Undetermined · NTSB WPR23FA092

CESSNA 414 — Modesto, CA

1 fatal High-time pilot
DateJanuary 18, 2023
LocationModesto, CA
AircraftCESSNA 414
Purpose of flightPersonal
ConditionsDay · Visual Meteorological Cond
Phase / occurrenceApproach Comm system malf/failure
Pilot age80
Pilot total time4,506 hrs · High time
Time in typeUnknown
Fatalities1

Probable cause

The pilot’s exceedance of the airplane’s critical angle of attack and failure to maintain proper airspeed during a turn to final, resulting in an aerodynamic stall and subsequent impact with terrain. Contributing to the accident was the pilot’s distraction due to a non-critical radio anomaly.

NTSB findings

  • Aircraft-Aircraft systems-Communications system-VHF communication system-Unknown/Not determined
  • Personnel issues-Psychological-Attention/monitoring-Attention-Pilot
  • Personnel issues-Task performance-Workload management-Task overload-Pilot
  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot
  • Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Lateral/bank control-Capability exceeded
  • Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained

What happened

Shortly after taking off, the pilot was instructed to change from the airport tower frequency to the departure control frequency. Numerous radio transmissions followed between tower personnel and the pilot that indicated the airplane’s radio was operating normally on the tower frequency, but the pilot could not change frequencies to departure control as directed. The pilot subsequently requested and received approval to return to the departure airport. During the flight back to the airport, the pilot made radio transmissions that indicated he continued to troubleshoot the radio problems.

The airplane’s flight track showed the pilot flew directly toward the runway aimpoint about 1,000 ft from, and perpendicular to, the runway during the left base turn to final and allowed the airplane to descend as low as 200 ft pressure altitude (PA). The pilot then made a right turn about .5 miles from the runway followed by a left turn towards the runway. A pilot witness near the accident location observed the airplane maneuvering and predicted the airplane was going to stall. The airplane’s airspeed decreased to about 53 knots (kts) during the left turn and video showed the airplane’s bank angle increased before the airplane aerodynamically stalled and impacted terrain. Postaccident examination of the airframe, engines, and review of recorded engine monitoring data revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.

Toxicology testing showed the pilot had diphenhydramine, a sedating antihistamine, in his liver and muscle tissue. While therapeutic levels could not be determined, side effects such as diminished psychomotor performance from his use of diphenhydramine were not evident from operational evidence. Thus, the effects of the pilot’s use of diphenhydramine was not a factor in this accident.

The accident is consistent with the pilot becoming distracted by the reported non-critical radio anomaly and turning base leg of the traffic pattern too early during his return to the airport. The pilot then failed to maintain adequate airspeed and proper bank angle while maneuvering from base leg to final approach, resulting in an aerodynamic stall and impact with terrain.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →