ATL03FA077

NTSB accident investigation · Cessna 414 · Waleska, GA · April 10, 2003

Accident · FatalField investigationFinal report
Date
April 10, 2003, 17:00 local (21:00 UTC)
Place
Waleska, GA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N822DBCessna 414
Weather
Instrument (IMC) · Day
Status
Completed · report January 24, 2005
Report
Approved by Office Director
Parties
Teledyne Continental Motors, Atlanta FSDO 11, Cessna Aircraft Co.
FAA report
20030410009179A
Case key
56811

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 maintain clearance from terrain.

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.

In flight collision with terrain/waterCruise - normal
Terrain condition - mountainous/hilly
Clearance - not maintainedPilot in commandCause
Visual lookout - inadequatePilot in commandCause

Analysis

The VFR repositioning flight departed Rome, Georgia en route to Canton, Georgia but never arrived. Late on the evening of April 10, 2003, the pilot's spouse contacted the local authorities when her husband did not arrive at home or call. The spouse stated that her husband flew out of Rome early Thursday morning headed to Augusta, Georgia to pick up an unknown number of passengers and fly them back to Rome, Georgia. The authorities confirmed that the passengers had arrived at their destination. The Civil Air patrol began a search and located the airplane on the side of "Bear Mountain" in Canton, Georgia, on April 11, 2003. The wreckage site was located 11.3 nautical miles west of Cherokee County Airport, Canton, Georgia, and 26 nautical miles east of Rome, Georgia on the west side of Bear Mountain. The mountains ridgeline runs northeast and southwest, near the town of Waleska, Georgia. The field elevation at the crash site was 1,750 feet above mean sea level (msl) and the peak of Bear Mountain was 2,268 feet msl. The upslope of the terrain at the site was estimated at 30-40 degrees. Examination of the airframe, flight controls, engine assembly and accessories revealed no anomalies.

Factual narrative

History of flight

On April 10, 2003 approximately 1700 eastern daylight time, a Cessna 414, N822DB, registered to Trace Aviation, Inc., and operated by the Airline Transport Pilot, collided with rising terrain in a wooded area of Bear Mountain in Waleska, Georgia. The repositioning flight was conducted under the provisions of Title 14 CFR Part 91, and visual flight rules. An instrument rules flight plan (IFR) flight plan was on file but not activated. The pilot received fatal injuries and the airplane was destroyed by impact and post-impact fire. The flight originated from Rome, Georgia on April 10, 2003 at an undetermined time.

Late on the evening of April 10, 2003, the pilot's spouse contacted the local authorities when her husband did not arrive at home or call. The spouse stated that her husband flew out of Rome early Thursday morning headed to Augusta, Georgia to pick up an unknown number of passengers and fly them back to Rome, Georgia. The authorities confirmed that the passengers had arrived at their destination. The Civil Air patrol began a search and located the airplane on the side of "Bear Mountain" in Canton, Georgia, on April 11, 2003.

The pilot filed an IFR flight plan with the Macon Automated Flight Service Station (AFSS), Macon, Georgia for departure from Richard B. Russell Airport, Rome, Georgia at 1530 to his base airport, Cherokee County Airport, Canton, Georgia, 37 nautical miles east of Rome, Georgia. No weather briefing was obtained for the flight.

Personnel information

A review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the pilot was issued an Airline Transport Pilot certificate on October 13, 1989, with ratings for airplane multiengine land and instrument airplane. Additionally, the pilot held a commercial pilot certificate with a rating for airplane single engine land. A review of records on file with the FAA Aero Medical Records revealed the pilot held a first class medical certificate issued on August 28, 2002, with restrictions that "the holder shall possess glasses for near and intermediate vision." The pilot reported on his application for the medical certificate that he had accumulated 4,500 total flight hours. Review of the pilot's logbook revealed the last recorded entry was an instrument flight conducted on January 13, 2003. The pilot's biennial flight review was completed on March 15, 2002.

Aircraft information

A review of airframe maintenance records revealed that the last recorded annual inspection was conducted on April 1, 2002, by S&S Aviation Company, Ball Ground, Georgia. The airframe had accumulated 6,723.2 hours. The tach time at the crash site could not be determined. The most recent pitot/static check was done on April 18, 2001. A review of the left engine maintenance records revealed that the engine had a total time as of December 31, 2002, of 3,575.9 hours and 577.7 since major overhaul. A review of the right engine maintenance records revealed that the engine had a total time as of December 31, 2001, of 4,465.6 hours and 577.7 since major overhaul.

Meteorological information

The Rome, Georgia, 1653 surface weather observation was winds from 320 degrees at seven knots, visibility of six statute miles in light rain, scattered clouds at 1,700 feet above ground level (agl), overcast ceiling at 2,300 feet agl, temperature nine degrees Celsius, dew point six degrees Celsius, and altimeter setting of 29.76. Visual meteorological conditions prevailed at the time of departure from Rome, Georgia. The pilot departed VFR from Rome, Georgia and did not activate his IFR flight plan.

Wreckage and impact information

The wreckage site was located 11 nautical miles west of Cherokee County Airport, Canton, Georgia, and 26 nautical miles east of Rome, Georgia and located on the west side of Bear Mountain. The mountains ridgeline runs northeast and southwest, near the town of Waleska, Georgia. The crash debris line extended 220 feet on a heading of 090 degrees, magnetic. The field elevation at the crash site was 1,750 feet above mean sea level (msl) and the peak of Bear Mountain was 2,268 feet msl. The upslope of the terrain at the site was estimated at 30-40 degrees. Three distinct craters were observed eight feet apart in a horizontal plane across the ground 40 feet downhill from the main wreckage.

Examination of the main wreckage revealed that the fuselage was on its right side, aligned on a westerly heading. The right engine nacelle was lodged beneath the main wreckage. The cockpit and fuselage were crushed aft and fire damaged. The left and right fuel selector valves were separated from the airframe. The right selector valve was in the off position and the position of the left selector valve could not be determined. Fuel system continuity could not be established due to damage. The position of the engine controls, switches, landing gear, and instrument readings could not be determined.

The left wing was fragmented and fire damaged. The left engine separated from the nacelle and was located inverted left of the main wreckage. The left wing nacelle and inboard portion of the wing remained attached to the fuselage. The inboard section of the left flap separated from the wing and was damaged, but was recovered and in a retracted position. The outboard section of the left flap remained attached to the wing. The left aileron was damaged. The left main fuel tank and auxiliary fuel tanks were ruptured and fire damaged. The left main landing gear actuator was destroyed.

The right wing was separated, fragmented, and fire damaged. The right engine separated from the nacelle and was located 50 feet uphill from the main wreckage. A 68-inch section of the outboard right wing was separated from the wing. The right flap separated from the wing and was damaged. The right aileron separated from its hinge points and was damaged. . The right main fuel tank and auxiliary fuel tank were ruptured and fire damaged. The right main landing gear strut and gear remained in the gear well. The right main landing gear actuator was destroyed. Soot observed under the empennage spread up the sides of the fuselage, but not aft.

Examination of the left engine revealed the oil sump was crushed and broken. The exhaust system and induction tubes were crushed and broken. The cylinder cooling fins were broken on the right side. Piston movement was observed on cylinders No. 2, 3, 4, and 6 when the engine was rotated. The right magneto separated and the left magneto was broken at the mount. The ignition leads were broken. The right magneto drive was rotated and spark was obtained. The left magneto case was crushed and the drive would not rotate. The top spark plugs' electrodes on cylinders Nos. 2, 3, and 4 were worn out-normal and the no.4 bottom spark plug electrode was oil soaked when compared to the Champion Aviation Check-A-Plug Card. The top and bottom spark plugs at cylinders nos. 1 and 5 were broken off and could not be removed. The crankshaft was rotated 360 degrees and continuity was confirmed through the accessory section. The alternator, starter, propeller governor, and tach generator were separated from the engine. The vacuum pump coupler was intact and the drive turned freely. The fuel pump coupler was intact and dry, and the pump drive turned freely. The fuel manifold valve diaphragm was intact, the screen was clean and the chamber was dry. The fuel control unit screen was free of debris. The turbocharger remained attached to the nacelle. The impeller/turbine would not rotate. The impeller blades were bent and broken scoring was present inside the compressor housing. The turbine blades did not show visible damage.

Examination of the right engine revealed that the oil sump was crushed and breached. The engine exhaust and the induction tubing were crushed and broken. Both magnetos separated from the engine. One magneto was r

Aircraft

Registration
N822DB
Reported as
Cessna 414
Category
Airplane
Serial number
414-0813
Airframe hours
5,078
Engines
Continental TSIO-520-NB, 335 horsepower, reciprocatingContinental TSIO-520-LcNB, 335 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
James Carr Gilmore
Registered owner
Trace Aviation
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2002
Departed
RMG · Rome, GA
Destination
47A · Canton, GA
Flight plan
IFR
Airport
47A · Cherokee County

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
57
Injuries
Fatal
Certificates
Private, Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
March 15, 2002
Seat
Left
Toxicology
Performed
Flight hours
4,500 total · 245 in this make and model

Weather

Conditions
Instrument (IMC) · Day
Wind
300° at 17 knots
Visibility
6 statute miles
Lowest ceiling
2,000 ft overcast
Temperature
41 °F, dew point 39 °F
Altimeter
29.71 inHg
Observed at
RMG, 23 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.