United States of America

The pilot had received a weather briefing and was aware of the weather conditions west and north of the airport. The pilot was issued the flight clearance as filed, and was assigned an initial altitude of 2000 feet. Approximately five minutes into the flight, the air traffic controller questioned the pilot concerning the assigned heading. The controller stated that the pilot 'sounded extremely strained' and replied, 'N269M is in trouble.' Radar altitude data showed a rapid loss of altitude for N269M; the last radar altitude data showed the flight at 2800 feet. The airplane collided with the ground in a nose low attitude. Weather radar data from the Miami Weather Surveillance Radar-1988, Doppler (WSR-88D) showed a large, intense convective cell just west of Boca Raton between 1530:15 and 1535:57. Moderate to very heavy rain showers were associated with the convective activity. A review of the radar data showed that N269M was 3.5 to 4.0 miles north of the core of the large convective cell.

The aircraft collided with trees and mountainous terrain about 9,500 feet msl. The wreckage was spread across the lee side of a mountain, in a grassy meadow surrounded by high mountainous terrain on all sides. The area, about 100 feet in front of the aircraft, was a rocky embankment which sloped upward approximately 30 degrees. About 100 feet from the tail of the aircraft, the terrain dropped off into a steep cliff, which sloped down about 65 degrees. At the base of the cliff was a valley, which was about 1/4 mile wide. The farthest piece of debris was found 410 feet away from the main wreckage site in a grove of trees. Fifteen tree disturbances were noted in the grove. The first disturbance began near the tops of the trees and continued in a descending path. Much of the airframe exhibited semicircular impressions consistent with the trunk diameters of the disturbed trees at the accident site. Organic material transfer was evident in the impressions. An analysis of the meteorological data showed that a clear or scattered cloud condition was likely in the accident area, and visibility was probably unrestricted. It also showed that an extended north-northwestward/south-southeastward cloud band was located over the Sierra Nevada Mountains about 9 to 10 miles southwest through west of the accident location around the time of the accident. The analysis estimated that the winds aloft at 10,000 to 12,000 feet msl in the mountains were from approximately 270 degrees at 40 to 45 knots. Further, moderate or greater turbulence and strong updrafts and downdrafts were reported along the pilot's route of flight. No mechanical discrepancies were found with the airframe or either engine during the postaccident examination.

The flight crew was positioning the airplane in preparation for a revenue flight when it crashed 2 nautical miles (nm) short of the runway during a second instrument landing system approach in instrument meteorological conditions. Except for the final 48 seconds of the 25- minute flight, the captain was the flying pilot, and the first officer was the nonflying pilot. When the airplane was about 0.5 nm inside the outer marker on the first approach, the compass warning flag on the captain's course deviation indicator appeared, indicating that the heading display was unreliable. The airplane deviated from the localizer centerline to the left but continued to descend. After about 1 minute, during which time the airplane's track continued to diverge from the localizer centerline, the flight crew executed a missed approach. The flight crew then unsuccessfully attempted to clear the compass flag by resetting circuit breakers. The captain directed the first officer to request a second approach. Contrary to company crew coordination procedures, the flight crew did not conduct an approach briefing or make altitude callouts for either approach. Although accurate heading information was available to the captain on his radio magnetic indicator, he experienced difficulty tracking the localizer course as the airplane proceeded past the outer marker on the second approach. The captain transferred control to the first officer when the airplane was 1.9 nm inside the outer marker. The airplane then began to deviate below the glideslope. The descent continued through the published decision height of 200 feet above ground level, and the airplane struck 80-foot-tall trees. Post accident testing revealed that the first officer's instruments were displaying a false full fly-down glideslope indication because of a failed amplifier in the navigation receiver. The glideslope deficiency was discovered 2 months before the accident by another flight crew. An FAA repair station attempted to resolve the problem and misdiagnosed it as "sticking" needles in the cockpit instruments. The operator was immediately advised of the problem. The operator's minimum equipment list for the airplane required that the problem be repaired within 10 days, but the operator improperly deferred maintenance on it for 60 days and allowed the unairworthy airplane to be flown by the accident flight crew. The airplane was not equipped with, nor was it required to be equipped with, a ground proximity warning system, which would have sounded 40 seconds before impact.

After departing on an IFR flight in VFR conditions, the flight had been cleared to climb from 3,000 to 4,000 feet, when the right engine lost power. The pilots diverted toward an uncontrolled airport, secured the right engine, & cancelled their IFR clearance. They made an approach to land on runway 15, then attempted a single engine go-around. During the go-around, the airplane yawed/rolled to the right in what the passenger believed was a VMC roll. It then struck power lines & crashed in a right wing low attitude. Investigation revealed that both pilots held multi-engine ratings. The owner said the pilot (PIC) had flown the airplane for a short time on 12/21/98; however, no other record was found to verify that either the pilot or copilot had flight experience in this make/model of airplane. Examination of the wreckage revealed evidence that the flaps were retracted, the landing gear was in transit, the left propeller was operating with power, & the right propeller was feathered. The airplane had a history of fuel flow fluctuations in the right engine. The diaphragm (P/N 364446) in the right engine distributor valve assembly was found ruptured. It was an old style diaphragm, which was colored black. Bendix Service Bulletin RS-76, issued 11/15/80, called for replacement of the black diaphragm with a red fluorosilicone diaphragm (P/N 245088) at overhaul. The engine was overhauled in June 1992. During maintenance in December 1997, both fuel system injectors & nozzles were tested; however, the distributor valve assembles were not tested. Calculations showed the airplane was loaded 116.3 lbs over the maximum allowable gross weight & 1.3 inches forward of the allowable CG range.

The pilot was reported to be in a hurry as he positioned two aircraft and picked up the accident aircraft for his final positioning leg. He told company personnel he had a birthday party to go to and his family confirmed this. The pilot reported to company personnel that he was departing on runway 3 and that he would report in on his arrival at the destination. No further contacts with the flight were made and the wreckage of the aircraft was discovered off the end of the departure runway about 40 minutes after his reported takeoff. Examination showed the aircraft had run off the left side of the runway about 800 feet from the end and then crossed over the runway and entered into the woods at the departure end of the runway. Post crash examination showed no evidence of pre crash failure or malfunction of the aircraft structure, flight controls, or engine. The onboard engine computer showed the engine was producing normal engine power and the aircraft was traveling at 98 knots when electrical power was lost as it collided with trees. The aircraft's control lock was found tangled in the instrument panel near the left control yoke where it is normally installed and the lock had multiple abnormal bends, including a 90 degree bend in the last 1/2 inch of the lock where it engages the control column. Removal of the control lock and checking the flight controls for freedom is on the normal pilots checklist. The pilot was also found to not be wearing his shoulder harness.

The pilot initiated an ILS approach with rain and fog. Approach flaps were maintained until the runway was sighted, and then landing flaps were set. The airplane landed long, overran the runway, struck the ILS localizer antenna on the departure end of the runway, and came to rest at the edge of a mobile home park. The airplane and two mobile homes were destroyed by fire. Vref had been computed at 110 Kts. The PIC reported a speed on final of 130 Kts, while the SIC said it was 140 Kts. Radar data revealed a 160 knots ground speed from the outer marker until 1.8 miles from touchdown. The airplane passed the control tower, airborne, with 2,500 feet of runway remaining on the 6,500 foot long runway. Performance data revealed that the airplane would require about 2,509 feet on a dry runway, and 5,520 feet on a wet runway. The airplane was not equipped with thrust reversers or anti-skid brakes. The PIC was the company president, and the SIC was a recent hire who had flown with the PIC three previous times. The PIC was qualified for single-pilot operations in the airplane, and had been trained to fly stabilized approaches.

During the takeoff roll, while passing 45 knots indicated airspeed, ice formed between the inner and outer panes of the airplane's windshield, obscuring the crew's vision. The flight crew aborted the takeoff, the airplane drifted off the left side of the snow covered runway, and caught fire. The crew reported the airplane and windshield were cold soaked and the temperature was -10 degrees Fahrenheit. The windshield anti-ice system blows air from a combustion heater between the windshield glass panes. The air source for the heater, once the airplane has forward airspeed, is two leading edge wing scoops. The crew told the NTSB investigator that the taxi time was too short for the windshield to warm up, and that during the taxi, snow was circulated around the airplane and into the wing scoops.

The pilot landed at Watertown, loaded and off-loaded cargo, and departed without getting out of the airplane. A witness reported seeing the airplane over the runway at an altitude of about 50 feet agl. The airplane was described to be bouncing and buffeting. Another witness reported the weather as overcast with occasional snow flakes. The airplane then descended, impacted the terrain and exploded. Post accident inspection revealed a 1/2 to 3/4 inch thick ridge of rime ice along the leading edge of the left horizontal stabilizer. Pieces of arc shaped ice were located along the wreckage path. Inspection of the wreckage failed to reveal any preimpact failure/malfunction of the engine or airframe which would have prevented flight.

The airplane departed runway 1L and radar data indicated the airplane maintained about a 110 knot ground speed for 37 seconds as it climbed to 1,400 feet msl (642 feet agl) with a 008 degree heading. The last radar 14 seconds later indicated the airplane's heading was 342 degrees and had a 130 knot ground speed. The winds were 290/11. Witnesses reported seeing the airplane flying low and slow, and then it made a turn like a "barrel roll" to the left before impacting the ground. Examination of the engines and airframe revealed no pre-existent anomalies. The left and right propellers exhibited leading edge damage and chordwise abrasions. The pilot had a total of about 1,175 flight hours with about 250 hours in the type and model aircraft. The copilot had 4,094 total hours, but had 10 hours of turbine time and no flight time in the type and model of aircraft. The pilot had indicated he was practicing simulated single engine failures. The gear was fully retracted. The trim settings were set for a right engine out situation. The flap selector was set to "UP" flaps, but the flaps were found in transit at approximately 2 degrees of flaps. The Airplane Flight Manual indicated that during "Engine Failure in Takeoff-Gear Fully Retracted" stated that the required airspeed before selecting flaps to 5 degrees was 140 KCAS. The Pilot's Operating Handbook stated the flaps take approximately 31 seconds to retract from 20 to 0 flaps, or 21 seconds to retract from 5 to 0 flaps.

About 26 minutes after takeoff while at 21500 feet, the pilot requested a non existent route. Seven minutes later, the passenger stated the pilot was light headed and fading then he had passed out. The passenger had once held a student pilot certificate and about 5 years earlier she had accrued 73 hours of flight time in Cessna 150/152 aircraft. The air traffic controller, and other pilots on the radio frequency tried to assist the passenger. The passenger was advised to provide oxygen for herself and the pilot, but she was unable. The airplane climbed to 34,200 feet where the airplane departed controlled flight, recovered, then departed controlled flight several more times before beginning a nose low descent. Witnesses reported hearing the airplane orbiting several times while flying above a cloud layer then observed the airplane orbiting beneath the clouds. While in a descending right wing low attitude, the airplane impacted the ground and came to rest submerged in a pond. Examination of the flight controls, engines, and propellers revealed no evidence of preimpact failure or malfunction. A discrepancy with the regulating valve was noted. Two small holes were noted in the cabin door seal. The left wing pressurization duct had been replaced about 8 years earlier but the right wing pressurization duct, had not been replaced. The ducts are on-condition components. There was no preimpact failure or malfunction noted with the barometric pressure switch, the cabin altitude annunciator bulbs, the safety valve, solenoid valve, or differential pressure/cabin altitude gauge. Testing for carbon monoxide for both was negative.