FTW96FA073

At 1350 cst, a McAlester FSS specialist gave a preflight briefing to a Cessna 421 pilot concerning IMC (instrument meteorological conditions) along the route & advised that VFR flight was not recommended. Cloud tops were at 12,000', & freezing level was at 1,600'. A PIREP at 1416 cst reported light mixed icing from 6,400' to 9,000' at Oklahoma City. At 1424 cst, the pilot departed Tulsa (VFR), then radar service was terminated. No further communication was received from the airplane. Radar data showed that it climbed westerly, reaching 9,800' at 1440 cst; during the next 88 seconds, its heading & altitude deviated until it descended through 3,200'. Ground witnesses saw the airplane descend out of low clouds in a 'flat spin' & crash. No preimpact mechanical failure was found. The airplane's gross weight was about 150 lbs over its maximum limit. In November 1995, the pilot received 10 hrs of Cessna 421 simulator training; his instructor noted in training records that he met minimum standards for VFR, but 'under IMC conditions,' he 'could not maintain altitude within 1,300 feet or heading within 40 degrees.' Postmortem toxicology tests showed 0.079 mcg/ml Nordiazepam (metabolite of Valium) in kidney fluid, 0.044 mcg/ml Desipramine (metabolite of Imipramine, an antidepressant) in spleen fluid, 0.733 mcg/ml Diphenhydramine (Benadryl) in spleen fluid, & 0.353 mcg/ml Diphenhydramine in lung fluid. These medications are not approved by the FAA for use while flying. The airplane was equipped for flight in icing & IFR conditions.

History of flight

On December 21, 1995, approximately 1442 central standard time, a Cessna 421C, N421EP, registered to and operated by Insured Titles of Tuscaloosa, Inc., was destroyed when it impacted terrain during an uncontrolled descent near Cleveland, Oklahoma. The instrument rated private pilot and his five passengers were fatally injured. The personal flight was conducted under Title 14 CFR Part 91 and originated in Tuscaloosa, Alabama, with a destination of Aspen, Colorado. After a refueling stop, the airplane departed the Tulsa International Airport in Tulsa, Oklahoma, approximately 1424. While on the ground in Tulsa, the pilot received a telephone weather briefing, but did not file a flight plan. According to witnesses, instrument meteorological conditions prevailed in the Cleveland area at the time of the accident.

At 1350, the pilot telephoned the McAlester Automated Flight Service Station and stated that he was "v f r here at Tulsa" with a destination of Aspen and requested a weather briefing. The briefer advised the pilot of an AIRMET in effect for instrument meteorological conditions along his route of flight "from Ponca City through ... western Kansas" and stated that "v f r is not recommended through that area." At 1424, the pilot was cleared for takeoff on runway 36L at the Tulsa International Airport. The airplane remained in contact with air traffic control until 1437, at which time the Tulsa Radar West controller advised the pilot that radar service was terminated. The pilot's acknowledgment of this transmission was the last recorded radio communication from the airplane.

Radar data provided by the FAA indicated that, between 1428:59 and 1440:27, the airplane was in a climb from 2,500 to 9,800 feet MSL. During the next 1 minute and 28 seconds, the data indicated the airplane descended to 5,400 feet MSL, climbed to 8,300 feet MSL, and then entered another descent. The last radar hit, recorded at 1441:55, indicated the airplane was approximately 0.1 nautical miles south of the accident site descending through 3,200 feet MSL. See the enclosed NTSB Recorded Radar Study for further details.

About 1440, a witness who was outside her residence, approximately 2 1/2 nautical miles east of the accident site, heard an airplane fly over headed west. The witness stated that she "heard only one engine and it was missing badly." The witness further stated that the airplane "was very low," but she was not able to see it due to the overcast. A plot based on the recorded radar data indicated that the airplane was approximately 8,500 feet MSL when it passed about 1/4 mile north of this witness's location.

Witnesses observed the airplane descend out of a cloud layer in a "flat spin," impact the ground, and "burst" into flames. One of the witnesses heard an airplane that "sounded like it was doing aerobatics," looked up and observed the airplane "drop straight down out of the clouds, going around and around with the nose and tail switching ends." This witness reported the weather conditions as a ceiling of 500 feet with "good" visibility below the clouds and "light snow flurries." Another witness stated that, when he first saw the airplane "in the flat spin," it was coming through a "scud layer of 500-1000 feet AGL."

A witness who was inside his residence approximately 1 nautical mile south of the accident site heard "an engine sputtering." The witness stepped outside, observed a twin engine airplane circle "like it was going to land," and then proceed westbound. A plot based on the recorded radar data indicated that the flight path of the accident airplane did not pass over the location of this witness.

Personnel information

The airplane was purchased by Insured Titles of Tuscaloosa, Inc., a company of which the pilot was president, in October 1995. From November 6 to November 10, 1995, the pilot attended a Cessna 421 initial pilot training program consisting of 20 hours ground instruction and 10 hours simulator instruction. A review of the course training records indicated that the pilot's completion status was unsatisfactory. According to the simulator instructor, the pilot's instrument scan was "extremely slow and insufficient to the extent that under IMC conditions he could not maintain altitude within 1300 feet or heading within 40 degrees when given even the simplest of tasks." The instructor's notes indicated that, on November 8, the pilot requested that "all remaining time in the simulator be given under VFR conditions with system orientation." On November 10, the instructor noted that the pilot's "continued poor aircraft control coupled with limited cockpit scan, awareness and system retention prevented satisfactory completion of system requirements even under VFR conditions."

The pilot had previously owned a Cessna 340A and had attended an initial pilot training course for this airplane from January 6 to January 10, 1992, and a recurrent course from February 25 to February 27, 1993. Review of the training records for these courses revealed that both were completed to VFR standards. According to the simulator instructor for the recurrent course, the pilot "was able to control the aircraft under the most least complicated problems presented," and met the "very minimum standards for VFR operations," but was "not within IFR standards at all."

The pilot's personal logbooks were not located during the investigation. According to a data sheet which the pilot completed prior to attending the Cessna 421 course in November 1995, he had accumulated a total flight time of 1,320 hours, a total multi-engine time of 633 hours, and a total instrument time of 135 hours.

Aircraft information

According to maintenance personnel at the fixed base operation (FBO) in Tuscaloosa, Alabama, where the airplane was based, the airplane logbooks were kept in the left wing locker. The logbooks were not recovered during the on scene examination of the airplane, and it is presumed that they were destroyed in the post-crash fire. Examination of records provided by the FBO in Tuscaloosa and a maintenance facility in Dallas, Texas, which had been performing the maintenance on the airplane for the previous owner, revealed no evidence of any uncorrected maintenance discrepancies. The last annual inspection was completed July 7, 1995, at an airframe total time of 3,414 hours.

The airplane was equipped with an IMC compatible avionics package which included an autopilot with a flight director system. When the airplane was manufactured, equipment required for flight into known icing conditions was installed.

Estimates indicated that the airplane was loaded over the gross weight limit at the time of the accident. Records from the July 1995 annual inspection indicated an empty weight of 5,501 pounds for the airplane and an empty weight center of gravity of 151.8 inches. The airplane had been modified in accordance with Supplemental Type Certificate SA5981SW; this modification increased the airplane's maximum takeoff weight from 7,450 pounds to 7,560 pounds with an allowable center of gravity range at 7,560 pounds of 153.0 to 157.5 inches.

According to FBO personnel at the Tulsa International Airport, the airplane received "a top off on fueling including the locker tank" before departing Tulsa. Estimates of the weights of the pilot and passengers were provided by FBO personnel, and baggage weight was estimated based on the on scene examination of the airplane. Weight and balance calculations were performed using tables provided by the manufacturer. As shown on the enclosed Weight and Balance Form, weight at the time of the accident was calculated at 7,710 pounds with a center of gravity of 155.3 inches.

Meteorological information

The following weather conditions were reported at 1453 for Tulsa International Airport, located 28 nautical miles southeast of the accident site: Measured cei