# NTSB CHI92FA104: Cessna 414, N69662, Freeland, MI, March 5, 1992

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: March 5, 1992, 15:04 local (20:04 UTC)
- Place: Freeland, MI
- Coordinates: 43.620189, -84.219413 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=43.6202&lon=-84.2194&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report September 29, 1993
- Report: Approved by Office Director
- Safety recommendations: Yes
- NTSB case key (mKey): 15284
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI92FA104
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15284/pdf
- Page: https://openairdocs.org/ntsb/CHI92FA104

## Probable cause

THE PILOT'S POOR JUDGEMENT IN ATTEMPTING FLIGHT AFTER THE AIRPLANE'S FUSELAGE WAS DAMAGED DURING A LOADING OPERATION. FACTORS WHICH CONTRIBUTED TO THE ACCIDENT WERE: THE OPERATOR'S FAILURE TO PROVIDE PROPER WEIGHT AND BALANCE DATA FOR THE AIRPLANE, THE PILOT'S FAILURE TO SUPERVISE THE LOADING OPERATION, AND HIS FAILURE TO ACCEPT THE SERVICES OF A MECHANIC TO INSPECT THE DAMAGE.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Airframe/component/system failure/malfunction, standing
  - fuselage - penetrated (contributing factor)
  - aircraft weight and balance - unavailable, company/operator management (contributing factor)
  - supervision - inadequate, pilot in command (contributing factor)
  - remedial action - not performed, pilot in command (contributing factor)
- Loss of control - in flight, approach - vfr pattern - base leg/base to final
  - flt control syst,elevator control cable/rod - jammed (cause)
  - operation with known deficiencies in equipment - attempted, pilot in command (cause)
- In flight collision with terrain/water, approach - vfr pattern - base leg/base to final

## Analysis

WHILE LOADING A PATIENT & HIS PERSONAL GEAR IN THE AIRCRAFT FOR AN AIR AMBULANCE FLIGHT, THE AIRCRAFT TIPPED ONTO ITS TAIL. AS A RESULT, THE TAIL BUMPER WAS FORCED UPWARD INTO THE BELLY OF THE EMPENNAGE. THE PILOT REFUSED THE OFFER TO HAVE A MECHANIC LOOK AT THE DAMAGE, AND REMARKED 'THIS HAS HAPPENED BEFORE.' AFTER TAKEOFF, THE PILOT RADIOED TO THE TOWER THAT HE HAD A JAMMED ELEVATOR, AND WAS COMING AROUND TO LAND. WHILE MANUEVERING ON A BASE LEG, CONTROL WAS LOST & THE AIRPLANE WAS OBSERVED TO CRASH WITH ONE WING PERPENDICULAR TO THE GROUND. ANOTHER AIRPLANE WAS IN THE TAKEOFF POSITION ON THE RUNWAY. THE AIRPLANE WAS CONFIGURED WITH A HOSPITAL LITTER/STRETCHER AND OXYGEN BOTTLE ON THE RIGHT SIDE OF THE CABIN. THERE WAS NO RECORD FOR THE APPROVAL FOR, OR INSTALLATION OF, THE STRETCHER. IN ADDITION, THERE WAS NO WEIGHT & BALANCE RECORD FOR THE AIRPLANE WITH THE STRETCHER INSTALLATION.

## Aircraft

- Registration: [N69662](https://openairdocs.org/deregistered/N69662-1992-08-20), registration cancelled 1992-08-20, S/N 4140621 (OpenAirDocs)
- Reported make and model: CESSNA 414
- Registry model: [Cessna 414](https://openairdocs.org/model/cessna-414) (registry code 2075908) (OpenAirDocs)
- Category: Airplane
- Serial number: 414-0621
- Airframe hours: 4106
- Engines: CONTINENTAL TSIO-520-NB2 310 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Part 135
- Operator: Airborne Flying Service, Inc.
- Registered owner: Tiffany Air, Inc.
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, February 28, 1992, 15 hours before
- Destination: MDW, CHICAGO, IL
- Flight plan: IFR
- Airport: MBS, Tri-City Intl Airport, runway 5, 8,002 × 150 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 28; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 2,057 total, 184 in this make and model, 1,961 as pilot in command, 169 in the last 90 days, 94 in the last 30 days, 10 in the last 24 hours

## Weather

- Conditions: Instrument (IMC), Day
- Wind: 40° at 11 knots
- Visibility: 1 statute miles
- Lowest ceiling: 9,500 ft broken
- Temperature: 39 °F, dew point 37 °F
- Altimeter: 30.00 inHg
- Observed at: MBS, 1 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 (OpenAirDocs).

- [Accident 19920305005079A](https://openairdocs.org/incident/19920305005079A), Mar 5, 1992: Cessna 414, Saginaw, MI, Destroyed, 3 fatal. On loading tail hit ramp. On takeoff reported jammed elevators wanted return. Traffic on runway. Lost control.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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