2 fatalities

18 Jan 2016: CESSNA 525 (N711BX) — Cedar Fort, UT

Cedar Fort, UT, United States

On 18 Jan 2016, a CESSNA 525 (registration N711BX) was involved in an aviation accident near Cedar Fort, UT. 2 people were killed. Investigators recorded the probable cause as: The pilot's loss of control due to spatial disorientation while operating in instrument meteorological conditions, which resulted in an exceedance of the airplane's design stress limitations, and a subsequent in-flight breakup. This summary draws on records from NTSB; 12 related events involving the same aircraft type or operator are linked below.

SourcesNTSBPrimary reportUpdated 1778583330Data APIEditorial standards

On January 18, 2016, a Cessna 525, N711BX, was destroyed following a loss of control and in-flight breakup while maneuvering near Cedar Fork, Utah. The pilot reported multiple instrument failures; both occupants sustained fatal injuries.

Accident Overview

On January 18, 2016, at about 1000 mountain standard time, a Cessna 525, registration N711BX, was destroyed after a loss of control and in-flight breakup while maneuvering at altitude near Cedar Fork, Utah. The airline transport pilot and his sole passenger sustained fatal injuries. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the personal cross-country flight, operated under 14 CFR Part 91. The flight departed Salt Lake City International Airport (SLC) around 0950, with an intended destination of Tucson International Airport (TUS), Tucson, Arizona.

Flight and Communication Sequence

At 0951:59, the pilot contacted SLC departure control, reporting a climb through 7,500 ft mean sea level (msl) for 10,000 ft. The controller cleared the pilot to Flight Level 230 (FL230) and removed speed restrictions. At 0952:21, the controller instructed the pilot to maintain 14,000 ft and asked his climb speed, which the pilot stated was 200 knots.

At 0955:01, approaching 14,000 ft, the pilot reported a Flight Management System (FMS) failure, switching to NAV, and would exceed the assigned altitude. After an unintelligible transmission, the controller instructed a descent to 14,000 ft and to maintain present heading. About 10 seconds later, the pilot reported an autopilot failure and requested a climb to visual meteorological conditions. The controller cleared the climb to FL180. The pilot confirmed and later stated he was climbing to clear skies, that his "number 2" was working, and his "altitude" had failed.

At 0956:32, the controller advised of traffic at FL190 and requested the airplane level at FL180. The pilot acknowledged. At 0956:45, the controller noted light precipitation ahead and offered vectors. The pilot accepted. At 0957:12, the pilot said he was hand flying and his altitude would not hold. Radar showed a right turn from southerly to southwesterly heading without clearance. At 0957:35, the pilot transmitted a MAYDAY, stating losing instruments and wanting to climb clear of weather. The controller cleared the pilot to FL230, then amended to FL310. The pilot confirmed but said he couldn't dial that in and was reading out to verify his secondary instruments.

At 0958:53, the controller issued a no-gyro left turn for vectors southeast. Radar showed the pilot initiated a right turn at 20,700 ft. By 0959:12, the airplane reached 21,300 ft in a right turn. The controller queried the turn, and the pilot replied he was trying to climb. At 0959:47, the controller lost altitude readout and asked for the altitude; no further transmissions were received. Between 0959:49 and 0959:58, the airplane descended from 21,300 ft to 16,000 ft, with a descent rate increasing to 36,000 fpm.

Witness Statements

The Utah County Sheriff's Office collected four witness statements. One witness heard a loud boom, then a motor sputtering, and saw a piece of the airplane falling on fire but could not identify it; he heard the crash but did not see the airplane. A second witness heard a boom but did not report seeing the airplane. A third witness heard an explosion inside his house, then went outside and saw debris falling. The fourth witness heard a loud explosion and the airplane descending, but did not hear impact.

Personnel Information

The pilot held an airline transport pilot certificate with multiengine land rating (April 8, 2008), commercial privileges for single-engine land, and a CE-525S type rating for single-pilot operations. According to his logbook, at the time of the accident he had 3,336 total hours (3,138 pilot-in-command, 2,015 multiengine, 1,588 turbojet all in the accident airplane). Recent flight time: 8.8 hours in the last 90 days, 8.8 in 60, 7.9 in 30. He was current and qualified for single-pilot operations. On December 1, 2014, he was issued a third-class medical with the restriction "Must wear corrective lenses." He had attended CE-525 recurrent training semi-annually since 2011, most recently August 7-9, 2015, completing 12.5 ground hours and 6 flight simulator hours satisfactorily. FlightSafety International (FSI) did not provide training specific to the dual Garmin GTN 750 units installed in the airplane in October 2014. The pilot had 97.8 hours in the accident airplane since that modification.

Aircraft Information

The Cessna 525 (serial number 525-0299) was a low-wing, T-tail configuration with retractable tricycle landing gear and pressurized cabin, capable of operating up to 41,000 ft. It was configured for up to 7 occupants and approved for single-pilot operations with the appropriate type rating. It was equipped with two Williams International FJ44-1A turbofan engines (1,900 lbs thrust each).

Maintenance

The most recent maintenance occurred on January 4, 2016, when both horizontal stabilizer deice boots were replaced at Mesa Citation Service Center, Mesa, Arizona. At that time, airframe time was 2,301.9 hours; left engine 2,257.1 hours; right engine 2,205.4 hours. The airplane had accumulated about 3 hours since that inspection.

Avionics

In October 2014, Sierra Industries installed a dual Garmin GTN 750 system, approved under FAA Form 337. The GTN 750 is an integrated GPS/NAV/COM/MFD with touchscreen controls. The airplane also had a Honeywell SPZ-5000 integrated flight guidance system (IFGS) including flight director, altitude alerting, and autopilot. The autopilot required a single directional gyro and two vertical gyro sources (VG-14A). The #1 VG-14A supplied the pilot's side EADI/EHSI; #2 supplied comparison data and the co-pilot's attitude indicator. Two AC inverters powered the gyros; a standby jet gyro indicator had 30 minutes of emergency power. In October 2014, several avionics were replaced, including dual GTN 750s, Garmin GTX33 transponders, and other components. The airplane also had two AM-250 barometric altimeters as part of RVSM modification, and an encoding altimeter found at the accident site indicating 5,280 ft with a barometric setting of 30.09 inHg.

Meteorological Information

At 0954, Provo Municipal Airport (16 nm southeast) reported wind calm, visibility 10 miles, scattered 3,000 ft, broken 3,500 ft, overcast 4,000 ft, temperature 0°C, dew point -3°C, altimeter 30.11 inHg. At 0955, South Valley Regional Airport (18 nm north-northeast) reported similar conditions with temperature 2°C and altimeter 30.09 inHg. An NTSB meteorologist reported that the airplane ascended through an icing layer during climb to FL210, with solid IMC likely from 9,000 ft to FL250, then layered clouds from FL250 to FL320. The flight operated in a layer with super-cooled large drop (SLD) icing and ice crystals. AIRMETs for icing and mountain obscuration were valid. No lightning strikes were recorded near the accident site.

Wreckage and Impact Information

Investigators examined the wreckage site the day after the accident. The wreckage was located in open, flat pasture about 1 nm southeast of Cedar Fort, Utah, and 28 nm south-southwest of SLC. The airplane had experienced an in-flight breakup; all structural components were within a rectangular area about 4,000 ft long and 1,500 ft wide on a 247° magnetic heading. The main wreckage consisted of the fuselage with cockpit and two seats, cabin with five seats, center wing section, and aft fuselage excluding empennage. The right wing and flap showed extensive thermal damage. The right main and nose landing gear were up; the left main gear separated. All airframe components except both engines were northeast of the main wreckage, including outboard wing sections, left horizontal stabilator section, and empennage. The left outboard wing was about 3,000 ft northeast, bent and twisted; the right outboard wing about 4,700 ft northeast with top skin separation. The empennage was about 1,700 ft east, intact except for left horizontal stabilator and elevator sections. The right engine and carry-through beams were about 300 ft north; fan blades showed no rotational scoring. The left engine was not located initially but was found on April 9, 2016, about 3,000 ft west-northwest of the main wreckage, with heavy impact damage. Flight control cables separated consistent with tension overload. Detailed examination of the engines and airframe revealed no mechanical anomalies that would have precluded normal operation.

Medical and Pathological Information

An autopsy by the Office of the Medical Examiner, Utah Department of Health, determined the pilot's cause of death as total blunt force injuries. FAA toxicology found no ethanol in muscle or brain; no testing for carbon monoxide or cyanide. Valsartan (Diovan) was detected in liver and kidney, a prescription medication for high blood pressure.

Tests and Research

Numerous avionics components were tested with no evidence of malfunctions or anomalies that would have precluded normal operation. The standby attitude indicator was examined on January 17, 2017, and showed no evidence of not operating normally before impact. Airplane performance data were collected but are not summarized here.

Contributing factors

Causes

PilotLateral/bank control — Not attained/maintainedEffect on operationCapability exceeded

Other contributing factors

Malfunction