Cessna 501 Loss of Control Near Smyrna, Tennessee
A Cessna 501 Citation pilot and six of his friends and family were killed when he lost control of the airplane and crashed within 3 min. after takeoff near Smyrna, Tennessee on May 29, 2021. The NTSB recently released its report, which explained what the safety board believed had happened. The board’s probable cause was a very common type in loss-of-control accidents. More challenging is trying to figure out why it happened.
On the morning of the accident the pilot topped off the fuel tanks and filed an IFR flight plan for Palm Beach International Airport (PBI). Around 10:20 a.m. he boarded the passengers, one of whom was a commercially certificated pilot with about 310 hr. of flight time. At about 10:27, he called Smyrna ground control for his clearance. He was cleared to PBI via radar vectors then as filed, to maintain 3,000 ft. and expecting flight level 330 10 min. after departure. His read-back was correct, and a minute later he called for taxi. He was cleared to taxi to runway 1, but was re-cleared to Runway 32 upon his request.
The current weather at Smyrna Airport (MQY) was wind 310 deg. at 10 kt, visibility 10 mi., overcast skies at 1,300 ft. AGL (above ground level), with a temperature of 14C (57F) and a dew point of 12C.
Smyrna Tower cleared the Cessna for takeoff at 10:51:55. “Citation ah six six bravo kilo Smyrna tower after departure turn right heading zero nine zero maintain three-thousand runway three two cleared for takeoff caution mower right of runway departure end.”
Altitude, pitch, track and roll of Cessna 501 Citation. Credit: NTSB
The pilot replied: “OK, we’re cleared for three two and we’re going zero nine zero at or above three-thousand for six six bravo kilo.”
The tower corrected him, “No, maintain three-thousand,” and he replied “and we’ll maintain three-thousand six six bravo kilo.”
After takeoff, the tower said “Citation eight bravo ah six bravo kilo contact Nashville departure,” and the pilot acknowledged.
Two minutes passed. Not hearing the Citation pilot check in, Nashville departure said “November six six ah bravo kilo departure are you on frequency?”
The pilot replied “ah six six bravo kilo with you.”
At 10:54:30 departure said “November six six bravo kilo say altitude you are radar contact three north of Smyrna fly heading of ah one three zero.”
Fourteen seconds later, departure repeated his call,”November six six bravo kilo did you copy your heading one three zero?”
The pilot replied “One three zero six six bravo kilo.” It was his last trans-mission.
An NTSB performance specialist used recorded ADS-B data from the FAA and an aerodynamic model of the airplane to create a physics-based estimate of the aircraft’s trajectory. The Cessna took off from Runway 32 and initially climbed straight ahead at 2,000 fpm. There was an overcast cloud deck at 1,300 ft AGL, and just as the pilot entered the overcast he began a right turn to his assigned heading while continuing his climb. Twenty seconds later he began gradually reducing pitch. But instead of leveling off at his assigned altitude of 3,000 ft., he began descending after reaching 2,900 ft.
Apparent angles in unaccelerated and accelerated flight. Credit: NTSB
At this point the pilot was displaying the well-known characteristics of somatographic illusion. As the FAA’s Pilot’s Handbook of Aeronautical Knowledge says in Chapter 17, Aeromedical Factors, “A rapid acceleration, such as experienced during takeoff, stimulates the otolith organs in the same way as tilting the head backwards. This action may create what is known as the “somatogravic illusion” of being in a nose-up attitude, especially in conditions with poor visual references.”
As the aircraft descended, the right bank increased to 60 deg. and the airspeed increased to 290 kt. Somatographic illusion also explains why the pilot overbanked. At 1,900 ft. the pilot reversed his pitch, again increasing it to an excessive 13 deg., and he reversed his roll, this time to an excessive 60 deg. left. He began his final overcorrection upon reaching 2,975 ft, pitching down 20 deg. and accelerating to over 350 kt. before striking the surface of Percy Priest Lake.
The NTSB’s examination of the wreckage and both engines showed no malfunctions or failures that would have prevented the pilot from operating normally. Neither the pilot nor his pilot-rated passenger reported any medical conditions or medication use that could account for the accident. Investigators concluded the pilot experienced spatial disorientation during a time of high workload and failed to properly use his instrumentation. The agency’s probable cause was “The pilot’s loss of airplane control during climb due to spatial disorientation.”
The pilot was a retired actor who had starred in Tarzan movies. He lived with his family in Brentwood, Tennessee, not far from MQY. He held a commercial pilot’s certificate and an instrument rating, and had also qualified as a helicopter pilot at the private pilot level. He had obtained a CE-500 type rating in March of 2020, 14 months before the accident. His logbook showed he had accumulated a total 1680.5 flight hours, of which 83 were in the aircraft involved in the accident. Of his 39.8 instrument flight hours, 5.9 were logged in the Citation. He had an FAA class II medical certificate, dated November 12, 2019, that stated he “must wear corrective lenses.”
The pilot’s stepdaughter said in an interview that she had flown with him and that he was very cautious and would not fly in any conditions that would make a passenger feel uncomfortable in the slightest. He was maintenance-conscious and recently had spent almost $100,000 upgrading the airplane. The aircraft was in the shop from November 2020 until February 2021.
Track of the accident aircraft over GoogleEarth imagery. Credit: NTSB and Google Earth
A family friend who was pilot-qualified said he had flown with the pilot in the Citation in late March, not long before the accident. He expressed concern about the pilot’s relative inexperience with the Citation and about the possibility that the airplane had been overloaded on the morning of the flight. According to this friend, the pilot had acquired a series of aircraft, each more complex than the last. His first airplane was a Cessna 172, the next a Beech Baron, and the third a Mitsubishi MU-2. According to FAA registration records, the Citation, tail number N66BK, was registered to a limited partnership in Brentwood on March 2, 2020.
An official at Flight Safety International’s Atlanta Training Center said in a letter to the NTSB that the pilot involved in the accident had attended a Citation II Part 61.63 Initial course at Atlanta between January 13-24, 2020. “He was not issued a type rating as he did not meet the requisite performance level to achieve a recommendation for the check.” He added that the pilot “completed 7 simulator sessions, for a total of 14 hr. of pilot flying time and acted as pilot-monitoring for a total of 12 hr. over the first 6 sessions. The last session was limited to 2 hr. of pilot flying.“
An instructor pilot who flew with the Cessna pilot in his MU-2 said he flew the MU-2 pretty well for his hour level. That instructor later flew with the pilot in the Citation from February 24, 2020 to March 8, 2020, for a total of 11.4 hr. He said he saw no issues with the pilot’s ability to fly the Citation in instrument meteorological conditions (IMC). He noted that the pilot was more familiar with the Garmin 750 installed in the MU-2 than the Garmin 430/530 in the accident aircraft. He added that in his opinion, the pilot needed more one-on-one training than the FSI simulator training provided.
The designated pilot examiner (DPE) who conducted his type rating check-ride on March 20 said he was a very competent pilot. His oral exam was “really good,” and during his flight test he performed very well. The DPE also verified that the accident pilot did have a valid class II medical certificate.
An earlier photo of the accident aircraft, registration N66BK, at Okeechobee County Airport in Florida. Credit: Wikipedia Commons
Aside from the pilot’s failure to complete the FSI simulator training course, most of the comments about the pilot’s skill and judgment level were positive. However, comments from another instructor who flew with him after he received his type rating told a different story.
That instructor, the chief instructor at the Wings of Eagles flight school in Smyrna, said he had flown with the accident pilot for about 25 hr. after he received his type rating. The instructor knew the pilot from having earlier conducted his original multi-engine training at the flight school. The instructor had about 10,000 hr. of jet time and about 3,000 hr. in CE-500 series airplanes. He said his flying with the pilot was not really instruction, but was about helping him get more comfortable flying the airplane.
The instructor said that the pilot was “always behind the airplane. The airplane was moving faster than what he could keep up with and he would miss things.” He was not a professional pilot, and he did not like to fly fast. He was a safe pilot, excellent at using checklists, but had trouble multi-tasking and maintaining situational awareness. He depended heavily on his iPad to visualize where the airplane was in time and space.
On one occasion, the instructor had taken the controls away from him because he was about to bust an altitude. The pilot preferred to hand-fly the airplane rather than learn the steps needed to use the autopilot. He also wanted to fly to bigger cities like New York and Las Vegas, but the instructor told him he was not ready to operate in those fast-moving environments.
The instructor noted that it is very easy for a pilot in that aircraft to mistakenly turn off the avionics master switches after takeoff rather than the igniters because they are located right next to each other. The pilot had accidentally done this twice on flights they had flown together. The instructor had listened to the ATC recording of the accident flight and could hear that the igniters were still on during the last ATC transmission. He said the aircraft was equipped with back-up instruments that would be usable if the avionics master switch was turned off.
Instrument Currency versus RatingsThe investigation showed that the pilot was conscientious and had good motor skills. He didn’t have the experience to complete a demanding initial jet training course, but he trained for and passed a type rating in the Citation, which was not easy. If the skies had been clear, he probably would have made it to PBI as planned. His missing competencies were autopilot skills, adequate instrument currency, and the necessary seasoning in a high-performance airplane.
The Citation was originally designed to be flown by two pilots. The FAA relented long ago and allowed the CE-501 and many other small turbine-powered airplanes to be flown by a single pilot. With that limitation, the pilot’s proficiency with the autopilot is a must. But the accident pilot had not mastered using the autopilot.
The pilot had owned the airplane for 14 months, but had only logged 83 hr. in it. That’s an average of six hours per month. Taking away the 36 or more hours he had receiving dual instruction or accompanied flying, he had only 47 hr. flying it alone—about 3 hr. a month. 14 CFR 61.57(c)(1) requires six instrument approaches, holding, and navigational tracking to be accomplished within the preceding six calendar months. The was down for maintenance for about three months, from November 2020 to February 2021. Without the pilot’s logbook, which was not provided in the accident report, we don’t know if he was instrument-current. Even if he was, 61.57 is a bare minimum and not nearly enough for a pilot new to an airplane to be proficient.
Finally, a type rating check is not easy, but a student who knows the Airman Certification Standards (ACS), studies and practices the required maneuvers has a good chance of passing. However, it must be noted that the rating does not provide seasoning or currency.
Any pilot can experience spatial disorientation. You must always be able to scan, read and follow the working flight and navigation instruments. That means you need highly developed instrument flying skills recently practiced before you take off into IMC.
—A former military, corporate and airline pilot, Roger Cox was also a senior investigator at the NTSB. He writes about aviation safety issues.
