Minden-Tahoe (Douglas County)

The pilot was conducting a personal cross-country flight in a turbofan-powered airplane. Shortly after departure, the airplane entered a witness-estimated 90° left bank with the nose parallel to the horizon; as the airplane began to roll out of the turn, the nose remained at or below the horizon before it dropped and the airplane impacted the ground. Flight track data revealed that, shortly after departure, the airplane's ground speed immediately began decreasing from its maximum of 141 knots during takeoff and continued decreasing until the last recorded data point, which showed that the airplane had a ground speed of 100 knots. The surface wind reported about 10 minutes before the accident was from 170° at 9 knots, gusting to 14 knots, which resulted in a 1- to 2-knot tailwind component. Given this information and the airplane's configuration at the time of the accident, the airplane's indicated airspeed (IAS) would have been between about 86 and 93 knots. The airplane's stall speed was calculated to be 100 knots IAS (KIAS) with a bank angle of 45° and 118 KIAS with a bank angle of 60°. Thus, the pilot failed to maintain airspeed or accelerate after departure, which resulted in an aerodynamic stall A pilot who had flown with the accident pilot twice before the accident reported that, during these flights, the pilot had flown at reduced power settings and slower-than-normal airspeeds. During the flight 1 year before the accident, he reached over and pushed the power levers forward himself. He also stated that every time he had flown with the pilot, he was "very behind the airplane." Postaccident examination of the engines revealed no signs of preimpact mechanical failures or malfunctions that would have precluded normal operation, and both engines exhibited circumferential rub marks on all rotating stages, blade tip bending opposite the direction of rotation, and debris ingestion through the gas path, indicating that the engine had power at impact. Further, the right engine full authority digital electronic control (FADEC) nonvolatile memory recorded no faults. (The left engine FADEC could not be downloaded due to damage.) The Airplane Flight Manual stated that the pilot must, in part, advance the throttle lever to the maximum takeoff detent for the FADEC's nonvolatile memory to record a logic trend snapshot 2 seconds after takeoff. The lack of a FADEC logic trend snapshot is consistent with the pilot not fully advancing the throttles during the takeoff and initial climb and is likely why he did not attain or maintain sufficient airspeed. The flight track data, pilot witness account, and airplane damage are consistent with the pilot failing to fully advance the power levers while maneuvering shortly after takeoff, which led to his failure to maintain sufficient airspeed and resulted in the exceedance of the airplane's critical angle of attack and a subsequent aerodynamic stall.

The commercial pilot departed for a cross-country, personal flight with no flight plan filed. No evidence was found that the pilot received a preflight weather briefing; therefore, it could not be determined if he checked or received any weather information before or during the accident flight. Visual meteorological conditions existed at the departure airport; however, during the departure climb, the weather transitioned to instrument meteorological conditions (IMC) with precipitation, microburst, and rain showers over the accident area. During the takeoff clearance, the air traffic controller cautioned the pilot about deteriorating weather conditions about 4 miles east of the airport. Radar data showed that, about 5 1/2 minutes after takeoff, the airplane had climbed to about 7,800 ft above ground level before it started a rapid descending right turn and subsequently impacted the ground about 9.6 miles east of the departure airport. Recorded data from the airplane’s Appareo Stratus 2S (portable ADS-B receiver and attitude heading and reference system) revealed that, during the last 15 seconds of the flight, the airplane’s attitude changed erratically with the pitch angle fluctuating between 45° nose-down and 75°nose-up, and the bank angle fluctuating between 170° left and 150° right while descending from 5,500 to 500 ft above ground level, indicative of a loss of airplane control shortly after the airplane entered the clouds. Several witnesses located near the accident site reported seeing the airplane exit the clouds at a high descent rate, followed by airplane parts breaking off. One witness reported that he saw the airplane exit the overcast cloud layer with a nose down pitch of about 60°and remain in that attitude for about 4 to 5 seconds “before initiating a high-speed dive recovery,” at the bottom of which, the airplane began to roll right as the left horizontal stabilizer separated from the airplane, immediately followed by the remaining empennage. He added that the left wing then appeared to shear off near the left engine, followed by the wing igniting. An outdoor home security camera, located about 0.5 mile north-northwest of the accident location, captured the airplane exiting the clouds trailing black smoke and then igniting. Examination of the debris field, airplane component damage patterns, and the fracture surfaces of separated parts revealed that both wings and the one-piece horizontal stabilizer and elevators were separated from the empennage in flight due to overstress, which resulted from excessive air loads. Although the airplane was equipped with an autopilot, the erratic variations in heading and altitude during the last 15 seconds of the flight indicated that the pilot was likely hand-flying the airplane; therefore, he likely induced the excessive air loads while attempting to regain airplane control. Conditions conducive to the development of spatial orientation existed around the time of the in-flight breakup, including restricted visibility and the flight entering IMC. The flight track data was consistent with the known effects of spatial disorientation and a resultant loss of airplane control. Therefore, the pilot likely lost airplane control after inadvertently entering IMC due to spatial disorientation, which resulted in the exceedance of the airplane’s design stress limits and subsequent in-flight breakup. Contributing to accident was the pilot’s improper decision to conduct the flight under visual flight rules despite encountering IMC and continuing the flight when the conditions deteriorated. Toxicology testing on specimens from the pilot detected the presence of delta-9-tetrahydrocanninol (THC) in heart blood, which indicated that the pilot had used marijuana at some point before the flight. Although there is no direct relationship between postmortem blood levels and antemortem effects from THC, it does undergo postmortem redistribution. Therefore, the antemortem THC level was likely lower than detected postmortem level due to postmortem redistribution from use of marijuana days previously, and it is unlikely that the pilot’s use of marijuana contributed to his poor decision-making the day of the accident. The toxicology testing also detected 67 ng/mL of the sedating antihistamine diphenhydramine. Generally, diphenhydramine is expected to cause sedating effects between 25 to 1,120 ng/mL. However, diphenhydramine undergoes postmortem redistribution, and the postmortem heart blood level may increase by about three times. Therefore, the antemortem level of diphenhydramine was likely at or below the lowest level expected to cause significant effects, and thus it is unlikely that the pilot’s use of diphenhydramine contributed to the accident.

The airplane was making a fire retardant drop over a mountain drainage valley when the wings separated from the fuselage. A videotape of the accident sequence showed the airplane as it flew down the valley and proceeded to make a fire retardant drop. When the drop was almost completed, the airplane's nose began moving up, and the airplane started to arrest its descent and level out. The nose of the airplane continued to rise, and the airplane's wings folded upward until they detached from the fuselage at the center wing box beam-to-fuselage attachment location. Close examination of the video revealed that the right wing folded upward first, followed by the left wing about 1 second later. Metallurgical examination of the center wing box lower skin revealed a 12-inch long fatigue crack on the lower surface of the right wing beneath the forward doubler, with two separate fatigue crack initiation sites at stringer attachment rivet holes (which join the external doubler and the internal stringers to the lower skin panel). The cracks from both initiation sites eventually linked up to create a single crack. The portion of the wing skin containing the fatigue crack was covered by a manufacturer-installed doubler, which would have hidden the crack from view and, therefore, prevented detection of the crack from a visual inspection of the exterior of the airplane. The investigation found that the airplane was probably operated within the maximum takeoff gross weight limits specified in the airplane flight manual. The airplane was delivered new to the U.S. Air Force (USAF) in 1957 and was retired from military service in 1978. The U.S. Forest Service (USFS) acquired it from the USAF in 1988 for use as a fire suppression tanker. Between 1978 and 1988, it was kept in a desert storage facility. It was transferred to a civilian contractor for firefighting operations and modified for that role, then sold to a Part 135 operator. The airplane was certificated by the FAA in the restricted category under a type certificate held by the USFS. A Lockheed study concluded that firefighting missions were substantially more severe than typical military logistics operations and aircraft operated in this role would require inspection intervals as much as 12 times more frequently than typical military transport usage for meeting damage tolerance requirements. Concerning the detectability of the cracks, Lockheed reported that nondestructive x-ray inspection methods in current industry and military depot level maintenance processes could have detected, with high confidence, the fatigue cracks when they were 0.50 to 0.75 inch long. Inspection intervals appropriate for this detectable crack size can be determined from a damage tolerance crack growth analysis; however, this requires an extensive knowledge of the operational loads environment and internal stresses of the C-130A wing such as would be found in a military depot level maintenance program. The operating limitations accompanying the restricted certificate specified that it be flown and maintained in accordance with the then-current (1988) USAF technical orders for the C-130A. The USAF depot level maintenance program was not included in the maintenance technical orders and was not individually specified on the certificate's operating limitations. The limitations letter did not specify compliance with USAF maintenance program modifications/amendments in technical orders issued after 1988. The operator devised a maintenance and inspection program based on the specified USAF maintenance technical order but did not develop a depot level inspection requirement to ensure continued long-term airworthiness and damage tolerance that would account for the stresses on the airplane resulting from its new firefighting role and the increasing age of the airplanes. Investigation found that there are five separate FAA-issued type certificates owned by five separate firms for the C-130As used as tankers. Although the five certificates have similar maintenance requirements, none are standardized, there is no depot level maintenance program specified for any of them, and none require full compliance with all military airworthiness technical orders. In 1991, the Department of Interior (DOI) began to doubt the continued airworthiness of the C-130A firefighting tanker fleet and was specifically concerned that the lack of a depot level maintenance program or any requirement for compliance with all military airworthiness technical orders could compromise the safety of the airplane. The DOI asked the FAA to standardize the type certificate for the C-130A and mandate improvements in the maintenance and inspection requirements. In a written opinion, the USAF agreed and urged the FAA to mandate that operators establish a depot level type continuing airworthiness program for the airplane and mandate compliance with all technical orders. In a series of meetings held in 1993, FAA management internally agreed that the DOI and USAF positions held merit and began to develop requirements. In late 1993, in a meeting between the FAA, DOI, USFS, and the airplane operators, the USFS and the operators objected to the idea of depot level maintenance programs and full compliance with all technical orders on the basis of the potential economic impact of these requirements. As of the time of the accident, the FAA had not standardized the existing five type certificates nor had they imposed any additional maintenance or inspection program requirements.

Shortly after takeoff from Minden-Douglas County Airport, while in initial climb, the airplane stalled and crashed. Both occupants were injured and the airplane was written off.