# NTSB DEN02FA034: Cessna 340, N341DM, Englewood, CO, March 24, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 24, 2002, 16:31 local (23:31 UTC) - Place: Englewood, CO - Coordinates: 39.49361, -104.867774 - Nearby events: https://openairdocs.org/map.md?lat=39.4936&lon=-104.8678&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report May 30, 2003 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Teledyne Continental Motors - NTSB case key (mKey): 54409 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN02FA034 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54409/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54409 - Page: https://openairdocs.org/ntsb/DEN02FA034 ## Probable cause 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 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, approach - faf/outer marker to threshold (ifr) - procedures/directives - not followed, pilot in command (cause) - fluid,fuel - starvation (contributing factor) - 1 engine (contributing factor) - Loss of control - in flight, approach - faf/outer marker to threshold (ifr) - aircraft control - not obtained/maintained, pilot in command (contributing factor) - stall/spin - inadvertent, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - mountainous/hilly ## Aircraft - Registration: [N341DM](https://openairdocs.org/deregistered/N341DM-2012-06-26), registration cancelled 2012-06-26, S/N 340-0347, built 1974 (OpenAirDocs) - Reported make and model: Cessna 340 - Registry model: [Cessna 340](https://openairdocs.org/model/cessna-340) (registry code 2076404) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 340-0347 - Airframe hours: 3977 - Engines: Continental TSIO-520-NB 310 horsepower reciprocating; Continental 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: fatal; 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 ## 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 20020324006099A](https://openairdocs.org/incident/20020324006099A), Mar 24, 2002: Cessna 340CESSNA, Denver, CO, No damage, 4 fatal. (-23) Aircraft departed gunnison, CO (gun) enroute to Denver, CO (apa) under an IFR flight plan. Weather briefing provided by duats. Aircraft had a current… ## Docket (34 files) The files NTSB released with the investigation on April 11, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54409. 18.6 MB in all. - Supplement S (item 1, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180197&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Meteorological Group Chairman Factual Report (item 2, .PDF, 940 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419287&FileExtension=.PDF&FileName=Meteorological%20Group%20Chairman%20Factual%20Report-Redacted.PDF - Witness Statements (item 3, .PDF, 276 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419288&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 4, .PDF, 927 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180203&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Transcript of Radio Communications (item 5, .PDF, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419289&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - Engineer Sketches (item 6, .PDF, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419290&FileExtension=.PDF&FileName=Engineer%20Sketches-Redacted.PDF - Reports from Federal Agencies - FAA (item 7, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419291&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%20-%20FAA-Redacted.PDF - Reports from Parties to the Investigation (item 8, .PDF, 459 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419292&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation-Redacted.PDF - Other Pertinent Forms and Reports (item 9, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419293&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419294&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419295&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 12, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419296&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo #1 - Initial impact, note left tip tank on the right (item 13, .PDF, 217 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180221&FileExtension=.PDF&FileName=Photo%20%231%20-%20Initial%20impact,%20note%20left%20tip%20tank%20on%20the%20right-Master.PDF - Photo #2 - Wide angle view of ravine (item 14, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180222&FileExtension=.PDF&FileName=Photo%20%232%20-%20Wide%20angle%20view%20of%20ravine-Master.PDF - Photo #3 - Left side forward, note crush angle (item 15, .PDF, 785 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180225&FileExtension=.PDF&FileName=Photo%20%233%20-%20Left%20side%20forward,%20note%20crush%20angle%20-Master.PDF - Photo #4 - Left side of aircraft (item 16, .PDF, 695 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180266&FileExtension=.PDF&FileName=Photo%20%234%20-%20Left%20side%20of%20aircraft-Master.PDF - Photo #5 - Rear view, note separation of fuselage (item 17, .PDF, 688 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180267&FileExtension=.PDF&FileName=Photo%20%235%20-%20Rear%20view,%20note%20separation%20of%20fuselage-Master.PDF - Photo #6- Separation between empennage and fuselage (item 18, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180269&FileExtension=.PDF&FileName=Photo%20%236-%20Separation%20between%20empennage%20and%20fuselage-Master.PDF - Photo #7 - Right wing, note nose crush angle (item 19, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180270&FileExtension=.PDF&FileName=Photo%20%237%20-%20Right%20wing,%20note%20nose%20crush%20angle-Master.PDF - Photo #8 - The fuel selector positions after impact (item 20, .PDF, 684 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180273&FileExtension=.PDF&FileName=Photo%20%238%20-%20The%20fuel%20selector%20positions%20after%20impact-Master.PDF - Photo #9 - The left propeller buried in the side of the ravine (item 21, .PDF, 788 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180275&FileExtension=.PDF&FileName=Photo%20%239%20-%20The%20left%20propeller%20buried%20in%20the%20side%20of%20the%20ravine-Master.PDF - Photo #10 - The left propeller partially excavated (item 22, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180277&FileExtension=.PDF&FileName=Photo%20%2310%20-%20The%20left%20propeller%20partially%20excavated-Master.PDF - Photo #11 - The right propeller above the ravine (item 23, .PDF, 804 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180280&FileExtension=.PDF&FileName=Photo%20%2311%20-%20The%20right%20propeller%20above%20the%20ravine-Master.PDF - Photo #12 - The left engine above the ravine (item 24, .PDF, 781 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180282&FileExtension=.PDF&FileName=Photo%20%2312%20-%20The%20left%20engine%20above%20the%20ravine-Master.PDF - Photo #13 - Cut vegetation near the right propeller (item 25, .PDF, 793 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180283&FileExtension=.PDF&FileName=Photo%20%2313%20-%20Cut%20vegetation%20near%20the%20right%20propeller-Master.PDF - Photo #14 - Cut vegetation near the right propeller (item 26, .PDF, 799 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180284&FileExtension=.PDF&FileName=Photo%20%2314%20-%20Cut%20vegetation%20near%20the%20right%20propeller-Master.PDF - Photo #15 - The right engine after retrieval (item 27, .PDF, 331 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180285&FileExtension=.PDF&FileName=Photo%20%2315%20-%20The%20right%20engine%20after%20retrieval-Master.PDF - Photo #16 - The left propeller after retrieval (item 28, .PDF, 413 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180288&FileExtension=.PDF&FileName=Photo%20%2316%20-%20The%20left%20propeller%20after%20retrieval-Master.PDF - Photo #17 - The right propeller (item 29, .PDF, 416 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180289&FileExtension=.PDF&FileName=Photo%20%2317%20-%20The%20right%20propeller-Master.PDF - Photo #18 - The right propeller (item 30, .PDF, 795 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180292&FileExtension=.PDF&FileName=Photo%20%2318%20-%20The%20right%20propeller-Master.PDF - Photo #19 - The left fuel valve (item 31, .PDF, 806 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180293&FileExtension=.PDF&FileName=Photo%20%2319%20-%20The%20left%20fuel%20valve-Master.PDF - Photo #20 - Inside look at the left fuel valve (item 32, .PDF, 812 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180294&FileExtension=.PDF&FileName=Photo%20%2320%20-%20Inside%20look%20at%20the%20left%20fuel%20valve-Master.PDF - Photo #21 - The left fuel valve Rulon seals and two separated O-rings (item 33, .PDF, 668 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180295&FileExtension=.PDF&FileName=Photo%20%2321%20-%20The%20left%20fuel%20valve%20Rulon%20seals%20and%20two%20separated%20O-rings-Master.PDF - Photo #22 - Left fuel valve Rulon seals with separated O-rings (item 34, .PDF, 797 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180296&FileExtension=.PDF&FileName=Photo%20%2322%20-%20Left%20fuel%20valve%20Rulon%20seals%20with%20separated%20O-rings-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.