LAX04FA031

NTSB accident investigation · Cessna 421B · Kelso, CA · October 29, 2003

Accident · FatalField investigationFinal report
Date
October 29, 2003, 12:22 local (20:22 UTC)
Place
Kelso, CA
Injuries
5 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N444AMCessna 421B
Weather
Visual (VMC) · Day
Status
Completed · report April 25, 2006
Report
Approved by Office Director
Parties
Cessna Aircraft Company, Teledyne Continental Motors, Federal Aviation Administration
Case key
58260

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 continued VFR flight into instrument conditions between cloud layers and with reduced visibility due to smoke that resulted in an in-flight loss of control from spatial disorientation, and the structural overload of the airframe during the subsequent high speed descent.

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.

In flight encounter with weatherCruise
Weather condition - haze/smokeFactor
Vfr flight into imc - continuedPilot in commandCause
Weather condition - cloudsFactor
Loss of control - in flightCruise
Aircraft control - not maintainedPilot in commandCause
Spatial disorientationPilot in commandCause
Airframe/component/system failure/malfunctionDescent - uncontrolled
Design stress limits of aircraft - exceededPilot in commandCause
Wing - overloadCause
Flight control,elevator - overloadCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The aircraft broke up in-flight during a high speed descent after encountering clouds and reduced visibilities aloft. The weather conditions included multiple cloud layers at 9,000, 12,000 and 16,000 feet, and reduced visibility aloft from smoke and haze from wilderness wild fires that were occurring over large portions of Southern California. The aircraft departed the airport toward a VORTAC to the west, approximately 30 nautical miles (nm) away. The first radar contact was at 1159, and the aircraft's Mode C transponder reported an altitude of 3,500 feet mean sea level (msl). By the time the aircraft reached the VORTAC, the altitude had increased to 4,900 feet msl. The aircraft continued to climb, passing through the VFR flight plan filed altitude of 8,500 feet msl, until it reached an altitude of 12,900 feet msl. The last 6 minutes of radar data reported the aircraft at various altitudes, starting at 11,000 feet msl and climbing to a maximum altitude of 12,700 feet msl. During the last 3 minutes of flight, radar data showed the aircraft made numerous left and right climbing and descending turns, eventually reversing course. The next to last radar return at 1221:24 indicated an altitude of 11,900 feet msl. Nineteen seconds later, the last radar return reported an altitude of 7,700 feet msl. The computed vertical speed between the last two radar returns was 13,263 feet per minute. The wreckage was distributed over a 0.2-nm distance, with the main wreckage approximately 0.5 miles northwest of the last radar return. The northern end of the debris path began with pieces of the left elevator, followed by sections of the right stabilizer and elevator, and more sections from both horizontal empennage surfaces. Pieces of the vertical stabilizer, rudder, and both ailerons were also found along the debris path. The southern 100 feet of the debris path contained the fuselage and both sets of wings, engines, and propellers. The aircraft impacted the ground inverted. The wings separated just outboard of the nacelles at the initial point of impact. Examination of the wreckage showed that all structural failures were the result of overload.

Factual narrative

History of flight

On October 29, 2003, at 1222 Pacific standard time (PST), a Cessna 421B, N444AM, experienced a loss of control and a subsequent in-flight breakup near Kelso, California. The owner/pilot was operating the airplane under the provisions of 14 CFR Part 91 of the Federal Aviation Regulations. The airline transport pilot and four passengers sustained fatal injuries; the airplane was destroyed. The personal cross-country flight departed Laughlin/Bullhead International Airport (IFP), Bullhead, Arizona, about 1155 PST, and was en route to Van Nuys, California. Day visual meteorological conditions prevailed, and a visual flight rules (VFR) flight plan had been filed. The primary wreckage was located at 35 degrees 01.310 minutes north latitude and 115 degrees 35.021 minutes west longitude.

The evening prior to the accident, the pilot contacted Hawthorne Flight Service Station (FSS) to obtain a FORECAST briefing for a noon departure the following day from IFP to Van Nuys. The briefer indicated the main concern would be layers of smoke due to fires as the flight crossed the San Gabriel Mountains, which are northeast of the Los Angeles basin, between Los Angeles and the Mojave Desert.

The morning of the accident, the pilot telephoned Hawthorne FSS for a weather briefing. The briefer advised the pilot of the following, in summary: an AIRMET for mountain obscuration along the coast; an "on-shore flow" pushing forest fire smoke inland; current Barstow-Daggett weather including clouds FEW015 and visibility 1.5 miles; current Van Nuys weather including clouds FEW200 and visibility 1 mile in haze/smoke; "most of the greater LA area has low visibility 1 to 4 miles," and an area forecast for the mountains and desert; clear or scattered cirrus clouds, and occasional visibilities 3 to 5 miles because of smoke and haze.

After receiving the weather brief, the pilot filed a VFR flight plan, departing IFP at noon, with an arrival time at Van Nuys around 1320. Initially the pilot reported, "We have slant Romeo equipment on board." After some discussion about the equipment on board the aircraft, they decided the flight plan should indicate slant India equipment.

The flight departed IFP at 1155 PST. The pilot asked IFP tower personnel to activate the VFR flight plan to Van Nuys.

Plotted Radar information obtained from Los Angeles Air Route Traffic Control Center (ARTCC) and Air Force Rescue Coordination Center (AFRCC) showed the total flight duration was 22 minutes 19 seconds. The aircraft departed IFP to the west, toward Goffs VORTAC, approximately 30 nautical miles (nm0 away. The first radar contact was at 11:59, and the aircraft's Mode C transponder reported an altitude of 3,500 feet mean sea level (msl). By the time the aircraft reached Goffs VORTAC, the altitude had increased to 4,900 feet msl. The aircraft continued to climb, passing through the filed altitude of 8,500 feet msl, until it reached a maximum altitude of 12,900 feet msl.

The last 6 minutes of radar data showed the aircraft at various altitudes, starting at 11,000 feet msl and climbing to maximum altitude of 12,700 feet msl. During the last 3 minutes of flight, radar data showed the aircraft made numerous left and right climbing and descending turns, eventually reversing course. The next to last radar return at 1221:24 indicated an altitude of 11,900 feet msl. The last radar return, 19 seconds later, showed an altitude of 7,700 feet msl. The computed vertical speed between the last two radar returns was 13,263 feet per minute (FPM).

Personnel information

A review of Federal Aviation Administration (FAA) airman records revealed the 89-year-old pilot held an airline transport pilot certificate with airplane single and multiengine land ratings. He also held the type rating for a DC-3.

The pilot obtained his student pilot's license on September 24, 1935. He obtained his private pilot's license on July 9, 1936; his commercial pilot's license on January 15, 1941; his instrument rating on April 14, 1941; and his airline transport pilot certificate on May 3, 1943.

The pilot held a third-class medical certificate that was issued on March 25, 2003. It had no limitations or waivers.

An examination of the pilot's logbook indicated an estimated total flight time of 11,371 hours. He logged 12 hours in the last 90 days and 3 hours in the last 30 days. Pilot logbook records from October 12, 1984, to October 12, 2003, indicated an estimated 1,237 hours in the accident airplane.

FAA records indicated that pilot purchased the airplane in February 1979.

The company insuring the accident airplane required the accident pilot to pass a physical examination given by an FAA approved Medical Examiner. He also had to successfully complete an Instrument Proficiency Check in the same make and model of airplane. Both of these requirements were to be completed within the past 12 months prior to the operation of the airplane.

The pilot's logbook indicated his last instrument proficiency check was completed on December 31, 1996. The pilot's last valid biannual flight review endorsement was completed on March 3, 2000.

The pilot's logbook contained endorsements indicating the pilot had successfully completed biennial flight reviews as required by FAR 61.56 on March 27, 2001, April 30, 2002, and April 11,2003. However, the CFI, who endorsed the logbooks, did not hold the instructor rating for multiengine airplanes.

Aircraft information

The airplane was a Cessna 421B, serial number 421B0367. A review of the airplane's logbooks revealed a total airframe time of 3,114.2 hours at the last annual inspection. The annual inspection was completed on December 20, 2002. The Hobbs hour meter read 3,114.2 at the last inspection. The Hobbs hour meter was destroyed and unreadable at the accident scene.

The airplane had a Teledyne Continental Motors GTSIO-520-H engine, serial number 218493R, installed on the left side. Total time on the engine at the last 100-hour annual inspection was 3,114.2 hours.

A Teledyne Continental Motors GTSIO-520-H engine, serial number 218446R, was installed on the right side. Total time on the engine at the last 100-hour annual inspection was 3,114.2 hours.

Fueling records at IFP established that the airplane was last fueled on October 28, 2003, with the addition of 53.7 gallons of 100LL-octane aviation fuel. Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure.

Meteorological information

A staff meteorologist for the National Transporation Safety Board prepared a factual report, which included weather for the departure area, route of flight, and destination. The weather conditions over the accident site included multiple cloud layers at 9,000, 12,000 and 16,000 feet, and reduced visibility aloft from smoke and haze from wilderness wild fires that were occurring over large portions of southern California.

The closest official weather observation station was Needles, California (EED), located 56 nm east of the accident site. Visual meteorological conditions were recorded for several hours before and after the time of the accident.

Weather observations from McCarran International Airport (LAS), Las Vegas, Nevada, located 79 nautical miles northeast of the accident site, reported reduced visibility due to smoke and haze around the time of the accident.

There were numerous pilot reports (PIREPs) describing limited visibility aloft due to smoke from the wilderness fires that were occurring in California.

Communications

The airplane was not in contact with any known facility at the time of the accident. The last known radio communication from the accident airplane was to the Bullhead local control tower. After takeoff the pilot requested that the controller contact Prescott flight service

Aircraft

Registration
N444AM
Reported as
Cessna 421B
Category
Airplane
Serial number
421B0367
Airframe hours
3,114
Engines
Continental GTSIO-520-H, 375 horsepower, reciprocatingContinental GTSIO-520-H, 375 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Robert S. Brown
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 1, 2002
Departed
IFP · Bullhead City, AZ
Destination
VNY · Van Nuys, CA
Flight plan
VFR

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
89
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
March 1, 2000
Seat
Left
Flight hours
11,371 total · 1,237 in this make and model · 12 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 48 °F
Altimeter
29.70 inHg
Observed at
EED, 56 nm away