Parker

The commercial pilot was executing a precision instrument approach at night in instrument meteorological conditions when the airplane collided with terrain about four miles short of the runway. A review of air traffic control communications and radar data revealed the pilot was vectored onto the final approach course but never got established on the glide slope. Instead, he made a controlled descent below the glide slope as he proceeded toward the airport. When the airplane was five miles from the airport, a tower controller received an aural low altitude alert generated by the Minimum Safe Altitude Warning (MSAW) system. The tower controller immediately notified the pilot of his low altitude, but the airplane collided with terrain within seconds. Examination of the instrument approach system and onboard flight navigation equipment revealed no pre-mishap anomalies. A review of the MSAW adaptation parameters revealed that the tower controller would only have received an aural alarm for aircraft operating within 5 nm of the airport. However, the frequency change from the approach controller to the tower controller occurred when the airplane was about 10.7 miles from the airport, leaving a 5.7 mile segment where both controllers could receive visual alerts, but only the approach controller received an aural alarm. A tower controller does not utilize a radar display as a primary resource for managing air traffic. In 2004, the FAA changed a policy, which eliminated an approach controller's responsibility to inform a tower controller of a low altitude alert if the tower had MSAW capability. The approach controller thought the MSAW alarm parameter was set 10 miles from the airport, and not the 5 miles that existed at the time of the accident. Subsequent investigation revealed, that The FAA had improperly informed controllers to ensure they understood the alarm parameters for control towers in their area of responsibility. This led the approach controller to conclude that the airplane was no longer her responsibility once she handed it over to the tower controller. Plus, the tone of the approach controller's aural MSAW alarm was not sufficient in properly alerting her of the low altitude alert.

En route from Arizona to California, the pilot became nauseous and began to vomit. The pilot advised air traffic that he was sick and radio contact was lost. The airplane had descended from 16,500 feet msl and was on an established course to his destination and level at 10,500 feet msl being flown by the autopilot. The last thing that he recalled was approaching his destination. When the pilot regained consciousness he looked outside the airplane to determine where he was. The surface was obscured in cloud cover. On his left side was a Navy F18 fighter plane, and they briefly communicated by hand signals. The F18 pilot indicated he should turn around towards land. The accident pilot determined that he was 186 nautical miles southwest of his destination and over the ocean. He reversed his course. The pilot attempted to contact air traffic without success; another aircraft relayed the pilot's message to air traffic. The pilot declared a medical emergency and advised that because of low fuel he would not be able to return to land. Within 10 minutes the fuel onboard was exhausted and the pilot configured the airplane for the best angle of glide and ditching at sea. Subsequently, the pilot descended through low stratus and ditched the airplane in the ocean at dusk. The pilot exited the airplane with a hand held VHF radio, two flashlights, a cell phone, and a trash bag for flotation; he climbed onto the top of the fuselage to await rescue. At this time it was dark. After about 30 minutes a Navy S3B circled the downed plane until a rescue helicopter arrived and rescued him. While at the pilot's Arizona residence he sprayed for bugs and insects using the pesticide 'Dursban.' During the process he opened the spray container to replenish the pesticide and the built-up pressure sprayed the vapor into his face. He cleaned himself up and then departed for the airport and the return flight to Palomar. He had bought food to eat during the flight, and shortly thereafter, he became sick in flight. The EPA as of June 8, 2000, has banned Dursban from the commercial market.

A Cessna 421 crashed after an inflight breakup. Investigation disclosed that the left outboard portion of the elevator assembly (including the balance weight) separated first, resulting in empennage flutter and subsequent in-flight breakup of the empennage. The left elevator outboard hinge and support structure exhibited evidence of hinge overtravel. The left horizontal stabilizer front spar had failed downward; rivets that attached the left outboard hinge to the rear spar of the left stabilizer had sheared; and the left elevator center hinge had been pulled off the rear spar. About 100 flight hours before the accident, maintenance was performed to repair the left elevator balance weight (which was loose) and to repair a damaged stiffener in the center structure of the horizontal stabilizer. However, when examined after the accident, the balance weight was tight and the repair to the stiffener was intact. All three occupants were killed.

About 9 1/2 minutes after departure from Denver-Arapahoe County Airport, while climbing, the crew declared an emergency, reporting airframe icing. The crew was vectored to Denver-Stapleton International Airport when the aircraft entered a controlled descent until it crashed in a prairie located about 13 miles east of Arapahoe Airport, northeast of Parker. The aircraft was totally destroyed upon impact and all 10 occupants were killed.