Cessna 421C Golden Eagle III

During a cross country flight, the pilot was informed by air traffic control that adverse weather was along his route of flight for terrain obscurement in clouds, precipitation, fog or mist. Turbulence was reported below 12,000 feet and occasional moderate rime or mixed icing was reported from the freezing level to 14,000 feet. Further along the route, the pilot reported to another controller that he was at 13,000 feet and descending. The controller inquired if the pilot 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 controller continued to inform the pilot of pilot reports from commercial aircraft flight crews of the reports of icing conditions, however, the pilot continued on his routing and again reported that the aircraft was "equipped." During the last transmissions from the pilot, he reported that he was "turning on (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." The pilot's last transmissions were "Ah, I'm in a little trouble," followed by "Ah, standby 9KM." Radar tracking indicated that the aircraft had been cruising at 16,500 feet before starting a gradual descent. The aircraft descended to 12,700 feet and it 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 before radar contact was lost. The aircraft was found 6 months later in an area of mountainous terrain. On site evidence indicated that the aircraft collided with trees and terrain in a nose low attitude with the majority of the wreckage contained in a large deep crater.

Northrepps Airfield has a single grass runway, orientated 18/36, and 1617 ft (493 m) long, with a down slope of 1.8% on Runway 18. On the day of the accident, the short grass was wet and an aftercast indicated that the wind at Northrepps was from approximately 210º at 10 to 13 kt. The pilot first flew an approach to Runway 18 and touched down close to the threshold; he subsequently reported that, looking at the slope of the runway ahead of him, he decided to go around and re‑position for a landing on Runway 36, to take advantage of the up-slope on that runway. The pilot stated that, during the approach to Runway 18, he had assessed that the braking effect of the wind would be insignificant in comparison to the braking effect that would be afforded by the uphill slope when landing on Runway 36. The pilot recalled seeing a “shortened” and “non‑standard” windsock mounted on a caravan adjacent to the Runway 18 threshold, but he did not believe that it could be relied upon for an accurate wind strength determination. He did not recall having seen the airfield’s other, larger, windsock. The approach for a short field landing on Runway 36 was normal and the pilot closed the throttles just before the threshold. The aircraft touched down close to the threshold, and the pilot immediately retracted the flaps. The pilot reported that he had lost two thirds of his touchdown speed by about the mid-point of the runway, and that the braking was within his expectations. He subsequently stated that he “seemed to get to a point… when I realised that I was effectively getting no braking at all from the wheels and the uphill slope had petered away”; he then experienced a sensation which he described as being similar to aquaplaning, with all braking authority seemingly lost. The aircraft continued along the runway, crossed the grassed overshoot area, ran over an earth bank beyond the end of the runway and came to rest on a public road just north of this bank. The pilot shut the aircraft down and all three occupants vacated the aircraft without difficulty.

The twin-engine airplane sustained substantial damage when it impacted the top of a single story industrial building and then impacted a landscape embankment and trees during an attempted single-engine go-around. The pilot reported that the left engine failed during initial climb. He feathered the left propeller and returned to the airport to execute an emergency landing. The pilot reported that he had "excessive speed" on final approach and "overshot the runway." When the airplane was at mid-field, the pilot elected to do a go-around. He did not raise the landing gear and the flaps remained about 15-degrees down. The airplane lost altitude and impacted the terrain about .5 miles from the airport. A witness reported seeing the airplane attempt to land on the runway twice during the same approach, but ballooned both times before executing the go-around. The Pilot's Operating Handbook (POH) "Rate-of-Climb One Engine Inoperative" chart indicated that about a 450-foot rate-of-climb was possible during the single-engine go-around if the airplane was in a clean configuration. The chart also indicated that a 350-foot penalty would be subtracted from the rate-of-climb if the landing gear were in the DOWN position, and additionally, a 200-foot penalty would be subtracted from the rate-of-climb if the flaps were in the 15-degree DOWN position. Inspection of the left engine revealed that the starter adapter shaft gear had failed. Inspection of the engine maintenance logbooks revealed that the Teledyne Continental Motors Service Bulletin CSB94-4, and subsequent revisions including the Mandatory Service Bulletin MSB94- 4F, issued on July 5, 2005, had not been complied with since the last engine overhaul on July 17, 1998. The service bulletin required a visual inspection of the starter adapter every 400 hours. The engine logbook indicated that the engine had accumulated about 1,270 hours since the last overhaul. The service bulletin contained a WARNING that stated, "Compliance with this bulletin is required to prevent possible failure of the starter adapter shaft gear and/or crankshaft gear which can result in metal contamination and/or engine failure."

The airplane received substantial damage on impact with trees, terrain, and a residence about one mile from the departure airport during instrument meteorological conditions. The airport elevation was 1,096 feet mean sea level. The personal flight was operating on an instrument flight rules (IFR) flight plan with a filed equipment suffix designating that the airplane was equipped with a Global Positioning System. Airplane records indicate that the airplane was equipped with a GPS but was not approved for IFR navigation. The pilot was issued a departure clearance to 3,000 feet and heading of 130 degrees. Radar data indicates that the airplane leveled off at an altitude approximately 2,000 feet during a 32 second period while executing a right turn to the assigned heading. Witnesses reported that the airplane impacted terrain in a right wing nose low attitude. Wreckage distribution and ground scarring was indicative of a high-speed impact with terrain. No anomalies that would have precluded normal operation of the airplane were noted. The calculated airplane weight was approximately 597 lbs above the maximum gross weight of the airplane.

The 14,000-hour airline transport pilot was hired to fly the owner of the airplane and his mother on a cross country flight. Approximately 3 hours and 15 minutes into the flight, the pilot reported that he had a rough running engine and declared an emergency. A review of ATC voice communications revealed that the pilot had changed his mind several times during the emergency about diverting to a closer airport or continuing to the intended destination. Prior to his last communication, the pilot informed ATC that he, "was not gonna make it." The sole survivor of the accident reported that the flight was normal until they approached their destination. He said, "all of a sudden the engines did not sound right." The right engine sounded as if the power was going up and down and the left engine was sputtering. The airplane started to descended and the pilot made a forced landing in wooded area. The cockpit, fuselage, empennage, and the right wing were consumed by post-impact fire. A review of fueling records revealed that the pilot had filled the main tanks prior to the flight for a total of 213.4 gallons; of which 206 gallons were usable (103 gallons per side). During the impact sequence, the left wing separated at the wing root and did not sustain any fire damage. No fuel was found in the tank, and there was no discoloration of the vegetation along the left side of the wreckage path or around the area where the wing came to rest. The left fuel selector was found set to the LEFT MAIN tank, and the right fuel selector valve was set between the LEFT and RIGHT MAIN tanks. This configuration would have allowed fuel to be supplied from each tank to the right engine. A review of the airplane's Information Manual, Emergency Procedures Engine Failure During Flight (speed above air minimum control speed) instructed the pilot to re-start the engine, which included placing both fuel selector handles to the MAIN tanks (Feel for Detent). If the engine did not start, the pilot was to secure the engine, which included closing the throttle and feathering the propeller. The propellers were not feathered. Examination of the airplane and engine revealed no mechanical deficiencies.

On 30 August 2004, shortly before 1200 Western Standard Time, the owner-pilot of a twin-engine Cessna Aircraft Company 421C Golden Eagle (C421) aircraft, registered HB-LRW, commenced his takeoff from runway 32 at El Questro Aircraft Landing Area (ALA). The private flight was to Broome, where the pilot intended resuming the aircraft delivery flight from Switzerland to Perth. The available documentation indicated that the flight segments en route to Australia had all been to international or major aerodromes. The pilot of a Cessna Aircraft Company 210 (C210) and his two passengers in the runway 32 parking area witnessed the takeoff. Those witnesses reported that the C421 pilot carried out a pre-flight inspection of the aircraft prior to boarding for the takeoff. During that inspection, he was observed preparing for, and conducting a fuel drain check under the left wing, and to have removed some weed-like material from the right main wheel. He then loaded a small amount of personal luggage into the aircraft cabin, before he and the sole passenger boarded. The C210 pilot witness, who reported having observed a number of twin-engine aircraft operations at another aerodrome, did not comment on the nature of the pilot's start and engines run-up checks. The passenger witnesses reported that the pilot of the C421 made a number of unsuccessful attempts to start the left engine, before reverting to starting the right engine. He then started the left engine and moved the aircraft clear of the C210 in order to conduct his engine run-up checks. The passenger witnesses reported that during those checks they heard a 'frequency vibration' as the C421 pilot manipulated the engines' controls. The witnesses at the parking area reported that the C421 pilot taxied the aircraft onto the runway and applied power to commence a rolling takeoff. They, together with a hearing witness located to the north of the ALA indicated that the engines sounded 'normal' throughout the takeoff. Witnesses who observed the takeoff reported that the aircraft accelerated away 'briskly'. The pilot witness stated that the take-off roll and lift-off from the runway appeared similar to other twin-engine aircraft takeoffs that he had observed. The witnesses at the parking area also stated that, shortly after lift-off from the runway, the aircraft banked slightly to the left at an estimated 10 to 15 degrees angle of bank and drifted left before striking the trees along the side of the runway and impacting the ground. There was no report of any objects falling from the aircraft, or of any smoke or vapour emanating from the aircraft during the takeoff. The aircraft was destroyed by the impact forces and post-impact fire. The pilot and passenger were fatally injured.

The airplane impacted a residence during a missed approach. After completing the en route portion of the instrument flight, a controller cleared the pilot to proceed direct to the initial approach fix for the global positioning satellite (GPS) approach to the airport. After being cleared for the approach, the airplane continued on a course to the east and at altitudes consistent with flying the GPS published approach procedure. Radar data indicated that at the missed approach point at the minimum descent altitude of 2,000 feet msl, the airplane made a turn to the left, changing course in a northerly direction toward rapidly rising mountainous terrain. The published missed approach specified a climbing right turn to 4,000 feet, and noted that circling north of the airport was not allowed. Remaining in a slight left turn, the airplane climbed to 3,300 feet msl over the duration of 1 minute 9 seconds. The controller advised the pilot that he was flying off course toward mountainous terrain and instructed him to make an immediate left turn heading in a southbound direction. The airplane descended to 3,200 feet msl and made a left turn in a southerly direction. The airplane continued to descend to 2,100 feet msl and the pilot read back the instructions that the controller gave him. The airplane then climbed to 3,300 feet, with an indicated ground speed of 35 knots, and began a sharp left turn. It then descended to impact with a house. At no time during the approach did the pilot indicate that he was experiencing difficulty navigating or request assistance. An examination of the airplane revealed no evidence a mechanical malfunction or failures prior to impact; however, both the cockpit and instrument panel sustained severe thermal damage, precluding any detailed examinations.

The pilot of the twin-engine accident airplane was on an IFR flight plan in instrument meteorological conditions when the right side nose baggage door opened. The pilot expressed concerns to air traffic control about baggage exiting the compartment and striking the right propeller. He requested a diversion to the nearest airport with an instrument approach. The flight was diverted as requested, and was cleared for a non precision instrument approach to a coastal airport adjacent to mountainous terrain. The flight was authorized to a lower altitude when established on the approach. A review of the radar track information disclosed that the pilot did not fly the published approach, but abbreviated the approach and turned the wrong direction, toward higher terrain, north of the approach course. The airplane was discovered in mountainous terrain, about 1,100 msl, and 1.5 miles north of the approach course. The crash path was initially at a shallow angle in the treetops, until the airplane struck larger trees. Post accident inspection of the airplane disclosed no evidence of any preimpact mechanical problems, other than the baggage door, which was still attached to the airplane.