California

The aircraft departed controlled flight and crashed near Helendale, California. The captain and the first officer were killed, and the airplane was destroyed. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 912 from San Bernardino County Airport (CNO), Chino, California, to Friedman Memorial Airport, Hailey, Idaho. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. A review of radar data and air traffic control (ATC) transcripts revealed that the flight departed CNO about 0858 and was cleared to climb to an altitude of 29,000 feet mean sea level (msl). About 0909:55, as the airplane was climbing through an altitude of 26,000 feet, the first officer requested a return to CNO. About 0910:01, the controller asked the first officer if he needed to declare an emergency, and the first officer replied that he did not. The controller then directed the flight crew to maintain an altitude of 24,000 feet. Mode C information for the flight showed that, from about 0910:12 to about 0910:59, the airplane descended from 26,500 to 24,000 feet at a rate of about 2,000 feet per minute (fpm). About 0911:08, the controller cleared the flight directly to HECTOR (a navigation fix) and asked the first officer to confirm that the airplane was in level flight at an altitude of 24,000 feet. The first officer did not respond. Radar data showed the airplane descending through 23,000 feet at a rate of about 6,500 fpm about that time. About 0911:24, while the airplane was descending at a rate of about 10,000 fpm, the first officer stated, “we’re declaring an emergency now.” No further transmissions were received from the airplane. No radar data were available after about 0911:35. Starting about 0911:47, mode C information was invalid. The airplane impacted high desert terrain (an elevation of 3,350 feet) about 3 miles southeast of Helendale. The accident site was located about 46 nautical miles (nm) north of CNO. A witness to the accident, who was located about 4.5 miles northwest of the accident site, stated that, after hearing the sound of a jet flying high overhead, he looked up and observed the accident airplane flying straight and level below a high, overcast cloud layer. He stated that the airplane then pitched “nose down a little” and “straightened again.” He also stated that, shortly thereafter, he observed the airplane’s nose pitch “straight down” until it impacted terrain. The witness reported that he did not notice whether the airplane was rotating about its longitudinal axis during the descent, but he did indicate that the airplane appeared to be intact without any components separating from the airplane during the descent. The witness added that he did not observe any smoke or fire before the airplane impacted terrain and that the airplane exploded into a “mushroom cloud” when it impacted terrain. San Bernardino County firefighters, who were performing controlled burns near the accident site, reported hearing an explosion about the time of the accident. The firefighters reported that they looked toward the direction of the explosion and saw a rising smoke cloud. None of the firefighters observed the airplane before the sound of the explosion. The firefighters drove to the accident site and were the first to arrive there. The firefighters extinguished small fires that had erupted as a result of the crash.

The airplane impacted a residence during a missed approach. After completing the en route portion of the instrument flight, a controller cleared the pilot to proceed direct to the initial approach fix for the global positioning satellite (GPS) approach to the airport. After being cleared for the approach, the airplane continued on a course to the east and at altitudes consistent with flying the GPS published approach procedure. Radar data indicated that at the missed approach point at the minimum descent altitude of 2,000 feet msl, the airplane made a turn to the left, changing course in a northerly direction toward rapidly rising mountainous terrain. The published missed approach specified a climbing right turn to 4,000 feet, and noted that circling north of the airport was not allowed. Remaining in a slight left turn, the airplane climbed to 3,300 feet msl over the duration of 1 minute 9 seconds. The controller advised the pilot that he was flying off course toward mountainous terrain and instructed him to make an immediate left turn heading in a southbound direction. The airplane descended to 3,200 feet msl and made a left turn in a southerly direction. The airplane continued to descend to 2,100 feet msl and the pilot read back the instructions that the controller gave him. The airplane then climbed to 3,300 feet, with an indicated ground speed of 35 knots, and began a sharp left turn. It then descended to impact with a house. At no time during the approach did the pilot indicate that he was experiencing difficulty navigating or request assistance. An examination of the airplane revealed no evidence a mechanical malfunction or failures prior to impact; however, both the cockpit and instrument panel sustained severe thermal damage, precluding any detailed examinations.

The aircraft broke up in-flight during a high speed descent after encountering clouds and reduced visibilities aloft. The weather conditions included multiple cloud layers at 9,000, 12,000 and 16,000 feet, and reduced visibility aloft from smoke and haze from wilderness wild fires that were occurring over large portions of Southern California. The aircraft departed the airport toward a VORTAC to the west, approximately 30 nautical miles (nm) away. The first radar contact was at 1159, and the aircraft's Mode C transponder reported an altitude of 3,500 feet mean sea level (msl). By the time the aircraft reached the VORTAC, the altitude had increased to 4,900 feet msl. The aircraft continued to climb, passing through the VFR flight plan filed altitude of 8,500 feet msl, until it reached an altitude of 12,900 feet msl. The last 6 minutes of radar data reported the aircraft at various altitudes, starting at 11,000 feet msl and climbing to a maximum altitude of 12,700 feet msl. During the last 3 minutes of flight, radar data showed the aircraft made numerous left and right climbing and descending turns, eventually reversing course. The next to last radar return at 1221:24 indicated an altitude of 11,900 feet msl. Nineteen seconds later, the last radar return reported an altitude of 7,700 feet msl. The computed vertical speed between the last two radar returns was 13,263 feet per minute. The wreckage was distributed over a 0.2-nm distance, with the main wreckage approximately 0.5 miles northwest of the last radar return. The northern end of the debris path began with pieces of the left elevator, followed by sections of the right stabilizer and elevator, and more sections from both horizontal empennage surfaces. Pieces of the vertical stabilizer, rudder, and both ailerons were also found along the debris path. The southern 100 feet of the debris path contained the fuselage and both sets of wings, engines, and propellers. The aircraft impacted the ground inverted. The wings separated just outboard of the nacelles at the initial point of impact. Examination of the wreckage showed that all structural failures were the result of overload.

The fire tanker airplane was on a cross-country positioning flight and collided with mountainous terrain while maneuvering in a canyon near the destination airport. Witnesses who held pilot certificates were on a mountain top at 7,900 feet and saw a cloud layer as far to the south as they could see. They used visual cues to estimate that the cloud tops were around 5,000 feet mean sea level (msl). They noted that the clouds did not extend all the way up into the mountain canyons; the clouds broke up near the head of some canyons. When they first saw the airplane, they assumed that it came from above the clouds. It was proceeding north up a canyon near the edge of clouds, which were breaking up. They were definitely looking down at the airplane the whole time. They saw the airplane make a 180-degree turn that was steeper than a standard rate turn. The wings leveled and the airplane went through one cloud, reappeared briefly, and then entered the cloud layer. It appeared to be descending when they last saw it. About 2 minutes later, they saw the top of the cloud layer bulge and turn a darker color. The bulge began to subside and they observed several smaller bulges appear. They notified local authorities that they thought a plane was down. Searchers discovered the wreckage at that location and reported that the wreckage and surrounding vegetation were on fire. The initial responders reported that the area was cloudy and the visibility was low. Examination of the ground scars and wreckage debris path disclosed that the airplane collided with the canyon walls in controlled flight on a westerly heading of 260 degrees at an elevation of 3,400 feet msl. The operator had an Automated Flight Following (AFF) system installed on the airplane. It recorded the airplane's location every 2 minutes using a GPS. The data indicated that the airplane departed Prescott and flew direct to the Twentynine Palms VORTAC (very high frequency omnidirectional radio range, tactical air navigation). The flight changed course slightly to 260 degrees, which took it to the northeast corner of the wilderness area where the accident occurred. At 1102:57, the data indicated that the airplane was at 11,135 feet msl at 204 knots. The airplane then made three left descending 360-degree turns. The third turn began at 6,010 feet msl. At 1116:57, the last recorded data point indicated that the airplane was at an altitude of 3,809 feet heading 256 degrees at a speed of 128 knots.

During a nighttime takeoff initial climb, the airplane collided with terrain near the airport. Witnesses reported watching the airplane accelerate on runway 12, rotate, and climb to 200 to 300 feet above ground level. The climb rate decreased and the airplane appeared to initiate a left turn, with the roll continuing to a wings vertical attitude. At this point the airplane descended into the terrain. One witness north of the accident site described the landing lights going from horizontal to vertical followed by a decrease in engine sound just before impact. According to the airplane owner, the pilot had never flown the accident airplane before the first leg to the accident location to drop off the owner and another passenger. Examination of the pilot records failed to locate any previous flight time in Cessna 300 or 400 series airplanes. In the last 30 days he had given instruction in a smaller light twin engine airplane. Post accident examination of the wreckage revealed the landing gear to be in the down position at the time of impact. The retractable landing lights were extended and the nose gear taxi light was destroyed. Both propellers exhibited symmetrical power signatures. No preimpact mechanical malfunctions or failures were identified. The impact site was east of the airport about 0.68 nautical miles. The departure direction is towards a mountain range with sparse population and few ground reference lights. The moon's disk was 25 degrees above the southeastern horizon and was 89 percent illuminated. The FAA AC61-23C Pilot's Handbook of Aeronautical Knowledge addresses the environmental factors and potential in-flight visual illusions, which could affect pilot performance. The reference material describes Somatogravic Illusion as, "a rapid acceleration during takeoff can create the illusion of being in a nose up attitude. The disoriented pilot will push the airplane into a nose low, or dive attitude. A rapid deceleration by a quick reduction of the throttles can have the opposite effect, with the disoriented pilot pulling the airplane into a nose up, or stall attitude."

The pilot lost control of his twin engine airplane and collided with terrain while returning to the departure airport after reporting an engine problem. Shortly after takeoff, about 4,000 feet msl, the pilot reported to ATC that he had an engine problem and would return to the airport. The radar plot reveals a steady descent of the airplane from 4,000 feet msl to the accident site, approximately 2 miles from the designated airport. Ground witnesses reported that they saw the airplane flying very low, about 500 feet agl, seconds prior to the accident apparently heading toward the departure airport. The witnesses reported consistent observations of the airplane "wobbling," then going into a steep knife-edge left bank before it dove into the ground. Witnesses at the airport said that the pilot sought out help in getting his radios operating prior to takeoff, telling the witness, "it's been four and a half months since I've been in an airplane, I can't even figure out how to put the radios back in." No fueling records were found for the airplane at the departure airport. The last documented fueling of the airplane was on October 31, 2002, with the addition of 56.2 gallons. Witnesses reported that the airplane did not take on any fuel immediately prior to the flight on May 4th. The flight was the first flight since the airplane received its annual inspection 2 months prior to the accident, and, it was the pilot's first flight after 4 months of inactivity. It is a common practice for maintenance personnel to pull the landing light circuit breakers during maintenance to prevent the fuel transfer pumps, which are wired through the landing light system, from operating continuously. The fuel transfer pumps move fuel from the forward part of the main fuel tank to the center baffle area where it is picked up and routed to the engine. It is conceivable that these circuit breakers were not reset by the pilot for this flight. Wreckage examination revealed a post accident fire on the right wing of the airplane and no fire on the left wing. Additionally, only a small amount of fuel was identified around the left wing tanks after the accident, and no hydraulic deformation was observed to the left main tank or the internal baffles. The landing gear bellcrank indicates that the landing gear was in the down position. The engine and propeller post impact signatures indicate that the left engine was operating at a low power setting (wind milling), while the right engine and propeller indicate a high power setting. Disassembly and inspection of the internal propeller hub components showed that the left propeller was not feathered. The left engine is the critical engine and loss of power in that engine would make directional control more difficult at slower speeds. The airplane owners manual states that "climb or continued level flight at a moderate altitude is improbable with the landing gear extended or the propeller windmilling." The single engine flight procedure delineated in the manual dictates a higher than normal altitude for a successful single engine landing approach.

The airplane collided with obstructions following a loss of power in one engine during a missed approach. Following the collision sequence the airplane came to rest upright about 500 feet from the approach end of the runway and was destroyed in a post-impact ground fire. The pilot told a responding sheriff's deputy and a Federal Aviation Administration (FAA) inspector that he made the ILS approach to land and initiated a missed approach. When he added power, the left engine sputtered and the airplane veered to the left. He activated the fuel boost pump, but the airplane contacted obstructions and crashed. The responding sheriff's deputy also observed the accident. He heard an engine of an airplane making unusual sounds. The engine "seemed to get quiet and then revved higher as if to climb." He looked in the direction of the sound and saw a series of blue flashes and then an orange fireball. The deputy reported that there was a dense fog in the area at the time. At the time of the accident, the airport's weather conditions were reported as 100 feet overcast and 1/4-mile visibility in fog. The landing minimums for the ILS approach are 200 feet and 1/2-mile. According to the operator's records, when the airplane departed from Ukiah, its gross takeoff weight was about 5,909 pounds. The pilot operating handbook (POH) for the airplane lists the following items in the single engine go around checklist: 1) Throttle full forward; 2) wing flaps up; 3) when positive climb rate achieved, gear up; 4) ensure the inoperative engine is feathered. For a gross weight of 5,900 pounds, and the existing atmospheric conditions, the single engine climb performance chart shows an expected positive rate of climb of 500 feet per minute if the airplane was configured correctly. The chart also lists the following subtractions from that performance for the listed condition: 1) -400 fpm for wind milling inoperative engine; 2) -350 feet for landing gear down; 3) -200 fpm for flaps extended to 15 degrees. Examination of the wreckage disclosed that neither engine's propeller was feathered, the landing gear was down and the flaps were extended to 10 degrees. Without the airplane configured correctly for the single engine missed approach, the net climb performance would be a negative 400 feet per minute. There were no discrepancies noted with the airframe examination. The engine examination revealed no mechanical anomalies with either engine that would have precluded normal operation. 14 CFR 135.224 states that a pilot cannot initiate an approach if the weather conditions are below landing minimums if the approach is started outside of the final approach fix. The pilot can continue the landing if they are already established on the approach and the airport goes below landing minimums. According to the operator's FAA approved operating specifications, the operator had not been approved for lower than standard landing minimums.

The airplane crashed into rising terrain after departure from an uncontrolled public airport. The runway used by the pilot is 4,600 feet long and has a 1.8 percent upward gradient. The density altitude was 4,937 feet msl, and a slight quartering tailwind existed at the time. The pilot held in position, powered up the engines, and started his departure. The airplane was observed using most of the runway length before rotation and then it assumed a higher than normal pitch attitude in the initial climb. Witnesses watched the airplane turn left following the route of a canyon and into rising terrain. The reciprocal runway departs towards decreasing elevations. In the area of the crash, two witnesses reported the airplane was at a low altitude, nose high, and wallowing just before it descended into a drainage area 0.69 miles from the runway. Post accident examination of the engines revealed worn camshaft lobes and tappets, which would negatively affect the ability of the engines to produce full rated power. One engine exhibited severe rust on the entire crankshaft. The accident site was located in a canyon, and the wreckage and ground scars was confined to an area about the diameter of the wing span. Major portions of the airframe and most of the engine accessories were consumed by a post accident fire. Examination of the wreckage established that all major components of the airframe and powerplants were at the site.

The airplane veered off the runway during a rejected takeoff, overran an airport sign, and impacted a hangar. The captain stated that during the after start checklist he moved the power levers to disengage the start locks on the propellers. Post accident examination found that the left propeller was still in the start lock position, while the right propeller was in the normal operating range. The captain was the pilot flying (PF) and the second-in-command (SIC) was the non flying pilot (NFP). After receiving their clearance, the PF taxied onto the runway and initiated the takeoff sequence. The SIC did not set and monitor the engine power during takeoff, as required by the company procedures. During the takeoff acceleration when the speed was between 40 and 60 knots, the captain released the nose gear steering control switch as the rudder became aerodynamically effective. When the switch was released, the airplane began immediately veering left due to the asymmetrical thrust between the left and right engine propellers. The PIC did not advise the SIC that he had lost directional control and was aborting the takeoff, as required by company procedures. The distance between where the PIC reported that he began the takeoff roll and where the first tire marks became apparent was about 630 feet, and the distance between where the marks first became apparent and where the airplane's left main landing gear tire marks exited the left side of the runway was about 220 feet. Thereafter, marks (depressions in the dirt) were noted for a 108-foot-long distance in the field located adjacent to the runway. Medium intensity tire tread marks were apparent on the parallel taxiway and the adjacent vehicle service road. These tread marks, over a 332-foot-long distance, led directly to progressively more pronounced marks and rubber transfer, and to the accident airplane's landing gear tires. Based on an examination of tire tracks and skid marks, the PIC did not reject the takeoff until the airplane approached the runway's edge, and was continuing its divergent track away from the runway's centerline. The airplane rolled on the runway through the dirt median and across a taxiway for 850 feet prior to the PIC applying moderate brakes, and evidence of heavier brake application was apparent only a few hundred feet from the impacted hangar. No evidence of preimpact mechanical failures or malfunctions was found with the propeller assemblies, nose wheel steering mechanism, or brakes.

On a final approach to runway 26 the flight crew was advised by a flight instructor in the traffic pattern that a wind shear condition existed about one-quarter of the way down the approach end of the runway, which the flight crew acknowledged. On a three mile final approach the flight crew was advised by the instructor that the automated weather observation system (AWOS) was reporting the winds were 060 degrees at 8 knots, and that he was changing runways to runway 08. The flight crew did not acknowledge this transmission. The captain said that after landing smoothly in the touchdown zone on Runway 26, he applied normal braking without any response. He maintained brake pedal pressure and activated the engine thrust reversers without any response. The copilot said he considered the approach normal and that the captain did all he could to stop the airplane, first applying the brakes and then pulling up on the thrust reversers twice, with no sensation of slowing at all. Considering the double malfunction and the mountainous terrain surrounding the airport, the captain elected not to go around. The aircraft subsequently overran the end of the 5,860 foot runway (5,260 feet usable due to the 600 displaced threshold), went through the airport boundary fence, across the perimeter road, and came to rest upright in a dry lakebed approximately 400 feet from the departure end of the runway. With the aircraft on fire, the five passengers and two crew members safely egressed the aircraft without injuries before it was consumed. Witnesses to the landing reported the aircraft touched down at midfield, was too fast, porpoised, and was bouncing trying to get the gear on the runway. Passengers recalled a very hard landing, being thrown about the cabin, and that the speed was excessive. One passenger stated there was a hard bang and a series of smaller bangs during the landing. Federal Aviation Regulations allowed 3,150 feet of runway for a full stop landing. Under the weather conditions reported just after the mishap, and using the anticipated landing weight from the load manifest (12,172.5 pounds), the FAA approved Cessna Flight Manual does not provide landing distance information. Post-accident examination and testing of various wheel brake and antiskid/power brake components revealed no anomalies which would have precluded normal operations.