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Aircraft: Cessna 180
Where: Seward, Alaska
Injuries: 1 fatal; 1 serious
Phase of Flight: Cruise Flight

On January 2, 2006, about 1100 Alaska standard time, a wheel-equipped Cessna 180 airplane, N212RF, sustained substantial damage when it collided with terrain during maneuvering flight, about 7 miles east of Seward, Alaska. The airplane was being operated by the pilot as a visual flight rules (VFR) personal cross-country flight under Title 14, CFR Part 91, when the accident occurred. The airline transport pilot received serious injuries, and the sole passenger received fatal injuries. Visual meteorological conditions prevailed, and no flight plan was filed. The flight departed the Quartz Creek airstrip, Cooper Landing, Alaska, about 1030.

A U.S. Coast Guard C-130 airplane from Coast Guard Air Station Kodiak, was flying in the area of the accident, and received an emergency signal from the accident airplane's emergency locator transmitter (ELT), about 1205. The Coast Guard airplane located the accident airplane on the Godwin Glacier, and relayed its location to the Rescue Coordination Center (RCC) in Anchorage, Alaska. A helicopter from the Alaska, Air National Guard, 210th Rescue Squadron, was dispatched to the scene, but was unable to reach the site due to clouds obscuring the accident site. After aborting several attempts to reach the site due to weather on the glacier, the helicopter made it to the site about 2000.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on January 4, the Air National Guard Para rescue technician who made initial contact with the pilot, said the pilot told him he had been flying up the glacier, encountered a downdraft, and was being pushed down. He said the pilot told him he turned down slope to "escape" when the airplane contacted the glacier. The rescue technician described the accident site as a snow-covered glacial slope of 10 degrees or less, about 4,100 feet in elevation, and noted that they were able to land their helicopter on the slope. He said the airplane contacted the glacier up slope from where it had come to rest, and that the landing gear had separated from the airplane, and lay upslope from the main wreckage.

During an interview with the NTSB IIC and an FAA Aviation Safety Inspector on, the pilot said he departed Cooper Landing for a private airstrip he frequents at Cape Junken, Alaska, which is typically a 30-minute flight. He said his general routine is to fly over Seward, cross a saddle near the top of the glacier at 4,500 feet above sea level, and proceed to Cape Junken. He said he did not recall anything out of the ordinary, and said there were no problems with the airplane or its engine. He said he does not have any independent recollection of the accident.

During a telephone conversation with the NTSB IIC on January 12, the aircraft commander of the Coast Guard C-130 airplane that located the wreckage said they were transiting the area of the accident when they received a signal from the accident airplane's emergency locator transmitter (ELT). He said the area had an overcast cloud cover, which was underneath them. He located clear air where they could descend, and returned to the accident site underneath the overcast. He said they could see up the glacier, and that there was about 200 feet of clearance between the saddle at the top of the glacier and the cloud cover. He said as they passed over the accident site approaching the saddle, their navigation instruments indicated a 40-knot headwind, and that the mountaintops on either side of the glacier were obscured by clouds. The aircraft commander said they were able to circle in a bowl near the accident site for a short time until deteriorating weather forced them back on top of the overcast.

In a written statement to the NTSB dated January 27, the pilot wrote that while maneuvering in the mountains at 4,500 feet altitude, he encountered what he believed was severe turbulence and downdrafts.

An area weather forecast, valid at the time of the accident, indicated areas of marginal VFR weather with rain and snow showers. The forecast does not indicate any turbulence. The closest automated weather reporting facility is at the Seward Airport, about 7 miles from the accident site. Observations taken during the timeframe of the accident indicate rapidly varying visibilities from 10 miles to less than 1 mile, and ceilings varying from 100 feet to 6,000 feet.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's inadequate weather evaluation, which resulted in an in-flight encounter with low ceilings, turbulence, and downdrafts in cruise flight, and the pilot's failure to maintain altitude/clearance while maneuvering, which resulted in an in-flight collision with terrain. Factors associated with the accident were low ceilings, turbulence, and downdrafts.
Source: National Transportation Board

Aircraft: Cessna 180A
Where: Mercer Island, WA
Injuries: None
Phase of Flight: Landing

A float-equipped Cessna 180A impacted the water during a landing on the waters of Lake Washington, near Mercer Island, Washington. The commercial pilot and his two passengers were not injured, but the aircraft sustained substantial damage. The 14 CFR Part 91 personal pleasure flight, which departed the waters of Roche Island, Washington, about one hour and fifteen minutes earlier, was being operated in visual meteorological conditions. No flight plan had been filed. There was no report of an ELT activation.

According to the pilot, he was landing in relatively smooth water in light and variable wind conditions. Just after touchdown, the aircraft encountered a large rolling wave that the pilot had not noticed prior to landing. As a result of passing over the wave, the aircraft was thrown back into the air to a height of at least 10 feet. At that point the pilot added power in order to initiate a go-around, but the aircraft did not have sufficient airspeed to maintain flight. It therefore dropped back onto the surface of the water with sufficient force to create substantial damage in the aircraft structure.

Although the pilot noticed a couple of small boat wakes when he circled the area prior to landing, he did not notice the large rolling wave/swell that he subsequently encountered. It was his opinion that the wave had been created by a large boat that had departed the area prior to his landing.

The National Transportation Safety Board determines the probable cause(s) of this accident/incident as follows: the pilot's inadequate visual lookout during an approach and landing in open water. Factors include a large wave/swell at the location where the pilot elected to land his float-equipped airplane.
Source: National Transportation Board

Aircraft: Cessna 182Q
Where:
Rutland, VT
Injuries:
None
Phase of Flight:
Landing

A Cessna 182Q, N97996, was substantially damaged during a landing at Rutland State Airport (RUT), Rutland, Vermont. The certificated private pilot was not injured. Visual meteorological conditions prevailed for the flight that originated at Burlington International Airport (BTV), Burlington, Vermont, at 1200. No flight plan was filed for the personal flight conducted under 14 CFR Part 91.

In a written statement, the pilot reported that she was originally headed for North Hampton, Massachusetts. While en route, she encountered moderate turbulence and haze, and elected to land at Rutland Airport. As she approached Rutland, she obtained wind information on three different occasions. Winds at the airport were reported as being from 270 to 280 degrees, about 20 knots.

The pilot elected to land on runway 01 instead of runway 31 because it was longer, and there were no trees on the end. She aborted the first landing attempt, because she was too high. On the second landing attempt, the pilot made a crosswind landing. Once on the ground, she began pumping the brakes, but couldn't stop the airplane from going off the end of the runway. The airplane traveled down a steep embankment and flipped over.

A Federal Aviation Administration (FAA) inspector interviewed the pilot over the telephone. According to the inspector, the pilot said that she floated down the runway, and had difficulty getting the airplane on the ground. Once on the ground, she did not have enough distance to abort the landing safely.

An FAA inspector performed an examination of the airplane. According to the inspector, the airplane sustained damage to both wings, the firewall was wrinkled, both wing struts were bent, and both propeller blades were damaged.

The pilot reported a total of 165 flight hours, of which, 47 hours were in make and model. The pilot also reported that there were no mechanical deficiencies.
Runway 01 was a 5,000-foot-long by 100-foot-wide asphalt runway.
Weather at Rutland Airport, at 1315, included winds from 260 degrees at 10 knots gusting to 23 knots, visibility 10 statute miles, and scattered clouds at 8,000 feet.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's failure to attain the proper touchdown point. A factor was the crosswind.
Source: National Transportation Board

Aircraft: Cessna 182G
Where:
Taylorsville, North Carolina
Injuries:
1 minor
Phase of Flight:
Takeoff

At 1333 Eastern Standard Time, a Cessna 182G, registered to a private owner, operating as a 14 CFR Part 91 personal flight, collided with an embankment on takeoff roll at Taylorsville Airport, Taylorsville, North Carolina. Visual meteorological conditions prevailed and no flight plan was filed. The airplane sustained substantial damage. The private pilot reported minor injuries. The flight originated from Teague-Grider Airport, Taylorsville, North Carolina.

The pilot stated he started his takeoff roll on the west runway, and just before rotation his seat slid backwards. The pilot reported that he "lost directional control" of the airplane and the airplane subsequently collided with an embankment.

Examination of the front seats revealed both seat track rails were buckled. The seat track pin holes were measured at 0.28 inches longitudinal and sideways dimensions. Air Worthiness Directive 87-20-03R2, Seat Tracks, requires inspection of all pin holes at 100-hour intervals. Replacement of the seat rail becomes mandatory once any dimension exceeds 0.42. No elongation of the seat track pin holes was noted.

Review of the Cessna 182 Pilot Operating Handbook, Section I, states in the BEFORE STARTING THE ENGINE checklist,"(1) Seats and Seat Belts-Adjust and lock."
Source: National Transportation Board

Aircraft: Cessna 182L
Where: Boca Raton, FL
Injuries: None
Phase of flight: Forced Landing

About 1315 eastern standard time, a Cessna 182L, operating as a Title 14 CFR Part 91 personal flight, crashed while attempting a forced landing in the vicinity of Boca Raton, Florida. Visual meteorological conditions prevailed and no flight plan was filed. The aircraft received substantial damage, and the commercially-rated pilot, the sole occupant, was not injured. The aircraft departed Pompano Beach Airpark about 15 minutes before the accident.

According to the pilot, on his return trip to his home base near West Palm Beach, his engine surged and lost power. He chose an uninhabited north-bound lane of the Florida Turnpike for a forced landing. The left wing impacted a road sign during the landing rollout, causing substantial damage. The pilot stated he did not observe wing tank fuel level before departure. He stated that about 50 gallons must have been siphoned from his tanks while parked at his home base.

According to an FAA inspector, the sign collision damaged the wing leading edge about 2 to 3 feet inboard of the wing tip. The collision caused deformation of the left wing spar, a wing rib, and the false front spar. Neither wing fuel tank was breached and about 1.5 to 2.5 gallons of 100 octane LL was the total fuel found in the aircraft. The fuel was removed from the aircraft at the time the salvager removed the wings for transport to a locked and secured salvage and storage facility at Fort Lauderdale, Florida.

At the storage facility where the aircraft was transported to and stored, the NTSB observed the aircraft engine start from its own battery source. Also observed was the fuel removed from the aircraft, post crash, and the amount measured to be 2.5 gallons. The engine was operated at about 2,000 rpm for about 10 minutes. Engine operation was smooth and responsive to cockpit controls. According to the Cessna 182L type certificate data sheets, the unusable fuel is 30 pounds or about 5.1 gallons.

The National Transportation Safety Board determines the probable cause(s) of this accident/incident as follows: The pilot's failure to perform a proper preflight inspection and refueling of the aircraft, resulting in an in-flight loss of engine power due to fuel exhaustion and a collision with a road sign during the emergency landing.
Source: National Transportation Board

Aircraft: Cessna A185E
Where: Clear Lake, MN
Injuries: 1 fatal
Phase of flight: Landing

A Cessna A185E amphibian airplane, piloted by a private pilot, was substantially damaged when it nosed over while landing on runway 18 at Leaders/Clear Lake Airport (8Y6), Clear Lake, Minnesota. Visual meteorological conditions prevailed at the time of the accident.. The pilot sustained minor injuries. The passenger died on July 23, 2006, as result of injuries sustained in the accident. The flight departed Jorgensen's Landing Seaplane Base (MY34), Prior Lake, Minnesota, at 0915.

Runway 18/36 (3,000 feet by 150 feet) consisted of turf, loose gravel and asphalt surface materials. The first portion of runway 18 was turf (700 feet by 150 feet). There was a gravel strip (400 feet by 20 feet), followed by an asphalt strip (1,900 feet by 20 feet) along the center of the remaining portion of the runway. The airplane touched down and subsequently nosed over in the turf area immediately following the runway threshold.

The airplane was equipped with amphibious floats. Each float was configured with a retractable landing gear system that comprised of a main gear and a forward gear.

The pilot stated that he circled the airport to observe the runway and wind direction. The pilot reported flying a normal traffic pattern. The pilot stated that during the landing the airplane initially touched down on the main landing gear, while he held the forward landing gear off the ground. The pilot reported that when the forward landing gear touched down the airplane "flipped onto its back."

First responders reported that they found the airplane upside down, facing north. Local authorities reported that the airplane was located in the grass area prior to the gravel and asphalt sections of the runway. There were two distinct ground scars leading up to the main wreckage. The width between the two ground scars was consistent with the width between the airplane's two floats. Relative to the runway direction, the right and left ground scars were 103 and 92 feet long, respectively.

At 0953, the automated weather observation system at St. Cloud Regional Airport (STC), located 7.2 nautical miles northwest of 8Y6, reported the winds were from 270 at 9 knots.

The pilot stated that "no cones were observed" marking the runway threshold. Photographs taken after the accident show several yellow cones marking the runway threshold. The airport manager stated that the cones were present at the time of the accident.

The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot's misjudged flare that resulted in a hard landing and subsequent nose over. A factor to the accident was the grass runway that the forward landing gear dug into during the hard landing, resulting in the amphibian airplane nosing over.

Source: National Transportation Board

Aircraft: Cessna A185F
Where: Grand Junction, CO
Injuries: 4 fatal
Phase of flight: Cruise and maneuvering

At 1817 mountain standard time, a Cessna A185F was destroyed when it impacted terrain approximately 20 miles east of Grand Junction, Colorado. The commercial pilot and three passengers were fatally injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the personal flight being conducted under Title 14 CFR Part 91. The flight originated at Walker Field, Grand Junction, Colorado, at 1812, and was en route to Eagle, Colorado.

According to employees at Timberline Aviation, the pilot landed at the airport between 1600 and 1630. He and his passengers left by automobile and were gone for about an hour. When they returned, they loaded a fiberglass shower enclosure into the airplane. At 1810:10, the pilot contacted ground control for taxi clearance. He was given his choice of runways 29 or 22 because the wind was from 230 degrees to 280 degrees at 24 knots. The pilot said he would taxi "half way down two nine and we'll take a look." At 1811:29, the pilot requested and was cleared for takeoff on runway 29 from the taxiway A4 intersection. [According to the controller, 5100 feet of runway was available for takeoff from the A4 intersection.] He was given his choice of a left or right turn to the northeast. The pilot said, "Let's see what the wind does here." The tower controller said that during the takeoff roll, the airplane drifted off the right side of the runway and stirred up a cloud of dust. Witnesses at Timberline Aviation said they, too, saw the dust cloud, but thought it was due to propeller wash or a wind gust. They said it was "windy as hell," and the winds were "howling." The controller said that as soon as the airplane lifted off the runway, it immediately "took on a pronounced crab to the left into the wind." The pilot remarked, "Well, that was gustier than I thought, guys. I would like the left turn out." The controller replied, "...looks pretty rough up there. Left turn out approved." After approving the pilot's request to cross the airport midfield, the controller remarked, "Sure does not look like an attractive flight this evening." The pilot answered, "No, but it is time to go home, so we'll get on up to Eagle. We'll see you guys in a couple of days." This was the last transmission from the pilot, recorded at 1814:26.

A Vail Jet Center employee coming to work noticed the pilot's automobile parked in the parking lot. The pilot's dog was still inside. He became concerned because she knew the pilot had departed the previous evening. She telephoned the pilot's fianc' and learned he did not come home the previous evening. She telephoned FAA's Automated Flight Service Station (AFSS) in Denver and reported the airplane missing. At 0722, FAA issued an Alert Notification (ALNOT). A searching helicopter located the wreckage at a location of 39 degrees, 08.933' north latitude, and 108 degrees, 24.948' west longitude, about 8 miles northeast of the Grand Junction Airport. The ALNOT was then cancelled.

PERSONNEL (CREW) INFORMATION
The pilot held a commercial pilot certificate with airplane single/multiengine land, single engine sea, and instrument ratings. He also held a flight instructor certificate with airplane single/multiengine and instrument ratings, and a mechanic's certificate with airframe and powerplant ratings and an inspector authorization. When the pilot applied for his second-class airman medical certificate, he estimated he had accumulated 4,400 hours total flying time, 75 hours of which were accrued in the previous 6 months. His medical certificate contained the limitation, "Must wear corrective lenses."

The pilot's logbook was not found. His family, however, gave an FAA inspector permission to examine the contents of the pilot's personal computer hard drive. The hard drive contained his flight log, with entries from 1987 to 2003. According to this data, the pilot had logged no less than 3,068.8 hours total flight time, and no less than 434 hours had been logged in the accident aircraft. His last flight review and FAA Wings VI proficiency was accomplished in a Cessna 340. His last tail wheel recurrency flight was dated January 20, 2003. His last flight in the airplane was for 8.3 hours.

According to the pilot's resume, he said he had been employed for 4 years (1994-1998) as a network engineer for an Eagle computer company. He also served as the company's pilot and flight instructor, and maintained its Cessna T210 and Cessna 340. From 1991 to1994, he was self-employed as an aircraft pilot and mechanic. From 1988 to 1991, an Avon, Colorado, company that had acquired a Cessna 414A employed him. He refurbished the airplane and placed it on an FAA 14 CFR Part 135 certificate (air taxi). He served as the company's pilot, charter pilot, and mechanic. From 1986 to 1988, he managed a maintenance shop and flight school for a private individual, and flew as a charter pilot. From 1970 to 1986, he maintained and delivered airplanes in the Caribbean, and crop-dusted for 3 years in Belize.

AIRCRAFT INFORMATION
The Cessna Aircraft Company manufactured the accident airplane, a model A185F (s/n 18502313), in 1974. It was equipped with a Continental IO-520-D engine (s/n 293424-R), rated at 300 horsepower, and a McCauley two blade, all-metal, constant speed propeller (m/n). According to the most recent FAA registration certificate, dated January 8, 2001, the airplane was certificated in the restricted category, and approved for "agriculture and pest control" operations only.

The airplane's maintenance records were not found. The pilot's personal computer hard drive contained a limited amount of maintenance information. According to the data, a factory-remanufactured engine and an overhauled propeller were installed, and an annual inspection was performed on September 27, 2000. Tachometer and total airframe time was 1,507.0 hours. The oil was changed and the oil filter was replaced at a tachometer of 1,550.0 hours, or 43.0 hours since the last annual inspection. Another annual inspection was performed at a tachometer time of 1,630.6 hours. The oil was changed at a tachometer time of 1729.0 hours. An additional 25 hours were flown after the oil change. Total airframe time was 1,754.0 hours at the time of the accident.

METEOROLOGICAL INFORMATION
According to the U.S. Naval Observatory, official sunset occurred in Grand Junction at 1832.

Nearby workmen said that on the evening of the accident, there was scattered rain showers of moderate intensity in the area.

Weather observed at Grand Junction (GJT), the point of departure; Rifle (RIL), the approximate midpoint, and Eagle (EGE), the destination, was as follows:
GJT (1753): Wind, 260 degrees at 22 knots, gusts to 28 knots; visibility, 10 statute miles (or greater); ceiling, 10,000 feet broken; temperature 18 degrees Celsius; dew point, -4 degrees Celsius; altimeter, 29.65 inches; remarks, precipitation discriminator, peak wind, 270 degrees at 29 knots, 40 minutes past the hour, sea level pressure 1007 millibars.

RIL (1753): Wind, 240 degrees at 6 knots; visibility, 10 statute miles (or greater); ceiling 10,000 feet overcast; temperature, 14 degrees Celsius; dew point, -3 degrees Celsius; altimeter, 29.63 inches; remarks, precipitation discriminator, sea level pressure 1011 millibars.

EGE (1755): Wind, 240 degrees at 13 knots, gusts to 29 knots; visibility, 10 statute miles (or greater); sky condition, few clouds at 2,900 feet, 3,800 feet scattered; ceiling, 4,700 feet broken; temperature, 12 degrees Celsius; dew point, -7 degrees Celsius; altimeter, 29.67 inches; remarks, precipitation discriminator.

WRECKAGE AND IMPACT INFORMATION
The wreckage was located on a horse refuge in Debeque Canyon, part of the Coal Creek drainage on the Grand Mesa, about 8 miles northeast of Grand Junction. The accident site was between two 6,500-foot ridgelines, oriented northwest to southeast and approximately one mile apart. The accident site was at the 5,900-foot level. The airplane impacted 30-degree upslope rocky terrain on a magnetic heading of 250 degrees and came to rest inverted. The impact heading was opposite that from Grand Junction to Eagle, and pointed back towards Grand Junction.

The engine was pushed aft towards the top of the cockpit area. Bark from a nearby scrub tree was embedded in the engine. The separated propeller lay nearby. The fuselage of the aircraft was crushed inward and aft. Both cabin doors separated from the fuselage. The right cabin door had a clothesline tied around the door handle. The front two seats were identified. The left seat was partially attached to the seat track; the right seat was ejected. Both seatbelts were attached to the fuselage structure, but neither was fastened. The rear two seats were not present, but two sets of unfastened seatbelts were observed in the aft cabin area.

The altimeter indicated 7,100 feet, and the Kollsman window was set to 29.74. The attitude indicator showed a descent, and the heading indicator indicated 150 degrees. These three instruments were the only intact instruments found at the accident site.

The right and left wing separated from the fuselage. The left wing was crushed aft along the leading edge in an accordion fashion. The left aileron and left flap separated from the wing. The strut was bent down and aft mid-span. The right wing was crushed aft along the leading edge in an accordion manner. The aileron and flap remained attached. The empennage was partially separated from the fuselage. The horizontal stabilizer remained attached to the tail cone. The leading edge of the right horizontal stabilizer was crushed aft along the leading edge in an accordion fashion. The left horizontal stabilizer was crushed aft on the inboard side of the leading edge. Both elevators remained attached. The left elevator torque tube was broken. The vertical stabilizer was crushed inward and aft, and was deflected to the left. The top of the rudder was bent aft. The rudder cables remained attached to the rudder. All flight controls were identified, and partial flight control continuity was established.

MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed on the pilot by the Mesa County Coroner's office in Grand Junction Colorado.

FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicological tests on the pilot. According to CAMI's report, there was no evidence of drugs and ethanol in muscle tissue. Carbon monoxide and cyanide tests could not be performed.

TESTS AND RESEARCH
Recorded NTAP (National Track Analysis Program) radar data retrieved from Denver's Air Route Traffic Control Center (ARTCC) was provided to search and rescue personnel, and this data was instrumental in locating the airplane. According to the data, the aircraft began a left turn away from runway 29 at 1813:23. At 1814:26, it crossed the airport midfield. Ground speed was 138 knots and the track was 091degrees. There were no altitude returns throughout the flight. The last radar contact was at 1816:45, when the airplane was at a location of 39 degrees, 08'18" north latitude, and 108 degrees, 24'54" west longitude. Its ground speed was 160 knots, and its heading had changed from a previous 063 degrees to 048 degrees.

An engine inspection was conducted. There was no evidence of pre-impact abnormalities.

ADDITIONAL INFORMATION
The two front seats were located near to the wreckage. The two rear seats were later located in the pilot's aircraft hangar in Eagle, Colorado. According to Title 14 CFR Part 91.107, (a)(3), "Each person on board a U.S.-registered civil aircraft must occupy an approved seat or berth with a safety belt and, if installed, a shoulder harness, properly secured about him or her during movement on the surface, takeoff and landing."

The aircraft was certificated in the restricted category and approved for "agriculture and pest control" operations only. According to Title 14 CFR Part 91.313(a)(1)(2), "No person may operate a restricted category aircraft (1) for other than the special purpose for which it is certificated, or (2) in an operation other than one necessary to accomplish the work activity directly associated with that special purpose." 91.313(d)(1) through (4) states, "No person may be carried on a restricted category civil aircraft unless that person (1) is a flight crew member. (2) is a flight crewmember trainee; (3) performs an essential function in connection with a special purpose operation for which the aircraft is certificated, or (4) is necessary to accomplish the work activity directly associated with that special purpose."

According to the Mesa County Sheriff's Office and Civil Air patrol, the pilot had a reputation as being a "cowboy," "thrill seeker," and "hot dog."

The pilot was involved in a non-fatal midair collision, at Greeley, Colorado (see DEN 99-F-A077A/B). At the time, he was giving flight instruction in a Cessna T210N.

In addition to the Federal Aviation Administration, parties to the investigation included the Cessna Aircraft Company and Teledyne Continental Motors.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's poor judgment and his failure to maintain aircraft control. Contributing factors were the high winds and downdrafts, and the pilot's self-induced pressure to go home.
Source: National Transportation Board

Aircraft: Cessna 195
Where: Aspen, CO
Injuries: 4 Fatal
Phase of Flight: In Flight

At approximately 1120 mountain daylight time, a Cessna 195 single-engine airplane was destroyed when it collided with terrain while maneuvering 7.4 miles northeast of Aspen, Colorado. The airplane was registered to and operated by the airline transport pilot. The pilot and his three passengers received fatal injuries. Visual meteorological conditions prevailed and a visual flight rules flight plan was filed, but not activated. The flight departed the Aspen-Pitkin County Airport (ASE) at 1106, and was enroute to the Front Range Airport, Watkins, Colorado, at the time of the accident.

According to family members, the pilot flew the airplane from the Front Range Airport to ASE earlier on the morning of the accident. After having breakfast at Aspen, the pilot and his passengers boarded the airplane for the return flight to Watkins.

Radar data depicted the airplane departing ASE, flying north down the Roaring Fork River Valley, then turning right to fly southeast up the Woody Creek Valley. The last radar return depicted the airplane at 8,388 feet msl (approximately 148 feet above the terrain).

At 1630, a missing aircraft report was issued by the FAA based on family concerns when the aircraft did not arrive at the Front Range Airport. The Civil Air Patrol commenced an aerial search. Approximately 0745, the search airplanes found the accident site in the Woody Creek Valley, approximately 5.5 miles east of the location of the last radar return.

PERSONNEL INFORMATION

The pilot held an airline transport pilot certificate with an airplane multi-engine land rating and type ratings in the Boeing 737, 757, 767, and 777 aircraft. He also held a commercial pilot certificate with an airplane single-engine land rating, and current flight instructor ratings for single-engine and instrument airplanes. The pilot was issued a first class medical certificate with the limitation "must wear corrective lenses and possess glasses for near and interim vision." According to the medical application, the pilot reported that he had accumulated a total of 5,800 flight hours. It is not known how many hours were accumulated in the accident airplane.

AIRPORT & SURROUNDING AREA INFORMATION

The ASE airport is located north of the city of Aspen at an elevation of 7,815 feet msl. A review of the Airport Facility Directory entry for ASE revealed that it stated that "unique VFR departure procedures exist." The departure procedures stated that "as soon as possible, but no later than crossing airport boundary, turn right to a heading of 360 degrees - a 30-degree right turn from runway heading - hold this heading for at least 2 miles from the airport. NOTE: It is recognized that aircraft performance will differ with aircraft type and takeoff conditions; therefore, the aircraft operator must have the latitude to determine whether takeoff thrust should be reduced prior to, during, or after flap retraction."

According to local pilots, the normal procedure for departing Aspen and flying to the Denver area is to fly north, down the Roaring Fork River Valley, until the aircraft has enough altitude to reach the Ruedi Reservoir. A review of this route on the sectional aeronautical chart revealed that after takeoff, the pilot would have had to fly the airplane north-northwest approximately 8 to 10 nautical miles toward the town of Basalt prior to turning east toward the Ruedi Reservoir. The Woody Creek Valley branches off the Roaring Fork River Valley approximately 3 miles north of the airport. The Woody Creek Valley is surrounded by rapidly rising terrain on each side, and terminates at the Williams Mountains, which have a ridgeline with elevations between 12,000 and 12,700 feet msl.

An NTSB database search for accidents occurring over a 16-year period in the vicinity of the Aspen airport revealed that there were 8 accidents, 4 of which involved fatalities, in the accident site area that cited the high mountains and aircraft performance exceeded as causal and/or contributing factors.

AIRCRAFT INFORMATION

The 1949 model 4-seat airplane was equipped with a 300-horsepower Jacobs R755-A2 radial engine. The aircraft maintenance records were not located during the investigation; however, an invoice and accompanying periodic aircraft inspection report indicated that the airplane underwent its last annual inspection at a tachometer time of 4,282.0 hours.

A calculation of weight and balance was conducted using estimated fuel and passenger weights. The estimated weight and balance was within the manufacturer's limitations.

METEOROLOGICAL INFORMATION

At 1053, the Aspen weather observation facility reported the wind from 330 degrees at 6 knots, visibility 10 statute miles, scattered clouds at 6,000 feet and broken clouds at 15,000 feet, temperature 23 degrees Celsius, dew point 4 degrees Celsius, and an altimeter setting of 30.01 inches of mercury. The density altitude was calculated by an NTSB investigator to be 10,518 feet.

WRECKAGE AND IMPACT INFORMATION

The accident site was located at 9,860 feet msl. The wreckage distribution path, including an area of broken and cut trees, was oriented along a measured magnetic heading of 257 degrees (almost opposite the direction of flight depicted on the radar track) and measured approximately 130 feet in length. A fire consumed the cockpit/cabin area. The empennage remained partially attached to the fuselage and sustained impact damage. The vertical stabilizer and rudder, and the left horizontal stabilizer and elevator remained attached to the empennage. The right horizontal stabilizer was found separated from the empennage, but came to rest next to the empennage. The outboard portions of the wings were separated from the airplane and displayed leading edge damage. The right wing came to rest under freshly broken trees. The wings' fracture surfaces displayed characteristics consistent with overload failure. Flight control continuity was confirmed from the rudder and left elevator to the cabin area; however, due to the wing damage, confirmation of aileron control continuity was not possible.

The engine sustained fire damage and remained attached to the airplane via control cables, and the propeller remained attached to the engine. Three cylinders were found separated from the crankcase and one was partially melted. Both propeller blades displayed chordwise scoring and fresh cuts were found in some of the fallen tree branches. The engine was relocated to a salvage facility where the spark plugs were removed and examined. The spark plugs appeared new and did not display any unusual wear or combustion properties. The engine's accessory section sustained impact and/or fire damage.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was not conducted on the pilot. A toxicological test on the pilot for carbon monoxide, cyanide, ethanol, and drugs was performed. The results were negative.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's poor in-flight decision to fly up a valley with rapidly rising terrain, which resulted in the airplane colliding with the terrain due to its climb performance being exceeded. A contributing factor was the high, rapidly rising, mountainous terrain.
Source: National Transportation Board

Aircraft: Cessna 206
Where: Homer, AK
Injuries: 2 minor, 1 uninjured
Phase of flight: Takeoff

About 1415 Alaska daylight time, a Cessna 206 airplane sustained substantial damage during a forced landing shortly after takeoff from the Homer Airport, Homer, Alaska. The airplane was being operated as scheduled domestic commuter flight. The commercial pilot was not injured; the two passengers sustained minor injuries. Visual meteorological conditions prevailed, and company flight following procedures were in effect.

During a telephone conversation with the National Transportation Safety Board investigator-in-charge on March 23, the pilot reported that just after takeoff from Runway 3, as the airplane climbed to 300 feet above the runway, the engine began to run rough, lose power, and vibrate violently. Unable to restore engine power, he turned the airplane left, 180 degrees, to attempt an emergency landing on Runway 21, but the airplane continued to descend, and collided with an area of snow-covered terrain about 500 feet north of Runway 21. It came to rest inverted, sustaining substantial damage to the wings, fuselage, and empennage.

A Federal Aviation Administration (FAA) airworthiness inspector from the Anchorage Flight Standards District Office traveled to the accident site to examine the airplane before it was recovered. The inspector reported that his examination of the engine revealed a cracked number four cylinder head, which was slightly separated from the cylinder barrel.

The 37-year old pilot held a commercial pilot certificate with airplane single-engine land, and multiengine land ratings. He also held a flight instructor certificate with airplane single-engine, and instrument airplane ratings.

The airplane had a total time in service of 10,542.8 hours. The airplane is maintained on an Approved Airworthiness Inspection Program (AAIP). The most recent inspection (event 1), was 15.7 hours before the accident.

According to the operator's AAIP inspection schedule, a compression test of the engine's cylinders is required during each Event inspection, at 50 hour intervals. During the most recent Event 1 inspection, the engine compression was noted as follows: Cylinder Number 1, 70 psi; Number 2, 70 psi; Number 3, 70 psi; Number 4, 70 psi; Number 5, 70 psi, Number 6, 74 psi.

The closest official weather observation station is Homer. At 1353, an Aviation Routine Weather Report (METAR) was reporting in part: Wind, 070 degrees at 8 knots; visibility, 10 statute miles; clouds and sky condition, clear; temperature, 34 degrees F; dew point, 45 degrees F; altimeter, 29.49 inHg.

The Homer Airport is equipped with a single, hard-surfaced runway on a 030 to 210 degree magnetic orientation. Runway 3 is 6,701 feet long by 150 feet wide. The airport elevation is 84 feet msl. The departure end of Runway 3's clearway extends about 1,800 feet beyond the runway's edge. The terrain within the clearway consists of snow-covered tundra. The terrain beyond the clearway consists of sparsely scattered spruce trees, which extends an additional 2,800 feet, and to the shores of Kachemak Bay.

All of the airplane's major components were found at the main wreckage area. It came to rest inverted, sustaining substantial damage to the wings, fuselage, and empennage.

The engine cowling and fuselage firewall were crushed and displaced aft. The engine sustained impact damage to the underside, and lower front portion of the engine. The engine oil sump was crushed upward against the case. Tundra was found imbedded in the engine oil cooler.

The right wing lift strut remained attached to the wing and its lower attach point. The left wing lift strut was attached to the wing, but was separated from its fuselage attach point. The left wing was separated from the fuselage and the carry-through was broken, and crushed aft. The entire empennage was separated from the fuselage.

The flight control surfaces remained connected to their respective attach points. Due to the impact damage, the flight controls could not be moved by their respective control mechanisms, but the continuity of the flight control cables was established to the cabin/cockpit area.

The cracked number four engine cylinder, was sent to the National Transportation Safety Board's Materials Laboratory for examination. A Safety Board metallurgist reported the aluminum head assembly was cracked between the 14th and 15th fins as numbered from the inboard end of the cylinder head. The crack propagated circumferentially approximately 300 degrees. Approximate length of the crack was 11.9 inches. The area of the separation was covered by a dark, heavy layer of material that was consistent with combustion products.
A magnified optical examination of the fracture surfaces on the cylinder assembly found fatigue progression features, which originated at multiple origins along the fracture surface.

September 9, 2009, the Federal Aviation Administration's Engine and Propeller Directorate Office, issued an airworthiness directive (AD) requiring a special reoccurring 50-hour inspection of all TCM IO-520 and IO-550 series reciprocating engines with Superior Air Parts, Inc., cylinders assemblies, part numbers SA52000-A1, SA52000-A20P, SA52000-A21P, SA52000-A23P, SA55000-A1, or SA55000-A20P, installed. The accident airplane's number four cylinder, part number SA52006-A1, and was not included in the AD.

The National Transportation Safety Board determines the probable cause(s) of this accident to be: The fatigue failure of the No. 4 engine cylinder head resulting in a loss of engine power. Contributing to the severity of the accident was the pilot's decision to attempt a low altitude turn back to the airport, resulting in a loss of control.

Source: National Transportation Board

Aircraft: Cessna U206G
Where: Killkarney Lake Idaho
Injuries: None
Phase of Flight: Landing

About 1320 Pacific daylight time, a Cessna U206G sustained substantial damage after striking powerlines while on final approach to Killkarney Lake, located approximately 5 nautical miles southwest of Rose Lake, Idaho. The commercial pilot and his two passengers were not injured. Visual meteorological conditions prevailed for the on-demand charter flight, which was operated under the provisions of Title 14, CFR Part 135, when the accident occurred, and a flight plan was not filed. The flight originated from Coeur d'Alene, Idaho, approximately 20 minutes prior to the accident.

In a written statement, the pilot reported that prior to the approach and landing he flew over the area at approximately 500 feet above ground level (AGL) to determine the direction of the wind and to look for logs and debris in the lake. The pilot stated that he was approaching the north end of the lake on a southerly heading and near the lake's edge at approximately 50 feet AGL when he saw the wires. The pilot reported that he immediately added full power to raise the nose when the top wire went over the top of the floats, catching the float struts. The pilot stated that the wire broke off the right side but was still entangled on the left side, pulling the airplane down. The pilot reported that he then pulled the nose up before impacting the water. Damage to the aircraft included the left hand front door frame post being cracked, the upper top cabin skin wrinkled, and the left hand cabin bulkhead bent.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's failure to maintain clearance with the powerlines on final approach which resulted in a hard landing. A factor contributing to the accident were the powerlines.
Source: National Transportation Board

Aircraft: Cessna 206H
Where: Mayville, NY
Injuries: 1 serious
Phase of Flight: Cruise

At 0615 Eastern Daylight Time, a Cessna 206H was destroyed after an in-flight explosion, and a subsequent forced landing to a field in Mayville, New York. The certificated commercial pilot was seriously injured. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed for the flight, between Chautauqua County Airport (DKK), Dunkirk, New York, and Port Meadville Airport (GKJ), Meadville, Pennsylvania. The business flight was conducted under 14 CFR Part 91.

The pilot reported that he departed Dunkirk at 0610. According to two Federal Aviation Administration (FAA) inspectors, who interviewed the pilot while he was in the hospital, the pilot stated that, after takeoff, he climbed the airplane to 4,000 feet. Just after level-off, the pilot checked the gauges "and found them to be all in the green." His power setting was 2,500 rpm and 25 inches of manifold pressure, and "as he was accustomed, he backed the throttle a hair to 24/24." The pilot then engaged the autopilot, and the engine was running smoothly, with no vibrations. "All was fine for about 35 to 40 seconds. Then he heard a loud explosion ('Kaboom!!') followed by an increase in engine rpm."

During the explosion, the pilot saw the engine cowls "bow up". The cowl fasteners also blew out, and fire came out through the fastener holes.

The pilot started to turn the airplane towards a field he had seen earlier. Meanwhile, "blue and yellow flames were constantly coming from the engine compartment and coming right around the window." During the turn, there was a second explosion. The pilot thought the engine was still running until that time, and quit after the second blast. After the second explosion, the cabin became completely engulfed in smoke. The pilot cracked the left window, and found an area where he could "sip" fresh air. The view ahead of him was completely black due to the amount of smoke.

The pilot continued toward what he thought was the field, based on his available vision to the side. However, during the final approach, the airplane struck trees. The pilot was surprised, and pulled full back on the yoke. The airplane then stalled, and fell straight to the ground.

After the pilot was released from the hospital, he provided amplifying information to the Safety Board. In a telephone interview, he stated that during the preflight, he checked the oil cap three times to make sure it was in and locked.

The pilot also confirmed that there was no problem with the engine prior to the first explosion. "It was purring like a kitten." After he leveled off the airplane, he set the power and engaged the autopilot. Less than a minute later, it seemed like a stick of dynamite went off. Blue flames and fire came through the cowling. The engine continued to run smoothly, and may have even sped up a little. There were no "clanking" sounds emanating from the engine before the first explosion.

Immediately after the explosion, the pilot put the flaps down, and turned towards a field he had seen. During the turn, a second explosion occurred. The dash was blown in, and there was so much fire and smoke, that visibility within the cockpit was reduced to the blackness of night. The pilot couldn't breathe, and he couldn't see, except out the side window. After the second explosion, the engine quit running.

A witness to the accident stated that he was inside his house when he heard the sound of the airplane's engine, then a "pop sound." He looked outside, and saw the airplane "about treetop high and the right front side was on fire...near the engine." He saw the airplane make several left turns, then lost sight of it behind the trees, and eventually located the wreckage by following rising smoke.

The accident occurred during civil twilight, about 20 minutes before sunrise.

PILOT INFORMATION
The pilot held a commercial pilot certificate with ratings for single engine land and multi-engine land airplanes. He reported that he had about 3,135 hours of flight time, and 100 hours in make and model.

AIRPLANE INFORMATION
The airplane was manufactured in May 1999, and according to the operator, had about 340 hours of operating time. The engine was a Textron Lycoming IO-540-AC1A5.

According to maintenance records, the "New Reciprocating Engine Certificate" was dated January 1, 1999. The engine was serviced with mineral oil for the first 50 hours. An annual inspection was completed at 100.0 hours. A Tanis engine preheater system was installed. Another annual inspection was completed at 201.7 hours. All six of the cylinder assemblies were removed and replaced due to high oil consumption. Another annual inspection was completed, at 300.0 hours.

WRECKAGE INFORMATION
On the day of the accident, an on-scene examination was conducted by a Rochester Flight Standards District Office (FSDO) FAA inspector, who was joined by the operator. According to the FSDO inspector, there were broken limbs in tree line near the wreckage. There was also a gash in the ground, from the tree line, about 50 feet, to the wreckage. The wreckage had been sprayed with water and foam by a local fire company. The airplane's cockpit, instrument panel, and fuselage were destroyed by fire. All three landing gear were collapsed. The right engine cowling was found on the left side of the airplane, near the propeller, while the left engine cowling was still attached. Removal of the left cowling revealed a 5-inch crack in the engine case, in the vicinity of the number 6 cylinder.

The engine was subsequently moved to a hangar owned by the operator, and the airframe was moved to a different location, belonging to a salvage company.

Arrangements were made to have representatives from Cessna Aircraft Company and Textron Lycoming, along with another FSDO inspector and an FAA inspector from the Wichita Aircraft Certification Office, join the FSDO inspector in examining the wreckage on the following day.

The group proceeded to operator's hangar for an engine examination. The oil suction screen was pulled, and metal particles and debris were found on it. The oil sump plug was removed and a mixture of water and a small amount of oil were drained out.

Fire damage was noted to the accessory case and the firewall, with fire damage more severe on the left side of the engine. The bottom of the engine-driven fuel pump was missing. The oil filler tube and the top portion of the oil dipstick were missing.

The engine was prepared for shipment to Textron Lycoming, Williamsport, Pennsylvania, for a teardown examination.

The group stopped at Dunkirk Airport to examine the ramp area and the airplane's parking spot. No oil was noted in either place. The group then proceeded to the salvage yard, and found the remainder of the wreckage still on the flatbed truck that had transported it.

Examination of the airframe remnants revealed that there was oil on the bottom surfaces of the wings and the empennage. The right engine cowling had oil on it in the vicinity of the oil filler cap. The left engine cowling exhibited evidence consistent with heat damage.

The engine underwent the teardown examination under Safety Board supervision at Textron Lycoming. The examination revealed that the engine's rear accessory section was fire-damaged, and both the right and left magnetos were melted. The oil filler tube was missing; however, the dipstick was still inserted into the engine. The oil filter was fire-damaged, and the bottom of the engine driven fuel pump was burned away. The fuel boost pump was intact. Externally, the engine oil pump was rusted and fire-damaged. There was light scoring on the internal body walls, but no damage to the impellers.

The engine would not rotate; however, engine continuity was confirmed, with the exception of the separated number 6 connecting rod. There was metal contamination in the oil sump. Internal timing could not be verified due to heat and rust damage to the accessory drive gears. All spark plugs were gray in color, with the exception of an oil/water-wet number 2 bottom plug, and a corroded number 4 top plug.

The connecting rod bearings had an appearance consistent with oil starvation and wiping. The number 6 connecting rod bearing was in pieces, in the sump. No damage was noted to any of the main bearings. The crankcase oil galley and oil holes were open and free of debris.

TESTS AND RESEARCH
The number 3, 5, and 6 connecting rod assemblies were forwarded to the Safety Board Materials Laboratory for examination. According to the metallurgist's factual report, the pieces from the number 6 rod were darkly discolored, "as if severely overheated." Further examination revealed that "mechanical damage completely obliterated fracture features on the smaller separated pieces of the connecting rod and cap."

One of the number 6 connecting rod bolts was separated. "The separated ends of the bolt were deformed by bending." The facture face of the head portion was completely destroyed by "post-separation damage," while the fracture face on the shank had "cup and cone features, typical of tensile overload. The 'intact' bolt from the connecting rod...was also deformed by bending."

The report also stated: "The crankshaft ends of connecting rods numbers 5 and 3 also had evidence of heat discoloration; however, significantly less severe than in rod number 6. The connecting rod bolts in both rods were intact but the bearing shells were deformed and heavily scored."

ADDITIONAL INFORMATION
Photographic evidence of the interior side of the right cowling revealed oil residue on the aft, bottom quadrant. The residue appeared generally to be unburned; however, there were specks of soot on, or imbedded in, the residue. There was also some light sooting on the aft, top quadrant of the interior side of the cowling, with heavy sooting near the cowling's aft, top edge.

Photographic evidence of the interior side of the left engine cowling revealed heavy sooting on the aft, upper quadrant. There was also scorching within the aft, upper part of that quadrant.

In an email, another Cessna 206H owner stated that the dipstick/oil filler cap on his airplane's engine required a "real firm" tightening, or it would back itself out. The owner also noted that two or three times he came back from flights, and the cap was "completely open." However, even though the cap was open, there was "no oil loss or indications of oil spewing out."

Textron Lycoming issued Mandatory Service Bulletin number 545, which required oil filler tube and clamp replacement on certain IO-540-AC1A5 engines. The serial number of the oil filler tube adapter determined which engines were affected; however, the accident engine was not one of them.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: An engine compartment explosion due to a fuel/fuel vapor leak of undetermined origin. A secondary explosion resulted from a lack of lubrication to the number 6 connecting rod bearing. Contributing to the pilot's injuries was his reduced visibility during the forced landing, resulting from a heavy concentration of smoke in the cockpit.
Source: National Transportation Board

Aircraft: Cessna T206H
Where: Chickaloon, AK
Injuries: 3 fatal
Phase of Flight: En route

About 1000 Alaska daylight time, a wheel-equipped Cessna T206H airplane was destroyed by impact and post-impact fire when it collided with mountainous terrain while maneuvering, about 23.5 miles east-northeast of Chickaloon, Alaska. The airplane was being operated as a visual flight rules (VFR) cross-country personal flight when the accident occurred.  The private certificated pilot and the two passengers received fatal injuries. Instrument meteorological conditions prevailed in the area of the accident. A VFR flight plan was filed from Homer, Alaska, to Whitehorse, Canada. The flight originated at the Homer Airport, about 0752.
At 0645, the pilot telephoned the Federal Aviation Administration (FAA) Kenai Automated Flight Service Station (AFSS) and filed a VFR flight plan. He stated, in part: "...departure point is Homer, proposed departure is 0800, altitude 5,500 feet (msl), route of flight is direct Potter Marsh (Anchorage, Alaska), direct Birchwood (Chugiak, Alaska), direct Palmer, then Gulkana, via Sheep Pass, Tahneta Pass, direct Northway, direct Whitehorse." He indicated the en route time as 4.5 hours, with 5.5 hours of fuel on-board the airplane.

The route of flight specified by the pilot included terrain that went from sea level to mountainous, and generally followed Alaska Highway 1 through the mountains. The mountainous portion of the flight, where the accident occurred, is located between Palmer, Alaska, and Gulkana, Alaska, and traverses Tahneta Pass. Commonly used points of geographical reference, eastbound along the highway from Palmer, are Sutton, Chickaloon, Sheep Mountain, Gunsight Mountain, Tahneta Pass, Eureka, Snowshoe Lake, Tazlina, Tolsona, and then Gulkana.

The pilot obtained a standard weather briefing about the route of flight. The flight service station specialist provided a synopsis that stated, in part: "...we got a stationary low just north of Fairbanks and another low in the eastern Gulf, basically just southwest of Yakutat. It's moving to the northeast at about 5 knots, it looks like the occluded front is arcing still south of your route, but that would be something to keep an eye on today." The specialist provided a weather advisory for Cook Inlet and Susitna Valley, valid through 0900, for isolated IFR conditions around Cook Inlet.

The AFSS specialist then provided current observations along the intended route and stated, in part: "Palmer just put out a special (observation) ten minutes ago, they're calm, with ceiling 2,300 feet broken, 4,100 feet broken, 5,000 feet overcast; heading into Tahneta Pass, I actually got a Sutton report this morning, calm conditions, with 3,500 feet scattered, ceiling 7,000 feet broken, 9,000 feet overcast; no word from Sheep Mountain and it appears that Eureka automated (observation) is not reporting; nothing from Snowshoe Lake either; from Gulkana, light winds at 4 knots, with ceiling 4,900 feet broken, 6,500 feet overcast, temperature and dew point still 7 degrees (C), altimeter, 29.48 (inHg), remarks indicate intermittent light rain conditions, higher northeast..." The specialist also stated that: "...I don't have any pilot reports anywhere along the route yet this morning."

The specialist then provided forecast en route weather conditions that included isolated IFR conditions around and in the vicinity of the Cook Inlet, valid until 0900; widely scattered rain showers in the Copper River basin with visibilities not expected to be any less than 5 miles. The Tahneta Pass conditions included a forecast of VFR with rain showers. The pilot concluded his briefing at 0655.

At 0748, the pilot contacted the Homer Flight Service Station (FSS) and obtained an airport advisory. The pilot's last radio contact with Homer FSS was at 0754, when his flight plan was activated as he departed.

Between 0930 and 1000, the airplane was observed to fly over a private airstrip located along Highway 1, about 1 mile west of Chickaloon. The airstrip is owned by a personal friend of the pilot.

The airplane did not arrive in Whitehorse, and was reported overdue at 1522. The pilot's son was familiar with the planned route of flight and began an aerial search for the airplane. He located the airplane, still burning, about 2100, at an elevation of approximately 3,700 feet msl, in tundra covered terrain, on the west face of Sheep Mountain.

The accident location is about 4 miles west of Sheep Mountain Lodge which is on Alaska Highway 1. Tahneta Pass, elevation about 3,000 feet msl, is located along the highway about 7 miles north-northeast of Sheep Mountain Lodge, and about 10 miles northeast of the accident site.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with airplane single-engine land and airplane instrument ratings. A review of the pilot's FAA medical records on file in the Airman and Medical Records Center located in Oklahoma City, revealed correspondence from the aerospace medical certification division that contained a 6-year authorization for the special issuance of a medical certificate due to the pilot's history of sleep apnea. The expiration date of the authorization was contingent on FAA medical examinations at the frequency prescribed in the Federal Aviation Regulations (FARs), and submission of a status report from the pilot's treating physician regarding his sleep apnea at 12-month intervals. In addition, the authorization contained instructions to the pilot that permitted an aviation medical examiner to issue a medical certificate that was not valid after (date), if there were no significant adverse changes to his medical condition, and cautioned the pilot that due to his history of sleep apnea and psychiatric difficulties, operation of an aircraft was prohibited at any time new symptoms or adverse changes occur, or any time medication and/or treatment was required.

The pilot applied for a third-class medical certificate from an aviation medical examiner. The pilot's FAA medical file contained correspondence from the aerospace medical certification division that informed the pilot he was eligible for a time-corrected, third-class medical certificate. The letter to the pilot indicated that the certificate superseded any previous issued certificates, and referred the pilot to the special issuance letter.

No personal flight records were located for the pilot. On the pilot's application for medical certificate, the pilot indicated that his total aeronautical experience consisted of about 1,440 hours, of which 50 were accrued in the previous 6 months.

AIRCRAFT INFORMATION

No maintenance records for the airplane were located. The pilot's son reported that records were carried in the airplane. He estimated the airplane had accumulated approximately 425 hours. Review of archived maintenance information from a maintenance facility in Anchorage, Alaska, revealed that the most recent annual inspection showed the airplane had accrued 300.1 hours on the recording tachometer, and 321 hours on the hobbs meter.

METEOROLOGICAL INFORMATION

The FAA provided weather data that was certified as a true copy of the original data used by the flight service station specialist to brief the pilot about the weather conditions along the planned route. The area forecast, issued at 0545 stated, in part: Cook Inlet and Susitna Valley, valid until 1800, clouds and weather, 4,000 feet scattered, 10,000 feet scattered to thin broken, separate layers above, tops at 22,000 feet, occasionally 4,000 feet broken. Widely scattered light rain showers. Until 0900, valley areas and near Cook Inlet, isolated ceilings below 1,000 feet; visibility, below 3 statute miles in mist. Outlook, valid from 1800 to 1200 on September 3, VFR in rain showers... Freezing level, 7,000 feet.

The area forecast for the Copper River basin, stated, in part: Valid until 1800, clouds and weather, 6,000 feet scattered, 11,000 feet broken to thinly scattered, separate layers above, tops at 25,000 feet. Widely scattered broken conditions at 6,000 feet; visibility, 5 statute miles in light rain showers. Outlook, valid from 1800 to 1200 on September 3, VFR in rain showers. Tahneta Pass, VFR in rain showers... Freezing level, 7,000 feet.

An amended terminal forecast for Palmer, issued at 0638 and valid from 0700 to 0400 on September 3, stated: Wind, calm; visibility, greater than 6 statue miles; clouds and sky condition, 2,300 feet scattered, 4,000 feet broken, 5,000 feet overcast. Temporary conditions from 0700 to 1100, 2,300 feet broken. From 1300, winds variable at 6 knots; visibility greater than 6 statute miles with showers in the vicinity, 7,000 feet broken. From 2100, winds variable at 6 knots; visibility greater than 6 statute miles with showers in the vicinity, 5,000 feet overcast.

The local observations included Aviation Routine Weather Reports (METARs) along the planned route, and included a 0553 automated observation from Palmer, that stated: Wind, 350 degrees (true) at 3 knots; visibility, 10 statute miles; clouds and sky condition, 3,000 feet broken, 3,800 feet overcast; temperature 48 degrees F, dew point, 46 degrees F; altimeter, 29.56 inHg. A special automated observation at 0632 at Palmer indicated: Wind, calm; visibility, 10 statute miles; clouds and sky condition, 2,300 feet broken, 4,100 feet broken, 5,000 feet overcast; temperature, 48 degrees F, dew point, 46 degrees F; altimeter, 29.56 inHg.

A METAR at 0555 from Jonesville, Alaska, located about 2.5 nautical miles northwest of Sutton, Alaska, indicated: Wind, calm; visibility, 5 statute miles; clouds and sky condition, 3,500 feet scattered, 7,000 feet broken, 9,000 feet overcast; temperature 46 degrees F, dew point, 45 degrees F; altimeter, 29.51 inHg.

The closest official weather observation station to the accident site is Sheep Mountain Lodge, Alaska, elevation 2,799 feet msl, located 4 nautical miles east of the accident. The observations are conducted at the lodge by a paid weather observer for the National Weather Service.

The first weather observation from the DAWN data at Sheep Mountain was listed as 0859. The DAWN data also contained a pilot report at 0900 from Sheep Mountain that contained the following: Routine pilot report; location, over Chickaloon Pass; type aircraft, Cessna 206; remarks, westbound, unable King Mountain area, clouds to the ground, returning Gulkana, weather conditions of rain.

During the course of the accident investigation, the NTSB IIC conducted a search for weather data on the internet, and obtained a copy of the Sheep Mountain weather observations that began at 0659 with subsequent observations at 0755, 0859, and 1005, and continued until the end of the day.

The first Sheep Mountain METAR observation of the day, obtained from the internet, was made at 0659, and was reported as: Wind, 220 degrees (true) at 4 knots; visibility, 1/2 statute mile in mist; clouds and sky condition, indefinite ceiling with a vertical visibility of 300 feet; temperature, 43 degrees F; dew point, 41 degrees F; altimeter, 29.45 inHg; remarks, estimated, [Tahneta] pass closed.

The next Sheep Mountain METAR, obtained from the internet, was reported as: Wind, 250 degrees (true) at 8 knots; visibility, 1 statute mile in mist; clouds and sky condition, indefinite ceiling with a vertical visibility of 300 feet; temperature, 43 degrees F; dew point, 41 degrees F; altimeter, 29.51 inHg; remarks, estimated, pass closed.

At 0859, the Sheep Mountain METAR, obtained from the internet and from the FAA, was reported as: Wind, 250 degrees (true) at 8 knots; visibility, 1/2 statute mile in mist; clouds and sky condition, indefinite ceiling with a vertical visibility of 300 feet; temperature, 45 degrees F; dew point, 43 degrees F; altimeter, 29.52 inHg; remarks, estimated, pass closed.

At 1005, the Sheep Mountain METAR was reported as: Wind, 220 degrees (true) at 8 knots; visibility, 1 statute mile; clouds and sky condition, indefinite ceiling with a vertical visibility of 300 feet; temperature, 45 degrees F; dew point, 43 degrees F; altimeter, 29.53 inHg; remarks, estimated, pass closed.

At 1408, the Sheep Mountain METAR included the first report of improved visibility of 3 statute miles in mist and the pass was estimated as marginal. These conditions persisted to the end of the day.

COMMUNICATIONS

There were no reports of communications between the pilot and any FAA facility after the pilot departed from Homer. The pilot did not request any weather updates when he departed Homer, and no en route requests for additional weather information were made.

WRECKAGE AND IMPACT INFORMATION

The NTSB IIC examined the airplane wreckage at the accident site after the wreckage was recovered. At the scene of the crash, the airplane was observed along the side of a small gully, with the nose of the airplane oriented on a magnetic heading of 310 degrees. A ground scar in the form of a disruption of the soil, from the first observed point of ground contact to the wreckage point of rest, was about 6 feet long. The airplane was resting upright on the south-facing slope of a tundra covered, easterly-oriented gully. The side of the gully was sloped about 40 degrees.

All of the airplane's major components were found at the main wreckage area. The right wing was positioned upslope and the left wing downslope. The entire cockpit and cabin, the engine compartment, and the majority of the right wing, were consumed by an extensive fire. Burned vegetation around the wreckage was confined to the immediate area of the fuselage and the upsloping side of the gully, along the right wing.

The wings remained in their normal position in relation to the fuselage, but the left wing was displaced slightly forward of its normal orientation. The upper wing attach points were consumed by fire. Each wing was consumed by fire from its inboard attach point to about mid span. The wing lift struts remained attached to their wing attach points, but each lower attach point was fire damaged. The wings and fuselage had extensive upward crushing of the underside of their structure, with almost no leading edge damage to either wing. Each wing flap and aileron remained attached to its respective attach points, but the inboard half of each wing flap was consumed by fire. The flaps appeared to be retracted. The outboard, trailing end of the left wing and left aileron had a slight upward curl. Each wing aileron and flap control cables was attached to its respective attach points.

The empennage aft of the cargo area was not fire damaged. The outboard end of the right horizontal stabilizer had a slight upward bend. The leading edges of the horizontal stabilizers were undamaged. The vertical stabilizer and rudder were undamaged.

The post-crash fire incinerated most of the cabin/cockpit area, with the upper crown and sides of the cabin/cockpit burned to the floor. Due to the post-impact fire damage, the flight controls could not be moved by their respective control mechanisms. The continuity of the flight control cables was established to the cabin/cockpit area.

The main landing gear were folded aft and upward against the bottom of the fuselage. The separated nose gear strut and wheel was located near the left wingtip.

Fire consumed the instrument panel, and extensively damaged the engine area. The lower portion of the engine was embedded in dirt and tundra. The engine sustained impact damage to the underside and front portion of the engine, and fire damage to rest of the engine. Two of the propeller blades were loose in the hub. One propeller blade was bent aft about 90 degrees about mid span, and had extensive chordwise scratching, "S" bending, torsional twisting, leading edge gouging and curling, and destruction of the tip. The second blade was embedded in the tundra on the right side of the engine. It had "S" bending, torsional twisting, and curling and destruction of the tip. The third blade was broken out of the propeller hub, positioned under the engine.

Following recovery, an examination of the engine revealed that the propeller assembly remained connected to the engine crankshaft. The crankshaft could be rotated by the propeller. Gear train continuity was established when the crankshaft was rotated by hand. The exhaust tubes were crushed and folded, producing sharp creases that were not cracked or broken along the crease. The throttle, mixture and propeller control cables were attached to their respective components. The turbocharger compressor vanes could be turned by hand.

The magnetos sustained extensive fire damage. Examination of the top massive center electrode sparks plugs revealed that each was dry and had no evidence of lead deposits.

ADDITIONAL INFORMATION

The FAA utilizes a network of weather observations from a variety of geographical locations, most of which, but not all, are located at airports. Weather observations are conducted by automated sensors both with and without any human augmentation, additions, or remarks, or solely by human observations. These observations are linked to the FAA's DAWN system, and are used by FAA personnel to provide weather briefings to pilots.

The National Weather Service, under the National Oceanic and Atmospheric Administration, also has a network of weather observations. Some, but not all of their observations, are used by the FAA.

According to FAA personnel at the Air Route Traffic Control Center (ARTCC) Anchorage, the paid weather observer at Sheep Mountain provides observations to the FAA by one of two methods. A computer, provided by the FAA, sends the weather data via phone line, to the FAA's Weather Message Switching Center Replacement (WMSCR) hub, located in the Continental U.S. The data, combined with other sources of weather information, is then routed to the FAA's DAWN system. The data is then accessible to the flight service stations. This sequence should take between 3 to 5 minutes.

If the observer does not have a computer, the weather observations should be called via phone line, to the Kenai AFSS. The information would either be left on a recorder, or provided directly to a flight service station specialist.

Neither ARTCC personnel, nor the paid weather observer at Sheep Mountain, could be certain how the weather observations for the accident date were entered into the FAA's DAWN system.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's continued VFR flight into instrument meteorological conditions, and subsequent collision with mountainous terrain while maneuvering. Factors contributing to the accident were weather conditions consisting of clouds/mist and low ceilings, and the pilot's failure to obtain in-flight weather advisories before entering mountainous terrain.
Source: National Transportation Board

Aircraft: CESSNA 207
Where: Aniak, AK
Injuries: 1 Uninjured
Phase of Flight: Forced Landing

About 1330 Alaska standard time, a Cessna 207 airplane sustained substantial damage when it lost engine power and collided with trees during a forced landing, about 16 miles northwest of Aniak, Alaska. The airplane was being operated as a visual flight rules (VFR), cross-country maintenance test flight from St. Mary's, Alaska, to Aniak, when the accident occurred. The commercial certificated pilot, the sole occupant, was not injured. Visual meteorological conditions prevailed, and VFR company flight following procedures were in effect.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the director of operations for the operator reported that the airplane's engine was recently installed by company maintenance personnel after it was overhauled. The engine was overhauled by a maintenance facility in Anchorage, and the pilot was putting flight hours on the engine. The director of operations said the pilot noticed a change in the engine oil pressure, and the engine began to lose power. The pilot made a forced landing in remote terrain. During the emergency landing, the airplane collided with trees and received damage to the right main landing gear, the nose gear, and the fuselage.

In the Pilot/Operator Aircraft Accident Report submitted by the pilot, the pilot reported that during the flight, the engine oil pressure was indicating about 50 psi. He made a slight change in the engine rpm and manifold pressure settings, and the oil pressure rose rapidly to the top of the operating range. The engine cylinder and oil temperature readings did not change. The pilot climbed the airplane to about 2,800 feet msl, and discussed the engine parameters with other company personnel via radio. As the airplane was approaching Aniak, the pilot said the engine lost power. He switched the fuel selector from the left tank to the right tank and activated the engine boost pump. Engine power was not restored, and he switched the selector back to the left tank. The pilot indicated the engine sounded as if it was firing on all cylinders, but only at an idle. The pilot also indicated that, "I do not know whether the left fuel tank was completely exhausted of fuel or not. The engine went from power to idle immediately, without any sputtering or coughing."

A Federal Aviation Administration (FAA) aviation safety inspector from the Anchorage Flight Standards District Office traveled to the accident scene and examined the accident airplane. He reported that the left fuel tank was empty. The right fuel tank contained about 15 gallons of fuel. He found no evidence of fuel leaking, and the engine and propeller controls were properly attached. The inspector started the engine, but due to broken engine mounts, the engine was not operated above an idle, however throttle movement was applied enough to elicit an increase in rpm.

The FAA inspector also reported that the operator sent the engine to a maintenance facility in Anchorage where it was installed and operated on an engine test stand. On April 16, the engine was operated on the stand at full power.

THE CAUSE
The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's improper fuel management, and subsequent fuel starvation during cruise flight. A factor contributing to the accident was unsuitable terrain for a forced landing.
Source: National Transportation Board

Aircraft: Cessna 208B
Where: Toksook Bay, AK
Injuries: None
Phase of Flight: Take off

On February 10, 2004, about 1652 Alaska standard time, a wheel-equipped Cessna 208B departed the runway and nosed over during the takeoff roll at the Toksook Bay Airport, Toksook Bay, Alaska. The airplane was being operated as a visual flight rules (VFR) scheduled passenger flight to Newtok, Alaska, under Title 14, CFR Part 135, when the accident occurred. The commercial certificated pilot, and the 6 passengers, were not injured. Visual meteorological conditions prevailed, and VFR company flight following procedures were in effect.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on February 12, the director of operations for the operator reported that the pilot was departing on runway 34. The runway surface had areas of packed snow and ice, and the director of operations indicated that he had received reports that a right crosswind was blowing from 070 degrees between 15 to 25 knots. According to the director of operations, the pilot said that about 300 feet after beginning the takeoff roll, between 30 to 50 knots airspeed, the airplane began to drift to the left, which he was unable to correct. The airplane departed off the left side of the runway and nosed over. The airplane received damage to the wings, fuselage, and empennage. Runway 34 at Toksook Bay is 3,200 feet long and 60 feet wide.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's inadequate planning and decision to initiate a takeoff into a crosswind that exceeded the airplane's demonstrated crosswind component, which resulted in a loss of directional control during the takeoff roll, and subsequent collision with terrain and nose over. Factors contributing to the accident were the crosswind, an icy runway, and the pilot's failure to abort the takeoff.
Source: National Transportation Board

Aircraft: Cessna 208B
Where: Auburn, AL
Injuries: None
Phase of Flight: Take off

On February 3, 2004, at 1400 central standard time, a Cessna 208B, lost right rudder control shortly after takeoff from the Columbus Metro Airport in Columbus, Georgia. The repositioning flight was operated under the provisions of Title 14 CFR Part 91, and visual flight rules. Visual meteorological conditions prevailed and no flight plan was filed. The pilot and co-pilot were not injured, and the airplane was not damaged. The flight departed the Columbus Metro Airport, in Columbus, Georgia on February 3, 2004 at 1340, enroute to Auburn-Opelika Airport in Auburn, Alabama.

According to the flight crew, during the takeoff roll the co-pilot noticed that the right rudder was not responding. Due to the high traffic volume at Columbus, Georgia they elected to proceed to the Auburn-Opelika Airport in Auburn, Alabama. During the flight they began to diagnose the problem. They found that the rudder trim was not responding and full deflection of the right rudder pedal did not have any effect. Further examination found the right rudder cable broken. The crew contacted their Chief Pilot and Director of Maintenance, and found out that there was nothing that could be done in-flight. The pilot asked that emergency vehicles meet them on runway 36 just as a precaution. The pilot did not declare an emergency. The airplane landed uneventfully on runway 36 and the pilot performed a normal shutdown.

Examination of the rudder cable found it separated at the trailing end of its attaching clevis. The cable and clevice were sent to the NTSB Materials Laboratory in Washington, DC for further examination.

Examination of the rudder cable by the NTSB Materials Laboratory found that the wire rope portion of the cable was fractured just inside the clevis fitting at the forward end of the cable. The strands of the wire rope had separated from each other over a distance of more than 1 foot from the cable end. The individual wires in most of the strands had not separated from each other or were separated over a much shorter distance. Visual examination of the fractured wire ends with the aid of a bench binocular microscope revealed that the wire fractures were aligned with each other within about 0.02 inch, and were located about 0.05 inch inside the end of the clevis fitting. Nearly all of the fractures were on a flat transverse plane, with no apparent necking down deformation, features typical of fatigue cracking. A few of the wires were fractured on a slant plane and did contain necking down deformation, features typical of overstress fracture; and a few of the wires had fractures with a mixture of fatigue and overstress features. Further examination of the clevis fitting revealed that the forward ends of the clevis tines were pinched together. The spacing between the tines was measured with calipers and found to be 0.18 inch near where the tines joined together and 0.13 inch near the tip. Visual examination of the inside surfaces of the tines of the clevis fitting revealed the presence of a dark rust-colored discoloration, typical of fretting or rubbing damage, adjacent to the tip of the tines. The exterior surface of the clevis fitting also contained imprint or rubbing marks from contact with the underside of the attachment bolt head and from the washer under the nut. On both sides of the clevis, the damage was found dominantly on the forward and aft of the attachment bolt hole (and much less on the upper and lower sides of the hole). The damage on this side was much more severe than on the other side.

According to Cessna Aircraft Company, as a result of this failure, Cessna is adding a spacer to the production process that will be placed between the rudder cable clevis and the rod end. This change will also be reflected in the Cessna Illustrated Parts Catalog.
Source: National Transportation Board

Aircraft: Cessna 210
Where: Arizona
Injuries: Two minor
Phase of Flight: Takeoff

A Cessna T210M veered off the runway and overturned during departure from Cliff Dwellers Lodge airstrip near Marble Canyon, Arizona. The private pilot and one passenger sustained minor injuries; the airplane sustained substantial damage. Visual meteorological conditions prevailed, and no flight plan had been filed.

The pilot stated that he landed at Cliff Dwellers Lodge in anticipation of launching on a rafting trip. Lodge personnel informed him that his party would be leaving from nearby Marble Canyon. He did not shut the airplane down and taxied back for takeoff on runway 22. He stated runway 22 was a 40-foot-wide dirt runway that was 3,820 feet long and the airport elevation was 4,217 feet.

He used 20 degrees of flaps and said the wind was calm. He thought the runway was rough and jostled the airplane more than he was used to. The pilot stated the airplane lifted off in ground effect and veered to the left. Then the left wing and landing gear dropped, and the airplane touched down off the runway in soft dirt. The landing gear sheared off, both wings contacted the ground, and the airplane overturned. A witness stated that the pilot departed from midfield and the runway sloped uphill in the direction of departure.

A routine aviation weather report (METAR) for Page, Arizona, 20 miles away on a bearing of 040 degrees, reported that the temperature was about 82 degrees at the time of the accident. The Safety Board investigator computed an approximate density altitude of 6,800 feet. The Pilot's Operating Handbook (POH) states that a minimum ground run takeoff can be accomplished using 20 degrees of flaps and leaving the ground in a slightly tail-low attitude. However, it directs the pilot to immediately level off and accelerate to a safe climb speed.

The National Transportation Safety Board determines the probable cause(s) of this accident/incident as follows: The pilot's failure to use all available runway and his failure to follow the prescribed short field takeoff procedure resulting in a loss of control during the takeoff roll. Factors were the short, rough, and rising runway, and the soft dirt surrounding the runway.
Source: National Transportation Board

Aircraft: Cessna 210L
Where: Great Falls, MT
Injuries: None
Phase of Flight: In Flight

Approximately 1110 mountain standard time, a Cessna 210L impacted trees while the pilot was trying to execute a low-altitude course reversal in mountainous terrain about 40 miles southeast of Great Falls, Montana. The private pilot, who was the sole occupant, was not injured, but the aircraft sustained substantial damage. The 14 CFR Part 91 business flight, which departed Great Falls in visual meteorological conditions about 25 minutes before the accident, entered an area of instrument meteorological conditions while en route to Cheyenne, Wyoming. No flight plan had been filed. The ELT was not set off by the impact, but was later activated by the pilot.

According to the pilot, while heading toward Cheyenne, lowering clouds, snow, and rising terrain made him stray from the route that he had planned. As he tried to maneuver through the mountainous terrain, he was initially able to stay below the clouds and clear of the ground. Eventually, he entered an area where his attempts to maintain clearance from the terrain resulted in the aircraft entering the bottom of the cloud layer. Because he was having trouble maintaining visual contact with the ground through the clouds and snow, he attempted to reverse his course, but clipped a tree during the turn. He immediately rolled the aircraft wings-level, and tried to maintain control as it collided with other trees and fell to the snow covered terrain. After the aircraft came to a stop, and the pilot assured himself there was not going to be a fire, he activated the ELT.

Around 0700 on the morning of the accident, the pilot called Great Falls Automated Flight Service Station for a weather briefing. At that time, he was advised that his planned route of flight was forecast to be VFR at the time he intended to depart. About 90 minutes prior to his departure, the pilot called back for an update briefing. He was then advised that although the route was still forecast to be mostly VFR, there was now an update that showed possible areas of mountain obscuration. At that time, the briefer advised the pilot that VFR flight was not recommended in areas of the forecast mountain obscuration.

The National Transportation Safety Board determines the probable cause(s) of this accident/incident as follows: The pilot's intentional continuation of a visual flight rules (VFR) flight into instrument meteorological conditions (IMC), and his failure to maintain clearance from the terrain. Factors include low ceilings, snow, mountainous/hilly terrain, and trees.
Source: National Transportation Board

Aircraft: Cessna T210L
Where: Auburn, AL
Injuries: 2 Minor, 1 Uninjured.
Phase of Flight: Landing

According to the pilot, while making a localizer approach to runway 36, in IFR conditions, the airplane broke out of the overcast at about 400 feet above ground level. The pilot forced the airplane down and landed about 2,000 feet past the runway's threshold at about 100 to 120 knots indicated airspeed. The pilot stated that he was unable to stop the airplane before it departed the end of the runway and collided with the airport's perimeter fencing. There were no mechanical problems reported by the pilot or discovered during the post-accident examination of the airplane.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's failure to attain the proper touchdown point during landing which resulted in an overrun and subsequent on ground collision with a fence.
Source: National Transportation Board

Aircraft: Cessna 310C
Where: Allentown, PA
Injuries: None
Phase of flight: Landing

The pilot performed one approach to the runway, and then executed a go-around "due to traffic." He raised the landing gear during the go-around and continued in the traffic pattern for another landing. During the second landing attempt, the pilot "neglected to lower the landing gear," and the underside of the airplane contacted the ground. The pilot reported no mechanical deficiencies with the airplane, and an examination of the airplane by a Federal Aviation Administration (FAA) inspector also revealed no deficiencies.

The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot's failure to lower the landing gear during landing.

Source: National Transportation Board

Aircraft: Cessna 320-D
Where:
El Paso, Texas
Injuries:
1 serious
Phase of Flight:
Takeoff

Approximately 1700 Mountain Daylight Time, a Cessna 320-D twin-engine airplane was destroyed when it impacted the airport ramp following a loss of control during takeoff initial climb from runway 26L at the El Paso International Airport (ELP), El Paso, Texas. The private pilot, who was the sole occupant, was seriously injured. Visual meteorological conditions prevailed, and a visual flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight. The cross-country flight was originating at the time of the accident and was destined for Roswell, New Mexico.

During a telephone interview, conducted by the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the pilot stated that he departed Roswell in the morning, and did not recall obtaining a weather briefing prior to the flight. The flight arrived at ELP between 0800 and 0900. The pilot left the airplane with an ELP maintenance facility, and requested they check a manifold pressure (MP) problem on the right engine. The pilot stated the right engine throttle had to be in the full forward position in order to maintain adequate manifold pressure while operating "at altitude."

According to the maintenance work order, the maintenance personnel test-ran the engine in an attempt to duplicate the reported problem and check for other indications. The personnel noted no faulty indications during the engine test run and during a visual inspection. Maintenance personnel pressure tested the turbocharger waste gate for operation and checked the waste gate oil lines for blockage. No anomalies were noted during the checks. Maintenance personnel found an aluminum sense line, which connected the controller and the upper deck air pressure reference, was leaking. The line was removed and replaced due to a "bad flare". Maintenance personnel test ran the engine again, and checked for leaks and operation indications of manifold absolute pressure. No anomalies were noted and all indications were "OK."

Prior to departing ELP, the pilot checked the weather radar, satellite, and text reports "because of high winds at El Paso and Roswell." The pilot stated because he grew up in New Mexico and Texas, he was careful about the potential of weather buildups and abnormally high winds. Personnel notified the pilot that the maintenance on the airplane was completed, and the pilot then "went over the work."

At 1643, the pilot contacted ELP ground control and reported that he was ready to taxi to the runway for departure to Roswell. According to the pilot, air traffic control asked the pilot if he wanted a midfield departure on runway 26L, which is a 9,025 feet long and 150 feet wide asphalt runway, and the pilot accepted the midfield departure clearance. Prior to takeoff, the pilot performed an engine run-up and the run-up was normal. Radar data and communication information provided by the Federal Aviation Administration (FAA) indicated the flight departed from the departure end of runway 26L.

At 1646, the air traffic controller reported the wind at 17 knots and gusting to 30 knots. At 1647, the air traffic controller reported a wind shear alert. At 1653, air traffic control cleared the pilot for takeoff from runway 26L with a left downwind departure. The pilot stated that after takeoff approximately 700-800 feet agl, and during the left turn, "he lost the left engine." The pilot felt the airplane was starting to roll, and the left engine gauges, #1 RPM and MP, "were falling to zero." The pilot retarded the right engine throttle, and "knew he had to land the airplane." He realized he would not be able to land back on runway 26L and attempted to land in a large open area, which contained a long taxiway. The pilot lowered the landing gear, flared the airplane, but did not recall the impact with the hard airport surface. In addition, the pilot estimated approximately 75 gallons of 100 low-lead fuel were on-board at the time of the departure.

A witness, a pilot and a mechanic for the maintenance facility, reported he observed the airplane shortly after it became airborne. The takeoff was normal and the landing gear was retracted. The airplane then made a 90-degree left turn to crosswind approximately 300 to 400 feet agl. The witness observed the left wing lower, and the airplane turned 90 degrees to an approximate heading of 100 degrees. "At that very moment, his left wing [came] down then the right then the left again. The aircraft was sinking at a very high rate." The witness reported the landing gear extended and the airplane disappeared behind some T-hangars.

Another witness, a pilot located on the airport at the time of the accident, stated he noticed an airplane that "seemed like it was in trouble." The witness stated the airplane appeared to have lost airspeed, rolled slightly to the left, and began to porpoise. The airplane then banked to the left, nosed downed, and impacted the taxiway left wing and 45 degrees nose down. The airplane bounced once, slid on the taxiway surface approximately 150 feet and came to rest.

Yet another witness, who was a pilot located on the airport at the time of the accident, stated he "noticed something terribly wrong with an aircraft that had just taken off runway 26." The airplane was departing into the wind, then turned left, pitched down, then leveled, and pitched nose up with tailwind. The witness stated, "the aircraft may have stalled then pitched nose down and then we knew he was coming down."

PILOT INFORMATION

The pilot held a private pilot certificate with airplane multiengine land, airplane single-engine land, and airplane instrument ratings. The pilot was issued a third class medical certificate with a limitation for vision correction. The pilot's most recent biennial flight review was completed on July 10, 2001, in the accident airplane. According to the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2), the pilot had accumulated 1,104 total flight hours, 950 multi-engine flight hours, and 909 flight hours in the accident airplane make and model.

AIRCRAFT INFORMATION

A review of the maintenance records revealed the airframe underwent its an annual inspection with a total time in service of 3,703.1 hours. The left engine, a Teledyne Continental Motors TSIO-520-BB, serial number 287587-R, underwent a 100-hour inspection with a total time of 669.3 hours since the engine was rebuilt and zero timed. The right engine, a Teledyne Continental Motors TSIO-520-BB, serial number 287663-R, was rebuilt and zero timed of installation. At the time of the accident, the airplane had accumulated approximately 70 hours since the last 100-hour inspection.

According to the most recent weight and balance computations for the airplane, the maximum gross weight was 5,520 pounds, the empty weight was 3,629.60 pounds, and the useful load was 1,890.40 pounds.

An Aeronautical Testing Service, Inc. 320D vortex generator kit was installed on the airplane as authorized by the Supplemental Type Certificate (STC) SA5757NM. The STC modification consisted of ninety vortex generators mounted on the wings and vertical fin and four metal strakes, one mounted on the inboard and outboard sides of the engine nacelle. As part of the STC, a flight manual supplement was placed in the existing Cessna 320D Owner's Manual.

A review of the flight manual supplement disclosed that the single engine climb performance at a gross weight of 5,474 pounds, at 5,000 feet msl, and a temperature of 41 degrees Fahrenheit, was 305 feet per minute. At a gross weight of 4,400 pounds, the single engine climb performance was 630 feet per minute. The single-engine climb performance at a gross weight of 5,474 pounds, at 10,000 feet msl, and a temperature of 23 degrees Fahrenheit, was 230 feet per minute. At a gross weight of 4,400 pounds, the single-engine climb performance was 540 feet per minute. The calculations were based on the following conditions: flaps and gear up, inoperative propeller - feathered, wing bank 5 degrees toward operating engine, full throttle, 2,600 RPM and mixture at recommended fuel flow. The rate of climb is to be decreased at 25 feet per minute for each 10 degrees Fahrenheit above standard temperature for a particular altitude.

METEOROLOGICAL INFORMATION

At 1551, the ELP weather observation facility reported the wind from 230 degrees at 21 knots, with gusts to 28 knots, sky clear, temperature 93 degrees Fahrenheit, dew point 34 degrees Fahrenheit, and an altimeter setting of 29.78 inches of mercury. The calculated density altitude was 7,272 feet msl. A peak wind from 240 degrees at 39 knots was recorded at 1505.

At 1651, the ELP weather observation facility reported the wind from 260 degrees at 22 knots, with gusts to 35 knots, sky clear, temperature 91 degrees Fahrenheit, dew point 34 degrees Fahrenheit, and an altimeter setting of 29.77 inches of mercury. The calculated density altitude was 7,163 feet msl. A peak wind from 240 degrees at 40 knots was recorded at 1624.

At 1658, the ELP weather observation facility reported the wind from 280 degrees at 22 knots, with gusts to 44 knots, sky clear, temperature 91 degrees Fahrenheit, dew point 34 degrees Fahrenheit, and an altimeter setting of 29.78 inches of mercury. The calculated density altitude was 7,153 feet msl. A peak wind from 240 degrees at 44 knots was recorded at 1655.

WRECKAGE AND IMPACT INFORMATION

Two FAA inspectors, and a representative from the airframe manufacturer examined the airplane at the accident site. An FAA inspector, a representative from the airframe manufacturer, and a representative from the engine manufacturer examined the airplane in a hangar located at ELP. According to the airframe representative, flight control continuity was established from all flight control surfaces to their respective cockpit controls. The left and right cockpit throttle controls were found in the retarded position, the mixture and propeller controls were found in the full forward position.

The right propeller assembly was separated from the propeller flange, and the right engine's propeller flange was partially separated from the crankshaft. The propeller hub was fractured into several pieces, and one blade remained partially attached to the hub. The blades displayed chordwise scratching, bending, and leading edge gouging. The left propeller assembly remained attached to the engine crankshaft, and two blades were separated from the propeller hub. The blade that remained attached to the hub displayed chordwise scratching and the blade tip was curled. One blade displayed leading edge gouging, chordwise scratching, and was twisted aft. The other blade was bent aft and displayed heavy gouging and scratching on the chamber side of the blade. The FAA inspectors reported there was a minimal amount of baggage/cargo on board at the time of the accident.

According to the engine representative, the left engine displayed damage to the left front. The #6 cylinder head and propeller governor were partially separated. All four of the engine mounts were separated. The right engine was intact and the accessories remained attached to their respective mounting structure. All four of the engine mounts were separated. The engines were removed and shipped to Teledyne Continental Motors for further examination by the NTSB.

TEST AND RESEARCH

The left and right engines were examined at the facilities of Teledyne Continental Motors, near Mobile, Alabama, under the supervision of the NTSB IIC. The inspection and disassembly of the left and right engines and accessories did not reveal any discrepancies that would have precluded operation of the engines prior to the accident. The fuel system components, with the exception of the right engine fuel metering unit, were bench flow tested with no anomalies noted. The right engine fuel metering unit was not bench flow tested due to a separated link rod. The reason for the reported loss of engine power was not determined.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The loss of engine power for undetermined reasons and the pilot's failure to maintain aircraft control.
Source: National Transportation Board

Aircraft: Cessna 414A
Where: Laupahoehoe, HI
Injuries: 3 Fatal
Phase of flight: Cruise and maneuvering

The airplane collided with trees and mountainous terrain at the 3,600-foot-level of Mauna Kea Volcano during an en route cruise descent toward the destination airport that was 21 miles east of the accident site. The flight departed Honolulu VFR at 0032 to pickup a patient in Hilo, on the Island of Hawaii. The inter island cruising altitude was 9,500 feet and the flight was obtaining VFR flight advisories.

At 0113, just before the flight crossed the northwestern coast of Hawaii, the controller provided the pilot with the current Hilo weather, which was reporting a visibility of 1 3/4 miles in heavy rain and mist with ceiling 1,700 feet broken, 2,300 overcast. Recorded radar data showed that the flight crossed the coast of Hawaii at 0122, descending through 7,400 feet tracking southeast bound toward the northern slopes of Mauna Kea and Hilo beyond. The last recorded position of the aircraft was about 26 miles northwest of the accident site at a mode C reported altitude of 6,400 feet. At 0130, the controller informed the pilot that radar contact was lost and also said that at the airplane's altitude, radar coverage would not be available inbound to Hilo. The controller terminated radar services.

A witness who lived in the immediate area of the accident site reported that around 0130 he heard a low-flying airplane coming from the north. He walked outside his residence and observed an airplane fly over about 500 feet above ground level (agl) traveling in the direction of the accident site about 3 miles east. The witness said that light rain was falling and he could see a half moon, which he thought provided fair illumination.

The area forecast in effect at the time of the flight's departure called for broken to overcast layers from 1,000 to 2,000 feet, with merging layers to 30,000 feet and isolated cumulonimbus clouds with tops to 40,000 feet. It also indicated that the visibility could temporarily go below 3 statute miles.

The debris path extended about 500 feet along a magnetic bearing of 100 degrees with debris scattered both on the ground and in tree branches. Investigators found no anomalies with the airplane or engines that would have precluded normal operation.

Pilots for the operator typically departed under VFR, even in night conditions or with expectations of encountering adverse weather, to preclude ground-holding delays. The pilots would then pickup their instrument flight rules (IFR) clearance en route. The forecast and actual weather conditions at Hilo were below the minimums specified in the company Operations Manual for VFR operations.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's disregard for an in-flight weather advisory, his likely encounter with marginal VFR or IMC weather conditions, his decision to continue flight into those conditions, and failure to maintain an adequate terrain clearance altitude resulting in an in-flight collision with trees and mountainous terrain. A contributing factor was the pilot's failure to adhere to the VFR weather minimum procedures in the company's Operations Manual.
Source: National Transportation Board

Aircraft: Cessna 421
Where: Pocatello, ID
Injuries: None
Phase of Flight: Climb

At approximately 1350 mountain standard time, a Cessna 421 experienced the in-flight separation of the inboard half of the right elevator while en route from Idaho Falls, Idaho, to American Falls, Idaho. The commercial pilot, who was the sole occupant, was not injured. The 14 CFR Part 91 aircraft repositioning ferry flight, which had been airborne for about 10 minutes, was being operated in visual meteorological conditions. No flight plan had been filed.

According to the pilot, while he was climbing through 9,400 feet for 10,500 feet, he heard a very large thud that he could feel through the control yoke. The event moved the control yoke back and forth, and although the pilot was not sure what had happened, he later said that it felt as if something had "...struck the elevator very hard." At that point, the pilot reduced power and headed toward the Blackfoot Airport. Although there initially seemed to be no significant aerodynamic effect, after about 60 seconds a very strong shudder/vibration began to occur, and the aircraft began a dive to the left. The pilot then reduced power further to maintain control. He then looked over his right shoulder, and was able to see the right stabilizer/elevator "fluttering violently." He then further reduced the power on the right engine, and added power to the left engine, which effectively crabbed the aircraft to the right and reduced the airflow over the right stabilizer/elevator. After taking the aforementioned remedial action, the aircraft stopped shaking/vibrating, and the pilot turned toward Pocatello Regional Airport in order to make use of its longer/wider runway. The pilot was eventually able to execute an emergency landing at Pocatello. After exiting the aircraft, the pilot discovered that the inboard one-half of the right elevator had departed the airframe while in flight.

A post-accident inspection by an FAA Airworthiness Inspector found that the bolt that connects the elevator trim tab actuator rod to the elevator trim tab horn was missing, and neither the actuator rod end nor the tab horn had failed. There was no evidence of a bird impact, and the pilot had not seen a bird at the time the event was initiated. In both his written statement, and during a post-accident telephone interview, the pilot stated that he had manually adjusted the elevator trim a number of times prior to the initiation of the sequence of events, and that not only did the system work correctly, but that he had felt no looseness, roughness, or vibration in the system. He further stated that because this was an FAA -approved ferry flight, he had performed an extensive preflight prior to departure, to include the flight controls and their actuation systems. He said that during this inspection he confirmed that there were no nuts or bolts missing from the flight control actuation system.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The separation of the bolt that attaches the elevator trim tab actuator rod to the elevator trim tab horn, resulting in violent flutter of the elevator, and eventually to the separation of the inboard half of the right elevator.
Source: National Transportation Board

Aircraft: Cessna 421B
Where: Telluride, CO
Injuries: 1 Fatal
Phase of Flight: En route

Approximately 0950 mountain standard time, a Cessna 421B was destroyed following impact with terrain near Telluride, Colorado. The non-instrument rated private pilot, the sole occupant in the airplane, was fatally injured. Instrument meteorological conditions prevailed for the cross-country personal flight that originated from Montrose, Colorado, approximately 35 minutes before the accident. The pilot had not filed a flight plan; family members said the pilot was en route to Las Cruces, New Mexico. The family reported the pilot missing and a search was commenced. Search and rescue team members located the airplane. There were approximately 18 to 24 inches of snow on the ground at the accident site.

Federal Aviation Administration (FAA) radar documented the airplane's departure from Montrose at approximately 0915, the airplane began a 1,792 feet per minute (fpm) rate of climb from 14,300 feet msl to 16,600 feet msl. The radar shows that 19 seconds later, the airplane lost 4,000 feet of altitude, or 12,631 fpm rate of descent. The airplane then climbed back to 13,300 feet msl at a rate of 1,448 fpm. One more primary radar return was recorded at 0948:34 (no altitude was documented), and then the airplane disappeared from radar.

PERSONNEL INFORMATION
The pilot's old flight logbook (his current logbook was never found) indicated that he received his private pilot license in 1970. The pilot purchased the aircraft in November of 1998, and he attended a Cessna 421B ground and flight training school, Double Eagle Aviation, Tucson, Arizona, in January of 1999. On his application for the school, he reported that he had 1,500 hours of single-engine flight time, and 1,500 hours of multiengine flight time. Instructors at the school reported that the pilot had good natural flying skills and was a quick learner. They did report that he was 'somewhat weak with instrument reference.'

The pilot reported on an insurance application that he had 3,700 hours of flight experience, and 200 hours of flight experience in the accident aircraft. The pilot did not have an instrument rating.

AIRCRAFT INFORMATION
The airplane was a twin engine, propeller-driven, pressurized aircraft, which was manufactured in 1974 by Cessna Aircraft Company. It could seat eight people. The airplane was powered by two Teledyne Continental GTSIO-520-H turbocharged, six cylinder, reciprocating, horizontally opposed, fuel injected engines, which had a maximum takeoff rating of 375 horsepower at sea level. At the time of the accident, the aircraft maintenance records and hour meter suggest that the airframe had accumulated approximately 3,154 hours.

Fuel purchase records from Montrose Regional Airport indicate that the aircraft received 108 gallons of 100LL aviation fuel.

METEOROLOGICAL CONDITIONS
At 0953, weather conditions at the Cortez Municipal Airport, Cortez, Colorado (elevation 5,914 feet), 22 nautical miles (nm) from the accident site, were as follows: wind 240 degrees at 5 knots; visibility 5 statute miles (sm) with snow showers; cloud condition broken 2,400 feet, overcast 3,200 feet; temperature 28 degrees Fahrenheit; dew point 28 degrees Fahrenheit; altimeter setting 29.84 inches of mercury.

At 0953, the weather conditions at the Animas Air Park, Durango, Colorado (elevation 6,684 feet), 45 nm from the accident site, were as follows: wind 110 degrees at 4 knots; visibility 1 sm with snow showers; cloud condition broken 800 feet, overcast 1,800 feet; temperature 25 degrees Fahrenheit; dew point 25 degrees Fahrenheit; altimeter setting 29.84 inches of mercury.

Snowmobilers, who were in the vicinity of the impact site, said snow showers made visibility less then 1/2 sm at approximately 0950. Telluride Regional Airport (elevation 9,078 feet), 045 degrees at 33 nm, reported having 6 to 8 inches of snow throughout the day. A pilot departing Telluride Regional Airport, on a heading of 300 degrees, at approximately 1015, said that it was clear right over Telluride. He said that as he climbed out he got into weather at 12,000 feet mean sea level (msl), and didn't break out until 22,000 feet msl. He also said that he experienced no icing or turbulence during his climb out.

WRECKAGE AND IMPACT INFORMATION
The airplane crashed in rolling mountainous terrain (elevation 8,250 feet) partially covered with 5 to 20 foot tall trees. Missing branches from the trees on a ridge line (elevation 8,500 feet) overlooking the first impact point suggest that the airplane was approximately 30 degrees nose low and in a 25 degrees right bank. The missing branches on the northwest side of the ridgeline were longitudinally oriented 320 degrees.

Descending the ridgeline towards a small valley below was a scattered debris path comprised of components of the right outboard wing: the right wing auxiliary (inboard) fuel tank, a 4 foot wing spar section, the right wing aileron, and the right wing tip main fuel tank. As the debris path crossed the 300-foot wide meadow, its ground track changed to 334 degrees. At this point, the terrain began to rise, and two 4x10 foot craters were located (860 feet from the debris field start point). Each crater contained propeller blades (five of the six blades were found, the sixth was found after the snow melted in the spring). Several small red plastic lens fragments were found approximately 10 to 14 feet to the right of the right hand crater. The left engine was found on the right side of the debris path, at the 990-foot point, and the right engine was found on the left side of the debris path, at the 1,150 foot point. Physical evidence at the accident site suggested that the airplane impacted the terrain, at the 860-foot point, inverted.

The fuselage and empennage were found 1,550 feet from the debris path start point. The last piece of wreckage, a wheel, was found 1,600 feet from the debris path start point.

All the major components of the airplane were accounted for at the accident site. The flight control surfaces were all identified, but control cable continuity could not be established due to impact damage. Both engines were severely impact damaged; neither crankshaft could be rotated. There was no evidence of pre- or post-impact fire. No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified.

MEDICAL AND PATHOLOGICAL INFORMATION
The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report, carbon monoxide and cyanide tests were not performed. No volatiles or drugs were detected in the muscle samples.

The National Transportation Safety Board determines the probable cause(s) of this accident/incident as follows: The non-instrument rated pilot's intentional flight into IMC, and his subsequent spatial disorientation that resulted in an inadvertent stall. A factor was the snow showers weather condition.
Source: National Transportation Board

Aircraft: Cessna 421C
Where:
Titusville, FL
Injuries:
3 Fatal
Phase of Flight:
Takeoff

About 1445 eastern standard time, a Cessna 421C crashed shortly after takeoff from the Space Center Executive Airport, Titusville, Florida, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The airplane was destroyed and the airline transport-rated pilot, commercial pilot-rated left front seat passenger, and one rear seat passenger were fatally injured. The flight originated about 5 minutes earlier.

One day before the accident flight, the airplane had been flown for about 1 hour and the pilot of the previous flight stated that there were no engine related discrepancies. He also stated that the fuel quantity total on landing was about 100 gallons. Before departure, based on a request from the pilot-in-command, 20 gallons and 10 gallons of fuel were added to the left and right main fuel tanks respectively. After the fueling the pilot-in-command was observed by the line service individual to check only the right main fuel tank for contaminants. The line service individual became involved in other duties and did not witness any more of the preflight of the airplane. He further stated that he heard both engines start and when the airplane was taxied past his position, both engines sounded normal. He did not witness the ground roll to takeoff but observed the airplane when it was about 200 feet above ground level in a shallow climb. During the climb the engines sounded normal and he then diverted his attention and did not witness the crash.

Several other witnesses reported seeing white smoke trailing the left engine and observed the airplane flying northbound. The airplane was then reported to bank to the left in about a 90 degree angle of bank. The airplane then pitched nose down, descended nose and left wing low, collided with trees then the ground and was mainly destroyed by post-crash fire.

Two-way radio communication was established before takeoff with air traffic control tower personnel.

WRECKAGE AND IMPACT INFORMATION

Examination of the wreckage at the accident site revealed that the airplane collided with trees then the ground while in a 60-degree nose-low attitude. The airplane was mainly destroyed by post-crash fire; however, examination revealed no evidence of an in-flight fire. All components necessary to sustain flight were attached to the airframe. Examination of the aileron, elevator, and rudder flight controls revealed no evidence of pre-impact failure or malfunction. The landing gear and flaps were determined to be retracted. Examination of the fuel selectors revealed that they were in the "off" position. The auxiliary fuel pump switches were determined to be in the low position as required by a placard for takeoff and landing. Additionally, all magneto switches were in the "off" position. The engines were removed for further examination.

Examination of the left engine revealed crankshaft, camshaft, and valve train continuity. Thumb compression was obtained for cylinder Nos. 1, 2, 3, and 5. A damaged exhaust valve pushrod for the No. 4 cylinder and contaminants between the No. 6 cylinder valves and valve seats prevented thumb compression on these two cylinders. No other mechanical failure or malfunction was noted to these two cylinders. The magnetos were found to be separated from the engine assembly; therefore, magneto to engine timing could not be determined. The magnetos were rotated by hand which revealed spark at all ignition towers. The engine-driven fuel pump driveshaft coupling was not failed. All fuel injector nozzles were removed and visual examination revealed no evidence of blockage. Examination of the throttle and fuel control unit revealed that the throttle body housing assembly was destroyed by the post-crash fire. The throttle position could not be determined however the mixture control was determined to be in the "idle-cutoff" position. Examination of the turbocharger components revealed that the variable absolute pressure controller assembly was destroyed by the fire. Examination of the wastegate revealed that it was slightly less than fully open. The turbocharger components were removed from the engine and sent to the manufacturer's facility for further examination. Examination of the returned components revealed that the Separator-Turbo, Oil Cessna Part Number 5155163-1 experienced fatigue failure of a section of pipe near a flange which is connected to the turbocharger oil outlet. Heat damage to all other components precluded testing. Examination of the remaining components revealed no evidence of pre-impact failure or malfunction. The propeller was removed for further examination which revealed no evidence of pre-impact failure or malfunction. Examination of impact signatures suggest that each propeller blade was at or near the low pitch setting at impact.

Examination of the right engine revealed crankshaft, camshaft, and valve train continuity. Differential compression of all cylinders revealed readings higher than 52/80. Both magnetos were found separated from the engine assembly; therefore, magneto to engine timing could not be determined. The magnetos were rotated by hand which revealed spark at all ignition towers. Examination of the engine-driven fuel pump drive shaft coupling revealed that it was not failed. All fuel injector nozzles were visually examined and found to be free of obstructions. Examination of the fuel control and throttle body unit revealed that the throttle was at the "idle" position and the mixture control was near the "full rich position." The turbocharger components were removed and sent to the manufacturer's facility for further examination. Examination of all turbocharger components revealed that heat damage precluded testing. The wastegate was in the fully open position. According to the manufacturer, inspection of the turbocharger components revealed no evidence of pre-impact failure or malfunction. The propeller was removed for further examination which revealed no evidence of pre-impact failure or malfunction. Examination of impact signatures suggest that each propeller blade was at or near the low pitch setting at impact.

MEDICAL AND PATHOLOGICAL

Postmortem examinations were conducted on the pilot, pilot- rated passenger and passenger. The cause of death for all three occupants was listed as multiple blunt force injuries.

Toxicological testing was performed on specimens of the first pilot. The results of the AFIP analysis were negative for cyanide, volatiles, and tested drugs. The results were positive for carbon monoxide, 6 percent saturation. The results of the HRMC analysis were negative for volatiles and tested drugs. The results were positive for carbon monoxide, .3 percent.

Toxicological testing was also performed on specimens of the pilot-rated pilot seated in the left seat. The results of the AFIP analysis were negative for volatiles, and tested drugs. Carbon monoxide was determined to be less than 1 percent. The results of the HRMC analysis were negative for volatiles, and tested drugs. Carbon monoxide analysis was not performed.

FIRE

Examination of the airplane revealed no evidence of in-flight fire.

TESTS AND RESEARCH

Metallurgical examination of turbocharger components was performed by the manufacturer's facility. Additionally, the NTSB Metallurgy Laboratory reviewed the manufacturer's report.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: Failure of the pilot-in-command to maintain VMC, resulting in the in-flight loss of control. Contributing to the accident was the fatigue failure of a section of pipe adjacent to a flange which connects to the turbocharger oil outlet of the left engine assembly.
Source: National Transportation Board

Aircraft: Cessna 421
Where: Tulsa, OK
Injuries: 3 fatal
Phase of flight: Landing

A Cessna model 421/ impacted trees and terrain following a dual loss of engine power during a visual approach to the Tulsa International Airport (TUL), Tulsa, Oklahoma. The private pilot and two pilot rated passengers were fatally injured. The airplane was owned and operated by the pilot. The cross-country flight originated at the Oakland County International Airport (PTK), Pontiac, Michigan, and the intended destination was the Richard Lloyd Jones Jr. Airport (RVS), Tulsa, Oklahoma. The airplane had requested to land at TUL prior to the accident. Visual meteorological conditions prevailed at the time of the accident.

The pilot and both passengers departed RVS for PTK about 0919 and arrived at PTK about 1251 for a business meeting. The airplane flew at 13,500 feet mean sea level (msl), resulting in a three hour and thirty-two minute flight. Prior to departing PTK the pilot requested the fixed base operator to “top it off, but nothing in the nacelles,” and the plane was subsequently serviced with 156 gallons of 100 octane low lead (100LL) aviation fuel. A line serviceman for the fixed base operator providing the fuel observed the pilot performing a preflight inspection prior to departing PTK. During the preflight the lineman observed the right main tank sump become stuck open. He estimated that five to six gallons of fuel was lost before the sump seal was regained, but the exact amount of fuel lost could not be determined. The pilot was heard to say “Great, that’s the side that burns more fuel.” The fuel lost as a result of the fuel spill was not replaced. The airplane departed PTK for RVS about 1803 and flew the return flight at 4,500 feet msl.

At 2147:53 the pilot checked in with Tulsa Approach Control and was cleared direct RVS. At 2157:50 the pilot stated he’d like to land at TUL and was given direction to enter a left base to Runway 18 Right (18R). At 2201:44 the pilot was told to switch to the local tower control frequency, which he did at 2201:47. The pilot was given clearance to land at 2201:56. At 2204:23 the pilot stated “Tulsa, we’ve exhausted our fuel.” The airplane was observed descending into a forested area, followed by a flash. The pilot did not inform either of the approach or tower controllers he had a fuel problem at any time prior to reporting the fuel exhaustion.

The pilot, age 51, held a private pilot certificate with ratings of airplane single-engine land, and airplane multi-engine land. His logbook indicated he had accumulated about 592 total flight hours, and about 67 hours in the accident airplane at the time of the accident. The front-seat passenger, age 43, held a private pilot certificate with a rating of airplane single engine land. His last FAA third-class medical certificate was issued on November 21, 2001, with no limitations.

The airplane was a twin engine, low wing aircraft. It was powered by two Continental GTSIO-520-D engines driving McCauley three-blade propellers. The last regularly occurring airframe inspection was an annual type on at a Hobbs time of 576.3 hours. An annual type inspection was also performed on each engine.

The airplane was configured with an eight tank fuel system. It included left and right main tanks (50 gallons usable fuel each wing), left and right auxiliary fuel tanks (35 gallons usable fuel each wing), optional auxiliary fuel tanks (13 gallons usable fuel each wing), and optional wing locker tanks (26 gallons usable fuel each wing). The left wing locker tank was placarded “INOP”, and the right wing locker tank was not used. This provided for a capacity of 196 gallons of usable fuel for the accident flight.

Weather at TUL at 2153 was reported as 10 miles visibility, skies clear, and temperature 75 degrees Fahrenheit. Winds were calm.

The airplane impacted trees and terrain about ½ mile north of TUL on the extended centerline of Runway 18R in Mohawk Park, property operated by the city of Tulsa, Oklahoma. The aircraft struck 50 to 60 foot tall trees on an approximate 180 degree magnetic heading. The debris field was approximately 200 feet long and 75 feet wide. The right main fuel tank was impact damaged, separated from the wing, and found near the base of the first tree strike. The fuselage came to rest inverted 200’ to the south of the first tree strike.

The right locker fuel tank was breached at the impact site and did not contain fuel. The left locker tank was placarded as “INOP” and not fueled for the flight. It was not breached and did not contain fuel. The main tanks were fragmented and separated from the wings due to tree impact. The outboard 13 gallon bladder style auxiliary tanks were breached by tree impact. No fuel contamination signatures were observed in the trees or ground vegetation in the wreckage path or debris field. The left outboard auxiliary tank did not contain fuel; and the right outboard auxiliary tank burned. The left inboard 35 gallon auxiliary tank was intact and did not contain fuel. The right inboard 35 gallon auxiliary tank was burned. It could not be determined if had been breached before the post-impact fire destroyed it.

One fuel flow indicator was sent to the NTSB vehicles recorder laboratory to attempt to recover flight data from the accident flight. The Digiflo-L™ contains non-volatile memory that retains setup information, fuel remaining and fuel used information, if power is removed from the unit. Data was recovered from the unit that indicated for the accident flight the Full Fuel setting was 196 gallons, Fuel Used was 170.8 gallons, and fuel remaining (based on the manually set Full Fuel setting) was 25.1 gallons.

The Office of the Chief Medical Investigator, Board of Medicolegal Investigations, located in Oklahoma City, Oklahoma, performed an autopsy on the pilot on July 11, 2010. The cause of death was attributed to internal injuries due to blunt force trauma.

The Office of the Chief Medical Investigator, Board of Medicolegal Investigations, located in Oklahoma City, Oklahoma, performed an autopsy on the pilot-rated passenger on July 12, 2010. The cause of death was attributed to internal injuries due to blunt force trauma.

The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot’s inadequate preflight fuel planning and management in-flight, which resulted in total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot’s use of performance-impairing medications.

Source: National Transportation Board

Aircraft: Cessna 421C
Where: Carson, WA
Injuries: 1 Fatal
Phase of Flight: En Route

At 1344 Pacific Standard Time, a Cessna 421C operated by the pilot as a 14 CFR Part 91 personal flight, was reported missing when radar contact and communications were lost over mountainous terrain about 15 nautical miles northeast of Carson, Washington. Visual and isolated instrument meteorological conditions prevailed in the area where the aircraft dropped from radar contact. A search was initiated, however, due to adverse weather conditions and rugged terrain, the wreckage was not located and the search was suspended. The pilot was presumed fatally injured. No flight plan had been filed; however, the pilot was utilizing flight following services. The flight departed from Scottsdale, Arizona, approximately 1030 Mountain Standard Time, with a final destination to Tacoma, Washington. No emergency locator transmitter signal was detected.

Six months later, the wreckage was located by two U.S. Forest Service personnel in an area of mountainous terrain about one-half mile south of the last radar target at North 45 degrees 52.154 minutes latitude and West 122 degrees 2.465 minutes longitude. Impact damage and a post-crash fire destroyed the aircraft. The pilot was fatally injured.

PERSONNEL INFORMATION

Federal Aviation Administration airmen records indicated that the pilot was issued a private pilot certificate for airplane single engine land. At this time, the pilot indicated a total flight time of 134 hours, with 12.5 hours as pilot-in-command.

The pilot was issued the airplane multi-engine land rating for private pilot privileges. At this time, the pilot indicated a total flight time of 350 hours, with 130 hours as pilot-in-command. The rating was attained in a Cessna 310, with a reported 12 hours total time in this aircraft.

At the time of the accident, the pilot held a second-class medical certificate. No waivers or limitations were identified.

The flight instructor/Designated Examiner, who signed the pilot off for the private pilot certificate in both the single and multi-engine aircraft, stated that the pilot had been working on his instrument rating since October 2005. He believed that the pilot had accumulated about 200 hours in the Cessna 421. The day before the accident, he spoke with the pilot. The pilot reported that he just accumulated 400 hours total flight time. The Examiner stated that he had flown with the pilot on several occasions, and that he had flown in the Cessna 421C with the pilot from Scottsdale to Tacoma on one of those flights.

The pilot's flight logbook was not located.

AIRCRAFT INFORMATION

Aircraft records indicated that the aircraft was manufactured in 1977. The aircraft held a standard class, normal category airworthiness certificate. The aircraft was equipped with two Teledyne Continental Motors GTSIO-520-L engines. The aircraft was also equipped with a deice boot system attached to the leading edges of the wings and stabilizers.

Maintenance records indicated that the aircraft was signed off for the completion of the Cessna Progressive Operation #4 Inspection. At the time of the inspection the aircraft had accumulated a total airframe time of 5,206 hours.

The last entry in the maintenance logbook was for the completion of a visual inspection of the exhaust system in compliance with AD 00-01-16. At this time the airframe total time was listed as 5,358.8 hours.

The engine logbooks indicated that the left engine, model GTSIO-520-L3B, s/n: 292435-R, was rebuilt/zero timed, by Teledyne Continental Motors, and installed. The last entry in the logbook indicated that the engine total time since major overhaul was 1,541.8 hours. During this maintenance visit, the oil and filter were changed and the engine was serviced with 12 quarts of oil. The engine was run and a leak check was accomplished.

The right engine, model GTSIO-520-L, s/n: R-245870.R, was overhauled by RAM Aircraft and installed. The last entry in the logbook indicated that the engine total time was 7,907.2 hours, with 1,207.7 hours since major overhaul.

Prior to departing from Scottsdale, the aircraft was fueled. The fueler stated that he was familiar with this aircraft and had seen this pilot before, however, he stated that this was the first time that the pilot was not with another person. The fueler stated that he topped off both wing main tanks and finished with the left side wing locker tank. A total of 152.2 gallons of 100LL fuel was added. During the brief conversation the fueler had with the pilot, he did not notice anything out of the ordinary with the pilot's behavior. The fueler stated that the pilot did a pre-flight check of the aircraft. Once the fueling was complete, the fueler stated that the engines were started and the pilot taxied the aircraft out to the runway and took off. The fueler did not provide any other services to the aircraft and noted nothing out of the ordinary with the operation of the aircraft or engines.

METEOROLOGICAL INFORMATION

Weather information provided by the Federal Aviation Administration indicated that the weather in the area about 35 miles south of the accident site reported moderate to occasional severe rime/mixed icing conditions in precipitation between 8,000 feet to 12,000 feet. The area of icing covered from 55 miles east of Seattle International Airport (SEA), to 70 miles south, to 40 miles west and was valid from 1324 to 1430 local time. Tacoma Narrows Airport was within this area of coverage to the southwest (15 nautical miles) of SEA.

Flight crews from commercial aircraft in the area issued pilot reports (PIREPs) to air traffic control. At 1228 local time a DeHavilland Dash-8 flight crew reported their location of 360 degrees from Battle Ground VOR at 40 miles, the flight encountered severe mixed icing from 13,000 feet descending to 11,000 feet. At 1246, another commercial flight crew reported at 340 degrees from Battle Ground VOR at 10 miles, the flight encountered moderate mixed icing climbing from 10,000 feet to 13,000 feet.

The Portland International Airport (PDX) aviation routine weather report (METAR) reported at 1255, a temperature of 07 degrees C., dew point of 06 degrees C., and wind from 170 degrees at 6 knots. The visibility was 5 statute miles, with an altimeter setting of 29.91" Hg. The clouds were broken at 600 feet and 2,500 feet, and overcast at 4,000 feet, with light rain and mist.

At 1343 a Special METAR for PDX indicated a temperature of 07 degrees C., a dew point of 06 degrees C., and wind from 170 degrees at 7 knots. The visibility was 6 statute miles, with an altimeter setting of 29.92" Hg. The clouds were scattered at 600 feet, broken at 2,900 feet and overcast at 3,700 feet, with light rain and mist.

AIRMETs Tango and Zulu were effective from 1245 to 1900 local for turbulence and icing conditions for Washington, Oregon, California and coastal waters. AIRMET Zulu reported occasional moderate rime/mixed icing conditions in precipitation between the freezing level and 14,000 feet. The freezing level was from 4,000 feet to 5,000 feet. AIRMET Tango reported occasional moderate turbulence below 12,000 feet due to strong low-level winds.

COMMUNICATIONS

At 1304, while in flight, the pilot contacted McMinnville Automated Flight Service Station (AFSS) and reported that he was 45 miles southwest of Redmond, Oregon, at 16,500 feet with a final destination to Tacoma, Washington, and requested weather along his route of flight.

The specialist reported that AIRMETS were in effect along the route for terrain obscurement in clouds, precipitation, fog or mist. Occasional moderate turbulence was reported below 12,000 feet. Occasional moderate rime or mixed icing was reported from the freezing level to 14,000 feet. The freezing level was from 3,000 feet to 5,000 feet. Instrument flight rule (IFR) conditions were forecast throughout Western Washington. East of the Cascades was "in good shape." The west side had few to scattered clouds from 700 feet to 1,000 feet. At 2,000 feet to 4,000 feet the clouds were broken, with variable overcast. Tacoma Narrows had a wind reported from 180 degrees at 9 knots, with a visibility of 4 miles with light rain and mist. The cloud conditions were scattered at 3,000 feet, a ceiling was broken at 3,800 feet and overcast at 4,900 feet. The temperature was 7 degrees C, with a dew point of 5 degrees C. The altimeter was 29.83" Hg. The Redmond altimeter was 29.82" Hg. The specialist reported that visual flight rules (VFR) flight was not recommended from the Cascades, westward due to terrain obscurement.

The pilot thanked the specialist for the help, and the conversation was concluded at 1307, with the specialist reporting to the pilot for additional weather he could contact flight watch on 122.0.

The NTSB Investigator-In-Charge requested from the Federal Aviation Administration a copy of the air traffic communications from 1335 local to 1426 local. The communications began with conversations between Seattle Air Route Traffic Control Center, R32 position, and several commercial aircraft within the sector before the pilot of N69KM made contact about 1345. The conversations began with the R32 controller reporting the icing conditions to the flight crews, and the flight crews responding with what actual icing conditions they were experiencing and at what flight altitudes.

The pilot of N69KM initially made contact with the R32 controller reporting that he was 13,000 feet and descending. The controller acknowledged the pilot and inquired if he was aware of the center weather advisory and the reports of severe rime ice in the direction that he was heading. The pilot acknowledged the controller by reporting that he was aware of the weather and that the aircraft was "equipped." The pilot also stated that he would get a deviation to the east "in a little bit." The pilot then asked for a report (weather) to the east.

The controller informed the pilot of the reports from flight crew in commercial aircraft, of the severe mixed icing conditions and numerous reports of moderate rime icing conditions. The pilot responded that he would deviate to the east and try a different field. The controller then asked the pilot if he was changing his destination. The pilot responded that he would come into Tacoma Narrows from the east if there were no reports coming in from the east. The controller responded that the weather would be moving to the east, the report he had of the severe rime icing was probably over a half hour old and that weather was moving to the northeast. The controller thought that maybe "to the west would be better or not."

The pilot again responded that he was "equipped." The remainder of the pilot's transmission was unintelligible, however, it was believed that he meant that the aircraft was equipped with de-icing equipment. The following transmission from the pilot was partially unintelligible, however he indicated that he was "turning on (the de-ice) equipment now." The controller recommended to the pilot to stay clear of the clouds. The pilot responded, "roger." The controller then asked the pilot if he was "going to orbit there for awhile." The pilot responded, "yes." followed by a partially unintelligible transmission of "getting some weather here."

After a short time, the controller asked the pilot what his intentions were and the pilot responded, "Ah, I'm in a little trouble." The controller responded, "are you in trouble now." The pilot responded, "Ah, standby." No further transmissions were received from the aircraft after this time.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in an area of mountainous terrain at 45 degrees 52.154 minutes north latitude, 122 degrees 02.465 minutes west longitude at an elevation of approximately 2,591 feet mean sea level. The area was covered with 100 foot plus tall deciduous trees and thick ground cover in the immediate area of the accident site. The debris path was over relatively flat terrain, with rising terrain to the east. Evidence of impact with tree tops was noted with wreckage found at the bases of these trees. The wreckage distribution path traveled on about a 320 degree magnetic heading. From the first evidence of tree impact to the furthest piece of wreckage (left side propeller blade), the total distribution path of wreckage was about 297 feet. At the beginning of the path, pieces of the right side winglet were located at the base of about 100 foot tall trees. The tree tops were broken off. Several trees were damaged for about 144 feet into the path before the first evidence of ground impact was noted. A large crater measuring about 40 feet in length and at least five feet deep contained the remains of the majority of the aircraft fuselage. Evidence of a post crash fire was noted. Within the crater, remains of the rudder, main landing gear tires, sections of the cabin and sections of the elevators were noted. Both engines were buried within this crater and deep enough that only the accessory section of one of the engines was visible. Four of the six propeller blades were either in or close proximity to the crater. The remaining two propeller blades were not located. The blades that were located were numbered by the investigative team and the part numbers were later matched to identify blade numbers 1, 3, and 4 as the blades for the left side engine. Blade #3 was the most severely damaged with blade tip curling and bending. The other blades displayed aft bending and chordwise scratching.

Flight control continuity was not possible, however, the investigative team was able to locate and identify both wing tips and empennage control surfaces.

MEDICAL AND PATHOLOGICAL INFORMATION

Skamania County Sheriff's Office personnel conducted a search for remains. A small amount of bone fragments were located. During the search a blue colored rubber urine bag was located that was intact and contained urine. The urine sample was sent to the Federal Aviation Administration Civil Aeromedical Institute, Oklahoma City, Oklahoma, however the specimen was unsuitable for analysis.

ADDITIONAL DATA/INFORMATION

Radar data tracking began at 1309 and indicated that the aircraft had been cruising at approximately 16,500 feet heading northwesterly. At 1335, the tracking began a gradual descent. At 1343 the aircraft had descended to 12,700 feet and began a turn to the right. During this turn, the aircraft's altitude changed rapidly beginning with an increase, followed by a rapid loss of altitude from 8,000 feet per minute descent to 10,600 feet per minute descent. The last target recorded was at 1344, at an altitude of 7,400 feet, at coordinates 45 degrees, 52 minutes, 46.800 seconds north latitude, 122 degrees, 02 minutes, 13.732 seconds west longitude.

The wreckage was not recovered from the accident site.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's failure to maintain aircraft control while maneuvering. icing conditions, clouds and the pilot's continued flight into known adverse weather were factors.
Source: National Transportation Board