LAX03FA147

The pilot lost control of his twin engine airplane and collided with terrain while returning to the departure airport after reporting an engine problem. Shortly after takeoff, about 4,000 feet msl, the pilot reported to ATC that he had an engine problem and would return to the airport. The radar plot reveals a steady descent of the airplane from 4,000 feet msl to the accident site, approximately 2 miles from the designated airport. Ground witnesses reported that they saw the airplane flying very low, about 500 feet agl, seconds prior to the accident apparently heading toward the departure airport. The witnesses reported consistent observations of the airplane "wobbling," then going into a steep knife-edge left bank before it dove into the ground. Witnesses at the airport said that the pilot sought out help in getting his radios operating prior to takeoff, telling the witness, "its been four and a half months since I've been in an airplane, I can't even figure out how to put the radios back in." No fueling records were found for the airplane at the departure airport. The last documented fueling of the airplane was on October 31, 2002, with the addition of 56.2 gallons. Witnesses reported that the airplane did not take on any fuel immediately prior to the flight on May 4th. The flight was the first flight since the airplane received its annual inspection 2 months prior to the accident, and, it was the pilot's first flight after 4 months of inactivity. It is a common practice for maintenance personnel to pull the landing light circuit breakers during maintenance to prevent the fuel transfer pumps, which are wired through the landing light system, from operating continuously. The fuel transfer pumps move fuel from the forward part of the main fuel tank to the center baffle area where it is picked up and routed to the engine. It is conceivable that these circuit breakers were not reset by the pilot for this flight. Wreckage examination revealed a post accident fire on the right wing of the airplane and no fire on the left wing. Additionally, only a small amount of fuel was identified around the left wing tanks after the accident, and no hydraulic deformation was observed to the left main tank or the internal baffles. The landing gear bellcrank indicates that the landing gear was in the down position. The engine and propeller post impact signatures indicate that the left engine was operating at a low power setting (wind milling), while the right engine and propeller indicate a high power setting. Disassembly and inspection of the internal propeller hub components showed that the left propeller was not feathered. The left engine is the critical engine and loss of power in that engine would make directional control more difficult at slower speeds. The airplane owners manual states that "climb or continued level flight at a moderate altitude is improbable with the landing gear extended or the propeller wind milling." The single engine flight procedure delineated in the manual dictates a higher than normal altitude for a successful single engine landing approach.

History of flight

On May 4, 2003, at 1453 Pacific daylight time, the pilot of a Cessna 411 twin engine airplane, N1133S, lost control and collided with terrain approximately 2 miles east of the Corona Municipal Airport, Corona, California. The pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The commercial pilot, who was the sole occupant, received fatal injuries. The airplane was destroyed. Day visual meteorological conditions prevailed, and no flight plan had been filed. The flight originated from the Corona airport around 1430, and was en route to Santa Monica, California.

According to Air Traffic Control (ATC) communications, and family members, the purpose of the flight was to deliver the airplane to Santa Monica Propeller for maintenance on one of the airplane's propellers. The pilot checked in with Southern California Approach (SoCal Approach) and requested flight following to Santa Monica. Approximately 3 minutes after checking in with SoCal approach, the pilot reported having engine difficulties and was returning to Corona. SoCal approach assisted the pilot with vectors to Corona Airport. SoCal approach lost radar contact with the airplane approximately 3 miles to the east of Corona Airport. So Cal approach advised loss of radar contact then instructed the pilot to change to the airport advisory frequency, which the pilot acknowledged.

The airplane flew over several witnesses who were within 1/2 mile of the accident site. They reported to the National Transportation Safety Board investigator-in-charge (IIC) that they observed the airplane flying "very low," about 300 to 500 feet msl. The airplane was heading toward the Corona airport. The witnesses reported consistent observations of the airplane "wobbling," then going into a steep knife-edge left bank before it dove into the ground. The wreckage was immediately located by police and fire rescue crews who extinguished a fire on the right side of the airplane.

Personnel information

The pilot obtained his third-class medical certificate on March 25, 2002. His medical was valid with no limitations.

Examination of the pilot's logbook and Federal Aviation Administration (FAA) records revealed the pilot received his commercial pilot certificate, single engine land, and instrument ratings through military competency on May 4, 1960. He received his multiengine land rating on May 17, 1999. The pilot had accumulated about 4,899 total flight hours with approximately 412 hours in the Cessna 411.

In the Riverside Automated Flight Service Station re-recording of the pilot requesting a weather brief, the pilot can be heard to say in a side conversation while he was waiting for a briefer, "Thank you very much for coming and helping I,...its been four and a half months since I've been in an airplane, I can't even figure out how to put the radios back in."

Aircraft information

The twin engine, low wing airplane was powered by two Teledyne Continental GSTIO-520-C engines. The airplane's serial number was: 411-0202. The airplane and engines underwent their last annual inspection on March 19, 2003, at an aircraft total time of 4,915 hours, and 86.5 hours since the last inspection in 2002. The total time since the last engine overhaul was 503 hours on the right engine and 563 hours on the left engine.

An aircraft logbook entry dated March 19, 2003, indicated the aircraft annual inspection was completed; however, the left propeller did not comply with AD 95-24-05 RI: "The propeller must be inspected by a certified person. Completion of AD 95-24-05RI will make the aircraft airworthy."

The mechanic who performed the last annual inspection provided copies of his discrepancy notes pertaining to the accident airplane to the Safety Board IIC. In those documents it is noted that the left propeller was leaking red dye.

According to Corona Aircraft Sales, the airplane had been placed on their sales lot to be sold. The airplane had not been flown since the completion of the annual inspection.

Air traffic control and radar data

Review of the Air Traffic Control (ATC) communications re-recording and radar plot data revealed that the pilot had been in communications with Southern California Approach. Upon initial contact with SoCal approach the airplane was observed by the controller to be heading east, away from Santa Monica. When the controller queried the pilot, the pilot said his GPS indicated he was heading the correct direction. The controller informed the pilot that he was heading east when Santa Monica was to the west, and gave the pilot an appropriate heading towards his stated destination. Approximately 3 minutes 15 seconds after initial contact with SoCal approach, and at an altitude of 4,000 feet, the pilot reported an "engine cutting out" and intended to return to Corona airport. The SoCal approach controller observed the airplane descend in altitude, assisted the pilot with vectors to Corona Airport, and expressed concern about the airplane's ability to maintain altitude. The pilot reassured the controller that he could maintain altitude. Approximately 3 miles east of Corona airport the controller reported that radar contact was lost and to switch to the airport advisory frequency. The pilot acknowledged this last communication.

Radar and radio communication re-recordings and data files were obtained from Southern California TRACON and a plot was generated by a private vendor for the Cessna Aircraft Company. A copy of the plot and communication transcripts is attached to this report. It shows the aircraft departing Corona airport, climbing to 4,000 feet, turning back towards Corona, and continuously descending until radar contact is lost at about 700 feet agl and 85 knots ground speed.

Wreckage and impact information

The airplane wreckage was located in a construction site on a small plateau approximately 30 feet above River Road to the east. The dirt plateau falls away into a drainage culvert approximately 75 feet below to the north. The construction site was barren of all trees and brush. The plateau had an approximate 20-degree slope downwards to River Road. The wreckage location was recorded with a global positioning system as latitude north 33 degrees 53.794 minutes, longitude west 117 degrees 34.275 minutes at an elevation of 590 feet.

All major components of the airplane were present at the accident site. The airplane was oriented on a bearing of 310 degrees magnetic. The airplane was laying upright with the landing gear collapsed underneath the fuselage. The nose, flight deck, and instrument panel of the airplane were completely destroyed. The engine control quadrant; throttle, propeller, and mixture control levers were all found parallel, in the full forward position. The circuit breaker panels had pulled apart. Most circuit breakers were popped or broken, posts sheared, and extended out of position.

The right wing exhibited fire damage outboard of the right engine. The entire right engine was twisted 90 degrees along its longitudinal axis so that the engine cylinders were directed vertically. The crankshaft propeller flange exhibited torsional shearing and the propeller was not attached to the engine. The right wing leading edge and fuel tip tank were crushed aft to the wing spar and thermally damaged. The right aileron was consumed by fire but the aileron spar was attached to its respective hinge points. The right aileron flight control cables were present and attached to the aileron bellcrank and push rod, which connect to the aileron.

The right side of the fuselage was split along an upper longitudinal rivet line and laying open from aft of the upper corner of the emergency exit to the leading edge of the horizontal stabilizer.

The last outboard quarter of the right horizontal stabilizer had a 20-degree bend upward. The rudder had skin wrinkles along th