, if he knew what it was. Investigators could find no record of the pilot having received a weather briefing from an official source before the flight. If he got weather information from a source such as the National Weather Service’s Aviation Weather web site, he could have gotten all the information he needed without leaving any footprints. But, the NTSB didn’t indicate he did something like that.
There were AIRMETs warning of IFR conditions in the area of the accident, with moderate icing up to Flight Level 180. The National Weather Service produces a “Current Icing Potential” report, which showed moderate to heavy icing likely around the accident site above 10,000 feet MSL at around the time of the accident. Weather radar showed a nasty mix of ice, dry snow, and supercooled liquid droplets. The cloud tops were at about 25,000 feet.
The Safety Board suggested that things began to unravel as the pilot’s workload increased inside while ice was accumulating outside. They said the airplane’s flying characteristics would have been altered by icing at the same time the pilot was responding to a handoff to the center controller, a clearance to a higher altitude, and a slight change in route. Because the airplane did not have cockpit voice, flight data, or video recorders, investigators have no way of knowing just how hectic things were getting. Their examination of what was left of the engines indicated that both were producing power, probably mid-level to high power, but there was no way to tell whether the pilot had to deal with engine power fluctuations as he did on the flight to Wichita the previous day. Although the co-pilot’s artificial horizon had been replaced, the Safety Board concluded that what the pilot was seeing on the instrument panel was nothing to bet your life on.
The NTSB determined that the probable cause of this accident was the airplane’s encounter with severe icing conditions, which resulted in structural icing, and the pilot’s increased workload and subsequent disorientation while maneuvering in IFR conditions with malfunctioning flight instruments, which led to the subsequent loss of airplane control. Contributing to the accident was the pilot’s decision to take off in IFR conditions and fly a single-pilot operation without a functioning autopilot and with malfunctioning flight instruments.
In its report, the NTSB avoided evaluating the pilot’s motivation in flying rather than waiting until all of the known deficiencies were fixed. While this would have involved some degree of speculation, it’s an area which could have provided all of us with valuable lessons in accident prevention. After all, pilots need to know when faith in FAA regulations should not be replaced by trust in a higher authority.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.