Fatigue, Weather, and Pilot Error | 14-Hour Duty Day Ends in Tragedy

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On February 14, 2014, Cessna 210L N732EJ was carrying out a Southern Seaplane revenue flight toward Birmingham, Alabama. The airplane had already been delayed by weather earlier in the trip. By the time the pilot reached the Birmingham area, the operation had extended well beyond the originally planned schedule.

The NTSB's investigation established that the pilot was operating the airplane under a company VFR-only qualification and was not current for night flight. After the weather delays, however, he continued toward Birmingham and obtained an IFR clearance from Birmingham Approach. The controller asked whether he was capable and qualified for IFR flight, and the pilot answered affirmatively.

At 2208 local time, the pilot contacted Birmingham Approach and requested the ILS Runway 24 approach. Controllers issued headings and altitudes to position the Cessna for the approach. At 2220:38, the controller instructed the pilot to turn right to 210 degrees and maintain 2,800 feet until established on the localizer.

Instead of continuing the instructed right turn, the airplane turned left. NTSB radar analysis found that the aircraft reached a bank angle of about 60 degrees, with a turn rate of approximately 11 degrees per second. About two seconds after the last radar return, the pilot transmitted, “say again for two echo juliet.” The controller immediately instructed him to level the wings and climb, but there was no further response.

The wreckage was found in wooded terrain about 0.3 nautical mile from the last radar target. Examination found no evidence of a preimpact failure or malfunction of the airframe, flight controls or engine. The NTSB also determined that the wind conditions were unlikely to explain the turn opposite the controller's instruction.

The NTSB determined that the probable cause was the pilot's failure to maintain control while being vectored to intercept the localizer during night IMC. The board also identified the operator's inadequate dispatch procedures as a contributing factor because they allowed the pilot to fly beyond his duty day, at night when he was not current, and in IMC despite the company's VFR-only qualification.

Accident facts

Date
14 February 2014
Aircraft
Cessna 210L Centurion
Registration
N732EJ
Flight
Southern Seaplane revenue cargo flight
Location
Near Clay, Alabama, northeast of Birmingham
NTSB case
ERA14FA120
Occupants
2
Fatalities
2
Aircraft damage
Destroyed
Investigation status
NTSB final report

Chronology of the event

14 February 2014
N732EJ begins a revenue flight after weather disrupts the planned schedule.
1
About 18:35 CST
The Cessna departs after a weather delay and later lands at Magee to wait for conditions to improve.
2
About 20:50 CST
The airplane reaches Jackson, Mississippi; the pilot continues toward Birmingham.
3
22:08 CST
The pilot contacts Birmingham Approach and requests an IFR clearance for the ILS Runway 24 approach.
4
22:20:38 CST
ATC clears N732EJ for the ILS approach and instructs a right turn to 210 degrees.
5
Seconds later
The airplane turns left and begins a steeply banked descent away from the instructed course.
6
About 22:20:54 CST
The final radar return shows the airplane at about 2,400 feet.
7
About 22:21 CST
The controller tells the pilot to level the wings and climb; there is no response.
8
Following morning
Search crews locate the wreckage; both occupants are fatally injured.
9

Sources

Source video

Source video

National Transportation Safety Board, investigation ERA14FA120.

Audio from the original air traffic control recording, sourced from public recordings and released investigation records. The reconstruction, animation and written account are our own.
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