Date & Time:
Jul 28, 1982 at 1922 LT
Type of aircraft:
Cessna 414 Chancellor
Operator:
Last Days Ministries
Registration:
N110VM
Flight Phase:
Takeoff (climb)
Flight Type:
Private
Survivors:
No
Schedule:
Lindale - Lindale
MSN:
414-0390
YOM:
1973
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
1
Pax on board:
11
Pax fatalities:
11
Other fatalities:
0
Total fatalities:
12
Captain / Total hours on type:
59
Aircraft flight hours:
2459
Circumstances:
7-seat aircraft took off with 4 adults and 8 children aboard. Aircraft rotated at about 2,000 feet down runway and climbed in a flat nose high attitude before settling into 30 feet trees about 4,223 feet from point of lift-off. Aircraft oscillated violently 2 or 3 times in the pitch axis during the 20-30 seconds flight. Aircraft was about 445 lbs over max gross weight and CofG was 4.26 inches aft of the aft limit. On 6/9/82 the pilot took a checkride to have a "centerline thrust only" restriction removed from his multi-engine rating. 59 of his 62 hrs multi-engine were as copilot. He had no formal C414 training and had recovered only 2 hours of instruction in conventional multi-engine aircraft. He had never been required to perform weight and balance computations in his military flying or any FAA exam or checkrides. Company management did not comply with insurance stipulations which required pilot of the flight to attend a Cessna flight training school, nor did the pilot satisfy the minimum hour requirements. FAA certificate examiner lost certificate on 7/10/82, history of incomplete or substandard checkrides. Occupants died of thermal burns and smoke inhalation.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
1. (c) preflight planning/preparation - inadequate - pilot in command
2. (c) aircraft weight and balance - not performed - pilot in command
3. (c) aircraft weight and balance - exceeded - pilot in command
4. (c) performance data - not understood - pilot in command
5. (c) lift-off - premature - pilot in command
6. (c) overconfidence in personal ability - pilot in command
7. (c) inadequate transition/upgrade training - company/operator management
8. (f) insufficient standards/requirements,operation/operator - company/operator mgmt
9. (f) inadequate certification/approval,airman - FAA (organization)
10. Stall/mush - uncontrolled - pilot in command
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Occurrence #2: in flight collision with object
Phase of operation: takeoff - initial climb
Findings
11. Object - tree(s)
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Occurrence #3: fire
Phase of operation: other
Findings
12. (f) passenger briefing - not performed - pilot in command
Phase of operation: takeoff - initial climb
Findings
1. (c) preflight planning/preparation - inadequate - pilot in command
2. (c) aircraft weight and balance - not performed - pilot in command
3. (c) aircraft weight and balance - exceeded - pilot in command
4. (c) performance data - not understood - pilot in command
5. (c) lift-off - premature - pilot in command
6. (c) overconfidence in personal ability - pilot in command
7. (c) inadequate transition/upgrade training - company/operator management
8. (f) insufficient standards/requirements,operation/operator - company/operator mgmt
9. (f) inadequate certification/approval,airman - FAA (organization)
10. Stall/mush - uncontrolled - pilot in command
----------
Occurrence #2: in flight collision with object
Phase of operation: takeoff - initial climb
Findings
11. Object - tree(s)
----------
Occurrence #3: fire
Phase of operation: other
Findings
12. (f) passenger briefing - not performed - pilot in command
Final Report:
N110VM.pdf89.49 KB