Executive/Corporate/Business

Prior to takeoff from Lambert Field/St. Louis International Airport, St. Louis, Missouri, the pilot contacted the operations manager at M. Graham Clark Airport, Point Lookout, Missouri, and asked about the current weather conditions there. The operations manager told the pilot that the weather was "pretty poor." The airplane took off from St. Louis, at 1411 cst. At 1447:12 cst, the pilot checked in with Springfield Approach Control. The pilot was told to expect the ILS approach to runway 2 at the Springfield-Branson Regional Airport. At 1501:01 cst, the pilot requested to go to Point Lookout and shoot the GPS to runway 11. Springfield Approach instructed the pilot to descend to 3,000 feet msl and cleared him for the approach. At 1507:08 cst, Springfield radar showed the airplane crossing the initial waypoint at 3,000 feet msl, and turn to 116 degrees approach heading. At 1507:17 cst, the airplane descended to 2,500 feet msl. At 1508:51 cst, Springfield Approach cleared the pilot to change to advisory frequency. "Call me back with your cancellation or your miss." The pilot responded, "Okay we're, we're RAWBE inbound and we will call you on the miss or cancellation." The operations manager at M. Graham Clark Airport said that he heard the pilot on the airport's common frequency radio say, "Citation 525KL is RAWBE inbound on the GPS 11 approach." At 1509:01 cst, Springfield radar showed the airplane begin a descent out of 2,500 feet msl. The last radar contact was at 1509:48 cst. The airplane was five nautical miles from the airport on a 296 degree radial, at 2,100 feet msl. At 1530 cst, the operations manager heard Springfield approach trying to contact the airplane. The operations manager initiated a search for the airplane. At 1430 cst, the weather observation at the M. Graham Clark Airport was 300 feet overcast, rain and mist, 3/4 miles visibility, temperature 53 degrees F, winds variable at 3 knots, altimeter 29.92 inches HG. Approach minimum weather for the GPS RWY11 straight in approach to Point Lookout are a minimum ceiling of 600 feet and visibility of 1 mile for a category B aircraft. An examination of the airplane wreckage revealed no anomalies. The results of FAA toxicology testing of specimens from the pilot revealed concentrations of Doxepin in kidney and liver. The Physicians' Desk Reference states that "... drowsiness may occur with the use of this drug, patients should be warned of the possibility and cautioned against driving a car or operating dangerous machinery while taking the drug." The physician who prescribed the Doxepin to the pilot said that he was using it to treat the pilot's "irritable bowel" condition. According to his wife, the pilot had not slept well for several nights, up to the day of the accident, due to problems he was having with the FAA. A friend, who spoke with the pilot just before the accident flight, confirmed the pilot saying "I haven't slept for three days." The friend stated further that the pilot "wasn't himself that day."

Shortly after being cleared for takeoff on runway 18 (3,899 feet by 150 feet, dry concrete) at Merrill C. Meigs Field, Chicago, Illinois, the airplane impacted into Lake Michigan, approximately 300 feet south of the end of the runway. The tower controller said that at the 3/4 field point, the airplane had not rotated. 'All I can see are lights [from the airplane]. At the point where he would have been at the end of the runway, [I] lost the lights.' A witness on the airport said that when the airplane went by, it 'didn't sound like most King Airs do at that point.' There was a pulsating sound, but it was not heavy. The witness said that the airplane was 'bouncing up and down on the [gear] struts, and wasn't coming off the ground.' NTSB Materials examination of the pilot's control yoke showed that there were small distortions in the holes of the column and the rod where the control lock would be inserted. A small crack was observed around 1/4 of the control lock rod hole. The control lock was a substitute for the original airplane equipment. The examination of the control lock showed 'several shiny scratches ... parallel to the length of the pin.' A small deformation was observed near the top of the pin part of the control lock. The company flight department's third pilot said that when they flew the airplane, they always placed the control lock in the pilot's side cockpit wall pocket, along with a car key and a remote hanger door opener. The car key and the door opener were found in the wall pocket during the on-scene investigation. The control lock was
recovered from the lake, 7 days later.

During the final approach, while executing a VOR-A instrument approach, the airplane landed hard, collided with the runway VASI display, and caught fire. The airplane had received radar vectors for the approach and was turned to a 20-degree intercept for the final approach course when 2.5 miles from the initial approach fix. Radar track data showed the airplane continued inbound to the field slightly left of course with a ground speed varying between 135 and 125 knots and a descent rate of approximately 700 feet per minute. The pilot said he descended through the clouds about 850 feet above ground level and saw the airport approximately 1 to 2 miles ahead. He noticed that he was left of the runway centerline and corrected to the right. He realized that he had overcorrected and turned back to the left. The pilot reported that he felt that the approach was stabilized although the descent rate was greater than usual. The airplane impacted the ground about 1,000 feet from the approach end of the runway abeam the air traffic control tower on an approximate heading of 185 degrees. The impact collapsed the landing gear and the airplane slid forward another 1,000 feet down the runway and came to rest approximately midfield on the runway. The pilot stated that he had not experienced any mechanical problems with the aircraft or the navigation equipment prior to the accident. A Special Weather Observation taken at the time of the accident contained the following: sky condition overcast at 500 feet; winds from 230 degrees at 3 knots; visibility 2 miles.

On approach to a private airstrip located near Santa Catalina La Tinta, the twin engine aircraft crashed in unknown circumstances 300 metres short of runway. The aircraft was destroyed and all six occupants were killed. Weather conditions at the time of the accident were poor with low clouds and rain falls. Thunderstorm activity was reported all along the route.

At 0314, the pilot reported to the Air Traffic Control (ATC) Tower that he wanted to divert from his destination to land at a closer airport, and was cleared for a visual approach. At 0325, the pilot issued a "Mayday." On final approach the airplane struck a building and wires about 1/2 mile short of the runway. Witnesses that saw the airplane just before impact said that the airplane was low, there was no in-flight fire, and the engine sounds "...appeared to be a fluttering sound as if air [was] passing through the propeller." The pilot had filed for a cruise altitude of 15,000 feet, with a time en route of 5 hours, and fuel on board 6 hours. Weight and balance calculations showed that the pilot was operating about 722 pounds above the maximum gross weight for the takeoff, climb, and maximum cruise power settings. The Pilot Operating Handbook calculations showed that most of the fuel would have been used during the flight. The engine and propeller examinations revealed that both engines were not producing power at impact (windmilling). There were no discrepancies found with the engines or propellers. Examination of the propellers revealed that they were not in the feather position and they were not in beta/reverse position. Line personnel at the departure airport confirmed that all the tanks were topped off (282 gallons added). It took the flight 32 minutes to reach a cruise altitude of 15,000 feet, which calculated to about 293.3 pounds (1 gallon of Jet "A" equals 6.7 pounds), and a flight time of 4.9 hours from takeoff to impact. Sample calculations indicated that the fuel burn rate would have caused the airplane to use 2,649.3 pounds of Jet "A" turbine fuel during the flight. The flight departed with all tanks full 384 gallons usable (2,572.8 pounds), which calculates to insufficient fuel for the completion of the flight. Two gallons of fuel was drained from the right nacelle tank at the crash site, and there was no evidence of in-flight leakage. The sample calculations do not consider performance degradation for operating the airplane above the maximum allowable gross weight, which would cause the fuel consumption to go up because more power was required for the overweight conditions. The pilot's flight plan was for economy cruise, plus the airplane was over gross weight at takeoff, and there are no performance charts for that condition. So, the performance was even poorer than shown on the maximum power chart for climb and cruise. Calculations of the maximum allowable fuel that could be on board the aircraft showed that only 1851 pounds of turbine fuel could be carried to start the flight at the maximum allowable weight, or about 3.2 hours of flight. The en route winds aloft at the airplane's altitude indicated a slight tailwind for half the flight and a headwind of about 15 knots for the remainder of the flight.

The pilot had the main and auxiliary fuel tanks filled and performed an abbreviated preflight prior to departing the Alpine Airport. The pilot did not perform an engine run-up prior to takeoff. The pilot stated that while the airplane was climbing through 100 feet agl, the left engine 'started to surge.' The pilot reported that he knew the airplane would not be able to climb at field elevation with one engine inoperative. The pilot switched the left engine's boost pump from low to high; however, the left engine continued to surge while the airplane lost altitude. The pilot initiated a forced landing with the landing gear and flaps retracted and the left propeller unfeathered. The airplane impacted the ground left wing tip first and a fire erupted, which damaged the left wing and left side of the fuselage. The left engine's spark plugs were found covered with thick black soot. The left engine's magnetos were rotated using an electric hand-held drill, and the left magneto did not produce any spark and the right magneto produced a spark in three of its six distributor cap posts. The left magneto's primary winding resistance and capacitor leakage were found to be beyond the manufacturer's specified limits. The internal components of both magnetos were covered in a dark oil and debris. The maximum takeoff weight for the accident airplane was 6,350 pounds; however, the takeoff weight at the time of the accident was calculated to be 6,509 pounds. The aircraft's single engine performance charts indicated that the airplane would obtain a 29 fpm climb at maximum gross weight with the inoperative engine feathered. The pilot operating handbook's supplement section indicated that the auxiliary fuel pump should only be used when the engine-driven fuel pump failed. A caution statement states in bold print, 'If the auxiliary fuel pump switches are placed in the HIGH position with the engine-driven fuel pump(s) operating normally, total loss of engine power may occur.'

While descending to Mankayan Airport on a flight from Poro Point, the crew encountered poor weather conditions with rain falls and limited visibility. The crew just requested the last weather bulletin for Mankayan when the aircraft struck the slope of a mountain and crashed about 20 km from Mankayan. All eight occupants were killed.

An aircraft mechanic stated one of the airplanes engines was making an unusual noise during takeoff. An Air Traffic Controller stated the flight used about 4,500 feet of runway before lifting off. About 1 minute after being cleared for takeoff, the pilot reported 'were coming around were losing a right engine'. The controller and a witness observed the airplane level off, sway to the left and right, and then descend. The pilot reported he was not going to make it. The airplane was lost from sight behind trees. Post crash examination of the airplane structure, flight controls, engines, and propellers showed no evidence of pre-crash failure or malfunction that would have prevented operation. The landing gear and wing flaps were found retracted. The left and right propellers were found in the low blade angle position and had similar damage. An NTSB sound study of ATC communications showed that at the time the pilot reported they were not going to make it, a propeller signature showed 1,297 rpm and another propeller signature of 2,160 rpm. The engine inoperative procedure contained in the Pilot Operating Handbook for the Cessna 421C, calls for the throttle on the inoperative engine to be closed, the mixture placed in idle cut-off, and the propeller feathered. The Pilot Operating Handbook also showed the airplane would normally use 2,000 feet of runway for takeoff under the accident conditions.

The airplane impacted the ground in a nose low, inverted attitude. The pilot reported, 'Jeff Tower, N34TM, I've just lost power on the right engine, eh, left engine.' The airplane's altitude was approximately 200 to 400 feet when the airplane's wings wobbled back and forth. The airplane's wings banked approximately 90 degrees to the left, and then the airplane nosed over and impacted the ground. White smoke was seen coming from the belly of the airplane for 1 to 2 seconds about 20 seconds prior to it impacting the ground. The terrain was a flat, hard packed field used for growing grass sod. Both the left and right propellers were found 12 to 18 inches under the hard packed soil. Rotational paint transfer patterns from the propeller blades onto the hard packed soil were evident. The left and right propeller blades exhibited chordwise scratching and leading edge polishing. The #2 cylinder piston was broken and the piston pin was still attached to the piston rod. The NTSB Materials Laboratory examination revealed the fracture face of the #2 exhaust valve stem was consistent with a bending fatigue separation. Both #2 and #6 exhaust valve guides showed heavy wear that ovalized the bores. The annual inspection conducted on March 15, 1999, indicated the compression on the left engine was 80/64, 50, 67, 70, 69, and 62.

During a cross-country flight, the pilot of the twin-engine airplane reported to air traffic control that he has 'lost an engine.' A witness observed the right engine hanging from its lower mounts as the airplane turned right and headed towards the nearest airport. The airplane impacted trees approximately 1 mile short of the runway threshold. Examination of the right engine propeller revealed that one of its blades was separated about mid-span. The separated tip section of the blade was not recovered. Metallurgical examination of the fracture surface revealed that the blade failed as a result of a fatigue crack that originated from corrosion pits on the camber surface (face) of the blade. The failed blade was examined approximately 6 hours prior to the accident in accordance with an airworthiness directive (AD 81-13-06 R2) that called for inspections of the blade for corrosion and fatigue. However, the inspections called out in the AD were only applicable to the blade fillet and shank regions, well inboard of the fracture location on the failed blade. Overhaul of the propeller in accordance with the propeller manufacturer's manual includes grinding of each blade to 'remove all visual evidence of corrosion.' According to the airplane's owner, the propellers had not been overhauled in the eight years that he had owned the aircraft. The maintenance records were destroyed in the accident, which precluded determination of the date and time of the last propeller overhaul. The accident airplane was being operated under Title 14 CFR Part 91, and therefore, the propellers were not required to be overhauled at specified intervals.