History of Flight
On January 9, 2021, at 1337 Pacific standard time, a Cessna 560, registration N3RB, was destroyed when it crashed near Warm Springs, Oregon. The pilot, the sole occupant, sustained fatal injuries. The flight was conducted under Title 14 Code of Federal Regulations Part 91.
The pilot had filed an instrument flight rules (IFR) flight plan to Boise Air Terminal/Gowen Field in Boise, Idaho. The reason for the flight could not be determined; however, family and acquaintances noted that the pilot usually traveled with his dog, and because he did not on this occasion, he likely planned to return that day. A friend stated that Boise was a typical lunch destination and that a same-day return trip would not be unusual.
Security video from a fixed base operator at the departure airport in Troutdale, Oregon, showed the pilot boarding at 1244 and closing the cabin door. FAA air traffic control audio recordings indicated that about five minutes later, the pilot contacted the clearance controller to open his IFR clearance. The controller provided the clearance, which the pilot read back correctly. About nine minutes later, the pilot stated he was ready to taxi and had information Foxtrot. The controller noted that information Golf was current and provided taxi instructions to runway 07. The pilot replied with only the altimeter setting, and the ground controller asked for full taxi instructions. The pilot complied, and at about 1300, the airplane began taxiing to the runway hold short line.
The airplane arrived at the hold short line about 1304. The ground controller asked if the pilot was ready for departure; the pilot replied, “just a minute.” About two minutes later, a partial transmission from the pilot was heard. The local controller asked twice if it was N3RB. The pilot confirmed, and the controller issued takeoff clearance. At 1307, the airplane departed.
The pilot then contacted Portland Approach and was instructed to climb and maintain 15,000 ft msl. The pilot responded “up to 15.” The controller confirmed radar contact and instructed a left turn to a heading of 310°. The pilot did not respond, and the airplane did not turn. Over the next minute, both Portland Approach and Troutdale Tower controllers made multiple attempts to contact the pilot. On the fifth attempt by the approach controller, the pilot responded and was again instructed to turn left. ADS-B data indicated that the airplane then began a left turn; after one minute, the controller issued a heading of 180° and told the pilot to expect vectors to the TIMEE intersection after reaching 10,000 ft. The pilot did not respond until the instructions were repeated.
About one minute later, at 10,000 ft msl and on a southbound heading, the controller cleared the pilot direct to TIMEE. The pilot responded, and the airplane began a left turn but was about 15° left of the required heading.
By 1315:30, at 12,000 ft msl, the controller asked the pilot to verify he was direct TIMEE. The pilot responded affirmatively, but the airplane’s track had not changed; it was flying directly toward Mount Hood, about 27 miles to the east-southeast.
After reaching 13,000 ft, the controller issued a right turn to 130°. The pilot repeated the instruction correctly but the airplane turned left. The controller asked if the pilot was flying direct TIMEE; the pilot replied, “I was.” The controller explained the airplane was flying northeast and provided another right turn to 130°. The pilot responded, and the airplane began a right turn, rolling out on a 130° track. The controller then issued a frequency change to Seattle Center. The pilot responded with the correct frequency, but about one minute later called back with a confirmation of the frequency.
At 14,000 ft, after contacting Seattle Center, the controller immediately issued a low altitude alert, stating the airplane was just above the minimum IFR altitude for that sector (the airplane was flying just south of Mount Hood’s peak). The controller cleared the pilot to 23,000 ft msl.
The pilot responded, and the airplane continued to climb. The controller asked if the pilot had radio problems; the pilot replied, “no, I think it’s cleared up now, radio loud and clear.” The controller then cleared the pilot direct to BOI.
About 1323, at 19,000 ft, the pilot was given a new frequency for Seattle Center. He responded with an incorrect frequency and was corrected. The pilot then contacted the new controller, who cleared him to 37,000 ft msl. The pilot responded, and the airplane continued toward BOI while climbing.
At 1327, at 27,000 ft, the airplane began deviating to the right while continuing to climb. The controller alerted the pilot he was about 30° right of course, but the pilot did not respond. The airplane climbed to 31,000 ft at 1328:45, then began to descend, entering a spiraling right turn with a 1-mile radius for about eight minutes. The last ADS-B target at 1336:27 showed a northwest heading at 3,800 ft.
The airplane impacted terrain in the Mutton Mountain Range at an elevation of 3,600 ft msl, about 450 ft north of the last ADS-B target.
Hikers in the vicinity photographed smoke from the debris field. One photo captured a single, circular contrail at high altitude above the accident site. The pilot of a nearby single-engine airplane also recorded the circular contrail on video. No smoke trails were evident. A commercial airline flight crew overflying the area saw the airplane just before impact and reported no vapors or smoke trailing from it.
Pilot Information
The pilot held a private pilot certificate and type ratings for the Grumman G-111 Albatross and Learjet. FAA records did not indicate a type rating for the Citation 560.
The pilot had taken Citation 560 training near the end of 2020 at a facility in Arizona. The facility owner, who provided some training, stated that the pilot initially planned to obtain his commercial pilot certificate, Citation type rating, and single-pilot exemption consecutively. A custom syllabus was developed, but after the first few flights, it became clear that while the commercial and Citation ratings were feasible, the single-pilot exemption would require more time. The decision was made to focus on crew training.
During training, the pilot had significant difficulty mastering the autopilot and the recently installed Garmin 750 avionics suite. The facility owner stated that the pilot struggled in high-workload environments, such as instrument approaches requiring multiple configuration changes, and that the Garmin 750 appeared to aggravate the situation. The instructor was never able to transition from “instructor” to “first officer” mode. The pilot made some progress on one flight but was inconsistent, and he struggled particularly with steep turns.
After more than a dozen flights over three weeks, the training was not complete. The pilot left to attend to business and planned to return. At that time, he had not performed to a level sufficient to be issued the type rating.
Since October 2020, the pilot had an arrangement with a contract pilot who flew the accident airplane while the pilot sat in the right seat. The contract pilot never saw the pilot fly; however, during one flight, the pilot stated he preferred to “hand fly” rather than use the autopilot because he did not consider himself a professional pilot.
Review of historical flight data and statements from acquaintances and other pilots indicated that the accident flight was likely the first time the pilot had flown the airplane solo.
Aircraft Information
Ownership of the airplane was transferred to the pilot in July 2020. As part of the sale, an avionics upgrade was performed in April 2020, which included a Garmin 650 Xi and 750Xi avionics suite, a Garmin 335R ADS-B transponder, and a GDL 69A datalink receiver.
The current maintenance records were not located and were presumed destroyed in the accident. The most recent recovered records indicated a Phase B check was completed on January 6, 2020, at an airframe total time of 13,727.8 flight hours. The airplane was serviced with 150 gallons of Jet A fuel six days before the accident.
Wreckage and Impact Information
Due to the Covid-19 pandemic, neither the NTSB nor the FAA responded to the accident site. Onsite photographic documentation was done by local law enforcement. A complete airframe and engine examination was later performed by representatives from the NTSB, FAA, Textron Aviation, and Pratt & Whitney Canada at a recovery facility.
Photographs showed a 1,500-ft-long debris field on an approximate heading of 330° magnetic. The entire airplane sustained significant fragmentation and thermal damage, with the right wing most fragmented. All major structural and flight control surfaces were recovered nearby. The thrust reverser assemblies were in the stowed position, and both engines showed damage consistent with operation at impact.
There was no evidence of bird strike, in-flight fire, or door opening.
Remnants of three emergency oxygen system mask assemblies were found. Two were damaged; the third mask remained in its housing, indicating the oxygen system had not deployed. According to the Pilot’s Operating Handbook, if cabin altitude exceeds 13,500 +/-600 ft, an altitude sensing switch actuates the passenger solenoid valve, supplying oxygen pressure to deploy passenger masks. The oxygen control panel was located, but the control valve switch was detached; its status at the time of the accident could not be determined. The oxygen cylinder valves were broken off; the tanks were empty, and the quantity at impact could not be determined.
Flight Recorders
The airplane was equipped with a cockpit voice recorder, which was recovered and sent to the NTSB Recorders Division. Examination revealed a pre-existing internal failure; the tape contained no data from the accident or any previous flights.
Medical and Pathological Information
During the pilot’s most recent medical examination on September 2, 2020, he reported seasonal allergies and the use of loratadine (Claritin), which is not considered impairing.
An autopsy by the Wasco County Medical Examiner’s Office determined the cause of death as generalized blunt force trauma, manner of death accident. Due to injury severity, only a limited external examination was performed; no specimens were submitted for toxicology testing. No natural disease was identified in the limited exam.
Personal medical records showed longstanding diagnoses including anxiety, depression, high blood pressure, seasonal allergies, glaucoma, and high cholesterol. His regular medications over the previous year included alprazolam and sertraline for psychiatric disease, atorvastatin and fenofibrate for cholesterol, lisinopril-hydrochlorothiazide for blood pressure, and three eye drops for glaucoma. In March 2020, he used cetirizine/pseudoephedrine (Zyrtec-D) for seasonal allergies. He did not report these medications during his most recent FAA medical exam.
Alprazolam is an FAA “Do Not Fly” medication; air medical examiners are instructed not to issue medical certificates to applicants who use it. Sertraline, an SSRI, cannot be taken unless authorized by the FAA. Cetirizine is a conditionally acceptable sedating medication for occasional use, not daily.
Family and friends who listened to the audio recordings of the pilot’s communications with ATC stated he was generally quiet and soft-spoken, and his voice sounded normal.
Tests and Research
Interpolation of ADS-B data during the spiraling descent indicated a right bank angle of between 60° and 70° and a descent rate of -2,500 to -5,000 ft/min to impact. The data also showed 50- to 100-knot groundspeed oscillations. Comparison with flight test data for the Citation 560 series showed that the accident airplane’s longitudinal dynamic characteristics were similar to the simulated phugoid response after a pitch disturbance for about 90 seconds.