LAX02FA214

NTSB accident investigation · Cessna 310I · San Dimas, CA · July 4, 2002

Accident · FatalField investigationFinal report
Date
July 4, 2002, 12:30 local (19:30 UTC)
Place
San Dimas, CA
Injuries
4 fatal, 9 serious; on the ground: 2 fatal, 9 serious
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N8145MCessna 310I
Weather
Visual (VMC) · Day
Status
Completed · report September 29, 2004
Report
Approved by Office Director
Parties
Federal Avitaion Administration, Teledyne Continental Motors, McCauley Propeller Systems, Cessna Aircraft
FAA report
20020704022089A
Case key
55136

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

the pilot's failure to maintain control of the airplane following a loss of power in one engine during takeoff. The reason for the loss of power in the left engine could not be determined. Contributing factors to the accident were the pilot's failure to retract the landing gear and to feather the inoperative engine propeller.

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 powerTakeoff - initial climb
Reason for occurrence undeterminedCause
1 engine
Forced landingEmergency landing after takeoff
Loss of control - in flightEmergency landing after takeoff
Aircraft control - not maintainedPilot in commandCause
Gear retraction - not performedPilot in commandFactor
Propeller feathering - not performedPilot in commandFactor
In flight collision with objectDescent - uncontrolled
Object - tree(s)

Analysis

The airplane impacted trees, terrain, and pedestrians after the pilot declared an emergency during takeoff from a nearby airport. Witnesses observed the airplane not climbing after takeoff and air traffic controllers heard the pilot declare mayday three times. The pilot did not elaborate on the emergency situation. Witnesses observed the airplane turn left over the shoreline of a reservoir where it impacted a tree with its left wing. One witness stated the left propeller was not turning as fast as the right propeller and he heard the engines backfiring. Post-accident examination of the aircraft revealed no flight control anomalies. The left engine's top spark plugs were covered with black soot and the piston and cylinders were dark in appearance, indicative of an overly rich fuel/air mixture. The reason for the excessively rich mixture was not determined. The left engine was successfully test run twice following the accident, once utilizing the systems and plumbing in the airframe, and the second time in an instrumented test cell. Examination of the wreckage did find irregularities in the wiring circuits for both boost pumps and their associated cockpit switches; however, the relationship of these irregularities to the loss of power is uncertain. Review of the airplane owner's manual revealed the emergency procedures for a loss of engine power after takeoff called for the retraction of the landing gear and the feathering of the propeller to obtain the maximum climb performance. The landing gear was not retracted and the left propeller was not feathered. Eighteen months prior to the accident, the pilot failed his first attempt to obtain his multiengine airplane rating due to improper emergency procedures during engine failure operations after liftoff. The pilot's total time in the same make and model as the accident airplane is unclear.

Factual narrative

History of flight

On July 4, 2002, at 1230 Pacific daylight time, a Cessna 310I twin-engine airplane, N8145M, was destroyed when it impacted terrain shortly after takeoff from the Brackett Field Airport, La Verne, California. The airplane was registered to, and operated by, the pilot. The commercial pilot and his pilot-rated passenger sustained fatal injuries. Two individuals on the ground received fatal injuries and nine individuals on the ground sustained serious injuries. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The local flight was originating at the time of the accident.

The Brackett Field air traffic controllers reported that the pilot made three consecutive mayday calls during the initial climb out from runway 26L; however, the pilot did not indicate the nature of the emergency. The controllers observed the airplane "not climbing" before the airplane descended behind trees.

A witness, located on a boat in the Puddingstone Reservoir, observed the airplane flying toward the west after departing Brackett Field. The witness was facing north. The airplane was approximately 100 feet above the ground. As the airplane approached the reservoir, the witness heard the engines "backfiring" and noted the right propeller was not turning as fast as the left propeller (as viewed facing the nose of the airplane). The witness also noted the landing gear were extended. The airplane turned toward the south and continued to lose altitude. The witness observed the airplane strike a tree with the right propeller (when viewed from the front of the airplane looking aft), "causing the plane to spin around." The airplane then struck a second tree, bounced back up into the air, and over the second tree. The witness then lost sight of the airplane.

Another witness located on the reservoir said that the propellers were turning. He said one could normally hear the engine power when taking off, but he could not hear engine power for the accident airplane. He observed the airplane turn left toward the shore and lose altitude. The airplane clipped a tree with the port side wing about halfway up the wing, "pulling the plane into a cartwheel." The main body of the airplane hit the second tree with the starboard side and spun around until impacting a picnic area.

The airplane came to rest along the shoreline of Lake Puddingstone in the Frank G. Bonelli Park, San Dimas, California. Park officials estimate that 200-400 people were at the lake near the time of the accident.

Personnel information

The pilot held a commercial pilot certificate with single engine land airplane, rotorcraft helicopter, and instrument airplane and helicopter ratings. He also held a private pilot certificate with multiengine land airplane privileges, which was limited to visual flight rules (VFR) operations only. In addition, the pilot held a flight instructor certificate for single engine land airplanes, rotorcraft helicopters, and instrument helicopters. The pilot held a Federal Aviation Administration (FAA) second-class medical certificate that was issued on October 12, 2001. The medical certificate did not contain any limitations or waivers.

According to the pilot's last pilot certificate application (airplane multiengine add-on rating), which was dated January 29, 2001, he had accumulated a total of 468 hours of airplane flight time and 4,396 hours of helicopter flight time. According to the application, he had accumulated a total of 13.3 hours in the Cessna 310, which is what the pilot used for the practical flight test. According to the FAA's certificate records for the pilot, he failed his multiengine add-on rating practical flight test on January 29, 2001, due to "Emergency Procedures: Engine Failure After Lift Off" and "Emergency Descent." Following the failed practical flight test, the pilot received additional flight instruction, which equated to 0.5 hours of flight time. On the 29th, the pilot was given another endorsement indicating he was "given additional instruction required for a retest after failure of the airplane multiengine land" flight test, and passed the practical flight test on the 29th.

Following the January 2001 practical test, the pilot logged 1.1 hours of multi-engine flight time; however, the last logbook entry was dated September 1, 2001. The pilot completed an application for the use of another Cessna 310 aircraft; adjacent to the pilot's name, was an entry for total time in the same make and model. Penned into that entry block was "92". A date was not affiliated with this pilot experience application.

The pilot-rated passenger held a private pilot certificate with single engine land airplane privileges. He also held a third-class medical certificate that was issued on November 29, 2001. The medical certificate stipulated that the airman must wear lenses for distant vision and possess glasses for near vision while exercising the privileges of his airman certificate. The passenger reported on the medical certificate application that he had accumulated a total of 180 flight hours. A review of his logbook revealed he logged a total of 153.8 hours of flight time, none of which was obtained in multiengine airplanes.

Aircraft information

The 1964 model airplane was issued an airworthiness certificate on July 13, 1964. The airplane was equipped with two Teledyne Continental Motors (TCM) IO-470 engines, each rated at 260 horsepower (left engine serial number 115276-4-U, right engine serial number 118267-70-U-R), and two McCauley constant speed, manually feathering, 2-bladed propellers.

A bill of sale closing statement indicated the pilot and his partner purchased the airplane on February 13, 2002. An aircraft registration application for N8145M was filled out by the pilot and his partner on February 8, 2002. On February 15, 2002, a Special Flight Permit was issued for the airplane in order to transport the airplane to a maintenance facility. The airplane was officially registered to the pilot and his partner on March 15, 2002.

The airframe logbooks revealed a period between February 16, 1993, and April 26, 2002, when no maintenance entries were made. According to those familiar with the airplane, it was awaiting sale during this time period. The February 1993 logbook entry was a determination of airworthiness for a ferry flight. The last entry prior to that was a July 1992 entry, which also determined airworthiness for a ferry flight. The last annual inspection prior to the ferry flights was completed on July 3, 1989, but an aircraft total time was not entered.

A logbook entry dated February 11, 1976, revealed the Hobbs meter was replaced at an aircraft total time of 3,108.5 hours. A logbook entry dated July 15, 1981, stated, "For TT [total time] add 4109 to Hobbs time."

A review of the aircraft maintenance records revealed complete engine histories were not available and their total times were unknown. According to separate engine entries, both dated May 7, 2002, the left engine's total time since its last major overhaul was 1,050 hours, and the right engine's total time since its last major overhaul was 850 hours. The Hobbs meter at the time of these entries was 2,052 hours.

The aircraft's last static system check was completed on April 26, 2002. The last annual inspection conducted on the airplane was completed on May 7, 2002. This annual inspection entry listed both the aircraft total time and the Hobbs meter reading as 2,052.0 hours. Adding the aircraft's hour meter reading at the accident site to 4,109, as instructed to in the logbook entry dated July 15, 1981, provides an aircraft total time of 6,166.1 hours.

According to those familiar with the airplane, the airplane's landing gear collapsed in June 2002. No mention of the repair work was found in the maintenance lo

Aircraft

Registration
N8145M
Reported as
Cessna 310I
Category
Airplane
Serial number
310I0145
Airframe hours
6,158.1
Engines
Continental IO-470-U, 260 horsepower, reciprocatingContinental IO-470-U, 260 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Michael A. Brand
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 7, 2002 · 5,160.5 hours before
Departed
POC · La Verne, CA
Airport
POC · Brackett Field, runway 26L, 4,839 × 75 ft, asphalt

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
44
Injuries
Fatal
Certificates
Commercial, Flight instructor, Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
January 29, 2001
Seat
Left
Toxicology
Performed
Flight hours
4,891 total · 15 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 7 knots
Visibility
5 statute miles
Lowest ceiling
None
Altimeter
29.95 inHg
Observed at
POC

Docket · 54

The files NTSB released with the investigation on July 16, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 42.2 MB in all.

ATC 3 - Sound Spectrum StudyItem 1 · .PDF · 81 KBWitness StatementsItem 2 · .PDF · 202 KBWreckage DiagramItem 3 · .PDF · 384 KBWeather ReportsItem 4 · .PDF · 104 KBTranscript of Radio CommunicationsItem 5 · .PDF · 125 KBPhoto 1. Aerial View of Accident Site (Sheriff)Item 6 · .PDF · 1.1 MBPhoto 2. Aerial View of Accident Site (Sheriff)Item 7 · .PDF · 1.1 MBPhoto 3. Aerial View of Accident Site (Sheriff)Item 8 · .PDF · 1.1 MBPhoto 4. Aerial View of Accident Site (Sheriff)Item 9 · .PDF · 1.1 MBPhoto 5. Wreckage Path From First Tree (Sheriff)Item 10 · .PDF · 1.2 MBPhoto 6. Second Tree & Pieces of Left Main (Sheriff)Item 11 · .PDF · 1.2 MBPhoto 7. Left Wing & Airplane Nose (Sheriff)Item 12 · .PDF · 957 KBPhoto 8. Right Wing & Fuselage Sections (Sheriff)Item 13 · .PDF · 994 KBPhoto 9. Main Wreckage with Right Engine in Foreground (Sheriff)Item 14 · .PDF · 1.1 MBPhoto 10. Cockpit & Cabin (Sheriff)Item 15 · .PDF · 922 KBPhoto 11. Left Engine & Propeller (Sheriff)Item 16 · .PDF · 1.1 MBPhoto 12. Left Engine & Propeller (Sheriff)Item 17 · .PDF · 1.0 MBPhoto 13. Right Engine, Cowling, Prop Piston (Sheriff)Item 18 · .PDF · 1.2 MBPhoto 14. Instrument PanelItem 19 · .PDF · 142 KBPhoto 15. Throttle Quadrant (Sheriff)Item 20 · .PDF · 967 KBPhoto 16. Fuel System SwitchesItem 21 · .PDF · 137 KBPhoto 17. Hobbs Meter (TCM)Item 22 · .PDF · 436 KBPhoto 18. Left Engine Fuel Metering Unit (TCM)Item 23 · .PDF · 524 KBPhoto 19. Right Engine Fuel Metering Unit & Throttle Body (TCM)Item 24 · .PDF · 722 KBPhoto 20. Left Engine Top Spark Plugs (TCM)Item 25 · .PDF · 345 KBPhoto 21. First Test Run of Left Engine (TCM)Item 26 · .PDF · 468 KBPhoto 22. Left Propeller Components (McCauley)Item 27 · .PDF · 671 KBPhoto 23. Right Propeller Components (McCauley)Item 28 · .PDF · 646 KBTeardown Pictures (Corona)Item 29 · .PDF · 1.8 MBFAA ReportItem 30 · .PDF · 110 KBCessna Aircraft Company ReportItem 31 · .PDF · 765 KBTeledyne Continental Motors Left Engine ReportItem 32 · .PDF · 2.4 MBTeledyne Continental Motors Right Engine ReportItem 33 · .PDF · 5.9 MBTeledyne Continental Motors Aircraft ExamItem 34 · .PDF · 58 KBMcCauley Propeller Systems ReportItem 35 · .PDF · 58 KBGarmin ReportItem 36 · .PDF · 27 KBPilot LogbookItem 37 · .PDF · 770 KBMEI LogbookItem 38 · .PDF · 690 KBPassenger LogbookItem 39 · .PDF · 111 KBExcerpts From Owner ManualItem 40 · .PDF · 250 KBChecklists Found in AirplaneItem 41 · .PDF · 461 KBFuel ReceiptItem 42 · .PDF · 141 KBPurchase InformationItem 43 · .PDF · 321 KBAirframe Log #3Item 44 · .PDF · 158 KBAirframe Log #2Item 45 · .PDF · 1.5 MBAirframe Log #1Item 46 · .PDF · 1.8 MBLeft Engine LogItem 47 · .PDF · 105 KBRight Engine LogItem 48 · .PDF · 90 KBAnnual Inspection RecordsItem 49 · .PDF · 351 KBMiscellaneous Records & ReceiptsItem 50 · .PDF · 1.6 MBCessna Service Kit & Service Bulletin InformationItem 51 · .PDF · 2.0 MBToxicological Report & Drug InformationItem 52 · .PDF · 117 KBStatement of Party Representatives to NTSB InvestigationItem 53 · .PDF · 335 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 54 · .PDF · 90 KB

FAA reports on this event · 1

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

Other investigations on N8145M · 1

Matched to the same aircraft by N-number and date.