CHI00FA265

NTSB accident investigation · Cessna 340A · Mission, SD · August 23, 2000

Accident · FatalField investigationFinal report
Date
August 23, 2000, 02:07 local (07:07 UTC)
Place
Mission, SD
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N34DDCessna 340A
Weather
Visual (VMC) · Not reported
Status
Completed · report January 2, 2002
Report
Approved by Office Director
FAA report
20000823036909A
Case key
50066

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 aircraft control not maintained by the pilot. A contributing factor was pilot fatigue.

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/waterClimb - to cruise
Exhaust system,manifold/pipe - cracked
Aircraft control - not maintainedPilot in commandCause
Fatigue(lack of sleep)Pilot in commandFactor

Analysis

The corporate airplane was destroyed on impact with rolling terrain and fire 1.3 nm northeast of the Mission Sioux Airport (0V6), Mission, South Dakota. The flight was en route to the Rapid City Regional Airport, Rapid City, South Dakota, which was located 114 nm on a magnetic bearing 284 degrees from 0V6. The 290 foot long wreckage path was oriented on a magnetic heading of 290 degrees. Night meteorological conditions prevailed at the time of the accident. A witness and communications with the airplane/pilot indicate that the pilot had a continuous duty time of approximately 21 hours that began at least at 0414 mountain daylight time on the day prior to the date of the accident. The wreckage was distributed along 230 feet with propeller slash marks at the beginning of the wreckage path. Both propellers displayed twisting. Postaccident component examination revealed a preexisting crack in the right turbocharger's exhaust but no indication of melting of the fuel lines in the adjacent area. No other system anomalies were noted.

Factual narrative

History of flight

On August 23, 2000, at 0207 central daylight time, a Cessna 340A, N34DD, was destroyed on impact with terrain and fire following departure from the Mission Sioux Airport (0V6), Mission, South Dakota. Night visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 business flight was not operating on a flight plan. The commercial pilot and two passengers were fatally injured. The flight was originating at the time of the accident and was en route to the Rapid City Regional Airport (RAP), Rapid City, South Dakota.

A line attendant and refueler reported to the Federal Aviation Administration that early in the morning of August 22, 2000, N34DD left for Mission, South Dakota, with the pilot at the controls. The main fuel tanks were full before the airplane left. The airplane returned from Mission at 1645 (Rapid City, South Dakota, is in the mountain time zone). Shortly thereafter, the airplane was serviced with 34.2 gallons of fuel in the main tanks, topping them off. He further stated the aircraft was about to be put away for the night when the pilot called him and said he was going back out on another trip to Mission. He said [the pilot] wanted him to put 10 gallons in each auxiliary fuel tank. He stated that he was only able to service the auxiliary fuel tanks with a total of 18.5 gallons of fuel. The pilot and two passengers departed Rapid City at approximately 1930. The two main fuel tanks and two auxiliary fuel tanks were full of fuel before the airplane left on its last flight.

A witness reported, "A/C departed Mission and started making bank to turn (u turn) then after coming out of its bank the a/c started to lose altitude. It looked like the A/C was about 50 ft. above the top of the big ridge. A/C was level, I saw sparks from the left engine - then heard a bang like a shotgun. Then the aircraft banked to left and went down out of sight. Then at about this time I heard the muffled sound of the crash (like crunching) then I saw the fire ball + smoke. Then I went to the University + told my brother ... to call police - ambulance - + fire trucks. I went to the crash site. Upon arrival I parked the pickup on top of the ridge + ran to the plane. I hollered out - no response..."

A second witness reported, "I saw an airplane leaving Antelope Airport. I saw the airplane travel around or near 2 to 3 miles northeast of Mission, SD. I heard the airplane sputter like something was wrong with the choke. Airplane dropped downwards. I heard a surge of power again in the engines. 2 or 5 seconds later I saw the airplane drop downwards. I saw a cloud of smoke and heard a loud pounding noise. I saw fire coming from where the airplane went down..."

A third witness reported, "We were parked on a dirt road standing outside my vehicle and noticed that a plane was taking off, the plane sounded like it was sputtering after it took off then it sounded like it was accelerating then I heard a loud bomb then seen a large ball of fire."

Personnel information

The pilot was 57 years old and employed as a pilot by the registered aircraft owner. He held a commercial pilot certificate with airplane single engine land, multiengine land and instrument airplane ratings. At the application of the pilot's second-class medical certificate on March 21, 2000, a total flight time of 900 hours was reported. The medical certificate had the restriction, "must wear corr lenses & possess glasses for near & intrm vision". A total flight time of 1,022 hours of which 24 hours in this make and model was reported in the National Transportation Safety Board's (NTSB) 6120.1/2 form (pilot/operator aircraft accident report). The pilot completed a Cessna 340A initial training course on August 11, 2000.

Aircraft information

The Cessna 340A, serial number 340A0308, was purchased on July 24, 2000, by the registered owner. The airplane was modified through a RAM series VI conversion with the installation of vortex generators and an increase in the horsepower rating of the engines. According to logbook entries dated July 24, 2000, the airplane received an annual inspection at a total airframe time of 3,819 hours. The airplane was powered by two Continental TSIO-520-KCNB engines with the right engine being serial number R-504286 and the left engine being serial number L-228274 installed on November 26, 1996. According to logbook entries dated July 24, 2000, both engines received a 100-hour inspection at 646 hours since their major overhaul and at a total engine time of 1,655 hours.

Airworthiness Directive (AD) 75-23-08, revision 05, pertains to the inspection and parts replacement of the engine exhaust system. AD 75-23-08 was superceded by AD 2000-01-16, which pertains to the detection and correction of cracks and corrosion in the exhaust system. The airplane's AD compliance record indicates that AD 2000-01-16, paragraphs b, c, d, e, and f was recorded as complied with on July 24, 2000 at a Hobb's time of 3,819 hours.

Meteorological information

The Miller Field Airport, Valentine, Nebraska, automated surface observing system recorded at 0152, wind from 070 degrees at 3 knots, 8 sm visibility, clear sky conditions, temperature of 19 degrees C, dew point of 18 degrees C and an altimeter setting of 30.07 inches.

The RAP automated surface observing system recorded at 0155, wind from 300 degrees at 4 knots, 10 sm visibility, clear sky conditions, temperature of 18 degrees C, dew point of 14 degrees C and an altimeter setting of 30.10 inches.

The U.S. Naval Observatory reported that at 2400 central standard time, the fraction of the moon illuminated was 0.45.

Wreckage and impact information

The wreckage path extended for a length of approximately 230 feet along a magnetic heading of 290 degrees. The airframe was 186 feet from eastern edge of the wreckage path and oriented on a tail to nose magnetic heading of 160 degrees. The GPS location of the airframe was 43 degrees 19.52 minutes north, 100 degrees 36.63 minutes west at an elevation of 2,688 feet msl. The eastern 37 feet of ground scarring contained a propeller spinner, propeller dome and a landing gear mirror. Forty-seven feet from the ground scar's eastern edge, three 3-foot parallel curvilinear marks were noted. Each curvilinear mark was separated from each other by one foot and was 5 inches, 10 inches and 12 inches in depth. The increase in depth proceeded the east to west. Both engines were separated from the airframe. Both propellers were separated from the engines and exhibited bending and twisting.

The flight control cables were traced from the elevator and rudder to the control column. The right aileron control cable was traced to the cabin area. The left aileron control cable was traced from the center of the cabin area to the main spar attach point.

The rudder trim actuator was extended 1-1/4 inches, which was equivalent to a position beyond the right limit of travel. The elevator trim actuator was extended 1-1/4 inches or an equivalent 10 degrees tab down.

There was a four-link extension of the chain leading from the control cable to the number one sprocket of the flap-actuating wheel. The extension was equivalent to a retracted flap position.

Both main landing gears were in a retracted position.

Both engine fire-extinguishing bottles located along the debris path indicated a pressure of approximately 500 psi.

Medical and pathological information

The Clinical Laboratory of the Black Hills, Rapid City, South Dakota, conducted an autopsy of the pilot.

Federal Aviation Administration (FAA) toxicological test results indicated the presence of 11 (mg/dL, mg/hg) ethanol in kidney, 3 (mg/dL, mg/hg) acetaldehyde in kidney, 0.343 (ug/ml, ug/g) diphenhyramine in kidney and 2.991 (ug/ml, ug/g) diphenhydramine in liver.

In its investigations, the NTSB routinely requests complete toxicolog

Aircraft

Registration
N34DD
Reported as
Cessna 340A
Category
Airplane
Serial number
340A-0308
Airframe hours
3,819
Engine
Continental TSIO-520-KCNB, 335 horsepower, reciprocating
Damage
Destroyed
Fire
Unknown
Flight
Business · Part 91
Registered owner
Action Mechanical
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 24, 2000 · 129 hours before
Departed
0V6
Destination
RAP · Rapid City, SD
Airport
0V6 · Mission Sioux

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
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,022 total

Weather

Conditions
Visual (VMC) · Not reported
Wind
70° at 3 knots
Visibility
8 statute miles
Lowest ceiling
None
Temperature
145 °F, dew point 57 °F
Altimeter
30.00 inHg
Observed at
VTN, 28 nm away

Docket · 28

The files NTSB released with the investigation on December 3, 2001, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.0 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2Item 1 · .PDF · 396 KBMaterials Laboratory 15 - Factual Report No. 01-99 Turbocharger and Exhaust PipeItem 2 · .PDF · 2.5 MBWitness Statements and Record of InterviewItem 3 · .PDF · 1.5 MBWreckage DiagramItem 4 · .PDF · 60 KBWeather and Moon DataItem 5 · .PDF · 195 KBSummary of Tapes 1 & 2 from HON AFSSItem 6 · .PDF · 286 KBContinental Motors Engine Teardown ReportItem 7 · .PDF · 1.5 MBHoneywell Teardown ReportItem 8 · .PDF · 1.7 MBPilot CertificateItem 9 · .PDF · 71 KBNTSB Interpretation of Blood Alcohol Levels Found in Transportation OperatorsItem 10 · .PDF · 104 KBAirworthiness Directive Compliance RecordItem 11 · .PDF · 71 KBStatement of Party Representatives to NTSB InvestigationItem 12 · .PDF · 413 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 13 · .PDF · 223 KBToxicological ReportItem 14 · .PDF · 70 KBPhoto 1. Wreckage PathItem 15 · .PDF · 60 KBPhoto 2. Main WreckageItem 16 · .PDF · 69 KBPhoto 3. Main WreckageItem 17 · .PDF · 66 KBPhoto 4. Main WreckageItem 18 · .PDF · 78 KBPhoto 5. Main WreckageItem 19 · .PDF · 44 KBPhoto 6. Main Wreckage ( No Negative )Item 20 · .PDF · 51 KBPhoto 7. Main Wreckage ( No Negative )Item 21 · .PDF · 44 KBPhoto 8. Main Wreckage ( No Negative )Item 22 · .PDF · 46 KBPhoto 9. PropellerItem 23 · .PDF · 89 KBPhoto 10. PropellerItem 24 · .PDF · 93 KBPhoto 11. Propeller ( No Negative )Item 25 · .PDF · 96 KBPhoto 12. Propeller ( No Negative )Item 26 · .PDF · 88 KBPhoto 13. Curvilinear MarksItem 27 · .PDF · 97 KBPhoto 14. Right Turbocharger/exhaust area ( No Negative, FAA Photo )Item 28 · .PDF · 63 KB

FAA reports on this event · 1

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