# NTSB LAX03FA067: Cessna 414, N127WW, Palm Springs, CA, January 14, 2003 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: January 14, 2003, 13:59 local (21:59 UTC) - Place: Palm Springs, CA - Coordinates: 33.849998, -116.483329 - Nearby events: https://openairdocs.org/map.md?lat=33.8500&lon=-116.4833&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 2 minor - Status: Completed, report March 26, 2007 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Federal Aviation Administration, Teledyne Continental Motors - NTSB case key (mKey): 56350 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03FA067 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56350/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56350 - Page: https://openairdocs.org/ntsb/LAX03FA067 ## Probable cause The flight instructor's improper selection of the high boost position for the operating right engine while on base leg to land, which resulted in a loss of engine power of the right engine. Factors associated with the accident are the left engine's loss of power for an undetermined reason, the flight instructor's failure to feather the propellers of the affected engines, and his failure to maintain directional control, which resulted in an off-airport forced landing. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, approach - vfr pattern - base leg/base to final - 1 engine - loss,total (contributing factor) - reason for occurrence undetermined - fuel tank selector position - improper, pilot in command(cfi) (cause) - 1 engine - loss,total (cause) - directional control - not maintained, pilot in command(cfi) (contributing factor) - propeller feathering - not performed, pilot in command(cfi) (contributing factor) - Forced landing, emergency descent/landing - On ground/water encounter with terrain/water, emergency descent/landing - terrain condition - ravine ## Analysis The certificated flight instructor (CFI) was providing multiengine training to one of the two owner/pilots aboard during an IFR cross-country flight. Upon reaching cruise altitude, both left and right engine fuel selectors were turned from the main fuel tanks to the auxiliary tanks. Shortly after selecting the auxiliary tanks, the left engine lost power. Power was restored after the fuel selector was returned to the main tank, and the CFI elected to continue the flight. During approach to land at the destination airport, the CFI simulated a left engine failure by reducing power on that engine to "zero thrust." The left propeller was intentionally not feathered. While on the base leg, about to turn final, the left engine began to surge, pulling the airplane away from the airport. The CFI stated that he took the controls, and increased power on both engines, but the airplane continued to move away from the runway. He stated that the left engine continued to surge, and the right engine began to lose power. He indicated that he turned the boost pumps for both engines from the low to "ON" (high) position without any noticeable difference in power. He did not feather either propeller, and made a forced landing off airport in a sandy ravine. All pilots indicated that there was ample fuel aboard the airplane at the time of the engine problems, and that the fuel tank selectors were on the main tanks. Postaccident inspection disclosed that the left main and auxiliary fuel tanks had been breached during the accident. The right main and auxiliary tanks were intact, with a usable quantity of fuel remaining in the right main. The left engine had damage that precluded a test run. It was disassembled, and no evidence of any preimpact mechanical anomaly was discovered. The left engine driven fuel pump was not tested. The left engine's fuel boost pump ran noisily for a short period, and then overheated. The right engine was successfully run on a test stand. An inspection of the right engine's spark plugs prior to the engine run revealed that the engine had operated in an overly rich state just prior to the accident. The right engine's fuel boost pump functioned normally. The airplane's flight manual cautions that if the boost pump switch is moved to the high position while the engine driven fuel pump is operating, an overly rich condition may result in a total loss of engine power. ## Factual narrative HISTORY OF FLIGHT On January 14, 2003, at 1359 Pacific standard time, a Cessna 414, N127WW, lost engine power and made an off airport forced landing at Palm Springs, California. The owner operated the airplane under the provisions of 14 CFR Part 91. The airplane sustained substantial damage. The commercial multiengine pilot undergoing instruction (PUI) was located in the left seat, and received serious injuries. The certified flight instructor (CFI) in the right seat, and a pilot rated passenger in the passenger compartment had minor injuries. Visual meteorological conditions prevailed for the cross-country flight. An instrument flight rules (IFR) flight plan had been filed. The flight departed Zamperini Field (TOA), Torrance, California, at 1145. The flight was destined for Palm Springs International Airport (PSP). The wreckage was at a global positioning system (GPS) coordinates of 33 degrees 51 minutes north latitude and 116 degrees 29 minutes west longitude. Responding Palm Springs Police Department officers interviewed the pilots after the accident. The CFI reported that as they turned towards final, the left engine began to surge and the airplane yawed to the right. He went through the emergency procedures but the airplane continued to lose airspeed and altitude. While maneuvering to the landing spot, the CFI noted that the fuel selectors were positioned to the MAIN fuel tanks, and the gauges showed 25 gallons in each wing. The responding officers verified that the master switch and the magnetos were in the OFF positions, the landing gear handle was in the retracted position, and the flaps were retracted. They also noted that the fuel boost pump switches were "fully on." The fuel selector handles were in the OFF position. The officers inspected the fuel tanks and noted that the left side fuel tanks were empty, with the odor of fuel present under the damaged wing. The two outer right wing fuel tanks each had fuel remaining in them. CFI Statement (seated in the right seat) The CFI reported that on the day prior to the accident, during the preflight inspection, he noted that the left alternator circuit breaker had been tripped to the OPEN position, and he reset it. They started the engines and cross-fed fuel from the opposite main fuel tanks priming the engine via the emergency fuel pump ON position. Normal fuel flow was established and the engines were operating normally. They tested the airplane system per the BEFORE TAKEOFF checklist, with no discrepancies noted. As they taxied to the fueling area there was a discussion about the left alternator, which had recently been replaced. They did not know if it was on line or not. The PUI had informed him that during the ferry flight to reposition the airplane from Palomar Airport, Carlsbad, California, to TOA, the pilot noted that the left alternator was inoperative. However, during the taxi, no discrepancies were noted with the left alternator. The airplane was fueled to capacity; 100 gallons in the main fuel tanks, and 40 gallons each in the auxiliary and nacelle locker fuel tanks for a total of 80 gallons. The airplane was taxied to the hangar where they adjourned to start the ground school portion of the training. They spent the next 6 hours reviewing airplane systems. They met the next day to complete the ground school instruction. The pilots again performed the preflight inspection, which included sampling the fuel sumps, where about 1 quart of water was removed from the right wings' innermost rear sump. The water was not "clean; it was cloudy and contained sediment." They continued to sample the fuel until "clear fuel was detected." The airplane was started normally and they received an IFR flight plan to PSP via Thermal, California, and Blythe, California, reaching an altitude of 25,000 feet (flight level - FL250) to conduct high altitude operations. After reaching FL250, the airplane was configured for 65-percent power and the air-to-fuel mixture was adjusted to the recommend values. At that point, the CFI switched from the main fuel tanks to the auxiliary fuel tanks. Moments later, the left engine "dropped off line," and no fuel flow was evident on the fuel gauge. He then moved the left fuel selector back to the left main fuel tank. He advised Southern California Air Route Traffic Control Center (SoCal ARTCC) of the situation, and initiated a slow right circling descent towards Blythe airport. The left engine did not immediately come back on line, and it took a few minutes before the engine regained power. The CFI reported that they stabilized the airplane's altitude at 15,000 feet and elected to continue on towards Thermal. At that point both engines were operating normally. He stated that the left fuel selector was positioned to the MAIN fuel tank, and the right fuel selector was positioned to the AUXILIARY fuel tank. The CFI reported that because the engines were operating normally, he moved the left fuel selector from the MAIN fuel tank back to the AUXILIARY fuel tank. The left engine continued to operate normally. He stated that they performed flight maneuvers that included medium and steep bank turns, unusual attitudes, and various simulated emergency conditions. During the airwork, the fuel selectors were both positioned to the MAIN fuel tanks, and they initiated the fuel transfer process from the nacelle locker tanks to the main fuel tanks. The CFI stated that the engines were operating normally, and they continued the flight towards PSP, their original destination so they could refuel and switch pilots. At 8,500 feet, he radioed the PSP approach controller with a request to circle PSP airport, and simulate single engine operations (an engine out condition). The PSP controller acknowledged and approved their request. The flight proceeded direct to PSP at 3,500 feet and was instructed to contact tower personnel; a tower controller cleared them to land on runway 31L. The CFI then simulated a left engine failure by reducing the power with the throttle. The PUI initiated the emergency procedures by increasing mixture to rich, propellers to high rpm (revolutions per minute), and right throttle full forward. The PUI performed a "drag check" to ensure the landing gear and wing flaps were retracted. The PUI then identified the left engine as inoperative and verified by closing the left throttle. When the PUI went to feather the left propeller the CFI blocked him, and then set power on the left engine to simulate "zero thrust and trimmed for that condition." The PUI circled the airplane to the right, towards the operating engine, and during the descent, the power on the right engine was reduced to 29.5 inches manifold pressure (MAP) and 2,400 rpm. The CFI reported that they orbited the airplane a couple of times before establishing the airplane on the right downwind leg for runway 31L. As they turned from base to final, left wing high, the left engine started to "surge wildly, rotating the [airplane] clockwise 180 degrees from our previous heading and outbound perpendicular from the runway." They arrested the turn by leveling the wings, lowering the pitch attitude, and "bringing power up on both throttles." The CFI reported at that point he took over the flight controls. The power increased on the left engine, which continued to surge "with a higher frequency," and power on the right engine began to drop off progressively. They attempted to stabilize the power situation on the left engine and restore power to the right engine by placing the auxiliary fuel pump switches from the LOW position to the ON position. However, there was not a noticeable change in either engine. The airplane yawed to the right towards a housing development with surface streets and power lines in their route of flight. The airplane continued to lose altitude. He had the PUI inform PSP tower that they had an actual emergen ## Aircraft - Registration: [N127WW](https://openairdocs.org/deregistered/N127WW-2008-10-01), registration cancelled 2008-10-01, S/N 414-0260, built 1972 (OpenAirDocs) - Reported make and model: Cessna 414 - Registry model: [Cessna 414](https://openairdocs.org/model/cessna-414) (registry code 2075908) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 414-0260 - Airframe hours: 1658.9 - Engines: Teledyne Continental TSIO-520-NB 335 horsepower reciprocating; Teledyne Continental TSIO-520-NB 335 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Allied Eagles - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2002, 17.8 hours before - Departed: TOA, Torrance, CA - Destination: PSP, Palm Springs, CA - Flight plan: IFR - Airport: PSP, Palm Springs Regional ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 52; injuries: none; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2; last flight review May 1, 2002; seat: right; flight hours: 10,043 total, 95 in this make and model, 9,793 as pilot in command, 151 in the last 90 days, 53 in the last 30 days, 3 in the last 24 hours - Pilot; age 59; injuries: serious; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3; last flight review February 1, 2002; seat: left; flight hours: 2,264 total, 3 in this make and model, 2,087 as pilot in command, 57 in the last 90 days, 16 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 32 °F - Altimeter: 30.06 inHg - Observed at: PSP, 2 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 20030114000579A](https://openairdocs.org/incident/20030114000579A), Jan 14, 2003: Cessna 414, Palm Springs, CA, Substantial damage. (-23) N127WW, Cessna C414 crashed under unknown circumstances two miles north of the Palm Springs, CA regional airport at 1414 PST. Substantial damage and… ## Docket (14 files) The files NTSB released with the investigation on December 27, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56350. 5.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 685 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270167&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Passenger Statement (item 2, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270168&FileExtension=.PDF&FileName=Passenger%20Statement-Master.PDF - Photo 1 - Main Wreckage (L-08) (item 3, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270169&FileExtension=.PDF&FileName=Photo%201%20-%20Main%20Wreckage%20(L-08)-Master.PDF - Excerpt ATC Report (item 4, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440880&FileExtension=.PDF&FileName=Excerpt%20ATC%20Report-Redacted.PDF - Excerpt report from Palm Springs Police Department (item 5, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440881&FileExtension=.PDF&FileName=Excerpt%20report%20from%20Palm%20Springs%20Police%20Department-Redacted.PDF - Airframe Logbook (item 6, .PDF, 892 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270172&FileExtension=.PDF&FileName=Airframe%20Logbook-Redacted.PDF - Excerpt Left and Right Engine Logbooks (item 7, .PDF, 766 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270173&FileExtension=.PDF&FileName=Excerpt%20Left%20and%20Right%20Engine%20Logbooks-Redacted.PDF - Fuel Pump Inspection Report (item 8, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270174&FileExtension=.PDF&FileName=Fuel%20Pump%20Inspection%20Report-Redacted.PDF - Fuel Receipt (item 9, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440882&FileExtension=.PDF&FileName=Fuel%20Receipt-Redacted.PDF - Teledyne Continental Motors Report (item 10, .PDF, 558 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440885&FileExtension=.PDF&FileName=Teledyne%20Continental%20Motors%20Report-Redacted.PDF - Maintenance Inspection of Airplane at Accident Site (item 11, .PDF, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440883&FileExtension=.PDF&FileName=Maintenance%20Inspection%20of%20Airplane%20at%20Accident%20Site-Redacted.PDF - RAM Conversion - STC (item 12, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270178&FileExtension=.PDF&FileName=RAM%20Conversion%20-%20STC-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 319 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270180&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 14, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440884&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; 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.