LAX01FA026

NTSB accident investigation · Cessna 340A · Julian, CA · October 26, 2000

Accident · FatalField investigationFinal report
Date
October 26, 2000, 10:58 local (17:58 UTC)
Place
Julian, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N4347CCessna 340A
Weather
Instrument (IMC) · Day
Status
Completed · report May 21, 2002
Report
Approved by Office Director
Parties
TELEDYNE CONTINENTAL MOTORS, FAA FLT STNDS DIST OFFICE, CESSNA AIRCRAFT COMPANY, LENAIR AVIATION INC.
FAA report
20001026038889A
Case key
50548

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

Total blockage of the instrument static system due to ice.

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.

Airframe/component/system failure/malfunctionCruise
Pitot/static system - iceCause
Pitot/static system - blocked(total)Cause
In flight collision with terrain/waterCruise
Terrain condition - mountainous/hilly

Analysis

During en route cruise flight at an assigned altitude of 11,000 feet (msl) in instrument meteorological conditions, the airplane impacted mountainous terrain at 5,300 feet, in wings-level, descending flight. During the final 12 minutes of the flight (from 1046 to 1058 Pacific daylight time), recorded military search radar height values (primary radar returns) show the aircraft in a steady descent from 11,000 feet to 5,600 feet, where radar contact was lost. During the same time interval, recorded Mode C altitudes received at Los Angeles Air Traffic Control Center (Center) and SoCal Terminal Radar Approach Control (TRACON) indicated the aircraft was level at 11,000 feet. At 1055:49, when the pilot was handed off from SoCal TRACON to Los Angeles Center, the pilot checked in with the Center ". . . level at one one thousand." At 1057:28, the pilot asked the Center controller "what altitude you showing us at" to which the controller responded "not receiving your mode C right now sir." At 1057:37, the pilot transmitted "o k we'd like to climb to vfr on top, our uh altimeter just went down to uh fifty three hundred." The controller approved the pilot's request to climb to VFR conditions on-top and, at 1057:54, the pilot responded "roger we're out." No further transmissions were received from the aircraft. The airplane was equipped with a single instrument static pressure system with two heated static ports. The static system and static system instruments were damaged or destroyed by impact and post-crash fire sufficiently to preclude post-accident testing.

Factual narrative

History of flight

On October 26, 2000, at 1058 hours Pacific daylight time, a Cessna 340A, N4347C, was destroyed when the aircraft impacted mountainous terrain near Julian, California. The airline transport certificated pilot and the commercial certificated second pilot were fatally injured. Instrument meteorological conditions prevailed for the business flight conducted under 14 CFR Part 91 by Marko Foam Products, Inc., of Corona, California. The aircraft departed from the John Wayne Airport - Orange County, Santa Ana, California, at 1031, destined for Calexico, California, and was operating on an instrument flight plan.

About 2 minutes prior to the loss of radar contact, while en route in instrument flight conditions between the Oceanside VORTAC and the Julian VORTAC (radio navigational aides), the flight was handed off to the Los Angeles Air Route Traffic Control Center. The pilot checked in with the center at 11,000 feet and, a short time later, asked what altitude the center showed him to be at on radar. The controller replied that he was not receiving the airplane's mode C altitude information. The pilot then asked for clearance to climb to VFR conditions on top. He reported ". . . our uh altimeter just went down to uh fifty three hundred." He reported the airplane was in the tops of the clouds and needed to go up about 1,000 feet. The controller cleared the aircraft to climb and maintain VFR conditions on top and, a short time later, radar contact was lost.

Personnel information

The pilot was the Charter chief pilot at Lenair Aviation at John Wayne Airport and had about 20,000 hours of flight experience. His first-class medical certificate was issued October 2, 2000.

The chief flight instructor of Lenair said that his company regularly provided pilot services to the owner of the accident aircraft. Because they were providing pilots only, the flight operation was conducted under 14 CFR Part 91. On the day of the accident, Lenair assigned the pilot to fly the aircraft to Calexico to pickup employees of the owner and return them to Corona, California, and then return the airplane to John Wayne airport.

The chief flight instructor also said that the second pilot was neither an employee of Lenair nor an assigned crewmember. He was aboard the aircraft without Lenair's knowledge or consent. The pilot who was assigned the trip had, unbeknownst to Lenair, apparently offered the second pilot the opportunity to "ride along." The second pilot was not affiliated with the aircraft owner.

Aircraft information

The previous flight of the aircraft was on October 24, 2000. The pilot who flew that flight reported the aircraft was equipped and certified for flight in instrument meteorological conditions, there were no mechanical discrepancies on the aircraft, and that the model 400 autopilot functioned normally. The aircraft was originally manufactured and equipped for approved flight into known icing conditions; however, the windshield heated plate had been removed. The pilot who flew the previous flight believed the remainder of the de-ice equipment was functional although he hadn't had occasion to use it.

The owner of the aircraft reported that the aircraft was only washed when he specifically instructed the washing service to clean it. It was last washed on October 16, 2000, just before he flew the airplane to Colorado Springs, Colorado, and back. He reported that, on that trip, which cruised at 16,500 feet mean sea level (msl), there were no irregularities in any of the instrumentation, in particular, none in the pitot-static instruments.

The last regular maintenance was an annual inspection on January 19, 2000, when the aircraft's total flying time was 3,181.5 hours. The manager of the maintenance facility, which performed the inspection, said the de-ice boot function would have routinely been tested by external visual and tactile examination during ground run-up. According to the shop work order, "several small splits" in the wing de-ice boots were repaired. Airworthiness directive 96-20-07 relating to pressure testing the combustion chamber of the cabin heater was accomplished.

Two maintenance activities were accomplished in the interim following the inspection up to the time of the accident. On May 4, 2000, the right-hand (copilot) attitude indicator was overhauled and replaced, the de-ice boots were "clean[ed] and dressed," and the cockpit seats were reupholstered. On June 30, 2000, the de-ice boot electrical lead on the number 3 blade of the right-hand propeller was replaced and the de-ice ammeter was removed, overhauled, and replaced at aircraft total flight time of 3,233 hours.

According to the aircraft logbooks, new de-ice boots were installed on the horizontal stabilizer on January 23, 1997.

On December 22, 1999, the altimeters and static system were tested and certified in accordance with FAR 91.411 (FAR part 43, appendix E), and the transponder was tested and certified in accordance with FAR 91.413 (FAR part 43, appendix F). The manager of the repair station that performed the pitot/static and transponder tests reported it is normal practice in the course of the static system test to first slightly pressurize the static system (about 200 feet altitude) and open the static system drains to expel any accumulated moisture.

According to production records, provided by Cessna Aircraft, the airplane was manufactured April 5, 1978, with optional equipment installed for flight in known icing conditions. Cessna drawing 5300960, titled "Kit Installation - Known Icing, Model 340," shows this equipment as heated static ports, an electrically heated windshield panel, surface de-ice boots, and propeller de-ice boots. According to the Cessna Pilot's Operating Handbook for the model 340A aircraft, an electrically heated pitot tube was standard equipment.

Also according to the production records, the aircraft did not come from the factory with flight instrumentation installed on the right-hand (copilot's) instrument panel and, according to the Cessna party representative, this means that aircraft would have been delivered with a single static system. The aircraft was equipped with an EA-401A encoding altimeter on the left-hand (pilot's) instrument panel and did have a standby altimeter installed on the right-hand panel. According to the operator, the right-hand panel instrumentation included an attitude indicator (artificial horizon), directional (heading) gyro instrument, airspeed indicator, altimeter, and rate-of-climb indicator. Entries in the aircraft logbook stated that "standby" directional gyro instrument and airspeed indicators were installed on the right panel on February 18, 1982. An attitude gyro instrument was installed on August 22, 1984.

According to the Cessna Pilot's Operating Handbook, there are three switches on the left side of the cockpit which operate the de-icing equipment; one for surface de-ice (boots), another for "Pitot Heat" and a third for "Stall and Vent Heat." The third switch, "Stall and Vent Heat," when turned on, supplies electrical power to the static vent heaters, the stall vane heaters, and the wing locker fuel tank vent heater. The "Pitot Heat" switch provides electrical power to the pitot tube heater element only. According to the Cessna Aircraft company party representative, the "Pitot Heat" switch and the "Stall and Vent Heat" switch are adjacent to one another on the switch panel. A supplement to the handbook describes the equipment and provides instructions for preflight functional testing of the heaters.

Meteorological information

The chief flight instructor at Lenair Aviation reported that the pilot obtained a weather briefing and filed an instrument flight plan using Lenair's DUATs weather access computer before going to the aircraft.

According to the Factual Report of the Safety Board's Air Traffic Specialist (see Com

Aircraft

Registration
N4347C
Reported as
Cessna 340A
Category
Airplane
Serial number
340A0538
Airframe hours
3,182
Engine
Continental TSIO-520-NB, 325 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Registered owner
Marko Foam Products, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 19, 2000
Departed
SNA · Santa Ana, CA
Destination
CXO · Calexico, CA
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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
61
Injuries
Fatal
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
August 9, 2000
Flight hours
20,000 total · 180 in this make and model · 150 in the last 90 days · 73 in the last 30 days
Role
Other flight crew
Age
33
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
March 16, 2000
Flight hours
338 total · 5 in the last 90 days · 1 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
100° at 3 knots
Visibility
10 statute miles
Lowest ceiling
700 ft broken
Temperature
55 °F, dew point 52 °F
Altimeter
29.00 inHg
Observed at
RNM, 19 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.