DEN02FA034

NTSB accident investigation · Cessna 340 · Englewood, CO · March 24, 2002

Accident · FatalField investigationFinal report
Date
March 24, 2002, 16:31 local (23:31 UTC)
Place
Englewood, CO
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N341DMCessna 340
Weather
Instrument (IMC) · Day
Status
Completed · report May 30, 2003
Report
Approved by Office Director
Parties
Cessna Aircraft Company, Teledyne Continental Motors
FAA report
20020324006099A
Case key
54409

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 NTSB’s determination of the probable cause, and any contributing factors.

the pilot not following procedures/directives (flying a landing approach with the left fuel selector in the auxiliary position). Contributing factors were the loss of the left engine power due to fuel starvation, the pilot's failure to maintain aircraft control, and the subsequent inadvertent stall into terrain.

Analysis

The pilot was flying a three leg IFR cross-country, and was on an ILS approach in IMC weather conditions for his final stop. Radar data indicated that the pilot had crossed the final approach fix inbound and was approximately 3 nm from the runway threshold when he transmitted that he had "lost an engine." Radar data indicates that the airplane turned left approximately 180 degrees, and radar contact was lost. A witness said "the airplane appeared to gain a slight amount of altitude before banking sharply to the left and nose diving into the ground just over the crest of the hill." Postimpact fuel consumption calculations suggest that there should have been 50 to 60 gallons of fuel onboard at the time of the accident. Displaced rubber O-ring seals on two Rulon seals in the left fuel valve and hydraulic pressure/deflection tests performed on an exemplar fuel valve suggest that the fuel selector valve was in the auxiliary position at the time of impact. The airplane's Owner's Manual states: "The fuel selector valve handles should be turned to LEFT MAIN for the left engine and RIGHT MAIN for the right engine, during takeoff, landing, and all emergency operations." No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified.

Factual narrative

The factual narrative1,288 words

History of flight

On March 24, 2002, at 1631 mountain standard time, a Cessna 340, N341DM, was destroyed when it collided with terrain while on final approach to Centennial Airport, Englewood, Colorado. The airline transport pilot and his three passengers were fatally injured. The airplane was being operated by Lear 171 Inc., of Billings, Montana, under Title 14 CFR Part 91. Instrument meteorological conditions prevailed for the cross-country flight that originated from Gunnison, Colorado, at approximately 1545. The pilot was flying under an instrument flight rules (IFR) flight plan.

The pilot called Denver Flight Service Station at 0818 to file a three-leg IFR flight plan from Denver, Colorado, to Aspen, Colorado, to Gunnison, Colorado, and return to Denver. The refueler at Centennial Airport said that he topped off the main (wing-tip) tanks with 62 gallons (approximately 31 gallons per side) at 1232. This would have given the pilot 100 gallons usable fuel total. The refueler said at 1250, the pilot requested that an additional 20 gallons of fuel be put in each auxiliary tank. The owner of the airplane said that the auxiliary fuel tanks, which had a 31.5 gallon capacity, were not used for every flight. He further stated that they normally left 2 to 5 gallons [an unknown amount] of "slosh" fuel in them to keep the rubber fuel bladders in good shape. The pilot departed Centennial Airport with approximately 140 gallons of fuel.

The pilot flew to Aspen (96 nautical miles (nm)) and picked up his three passengers. He then departed for Gunnison (42 nm) where the passengers owned a ranch. They were on the ground less than an hour, when they departed for Centennial Airport at approximately 1545. The pilot had requested an altitude of 17,000 feet, and estimated that he would fly the 118 nm (direct) in 42 minutes. Denver Terminal Radar Approach Control (TRACON) radar data indicates that the airplane began its descent from 17,000 feet at 1616. At 1621:03, the pilot was told by the TRACON controller, to expect light to moderate icing at 8,000 feet. The airplane leveled off at 8,300 feet for approximately 30 seconds before it crossed Casse (Centennial Airport's Initial Approach Fix), and then began its final descent to runway 35R on the Instrument Landing System (ILS).

At 1628:56, approximately 2.5 nm before Casse, the airplane was cleared to land on runway 35R. At approximately 1630:52, the radar data indicates that the airplane began to turn left (westbound) at 7,200 feet. At 1631:24, the pilot transmitted that "41DM [N341DM] lost an engine," and at 1631:30, he exclaimed "oh sh__"! Radar data indicates that the airplane completed a 180 degree turn (approximately 6 degrees per second), then radar contact was lost.

One witness said the airplane was flying "about 150 to 200 feet from the ground," and when it "attempted to clear the approaching hill, it tipped 90 degrees to the left (right wing straight up)." Another witness said the airplane was flying "very low," and "it appeared to gain a slight amount of altitude before banking sharply to the left and nose diving into the ground just over the crest of the hill. He exited the highway, ran to the crash site, but observed no movement from the aircraft.

Personnel information

According to the pilot's personal flight log book, he started flying in September 1966. He received his airline transport pilots certificate on March 12, 1989. His flight logbook indicates that, at the time of the accident, he had a total of 3,563 hours of flight experience, of which 2,580 hours was in multiengine aircraft. He had approximately 560 hours in make and model. He had flown an estimated 239 hours during the 12 months before the accident. His last Federal Aviation Administration (FAA) medical, a class two, was taken on August 31, 2000. His last flight review was successfully completed on September 21, 2001. On December 14 through 16, 2000, he attended Flight Safety's training program for the Cessna 340, and on September 17 through 21, 2001, he attended their program on the Cessna 441.

The pilot flew the airplane (N341DM) on three occasions during January 2002; the last flight was on January 24, 2002. He also flew a Cessna 441 (N88727) on five occasions during January 2002, and the last flight in that airplane was on January 29, 2002. During most of February he was on vacation in South America, and did not fly again until March 3, 2002. That flight was with another pilot (in a Cessna 421, N421HW), and the accident pilot did not log the flight in his flight log book. During this flight, the other pilot reported that the accident pilot flew two to three instrument approaches. The pilot did fly the accident airplane on March 19, 2002, and that was his last flight before the accident.

Aircraft information

The airplane was a twin engine, propeller-driven, retractable landing gear, five seat airplane which was manufactured by Cessna Aircraft Company in 1974. It was powered by two Continental TSIO-520-NB, six cylinder, reciprocating, horizontally opposed, direct drive, air cooled, fuel injected, turbo-charged engines, which had a maximum takeoff rating of 310 horsepower at sea level. The airplanes records indicated that the last annual inspection was completed on July 12, 2001. The airplane's Hobbs meter indicates that at the time of the accident, the airframe had approximately 3,977 hours of flight time (127.6 hours since the annual on July 12, 2001). The engine maintenance records indicate that the left engine had 1,091 hours since rebuild and the right engine had 1,185 hours since rebuild (Continental's recommended TBO is 1,600 hours).

The airplane had been modified with a RAM II conversion (STC-SA2346SW) in 1981, and an Aeronautical Testing Service (now owned by Boundary Layer Research) Vortex Generator Kit (STC-SA5198NM) in January of 1996. These modifications increased the maximum gross weight from 5,990 pounds to 6,305 pounds, increased the maximum horsepower from 285 to 310, and reduced the Vmc from 84 knots to 73 knots. The airplane was equipped with two 50 gallon (usable) main wing tip tanks and two 31.5 gallon (usable) auxiliary tanks. The airplane's Owner's Manual states that the main tanks must be selected for the first 90 minutes of flight before auxiliary tanks should be selected. When auxiliary tanks are selected, the surplus fuel is returned to the main tanks. The owner of the airplane estimated that this could be as high as 17 to 18 gallons of fuel in a 50 minute period.

The airplane's Owner's Manual also states: "The fuel selector valve handles should be turned to LEFT MAIN for the left engine and RIGHT MAIN for the right engine, during takeoff, landing and all emergency operations."

The airplane was equipped with the following anti-icing and deicing equipment: pneumatic boots for the leading edges of the wings and empennage, electrically heated front pilot windows, electrically heated propellers, electrically heated pitot static system, and electrically heated stall vain.

Meteorological information

At 1641, the weather at Centennial Airport (elevation 5,883 feet) 360 degrees 3.5 nm from the accident site, was as follows: wind 050 degrees at 10 knots; visibility 5 statute miles; broken clouds at 900 feet and overcast clouds at 1,500 feet; temperature 25 degrees Fahrenheit, dew point 21 degrees Fahrenheit; altimeter setting 29.86 inches. A King Air pilot, who flew the ILS approximately 10 to 15 minutes after the accident aircraft, said that she experienced solid instrument meteorological conditions (IMC) from 11,000 feet down to 6,500 feet. She said that she had all available electrical anti-icing devices turned on; including engine inlet heat, window heat, propeller heat, and pitot heat. She said that she experienced occasional light to moderate icing conditions during her ILS approach, and she inflated her pneuma

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 engine power(total) - nonmechanicalApproach - faf/outer marker to threshold (ifr)
Procedures/directives - not followedPilot in commandCause
Fluid,fuel - starvationFactor
1 engineFactor
Loss of control - in flightApproach - faf/outer marker to threshold (ifr)
Aircraft control - not obtained/maintainedPilot in commandFactor
Stall/spin - inadvertentPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - mountainous/hilly

Aircraft

Registration
N341DM
Reported as
Cessna 340
Category
Airplane
Serial number
340-0347
Airframe hours
3,977
Engines
Continental TSIO-520-NB, 310 horsepower, reciprocatingContinental TSIO-520-NB, 310 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Lear 171 Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 12, 2001 · 128 hours before
Departed
GUC · Gunnison, CO
Destination
APA · Englewood, CO
Flight plan
IFR

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
63
Injuries
Fatal
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
September 15, 2001
Seat
Left
Toxicology
Performed
Flight hours
3,563 total · 560 in this make and model · 3 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
50° at 10 knots
Visibility
5 statute miles
Lowest ceiling
1,500 ft overcast
Temperature
28 °F, dew point 25 °F
Altimeter
29.86 inHg
Observed at
APA, 4 nm away

Docket · 34

The files NTSB released with the investigation on April 11, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 18.6 MB in all.

Supplement SItem 1 · .PDF · 30 KBMeteorological Group Chairman Factual ReportItem 2 · .PDF · 940 KBWitness StatementsItem 3 · .PDF · 276 KBMaps or Charts of Accident Area, Wreckage DiagramsItem 4 · .PDF · 927 KBTranscript of Radio CommunicationsItem 5 · .PDF · 207 KBEngineer SketchesItem 6 · .PDF · 153 KBReports from Federal Agencies - FAAItem 7 · .PDF · 92 KBReports from Parties to the InvestigationItem 8 · .PDF · 459 KBOther Pertinent Forms and ReportsItem 9 · .PDF · 2.5 MBStatement of Party Representatives to NTSB InvestigationItem 10 · .PDF · 60 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 11 · .PDF · 45 KBToxicological ReportItem 12 · .PDF · 54 KBPhoto #1 - Initial impact, note left tip tank on the rightItem 13 · .PDF · 217 KBPhoto #2 - Wide angle view of ravineItem 14 · .PDF · 216 KBPhoto #3 - Left side forward, note crush angleItem 15 · .PDF · 785 KBPhoto #4 - Left side of aircraftItem 16 · .PDF · 695 KBPhoto #5 - Rear view, note separation of fuselageItem 17 · .PDF · 688 KBPhoto #6- Separation between empennage and fuselageItem 18 · .PDF · 214 KBPhoto #7 - Right wing, note nose crush angleItem 19 · .PDF · 212 KBPhoto #8 - The fuel selector positions after impactItem 20 · .PDF · 684 KBPhoto #9 - The left propeller buried in the side of the ravineItem 21 · .PDF · 788 KBPhoto #10 - The left propeller partially excavatedItem 22 · .PDF · 228 KBPhoto #11 - The right propeller above the ravineItem 23 · .PDF · 804 KBPhoto #12 - The left engine above the ravineItem 24 · .PDF · 781 KBPhoto #13 - Cut vegetation near the right propellerItem 25 · .PDF · 793 KBPhoto #14 - Cut vegetation near the right propellerItem 26 · .PDF · 799 KBPhoto #15 - The right engine after retrievalItem 27 · .PDF · 331 KBPhoto #16 - The left propeller after retrievalItem 28 · .PDF · 413 KBPhoto #17 - The right propellerItem 29 · .PDF · 416 KBPhoto #18 - The right propellerItem 30 · .PDF · 795 KBPhoto #19 - The left fuel valveItem 31 · .PDF · 806 KBPhoto #20 - Inside look at the left fuel valveItem 32 · .PDF · 812 KBPhoto #21 - The left fuel valve Rulon seals and two separated O-ringsItem 33 · .PDF · 668 KBPhoto #22 - Left fuel valve Rulon seals with separated O-ringsItem 34 · .PDF · 797 KB

FAA reports on this event · 1

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