Santa Ana-John Wayne

Earlier on the day of the accident, the flight crew had conducted a patient transfer from a remote airport to another nearby airport. Following the patient transfer, the flight crew departed under night conditions to return to their home base. Review of air traffic control (ATC) communication, as well as cockpit voice recorder (CVR) recordings, showed that the flight crew initially was cleared on the RNAV (GPS) runway 17 instrument approach. The approach plate for the instrument approach stated that circling to runway 27R and 35 was not authorized at night. Following the approach clearance, the flight crew discussed their intent to cancel the approach and circle to land on runway 27R. Additionally, the flight crew discussed with each other if they could see the runway. Once the flight crew established visual contact with the runway, they requested to squawk VFR, then the controller cleared them to land on runway 17. The flight crew then requested to land on runway 27. The controller asked the pilot if they wanted to cancel their instrument flight rules (IFR) flight plan, to which the pilot replied, “yes sir.” The controller acknowledged that the IFR cancellation was received and instructed the pilot to overfly the field and enter left traffic for runway 27R and cleared them to land. Shortly after, the flight crew asked the controller if the runway lights for runway 27R could be increased; however, the controller informed them that the lights were already at 100 percent. Just before the controller’s response, the copilot, who was the pilot flying, then asked the captain “where is the runway.” As the flight crew maneuvered to a downwind leg, the captain told the copilot not to go any lower; the copilot requested that the captain tell him when to turn left. The captain told him to turn left about 10 seconds later. The copilot stated, “I see that little mountain, okay” followed by both the captain and co-pilot saying, “woah woah woah, speed, speed” 3 seconds later. During the following 5 seconds, the captain and copilot both stated, “go around the mountain” followed by the captain saying, “this is dicey” and the co-pilot responding, “yeah it’s very dicey.” Shortly after, the captain told the copilot “here let me take it on this turn” followed by the co-pilot saying, “yes, you fly.” The captain asked the copilot to watch his speed, and the copilot agreed. About 1 second later, the copilot stated, “speed speed speed, more more, more more, faster, faster… .” Soon after, the CVR indicated that the airplane impacted the terrain. Automatic dependent surveillance – broadcast (ADS-B) data showed that at the time the flight crew reported the runway in sight, they were about 360 ft below the instrument approach minimum descent altitude (MDA), and upon crossing the published missed approach point they were 660 ft below the MDA. The data showed that the flight overflew the destination airport at an altitude of about 775 ft mean sea level (msl), or 407 ft above ground level (agl), and entered a left downwind for runway 27R. While on the downwind leg, the airplane descended to an altitude of 700 ft msl, then ascended to an altitude of 950 ft msl while on the base leg. The last recorded ADS-B target was at an altitude of 875 ft msl, or about 295 ft agl.

The pilot and four passengers were nearing the completion of a cross-county business flight. While maneuvering in the traffic pattern at the destination airport, the controller asked the pilot if he could accept a shorter runway. The pilot said he could not, so he was instructed to enter a holding pattern for sequencing; less than a minute later, the pilot said he could accept the shorter runway. He was instructed to conduct a left 270° turn to enter the traffic pattern. The pilot initiated a left bank turn and then several seconds later the bank increased, and the airplane subsequently entered a steep nose-down descent. The airplane impacted a shopping center parking lot about 1.6 miles from the destination airport. A review of the airplane's flight data revealed that, shortly after entering the left turn, and as the airplane’s bank increased, its airspeed decreased to about 59 knots, which was well below the manufacturer’s published stall speed in any configuration. Postaccident examination of the airframe and engines revealed no anomalies that would have precluded normal operation. It is likely that the pilot failed to maintain airspeed during the turn, which resulted in an exceedance of the aircraft's critical angle of attack and an aerodynamic stall.

According to the pilot, about 15 minutes before reaching the destination airport during descent, the engine lost power. The pilot switched fuel tanks, and the engine power was momentarily restored, but the engine stopped producing power even though he thought it "was still running all the way to impact." The pilot conducted a forced landed on a highway at night, and the right wing struck an object and separated from the airplane. The airplane came to rest inverted. According to the Federal Aviation Administration (FAA) aviation safety inspector (ASI) that performed the postaccident airplane examination, the fuel lines to the fuel manifold were dry, and the fuel manifold valves were dry. He reported that the fuel strainer, the diaphragm, and the fuel filter in the duel manifold were unremarkable. Fuel was found in the gascolator. The FAA ASI reported that, during his interview with the pilot, "the pilot changed his story from fuel exhaustion, to fuel contamination." The inspector reported that there were no signs of fuel contamination during the examination of the fuel system. According to the fixed-base operator (FBO) at the departure airport, the pilot requested 20 gallons of fuel. He then canceled his fuel request and walked out of the FBO.

The accident occurred during a dark night departure from a private unlighted airstrip. The pilot had landed, assisted by the headlights of a car, on the landing strip/road about 1830. After dropping off a passenger, he departed about 1900. The departure direction was towards a sparsely populated area of rolling hills. Local area residents reported hearing a plane depart, followed by a loss of engine sound, and an impact in a grape vineyard. Examination of the wreckage revealed that the airplane impacted the ground in a nose down attitude. According to maintenance records, the last recorded annual inspection occurred 12 months and about 299.5 flight hours prior to the accident. Approximately 5 months before the accident, the FAA Certified Repair Station (CRS) that performed the maintenance on the airplane had given the pilot/owner a 15-item list of "grounding discrepancies." The discrepancies were: Cracked nose cowling; fraying seat belts; LH mag switch broken; LH window cracked; LH windshield crazed; stall warning inoperative; turbine inlet temperature inoperative; door latch safety inoperative; several hydraulic components leaking; main gear trunion pins worn; several cracks in wing lower skins; fuel leaks; loose rivets on RH flap; wing spar bolts loose; and elevator trim cable frayed. According to the CRS manager, the only item that had been repaired prior to the accident was the cracked nose cowling. However, an engine log entry indicated the TIT gage had also been replaced. Additionally, several witnesses reported that the pilot had been flying the airplane with an inoperative landing gear retract system for about 4 months. During post accident examination of the wreckage, investigators were able to verify that many of the listed discrepancies still existed; however, none of these discrepancies could be directly linked to the accident.

During en route cruise flight at an assigned altitude of 11,000 feet (msl) in instrument meteorological conditions, the airplane impacted mountainous terrain at 5,300 feet, in wings level, descending flight. During the final 12 minutes of the flight (from 1046 to 1058 Pacific daylight time), recorded military search radar height values (primary radar returns) show the aircraft in a steady descent from 11,000 feet to 5,600 feet, where radar contact was lost. During the same time interval, recorded Mode C altitudes received at Los Angeles Air Traffic Control Center (Center) and SoCal Terminal Radar Approach Control (TRACON) indicated the aircraft was level at 11,000 feet. At 1055:49, when the pilot was handed off from SoCal TRACON to Los Angeles Center, the pilot checked in with the Center ". . . level at one one thousand." At 1057:28, the pilot asked the Center controller "what altitude you showing us at" to which the controller responded "not receiving your mode C right now sir." At 1057:37, the pilot transmitted "o k we'd like to climb to vfr on top, our uh altimeter just went down to uh fifty three hundred." The controller approved the pilot's request to climb to VFR conditions on-top and, at 1057:54, the pilot responded "roger we're out." No further transmissions were received from the aircraft. The airplane was equipped with a single instrument static pressure system with two heated static ports. The static system and static system instruments were damaged or destroyed by impact and post-crash fire sufficiently to preclude post-accident testing.

The captain said the airplane felt 'sluggish' during the takeoff roll. At V1/Vr, the airplane was rotated for liftoff. It climbed 10 feet, 'shuddered,' and sank. The captain elected to abort the takeoff. He landed the airplane on the runway, applied brakes and deployed the drag chute. The drag chute separated and the airplane went off the runway, down a hill, through a fence, across a road and grassy area, across another road, through a chain link fence, and collided with a power pole. The captain said they had calculated the takeoff performance using inappropriate tables, and failed to consider the wet runway and wind shift. The drag chute riser fractured at a point where it passed through a lightning hole. The lightning hole bore no evidence of a nylon grommet having been installed.

After touching down to scoop another load of water, the pilot added power and the aircraft pitched forward. The pilot heard a pop and felt a sudden decelerative force. When the nose began to bowsuck, he applied more back pressure but the aircraft did not respond. The floor split open and water began rushing into the cockpit. The left nose gear door locking pin was found separated from its hydraulic actuator. It displayed a bend that corresponded to its retracted position in the pin guide. The deformation prevented investigators from reinserting the damaged pin back through the guide. The left mycarta block remained attached to the door and did not exhibit any damage.

Shortly after takeoff, the pilot radioed the air traffic control tower declaring an emergency and stating his intent to return for landing. He stated that he had taken off with an external boarding ladder attached to the aircraft. Several witnesses reported that the aircraft's downwind leg was too close to the airport causing the aircraft to overshoot the turn to the final approach course, and that the pilot increased the aircraft's bank angle as he tried to align the aircraft with the landing runway. As the aircraft was intercepting the final approach course, it abruptly rolled inverted, the nose dropped, and the aircraft spiraled onto the roof of an industrial building. A Boeing 757 aircraft, landing on the same runway, had passed over the accident site 2 minutes and 17 seconds earlier. The B-757 was cleared to land before the accident aircraft received a takeoff clearance and was on the runway when the pilot declared the emergency and turned downwind. The local controller did not issue a wake turbulence advisory. Experienced MS760 pilots reported that the aircraft will exhibit no adverse performance or safety affects with the boarding ladder attached.

A Beech liner, Boeing 757 and Israel Westwind (WW) were vectored for landings on runway 19R. The 757 and WW were sequenced for visual approaches behind the Beech. Before being cleared for visual approach, the WW was closing 3.5 miles from the 757 on a converging course. The 757 and WW crews were told to slow to 150 knots. The 757 slowed below 150 knots and was high on final approach with a 5.6° descent. The WW continued to converge to about 2.1 miles behind the 757 on a 3° approach. ATC did not specifically advise, and was not required by ATC handbook to advise, the WW pilots that they were behind a Boeing 757. Captain discussed possible wake turbulence, flew ILS 1 dot high, noted closeness to the 757 and indicated there should be no problem. While descending thru approximately 1,100 feet msl, the WW encountered wake turbulence from the 757, rolled into a steep descent and crashed. The crew lacked specific wake turbulence training. Chlorpheniramine (common over-the-counter anti-histamine; not approved for flying) detected in pilot's lung tissue (0.094 ug/ml).

Several mechanic witnesses at the airport said the right engine backfired and trailed black smoke during the takeoff ground roll. Reportedly, the takeoff roll was about 80% longer than normal. Witnesses said the aircraft staggered off the ground, was slow and never got above 100 feet agl. The pilot reported to the tower that the flight had to come back to the runway. Shortly thereafter, witnesses saw the aircraft enter a steep left turn, apparently stall, then crash into some tennis courts. An investigation revealed evidence that the right engine had lost power. A modification kit for the fuel injector reference air lines was incorrectly installed and allowed an unfiltered air source. Spectral analysis of residue (from the right engine turbocharger compressor) revealed that it had the same composition as the alternate air door seal. Traces of the material were found in the fuel injector reference air line. All five occupants were killed.