CEN12FA606

NTSB accident investigation · Cessna 421B · Fort Worth, TX · September 5, 2012

Accident · Serious injuriesField investigationFinal report
Date
September 5, 2012, 09:49 local (14:49 UTC)
Place
Fort Worth, TX
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N69924Cessna 421B
Defining event
Takeoff: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report June 19, 2013
Report
Approved by Office Director
NTSB office
Central Region
Parties
Continental Motors, Inc, FAA/FSDO, Cessna Aircraft Company
FAA report
20120905024829A
Case key
84930

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

On this page

Probable cause

The pilot's failure to maintain airplane control on takeoff, which resulted in an inadvertent stall. Contributing to the accident were the unlatched nose cargo door, the pilot’s diverted attention, and the pilot's mental ability to handle the emergency situation.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 421B: 11 casesAll aircraft: 9,295 casesProbable cause
Mental/emotional state: stressPersonnel issues › Psychological · PilotCessna 421B: 1 caseAll aircraft: 14 casesProbable cause
Equipment/furnishings: cargo compartmentsAircraft › Aircraft systems · MalfunctionCessna 421B: 1 caseAll aircraft: 2 casesProbable cause
Attention/monitoring: attentionPersonnel issues › Psychological · PilotCessna 421B: 1 caseAll aircraft: 226 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The commercial pilot was distracted by the nose cargo door popping open during takeoff; the airplane stalled and collided with trees off the end of the runway. The pilot said there were no mechanical problems with the airplane or engines and that he was fixated on the cargo door and lost control of the airplane. He also said that due to stress, he was not mentally prepared to handle the emergency situation.

Factual narrative

HISTORY OF FLIGHT On September 5, 2012, at 0949 central daylight time, N69924, a Cessna 421B twin engine airplane, sustained substantial damage after colliding with trees shortly after takeoff from Fort Worth Spinks Airport (FWS), Fort Worth, Texas. The airline transport rated pilot and the passenger were seriously injured. A visual flight rules flight plan was filed for the flight that was destined for Stinson Municipal Airport (SSF), San Antonio, Texas. Visual meteorological conditions prevailed for the flight conducted under 14 Code of Federal Regulations Part 91. There were several witnesses to the accident. One witness was an air traffic controller, who had cleared the airplane for takeoff on Runway 17R. He said that as the airplane passed by the control tower on the takeoff roll, both engines sounded normal and were in sync. The airplane rotated near taxiway foxtrot and began a "low and slow" climb. When the airplane was approximately 200 feet high, the pilot announced that a door had popped open and he needed to return to land. The controller approved the request. He then saw the airplane make a right turn followed by a left turn and then collide with trees in a left "side slip." He said it was approximately two seconds from the time the pilot reported the open door to the time the accident occurred. Two Federal Aviation Administration (FAA) maintenance technicians were working near the departure end of Runway 17R when they first saw the airplane. According to one of the technicians, he said the airplane was approximately 150 feet away from him as it passed by from his right to left. He said the airplane was low and slow and not climbing as expected. The airplane cleared the airport perimeter fence by approximately 30-50 feet. The technician said the airplane then began to “fish tail” and was about to stall. He said the airplane’s left wing dipped down followed by the right wing, then back to the left. The airplane then collided with the trees in a left yaw and caught on fire. The technician said the engines were operating and were in sync, but he could not specifically recall if the engines were operating at full power due to the prevailing wind which may have reduced the decibel level of the engine noise. The technician did not remember seeing any doors open on the airplane. The pilot said that he performed a preflight inspection of the airplane and remembered "banging" on the nose cargo door. He said the door was latched, but not locked. After the inspection, he and the passenger got on board the airplane. The pilot sat in the front left seat, and the passenger sat directly behind the pilot in the aft facing seat. The pilot said that he started the engines; taxied to the runway, performed an engine run-up, and then departed. He said he performed a reduced power (approximately 80 percent) takeoff, which resulted in a longer than normal takeoff roll. The pilot said that as soon as he rotated the airplane at “blue line” and began toclimb, the nose cargo door popped completely open. The door appeared like it was going to come off the hinges and into the cockpit. The pilot said he then turned around and told the passenger that the cargo door had popped up and they had to return and land. Then he called air traffic control. Within seconds, the pilot felt the airplane shudder as if it was about to stall, so he immediately lowered the nose. The airplane collided with trees; then hit the ground hard, flipped over, and caught on fire. The pilot was able to open the main door and both he and the passenger exited to safety. The pilot said there were no mechanical problems with the airplane and that he was fixated on the unlatched nose cargo door and lost control of the airplane. He said he was dealing with a lot of stress in his personal life and was not prepared to handle the emergency situation. The passenger said that when the airplane began to climb, it seemed slower than normal. At that point, the pilot turned around and told him a cargo door had opened and they needed to go back and land. The passenger had to turn around in his seat to hear what the pilot was saying, and when he looked forward, he realized that they were going to crash. He did not see the nose cargo door. The passenger said the airplane “dipped” before it made a descending left-hand turn toward the ground. He said he immediately turned around and tightened up his seatbelt before the airplane hit the ground hard and flipped over. PERSONNEL INFORMATION The pilot held an airline transport pilot rating for airplane multi-engine land along with a commercial certificate for airplane single-engine land. He also held an airframe and power plant mechanic certificate. The pilot’s last FAA First Class medical was issued on December 9, 2011, with a restriction for glasses. He reported a total of 3,800 hours of which 897 hours were in the same make and model as the accident airplane. WRECKAGE AND IMPACT INFORMATION The airplane came to rest in clearing surrounded by small trees and brush on a heading of 240 degrees. The wreckage was inverted and mostly consumed by postimpact fire. The initial impact point was a stand of 20-30 foot tall trees. Numerous cut branches were strewn around the wreckage path that exhibited flat, angular cuts. The entire airplane was accounted for at the accident site. The initial impact point from where the airplane struck the trees to where the wreckage came to rest was approximately 150-200 feet. Examination of the airplane revealed the flaps were in the fully retracted position and the landing gear was in the down and locked position. The elevator trim was neutral and the aileron trim was pulled beyond it's stop from impact forces. Flight control continuity was established for all flight control surfaces to the cockpit. The left aileron cable was broken and one of the fractured ends exhibited broom straw signatures. The other end was melted into a melted section of the wing. The aileron sectorwas thermally damaged. Examination of both engines revealed no mechanical deficiencies that would have precluded normal operation at the time of the accident. METEOROLGICAL INFORMATION Weather at FWS at 0952 was reported as wind from 210 degrees at 4 knots, visibility 10 miles, clear skies, temperature 30 degrees Celsius, dew point 19 degrees Celsius, and a barometric pressure setting of 29.92 inches of Hg.

Aircraft

Registration
N69924
Reported as
Cessna 421B
Category
Airplane
Serial number
421B0553
Airframe hours
10,056.8
Engines
Cont Motor GTSIO-520-C, 340 horsepower, reciprocatingCont Motor GTSIO-520-C, 340 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Business · Part 91
Operator
Campbell John
Registered owner
Campbell John
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 9, 2012
Departed
FWS · Fort Worth, TX
Destination
SSF · San Antonio, TX
Flight plan
VFR
Airport
FWS · Fort Worth Spinks Airport, runway 17R, 6,002 × 100 ft, asphalt

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
46
Injuries
Serious
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Flight hours
3,800 total · 897 in this make and model · 3,718 as pilot in command · 31 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 4 knots
Visibility
10 statute miles
Temperature
86 °F, dew point 66 °F
Altimeter
29.92 inHg
Observed at
FWS

Docket · 9

The files NTSB released with the investigation on April 24, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.5 MB in all.

FAA reports on this event · 1

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