If you’ve ever heard a nagging little voice somewhere in your head saying, “I shouldn’t be making this flight,” this accident just might be the thing that causes you to give that nagging little voice a bit more attention next time. This past March, the NTSB completed its investigation into the February 27, 2017, accident in which a twin-engine Cessna T310Q hit three houses about three minutes after taking off from the Riverside Municipal Airport (KRAL), Riverside, California. The pilot and three passengers were killed. One passenger survived, and what she told investigators played an important role in helping them determine what happened.
On the surface, this flight should have had everything going for it: an experienced pilot, an airplane that had undergone an annual less than four weeks before the accident, and instrument meteorological conditions (IMC) on the benign side. Clearly, something—or things—went wrong, resulting in the NTSB stating in its probable cause that the accident was due to the pilot failing to maintain airplane control upon entering IMC. This resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall. Contributing to the accident was the pilot’s personal pressure to complete the flight.
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The pilot held an Airline Transport Pilot certificate for single-engine land airplanes and a commercial ticket for multi-engine land airplanes, along with an instrument rating that goes with an ATP certificate. He was also a flight instructor for airplane single-engine and multiengine land airplanes and a CFII. He had received an FAA second-class medical certificate about four months before the accident that just required corrective lenses. The pilot was 83 years old and at the time of the medical exam reported a total flight time of 9,600 hours, with 21 hours in the previous six months.
The pilot and his wife were on the trip to Riverside because their younger granddaughter was participating in a cheerleading competition. With them on the trip were their daughter, their older granddaughter and the daughter’s friend, who also had a daughter in the competition. They had flown from Norman Y. Mineta San Jose International Airport (KSJC) at San Jose, California, to KRAL on the Friday before the accident.
The pilot and his wife had owned the airplane for about 10 years. The T310Q was built in 1974 and had two turbocharged Continental TSIO-520J engines rated at 310 horsepower. At its annual inspection on February 1, 2017, the airplane had 4,830 flight hours, and the engines each had 1,265 hours since overhaul.
At about noon on the following Monday, the pilot and passengers returned to KRAL and put their baggage on board the airplane. They then boarded, and the pilot started the right engine. However, the pilot was unable to start the left engine. They deplaned and went to the terminal. A short while later, they reboarded but had to deplane again, apparently because the pilot had radioed the KRAL tower asking for a VFR clearance to KSJC, and the controller told him he needed to file IFR. It was IFR due to visibility and low ceilings. They went back to the terminal, and the pilot went into the pilot store at the flight school. There he saw an employee of the flight school, whom he had seen that past Saturday when he had the airplane refueled.
The employee told investigators that the pilot bought some approach plates and an en route chart on Saturday. He said that on the day of the accident, the pilot appeared to be rushed and bumped into a merchandise rack in the middle of the pilot store. The employee said the pilot asked if he knew how to file an IFR flight plan, which you might think would be an unusual question for an ATP-rated pilot to be asking. The employee said that he pointed to a sheet of paper on the wall that had a bunch of phone numbers on it and suggested that he call flight service at 1 (800) WX-BRIEF. The employee said the passengers came into the store, and the pilot told them not to follow him and to go back to the waiting area. The employee said he gave the pilot a Post-it Note, the pilot wrote down the phone number, walked out and, according to the NTSB, contacted flight service and filed an IFR flight plan.
The employee went to where the passengers were waiting. According to what he told investigators, they told him they were anxious to get home. “One said she had to work the next morning. So in my opinion, I believe there was a little pressure for the pilot. I’m presuming, but it looked like the man wanted to get everyone home that day,” the employee said in a statement.
The surviving passenger told the NTSB’s Investigator-In-Charge that the pilot’s wife was becoming anxious and was putting pressure on the pilot to get airborne. The survivor said that she offered to rent a car so they could drive home, but the pilot’s wife insisted that they would return to San Jose in the airplane.
The flight school employee said he went back to his office to get the phone number of a taxi company and took it to one of the passengers. He noticed that another passenger was on the phone, apparently trying to arrange transportation with a cab or car company. The employee said that he told someone else about what he had been observing, and both of them told someone working at airport operations. The airport operations official said he would alert the control tower, according to the flight school employee.
It was at about 4:02 p.m., roughly four hours after the group arrived at the airport, that the pilot radioed the ground controller in the Riverside contract tower requesting his IFR clearance to San Jose. The controller issued the clearance, which included an instruction to fly an obstacle departure procedure, necessary to avoid trees and rising terrain. The pilot’s response to the clearance: “Roger, we missed the first part of the clearance, please, uh, San Jose, ah, direct Paradise, I am unfamiliar with the obstacle procedure.” The controller asked, “Is there somebody else that’s flying with you?” The pilot responded, “No sir, now, go ahead, okay, go ahead.” The controller asked, “Okay, are you familiar with the obstacle procedure?” The pilot then contradicted himself and radioed, “Affirmative, sir.”
At 4:03:53, the controller repeated the IFR clearance and, at 4:04:35, the pilot radioed, “Roger, stand by one.” Almost seven minutes later, the pilot radioed the controller saying he was ready to taxi for takeoff. The controller responded, “You need to read back your clearance first.” The pilot’s response: “Right.”
The pilot then proceeded with a readback but got it wrong. The controller admonished him, “I am going to read it again and, um, make sure you write it down exactly as I give it to you. Tell, advise when you are ready.” The pilot replied, but a portion of the transmission was unintelligible. Nonetheless, the controller issued a new clearance. The pilot made a mistake in reading it back, and the controller gave him a correction. The pilot finally got it right, and the controller issued a taxi clearance. However, the pilot missed part of the taxi clearance, the controller tried again, and the pilot got it all the second time. At 4:16:08, the controller advised the pilot that once he got to the runup area, he would give him the obstacle departure procedure for Runway 9.
At 4:20:42, when the controller radioed to ask if the pilot was ready for the obstacle procedure, the pilot replied, “Stand by.” It was about 11 minutes later that the pilot advised he was ready to copy the obstacle procedure. The procedure called for a climb to 1,700 feet on a heading of 089 degrees, then a climbing turn to a heading of 210 degrees to intercept the Paradise VORTAC 093 degree radial, then direct to the VORTAC. The controller read the procedure, and the pilot’s readback was correct.
At 4:32:58, the controller told the pilot to hold short of Runway 9 and to advise when he was ready for departure. There then was some back and forth when the pilot failed to properly acknowledge the hold-short instruction by giving his aircraft identifier and naming the runway of which he was holding short.
After receiving the IFR release on the interphone system, at 4:38:12 the controller cleared the flight for takeoff. A weather observation about a minute before showed that the wind was calm, visibility was 2 miles in light rain and mist, there were scattered clouds at 600 feet AGL, and there was an overcast ceiling at 4,200 feet AGL.
An employee at airport operations saw the airplane make an uneventful liftoff and initial climb. Radar picked up the airplane at 4:39:50, when it was at about 1,100 feet MSL, about 300 feet AGL, over the midpoint of the 5,401-feet-long by 100-feet-wide runway.
About 18 seconds later, the airplane was at 1,300 feet and had made a left turn to a heading of 070 degrees, not quite the correct heading as prescribed by the obstacle departure procedure.
The surviving passenger told the NTSB’s Investigator-In-Charge that the airplane shook during the climb, but she could hear the engines running continuously. She said that the airplane entered a cloud and then it began to vibrate violently as it started to descend. She said that as the airplane was descending, the pilot was manipulating the controls. The NTSB took that to indicate that the pilot had not become incapacitated. The woman said that she heard a horn sounding as the plane was turning in the cloud and descending. When the sound of a 1,000hz stall warning horn was plated for the survivor, she identified it as what she heard.
The airplane struck a chimney and part of the roof of a house about one mile northeast of the airport. The terrain at the accident site was about 800 feet MSL. It then hit a second house about 50 feet further along the wreckage path and went into a bedroom of a third house. Fire broke out, which destroyed one house and damaged the others.
Examination of the wreckage failed to reveal any problems with the engines or aircraft systems. Testing of the KRAL fuel supply showed no abnormalities. The propeller blades had damage that was consistent with rotation under power at impact. Investigators calculated that the airplane likely was about 300 pounds over its maximum gross weight with the center of gravity forward of the limit. They suggested that this could have affected the handling of the airplane and its stall characteristics.
The investigation couldn’t determine when the pilot might have last flown in instrument conditions, or when he last had an instrument proficiency check. The Safety Board found evidence that the pilot was not IFR current and pointed to his unfamiliarity with basic instrument flight planning procedures and the coaching he needed in correctly copying and reading back clearances. There were no indications of what might have been behind the delays when the pilot was telling the controller to “stand by.”
The Safety Board said it was unlikely that the pilot was impaired or incapacitated during the flight and that the FAA’s toxicology study showed no evidence of drug or alcohol use by the pilot. However, an autopsy did reveal that the pilot had coronary artery disease.
The pilot and passengers spent more than 4-1/2 hours trying to launch and had to deal with one hurdle after another. From what the NTSB tells us, it’s clear that one of the passengers heard a very loud inner voice tell her it was time to stop trying to fly and time to begin driving. The question not addressed in the NTSB’s report is what stopped the pilot from hearing and responding to a similar voice. Surely the evidence was there for a pilot-in-command to build a commanding case that it was time to pack it in.
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.