North Carolina

The flight was cleared for the ILS approach to runway 5R. The flight was at mid runway, at 2,100 feet, heading 049 degrees, at a speed of 163 knots, when the pilot stated "...missed approach." He was instructed to maintain 2,000, and to fly runway heading. Radar showed N41003 started a right turn, was flying away from the airport/VOR, descending. At a point 0.57 miles from the airport/VOR, the flight had descended to 1,500 feet, was turning right, and increasing speed. The flight had descended 400 feet, and had traveled about 0.32 miles in 10 seconds. When radio and radar contact were lost, the flight was 2.35 miles from the airport/VOR, level at 1,600 feet, on a heading of 123 degrees, and at a speed of 169 knots. The published decision height (DH) was 620 feet mean sea level (msl). The published minimum visibility was 1/2 mile. The published Missed Approach in use at the time of the accident was; "Climb to 1,000 [feet], then climbing right turn to 2,500 [feet] via heading 130 degrees, and RDU R-087 [087 degree radial] to ZEBUL Int [intersection] and hold." A witness stated that the aircraft was flying low, power seemed to be in a cruise configuration, and maintaining the same sound up until the crash. The reported weather at the time was: Winds 050 at 5 knots, visibility 1/2 statute mile, obscuration fog and drizzle, ceiling overcast 100, temperature and dew point 11 C, altimeter 30.30 in HG. At the time of the accident the pilot had 10 total flight hours in this make and model airplane; 33 total night flight hours; and 59 total instrument flight hours.

The pilot had left the airplane at Asheville on the day before the accident due to low cloud ceilings and visibility at Mountain Air Airport, his destination, and completed the trip by rental car. On the day of the accident the pilot returned the rental car and at 1656 departed Asheville in N396PM, enroute to Mountain Air Airport, 27 miles north of Asheville. The last radio contact with the pilot was at 1701:44, when the pilot told controllers at Asheville that he was in visual flight rule conditions, at 4,000 feet. The last radar contact with the flight was by FAA Atlanta Center, at 1704:00, when the flight was about 5 miles south of the accident site at 3,800 feet. The flight did not arrive at the destination, an emergency locator transmitter signal was received by satellite, and search and rescue operations were begun. The pilot and the wreckage of the airplane was located the next day about 1400. The airplane had collided with 75-foot tall trees, at about the 4,800-foot msl level on the side of Bullhead Mountain, while in a wings level attitude, while on a 170 degree heading. After the initial impact the airplane continued for another 300 feet, causing general breakup of the airplane. The main wreckage came to rest on a northerly heading. All components of the airplane were located at the crash site and there was no evidence of precrash failure or malfunction of the airplane structure, flight controls, airplane systems, engine, or propeller. A witness reported that the weather near the time of the accident on the Blue Ridge Parkway, located about 3/4 mile to the west of the crash site, was very foggy. Satellite images show clouds were present at the crash site and the Asheville airport, located 20 miles south-southwest of the crash site, reported overcast clouds 2,600 feet agl or 4,765 feet msl, and visibility 4 miles in haze, at the time of the accident. An Airmet for mountain obscuration due to clouds, mist, and haze was in effect at the time the pilot departed and the at the time of the accident. No record to show that the pilot received a weather briefing from a FAA Flight Service Station was found.

The flight was maneuvering in instrument meteorological conditions and was observed on radar making climbing and descending turns prior to making a final descending turn and being lost from radar. Examination of the crash site showed the airplane had impacted the terrain in a about a 90-degree nose down attitude. The crash site was about .09 miles from the last radar contact, when the airplane was 2,000 feet above ground level. Post crash examination of the airplane structure, flight controls, engines, propellers, and airplane systems showed no evidence of pre-crash failure or malfunction.

After an approach to runway 5, and touched down at 85 knots, the airplane yawed right, exited the runway, the right main landing gear collapsed, and the airplane nosed over. Examination of the airplane revealed that a right main wheel brake had locked up, and the landing gear had collapsed. Inspection of the right main landing gear assembly and all associated components could not provide any determination as to what caused the main wheel brake to lockup. The brake assembly was broken down into its component parts and inspected. No evidence of malfunction could be detected. No contamination of the hydraulic fluid was evident.

Examination of the area of the fire origin revealed that relay R2-53, the left heat exchanger cooling fan relay, was severely heat damaged, as were R2-54 and the other relays in this area. However, the R2-53 relay also exhibited loose terminal studs and several holes that had burned through the relay housing that the other relays did not exhibit. The wire bundles that run immediately below the left and right heat exchanger cooling fans and the ground service tie relays exhibited heat damage to the wire insulation, with the greatest damage located just below the R2-53 relay. The unique damage observed on the R2-53 relay and the wire damage directly below it indicates that fire initiation was caused by an internal failure of the R2-53 relay. Disassembly of the relay revealed that the R2-53 relay had been repaired but not to the manufacturer's standards. According to the manufacturer, the damage to the relay housing was consistent with a phase-to-phase arc between terminals A2 and B2 of the relay. During the on-scene portion of the investigation, three of the four circuit breakers in the left heat exchanger cooling fan were found in the tripped position. To determine why only three of the four circuit breakers tripped, all four were submitted to the Materials Integrity Branch at Wright-Patterson Air Force Base, Dayton, Ohio, for further examination. The circuit breakers were visually examined and were subjected to an insulation resistance measurement, a contact resistance test, a voltage drop test, and a calibration test (which measured minimum and maximum ultimate trip times). Testing and examination determined that the circuit breaker that did not trip exhibited no anomalies that would prevent normal operation, met all specifications required for the selected tests, and operated properly during the calibration test. Although this circuit breaker appeared to have functioned properly during testing, the lab report noted that, as a thermal device, the circuit breaker is designed to trip when a sustained current overload exists and that it is possible during the event that intermittent arcing or a resistive short occurred or that the circuit opened before the breaker reached a temperature sufficient to trip the device.

The flight had proceeded without incident until a visual approach was made to the destination airport, but a landing was not completed because of poor visibility due to ground fog. The pilot then requested vectors to another airport, and was advised by ATC that he was below radar coverage, and he could not be radar identified. The pilot stated he would proceed to a third airport; he was given a heading, instructed to proceed direct to the airport, and report the field in sight. He was told to over-fly the airport, and might be able to descend through a clearing in the clouds. An inbound air carrier flight reported instrument meteorological conditions on the final approach to a parallel runway. At a location of 1.13 miles east of the airport, the flight, for no apparent reason, turned south, away from the airport. The last radio contact with pilot was after ATC told him his heading was taking him away from the airport and he said he was turning back. The last known position of N201RH was 1.95 miles southeast of the airport, at 500 feet MSL. According to the statement of the passenger that was sitting in the co-pilot's seat, "...all we could see were city lights and darkness underneath us. We were in a right turn, when I saw the trees and subsequently hit it." According to the pilot's log book and FAA records revealed a limitation on his commercial pilot certificate prohibited him from carrying passengers for hire at night and on cross-country flights of more than 50 nautical miles. The records did not show any instrument rating. As per the entries in his personal flight logbook, he had accumulated a total of 1,725.2 total flight hours, 1,550.9 total single engine flight hours, and 184.3 total flight hours in multi-engine aircraft of which 145.6 hours were in this make and model airplane. In addition, the logbooks showed that he had a total of 487.3 cross country flight hours, 61.9 total night flight hours, and 21.6 simulated instrument flight hours.

The airplane bounced on landing and started to swerve on the landing roll. The pilot attempted a go-around. The left engine hesitated and the right engine developed power. The pilot lost directional control, the airplane went off the left side of the runway and collapsed the left main landing gear.

An aircraft mechanic stated one of the airplanes engines was making an unusual noise during takeoff. An Air Traffic Controller stated the flight used about 4,500 feet of runway before lifting off. About 1 minute after being cleared for takeoff, the pilot reported 'were coming around were losing a right engine'. The controller and a witness observed the airplane level off, sway to the left and right, and then descend. The pilot reported he was not going to make it. The airplane was lost from sight behind trees. Post crash examination of the airplane structure, flight controls, engines, and propellers showed no evidence of pre-crash failure or malfunction that would have prevented operation. The landing gear and wing flaps were found retracted. The left and right propellers were found in the low blade angle position and had similar damage. An NTSB sound study of ATC communications showed that at the time the pilot reported they were not going to make it, a propeller signature showed 1,297 rpm and another propeller signature of 2,160 rpm. The engine inoperative procedure contained in the Pilot Operating Handbook for the Cessna 421C, calls for the throttle on the inoperative engine to be closed, the mixture placed in idle cut-off, and the propeller feathered. The Pilot Operating Handbook also showed the airplane would normally use 2,000 feet of runway for takeoff under the accident conditions.

The pilot stated he checked the fuel quantity in the inboard fuel tanks, but may have omitted the outboard tanks. He departed and climbed to 100 feet where the airplane yawed right. He believed it was a gust of wind which he attempted to correct. At 200 feet, the pilot stated the airplane rolled hard right and impacted trees in a 60 degree nose down attitude. There was no indication of a left engine discrepancy prior to impact. The right engine was examined with no fuel found in the fuel lines, and trace fuel was found in the fuel servo. According to the accident pilot, he regularly flew between Washington-Dulles and Southport, North Carolina using only the inboard tanks. Because of this, he did not check the location of the fuel selector, nor did he necessarily check the fuel quantity in the outboard fuel tanks. The cockpit fuel selector for the right engine was found in the outboard tank location. The right outboard tank on this airplane was not breached, and contained no fuel. The takeoff checklist states the fuel selector should be on the inboard fuel tank prior to takeoff.

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.