CHI06FA076

NTSB accident investigation · Cessna 421B · Wheeling, IL · January 31, 2006

Accident · FatalField investigationFinal report
Date
January 30, 2006, 18:29 local (Jan 31, 2006, 00:29 UTC)
Place
Wheeling, IL
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N920MCCessna 421B
Weather
Visual (VMC) · Night
Status
Completed · report July 25, 2007
Report
Approved by Office Director
Parties
Teledyne Continental Motors, FAA, Dupage FSDO, Cessna Aircraft Company
FAA report
20060130007309A
Case key
63189

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 airspeed during the landing approach which led to an inadvertent stall and subsequent uncontrolled descent and impact with the ground.

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.

Loss of control - in flightApproach - vfr pattern - downwind
Airspeed - not maintainedUnknownCause
Stall - inadvertentUnknownCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The airplane was destroyed and the occupants fatally injured when it impacted the ground during approach to landing. Examination of the airplane, its engines and propellers, revealed no anomalies that were determined to have existed prior to impact. The propellers were found to have been in their normal operating range and neither propeller was in a feathered position. The quill shafts of both engines showed evidence of damage due to the production of torque. A sound spectrum examination of audio transmissions showed signatures that both engines were operating during the last two radio transmissions from the airplane. Based on radar data, communications and meteorological information obtained during the investigation, the airplane was operating in visual meteorological conditions below an overcast layer of clouds. The radar data showed the airplane as it approached the airport and as it entered a left hand traffic pattern for runway 34. Radio communications confirmed that the airplane had been cleared for a left hand traffic pattern to runway 34. The radar data showed the airplane as it made a turn to the left while its speed decreased to about 82 knots calibrated airspeed as of the last received radar return. This radar return was about 0.1 nautical miles from the accident site and 0.8 nautical miles and 216 degrees from the approach end of runway 34. The airplane owner's manual listed stall speeds ranging from 81 to 94 knots calibrated airspeed for airplane configurations including gear and flaps up to gear down and flaps 15 degrees, and bank angles from 0 to 40 degrees. Flap position could not be determined because the flap chain had separated from the flap drive motor. The owner's manual also listed an approach speed of 103 knots.

Factual narrative

This narrative was modified on July17, 2007.

History of flight

On January 30, 2006, at 1829 central standard time (CST), a Cessna model 421B, N920MC, piloted by a private pilot, was destroyed when it impacted the ground in Wheeling, Illinois. The airplane was in the landing traffic pattern for runway 34 at the Palwaukee Municipal Airport (PWK) when the accident occurred. The 14 CFR Part 91 business flight was operating in visual meteorological conditions and was on an instrument flight rules (IFR) flight plan. All four occupants were fatally injured. The airplane had departed from the Johnson County Executive Airport (OJC), Olathe, Kansas, about 1710.

According to communication records, the airplane received an IFR clearance and departed OJC at 1710. The airplane continued its flight to the Chicago area where an ILS runway 16 approach to PWK was executed. The IFR flight plan was cancelled and the airplane was cleared to land on runway 34 at PWK. The airplane subsequently impacted the ground approximately 0.9 miles and 210 degrees from the approach end of runway 34 at PWK.

Personnel information

The individual listed as the pilot in command (PIC) on the aircraft flight plan held a private pilot certificate with single engine land, multiengine land, and instrument airplane ratings. He also held a second class medical certificate that was issued on January 24, 2005. The medical certificate included a restriction that the pilot wear corrective lenses.

A review of the PIC's flight logbooks was conducted. Due to several mathematical errors that were discovered, re-totaling of the individual logbook entries was conducted. These totals revealed that the pilot had accumulated a total of 1,284.05 hours total flight experience including; 161.2 hours in single-engine airplanes, 1,052.65 hours in multiengine airplanes, and 70.2 hours in flight simulator devices. The records showed that 32.75 hours were logged in Cessna 421 airplanes. Of those 32.75 hours, 18.2 hours were obtained prior to the pilot having received the instruction required by 14 CFR 61.31 (g) to act as pilot in command of a pressurized airplane. In addition, of the 32.75 hours logged in Cessna 421 airplanes, 27.5 hours were obtained prior to the pilot having received dual instruction in a Cessna 421 airplane. A total of 5.25 hours of logged dual instruction in Cessna 421 airplanes was recorded in the pilot's logbook.

Another occupant held a commercial pilot certificate with single engine land, multiengine land, and instrument airplane ratings. The single engine rating was limited to private pilot privileges. This pilot also held a third class medical certificate issued on November 10, 2005. The medical certificate included a restriction that the pilot wear corrective lenses for near vision. On his most recent application for his airman medical certificate, he reported having in excess of 2,000 hours of flight experience including 40 hours in the preceding 6 months. The pilot's flight logbooks were not reviewed.

No determination could be made as to which front seat occupant was manipulating the controls prior to or at the time of the accident.

Aircraft information

The airplane was a Cessna model 421B, serial number 421B0884. It was a twin-engine, low-wing, retractable gear airplane. The airplane was equipped with wing and tail de-icing boots and propeller anti-ice and was approved for flight into known icing conditions. A review of the airframe logbooks revealed that the airplane had accumulated 5,436.8 hours total time in service as of the most recent annual inspection dated December 28, 2005.

The airplane was powered by 2 Teledyne Continental Motors model GTSIO-520-H engines. Each geared engine was rated to produce 375 horsepower at 2,275 propeller rpm. Each engine maintenance logbook was reviewed. During the review, a mathematical error relating to the accumulated time on the left engine was found. After taking this mathematical error into account it was found that the left engine, serial number 267029-R, had accumulated 1,782.8 hours total time and 455.5 hours since overhaul as of the December 28, 2005, annual inspection. The right engine, serial number 267035-R, had also accumulated 1,782.8 hours total time and 455.5 hours since overhaul as of the December 28, 2005, annual inspection.

According to Cessna Aircraft company records, the airplane was originally purchased from Cessna on March 21, 1975. Federal Aviation Administration (FAA) registration records showed that the airplane was purchased on August 27, 2004, by the hotel company owned by the pilot rated passenger. On May 12, 2005, the airplane registration was transferred to HK Golden Eagle, Inc. The pilot rated passenger was listed on the FAA registration documents as the president/secretary of HK Golden Eagle, Inc.

Meteorological information

The National Weather Service (NWS) Weather Depiction Chart for 1900 CST January 30, 2006, depicted a region of IFR conditions over northern Indiana and southwestern Michigan. Surrounding this area was an area of marginal visual flight rules (MVFR) conditions that covered portions of Wisconsin, Illinois, Indiana, and Michigan that included the accident site.

The NWS Current Icing Potential for 1800 CST depicted a probability of icing conditions over the Chicago area which ranged from about 10 percent at 3,000 feet, to about 70 percent at 5,000 feet. Several pilot reports of icing were recorded in the hours surrounding the accident time. One aircraft reported moderate rime icing between 2,500 and 7,000 feet about 15 minutes prior to the accident time.

PWK is equipped with an Automated Surface Observation System (ASOS) and is augmented by NWS certified weather observers. The surface observations at PWK reported a mixture of freezing precipitation and snow that started at 0649 CST and turned to light snow and mist which continued on and off through 1648 CST. No major accumulation of ice or snow was reported during the period. The observations surrounding the accident time were as follows:

At 1753 CST, wind from 310 degrees at 13 knots, visibility unrestricted at 10 statute miles, ceiling broken at 2,000 feet above ground level (AGL), overcast at 2,800 feet AGL, temperature -1 degrees Celsius (C), dew point temperature -4 degrees C, altimeter setting 29.81 inches of Mercury (Hg). Remarks: automated observation system, sea level pressure 1010.0 hectopascals (hPa), 6-hour precipitation less than 0.01 inches, temperature -0.6 degrees C, dew point -3.9 degrees C, 12-hour maximum temperature 2.8 degrees C, 12-hour minimum temperature -0.6 degrees C, 3-hour pressure tendency risen 1.9-hPa.

At 1836 CST, wind from 310 degrees at 9 knots, visibility unrestricted at 10 statute miles, ceiling overcast at 2,100 feet AGL, temperature -1 degrees C, dew point temperature -4 degrees C, altimeter setting 29.83 inches of Hg. Remarks: automated observation system, aircraft mishap.

Communications

Records indicate that an individual called the Columbia Automated Flight Service Station (AFSS) at 1543, filed an IFR flight plan, and obtained weather information for a flight from OJC to PWK. The caller identified N920MC as the registration number of the airplane when filing the flight plan. The caller also indicated that he was the pilot in command and provided his name and telephone number to the AFSS briefer when he filed the flight plan. The complete transcript of this communication is included in the docket material associated with this report.

At 1710, the accident airplane departed OJC and radio contact with air traffic control was established. Between 1710 and 1826, the airplane continued its flight to PWK while maintaining communications with the appropriate ATC facilities. At 1826, communication between the aircraft and the PWK air traffic control tower (ATCT) was established. The following is a transcript of radio co

Aircraft

Registration
N920MC
Reported as
Cessna 421B
Category
Airplane
Serial number
421B0884
Airframe hours
5,437
Engine
Continental GTSIO-520-H, 375 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 1, 2005
Departed
OJC · Olathe, KS
Destination
PWK · Wheeling, IL
Flight plan
IFR
Airport
PWK · Palwaukee Muni, runway 34, 5,000 × 150 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
59
Injuries
Fatal
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 1, 2004
Seat
Left
Toxicology
Performed
Flight hours
1,284 total · 33 in this make and model
Role
Other flight crew
Age
61
Injuries
Fatal
Certificates
Commercial, Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Right
Toxicology
Performed
Flight hours
2,000 total

Weather

Conditions
Visual (VMC) · Night
Wind
310° at 9 knots
Visibility
10 statute miles
Lowest ceiling
2,100 ft overcast
Temperature
30 °F, dew point 25 °F
Altimeter
29.81 inHg
Observed at
PWK, 1 nm away

Docket · 45

The files NTSB released with the investigation on March 30, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports. 32.9 MB in all.

Sound Spectrum Study - Specialist's Factual Report of InvestigationItem 1 · .PDF · 14 KBMeteorology 5 - Factual Report of Group ChairmanItem 2 · .PDF · 1.1 MBMedical Records InformationItem 3 · .PDF · 9 KBWitness ReportsItem 4 · .PDF · 170 KBRadar Track Plot (1)Item 5 · .PDF · 545 KBRadar Track Plot (2)Item 6 · .PDF · 391 KBRadar Track Plot (3)Item 7 · .PDF · 28 KBRadar Track Plot (4)Item 8 · .PDF · 13 KBATC Communication Summaries & TranscriptsItem 9 · .PDF · 205 KBFlight Service Station Briefing Transcript & Flight Plan InformationItem 10 · .PDF · 181 KBController StatementItem 11 · .PDF · 57 KBAircraft InformationItem 12 · .PDF · 35 KBOwners Manual ExcerptsItem 13 · .PDF · 190 KBPropeller TeardownItem 14 · .PDF · 68 KBToxicological ReportsItem 15 · .PDF · 173 KBStatement of Party Representatives to NTSB InvestigationItem 16 · .PDF · 331 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 17 · .PDF · 123 KBPhoto 1. View of Tail SurfacesItem 18 · .PDF · 1.3 MBPhoto 2. Overall View of Main WreckageItem 19 · .PDF · 1.2 MBPhoto 3. Overall View of Main WreckageItem 20 · .PDF · 1.1 MBPhoto 4. Right Propeller at Accident SceneItem 21 · .PDF · 1.3 MBPhoto 5. Left Propeller at Accident SceneItem 22 · .PDF · 1.4 MBPhoto 6. View of Main WreckageItem 23 · .PDF · 1.3 MBPhoto 7. Right Engine at Accident SceneItem 24 · .PDF · 1.3 MBPhoto 8. Overall View of WreckageItem 25 · .PDF · 1.3 MBPhoto 9. Left Engine at Accident SceneItem 26 · .PDF · 1.3 MBPhoto 10. Left Engine Prepared for DisassemblyItem 27 · .PDF · 1.2 MBPhoto 11. Left Engine Reduction Gear SectionItem 28 · .PDF · 1.3 MBPhoto 12. Left Engine Internal ViewItem 29 · .PDF · 1.3 MBPhoto 13. Left Engine Cylinders & PistonsItem 30 · .PDF · 1.2 MBPhoto 14. Left Engine Cylinders and PistonsItem 31 · .PDF · 1.3 MBPhoto 15. Left Engine Quill ShaftItem 32 · .PDF · 1.4 MBPhoto 16. Left Engine Quill Shaft - Detail ViewItem 33 · .PDF · 1.4 MBPhoto 17. Right EngineItem 34 · .PDF · 1.3 MBPhoto 18. Right Engine Internal ViewItem 35 · .PDF · 1.2 MBPhoto 19. Right Engine Reduction GearsItem 36 · .PDF · 1.3 MBPhoto 20. Right Engine Pistons & CylindersItem 37 · .PDF · 1.2 MBPhoto 21. Right Engine Pistons & CylindersItem 38 · .PDF · 1.2 MBPhoto 22. Right Engine Crankshaft and Connecting RodsItem 39 · .PDF · 1.2 MBPhoto 23. Right Engine Quill ShaftItem 40 · .PDF · 422 KBPhoto 24. Right Engine Quill Shaft Magnaflux ViewItem 41 · .PDF · 443 KBSecurity Video Still 1Item 42 · .PDF · 79 KBSecurity Video Still 2Item 43 · .PDF · 80 KBSecurity Video Still 3Item 44 · .PDF · 78 KBSecurity Video Still 4Item 45 · .PDF · 39 KB

FAA reports on this event · 1

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