ANC03FA066

NTSB accident investigation · Cessna 421C · Sitka, AK · July 4, 2003

Accident · FatalField investigationFinal report
Date
July 3, 2003, 16:00 local (Jul 4, 2003, 00:00 UTC)
Place
Sitka, AK
Injuries
5 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N777DXCessna 421C
Weather
Instrument (IMC) · Day
Status
Completed · report September 29, 2004
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
Cessna, Continental Motors, Juneau FSDO-05
FAA report
20030703033399A
Case key
57425

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to follow IFR procedures by not following the published approach procedures, which resulted in an in-flight collision with terrain. Factors contributing to the accident were a low ceiling, and the pressure induced by conditions/events (the open baggage door).

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Miscellaneous/otherCruise - normal
Door,cargo/baggage - openFactor
In flight collision with terrain/waterApproach - faf/outer marker to threshold (ifr)
Weather condition - low ceilingFactor
Ifr procedure - not followedPilot in commandCause
Pressure induced by conditions/eventsPilot in commandFactor
Terrain condition - mountainous/hilly

Analysis

The pilot of the twin-engine accident airplane was on an IFR flight plan in instrument meteorological conditions when the right side nose baggage door opened. The pilot expressed concerns to air traffic control about baggage exiting the compartment and striking the right propeller. He requested a diversion to the nearest airport with an instrument approach. The flight was diverted as requested, and was cleared for a nonpercision instrument approach to a coastal airport adjacent to mountainous terrain. The flight was authorized to a lower altitude when established on the approach. A review of the radar track information disclosed that the pilot did not fly the published approach, but abbreviated the approach and turned the wrong direction, toward higher terrain, north of the approach course. The airplane was discovered in mountainous terrain, about 1,100 msl, and 1.5 miles north of the approach course. The crash path was initially at a shallow angle in the treetops, until the airplane struck larger trees. Postaccident inspection of the airplane disclosed no evidence of any preimpact mechanical problems, other than the baggage door, which was still attached to the airplane.

Factual narrative

History of flight

On July 3, 2003, about 1600 Alaska daylight time, a Cessna 421C airplane, N777DX, was destroyed when it collided with terrain about 3 miles north of Sitka, Alaska, during an instrument approach to the Sitka Airport. The airplane was operated by the pilot as an instrument flight rules (IFR) personal cross country flight under Title 14, CFR Part 91, at the time of the accident. The pilot and the four passengers were fatally injured. Instrument meteorological conditions prevailed, and an instrument flight plan was filed. The flight departed Prince Rupert, British Columbia, en route to Anchorage, Alaska, about 1512.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on July 3, a specialist at the Sitka FAA Flight Service Station (FSS), said the pilot of the accident airplane reported to air traffic control (ATC) at Anchorage Center, that a forward baggage door on the right side of the airplane's nose had come open, and he was concerned baggage could be ejected into the right engine. He requested to divert to the nearest airport for landing to secure the door.

The airplane was diverted to Sitka, and was cleared for the GPS runway 11 instrument approach. The approach is principally a straight-in, nonprecision instrument approach, which necessitated the airplane flying past the airport, intercepting the instrument approach course, and approaching the airport from the northwest. The pilot contacted the Sitka, FAA Flight Service Station (FSS), and reported the airplane inbound on the approach. When the airplane did not arrive at the airport, the FSS specialist attempted to contact the airplane by radio. After failing to make contact, a search was initiated. On July 4, about 1200, searchers located the wreckage of the airplane on a steep, heavily wooded hillside, 3 miles north of the airport, at an elevation of 1,100 feet.

Injury to persons

All five occupants of the airplane received fatal injuries.

Damage to aircraft

The airplane was destroyed by impact and postcrash fire.

Personnel information

The accident airplane was co-owned by four pilots, three of whom were aboard during the accident. Due to the severity of the crash and postimpact fire, it could not be definitively determined who the flying pilot was at the time of the accident. A seating chart created by the Alaska State Troopers, who recovered the occupants remains, indicates that the left front pilot's seat was occupied by the individual who filed the accident IFR flight plan, and for the purposes of this report, he will be considered the flying pilot.

No personal flight records were located for the pilot, and all the aeronautical experience listed was obtained from a review of FAA records. The pilot was issued an FAA Third Class Medical Certificate on September 18, 2001, and held a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, helicopter, and instrument airplane. According to this medical certificate application dated September 18, 2001, the pilot had accumulated 9,200 total flying hours.

No record of a current biennial flight review was found, however the pilot had received recent annual recurrent training in the airplane, as required by the limited corporation directing co-ownership of the airplane. The airplane had been recently fitted with a new autopilot, and navigation/communications equipment by Autopilot Central, Tulsa Oklahoma. The pilot received training/checkout on the new systems from the installing company.

Aircraft information

The airplane was a model year 1975 Cessna 421C, twin-engine airplane. An annual inspection was completed on June 23, 2003, and the airplane had accumulated a total airframe time of 7,996 hours at the time of the inspection. The left engine had accumulated 3,040 total hours, and 208 hours since major overhaul. The right engine had accumulated 3,376 total hours, and 1,010 hours since major overhaul. On January 23, 2003, the airplane's instrumentation and communications equipment were upgraded with two Garmin Color Moving Map/GPS/NAV/COM, GNS-530 navigation systems. According to the surviving owner, the system was loaded with the latest Jeppesen navigation, airport, and approach databases, and certified for IFR operation. The airplane was also equipped with a fully coupled S-Tec autopilot during the installation.

Meteorological information

Prior to commencing the instrument approach to Sitka, the ATC specialist provided the 1553 Sitka weather information to the pilot, which included 10 miles visibility, wind 200 degrees at 10 knots, an overcast ceiling at 2,600 feet, temperature 12 degrees C, dewpoint 11 degrees C, and an altimeter setting of 29.83 inHg. The ATC specialist also advised that a DC-9 airplane had just completed the instrument approach, and reported breaking out at 400 feet msl, one and one-half miles out, and that conditions were deteriorating.

The weather forecast for southeast Alaska valid for the time of the accident included an AIRMET, calling for IFR conditions, mountains obscured, occasional ceilings below 1,000 feet msl, and visibility less than 3 miles in light rain and blowing rain.

Aids to navigation

The Sitka Global Positioning System (GPS) Runway 11 instrument approach is a nonprecision approach with a minimum descent altitude (MDA) of 580' msl. The instrument approach is northwest of Sitka, with a southeasterly inbound course. The charted initial approach fix (IAF) is "HESOK", 6.7 nm northwest of "TIPEH", the final approach fix (FAF), which is 4 nm northeast of "WEGWI", the missed approach point. The minimum crossing altitude for "TIPEH" is 1,500 msl. To the south side of the inbound approach course is open water, and to the north side is mountainous coastal terrain varying in elevation from sea level to over 3,000' msl. The charted holding/procedure turn area at "HESOK" is on the southwest side of the inbound course over open water. A copy of the GPS runway 11 approach chart is included in the docket for this report.

Radar coverage was available for the entire approach. According to radar data, the airplane was approaching Sitka from the southeast, tracking direct to "TIPEH". The airplane started to descend about 14 miles southeast of Sitka. As the airplane neared "TIPEH," it descended below 2,700' msl and commenced a descending right turn toward rising coastal terrain. The turn was completed over open water, and the airplane proceeded southeast on a course roughly paralleling the inbound approach course, but offset about 1.5 miles north of the inbound course centerline. The airplane continued to descend with the last radar hit at an altitude of 1,400' msl. The last radar hit also indicates the airplane was making a course correction to the right toward the course centerline. GPS coordinates from the accident site indicate the point of impact about 1,800 feet southeast from the last radar hit. A diagram of the airplane's radar track is included in the docket for this report.

Communications

According to FAA ATC tapes/transcripts, about 1521, the pilot advised ATC that a front baggage compartment door had come open, and requested to divert to the nearest airport for landing. ATC advised the pilot that Sitka was the nearest airport with an instrument approach, and provided vectors to Sitka, with an authorized descent to an altitude of 10,000 feet msl. ATC asked the pilot if he was declaring an emergency, and the pilot stated he was not. The pilot was told to fly direct to the Biorka Island Very High Frequency Omnirange (VOR) transmitter, and to expect the Localizer Type Directional Aid/Distance Measuring Equipment (LDA/DME) runway 11 instrument approach which has a MDA of 400' msl, or 381' height above terrain (HAT). ATC gave the pilot the current weather observation at Sitka, and

Aircraft

Registration
N777DX
Reported as
Cessna 421C
Category
Airplane
Serial number
421C0048
Airframe hours
7,981
Engine
Continental GTSIO-520-F-K, 435 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Bowl Aviation LLC.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 29, 2003
Departed
CYPR · Prince Rupert
Destination
SIT · Sitka, AK
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
9,200 total

Weather

Conditions
Instrument (IMC) · Day
Wind
200° at 7 knots
Visibility
0 statute miles
Lowest ceiling
2,600 ft overcast
Temperature
54 °F, dew point 52 °F
Altimeter
29.82 inHg
Observed at
PASI, 3 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.