LAX95FA076

NTSB accident investigation · Cessna 208B · Flagstaff, AZ · January 12, 1995

Accident · FatalField investigationFinal report
Date
January 11, 1995, 18:05 local (Jan 12, 1995, 01:05 UTC)
Place
Flagstaff, AZ
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N746FECessna 208B
Weather
Instrument (IMC) · Night/dark
Status
Completed · report February 14, 1996
Report
Approved by Office Director
FAA report
19950111001739A
Case key
28906

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 properly configure the aircraft fuel system prior to takeoff, and his failure maintain an adequate terrain clearance altitude while maneuvering to return to the airport. Factors in the accident were the dark night lighting conditions, low ceilings, restricted visibility conditions, and the pilot's diverted attention which resulted from activation of the airplane's fuel selector warning horn system.

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.

Miscellaneous/otherTakeoff - initial climb
Fuel system,selector/valve - switched off
Fuel tank selector position - not correctedPilot in commandCause
Warning system(other) - activated
Remedial action - initiatedPilot in command
In flight collision with terrain/waterManeuvering - turn to landing area (emergency)
Weather condition - low ceilingFactor
Weather condition - snowFactor
Light condition - dark nightFactor
Altitude - inadequatePilot in commandCause
Diverted attentionPilot in commandFactor
Clearance - not maintainedPilot in commandCause

Analysis

A witness located near the departure end of the runway saw the airplane initially climb in a normal manner, then stay below the clouds and make a shallow bank 180-degree left turn and descend below a tree line. Tower tapes revealed that the pilot twice transmitted that he was "coming back" to the airport during which the background sound of the "fuel selector off" warning horn was heard. The pilot then informed the controller "I've got to get back", and no warning horn was heard. The airplane collided with trees and came to rest about 6,500 feet sse of the runway's end. Prior to departure, the airplane was refueled with 40 gals of jet a (20 gals per tank), which increased the total fuel load to 148 gals. The flight manual required that the fuel balance between the left and right tanks be kept within 200 pounds, and suggested turning off one fuel selector to correct unbalance situations. The condition of one fuel selector turned off will cause the "fuel selector off" warning horn to sound. Exam of the aircraft revealed no evidence of preimpact failures. Prop blade butt signatures indicated it was operating in the governing range, and engine power was being produced at impact.

Factual narrative

History of flight

On January 11, 1995, about 1805 hours mountain standard time (mst), a Cessna 208B, N746FE, operated by Empire Airlines, Inc. as flight number 7551, collided with terrain, about 1.5 nautical miles (nm) south of the Flagstaff Pulliam Airport, Flagstaff, Arizona. The accident occurred while the pilot was attempting to return to the airport after taking off from runway 21. The airplane was transporting cargo under contract with Federal Express during the dark nighttime air taxi flight. Instrument meteorological conditions prevailed, and an instrument flight plan was filed. The airplane was destroyed, and the airline transport pilot was fatally injured.

Prior to taking off on the accident flight, the airplane was partially refueled, and it was loaded with cargo. The scheduled block out time was 1800.

At 1746, the local air traffic controller cleared N746FE (using radio call sign "Empire five fifty-one") to taxi for takeoff. The pilot indicated that he desired to fly under instrument flight rules to Phoenix, Arizona. A few minutes later, the controller informed the pilot that his departure would be delayed because air traffic was busy.

At 1801:56 the controller cleared N746FE for takeoff. The controller reported to the National Transportation Safety Board that he estimated the airplane became airborne about 3,000 feet down the runway. Nothing unusual was noted.

Another pilot, who was waiting for takeoff in a Beech King Air near the approach end of runway 03, reported that when the accident airplane passed over the departure end of runway 21, it had climbed 200 to 300 feet above the runway's surface. Nothing unusual was noted except that the airplane "did not seem to be climbing very well." The Beech pilot further reported that the airplane commenced turning left approximately 1/4 to 1/2 mile beyond the end of the runway. The rate of turn "seemed normal and not excessive."

At 1803:50 the controller instructed N746FE to contact Albuquerque Center, and three seconds later the pilot acknowledged the instruction.

Then, at 1803:57 the pilot stated "Five fifty-one's coming back in," which was followed 6 seconds later with "I'm coming back to the airport."

The controller asked the pilot if he had the airport in sight. The pilot replied at 1804:12 with the following brief statement: "No but I've got to get back." The controller then stated "OK Empire five fifty-one say nature of difficulty please." The pilot's reply was unintelligible. At 1804:25 the controller stated "Empire five fifty-one your not in sight cleared to land either runway."

The Beech King Air pilot provided the following account of his observations regarding the accident airplane's flight path:

After taking off, the airplane initially flew straight ahead, but then commenced a left 180-degree turn to an approximate heading of 030 degrees to parallel the runway. "The rate of turn seemed normal and not excessive (and the airplane) . . . did not seem to be climbing and may have even been descending." The Beech pilot further reported that the airplane "did not appear to be stalled or wobbling when last seen." The Beech pilot said that he lost sight of the airplane's lights when it descended behind trees. The crash site was located in a snow-covered hilly forest, approximately 6,500 feet south-southeast of the runway's departure end.

A Federal Express ramp agent, who was located at the airport, also observed the airplane depart. The agent indicated that the airplane passed "overhead (by) approximately 100 to 120 feet" and was climbing. The airplane then entered a left bank turn, lost altitude, and disappeared over a tree line.

Personnel information

The pilot held an airline transport pilot certificate, with single and multiengine land ratings, a multiengine sea rating, and several type ratings. The pilot also possessed a certified flight instructor certificate for single and multiengine airplanes which was last renewed in April of 1994.

Empire Airlines (the operator) hired the pilot in March of 1990. In April of 1993, the FAA approved the pilot to serve as a check airman in the Cessna 208. The pilot was authorized to give proficiency and line checks to the operator's pilots.

In March, 1994, the pilot completed recurrent academic and simulator training by Flight Safety International. In October, 1994, the pilot successfully completed a 1.4-hour-long flight competency check in the Cessna 208, which included normal and emergency procedures.

By the accident date, the pilot had logged about 10,000 hours of total flight time, of which about 2,000 hours were logged flying the Cessna 208 series airplanes. The pilot had logged about 2,000 hours of night flying time and about 800 hours of time flying in instrument weather conditions.

During the preceding 24-hour, 30-day, and 90-day period, the pilot had flown the Cessna 208 for 2, 36, and 100 hours, respectively. Also, during the preceding 90 days the pilot had flown about 25 hours at night. The operator's flight time records indicated that during the 30-day period which preceded the crash, the pilot had flown the accident airplane between Flagstaff and Phoenix over 34 times.

Family members reported that the pilot only flew airplanes for the operator, and recently he only flew Cessna 208s. The pilot resided near Flagstaff, and he was extremely familiar with the terrain which surrounded the airport.

Aircraft information

Refueling.

The airplane was manufactured in 1990, and it was equipped with 2 wing fuel tanks, each having a usable capacity of 165 gallons. In preparation for takeoff, around 1730, the airplane was fueled with 40.0 gallons of jet A fuel (20 gallons per tank), which increased the total fuel load to approximately 148 gallons (1,006.4 pounds).

Weight.

The maximum certificated airplane weight for flight into known icing conditions with the cargo pod installed was 8,550 pounds. On takeoff, the airplane's estimated gross weight was 7,963 pounds which included a cargo load of about 2,211 pounds.

Takeoff Distance.

Based upon Cessna and Federal Express supplied data and calculations, projections were made to determine the takeoff distance (required runway length) and the approximate altitude the airplane could have attained upon passing the end of the runway (assuming no snow). The airplane, as loaded, was calculated to have been able to climb to between 100 and 200 feet above the surface upon passing the runway end.

Flight Path Data.

Additional calculations were performed to determine the required rate of turn (degrees per second) necessary to arrive at the accident site assuming utilization of a normal departure climb speed profile and witness described flight path. After takeoff, an airplane commencing a left turn at an approximate rate between 3 and 6 degrees per second could arrive in the vicinity of the crash site while flying in an arc consistent with the accident airplane's observed flight path.

Maintenance.

The airplane's routine maintenance records, including engine condition trend monitoring/performance data, and nonroutine records involving avionics discrepancies, engine exceedences, and repetitive write ups, etc., were reviewed by the Federal Aviation Administration (FAA). No irregularities pertinent to the accident flight were identified.

The airplane's flight record logbook was recovered from the accident site. A review of the logbook revealed no evidence of pertinent squawks or deferred items.

Fuel System Operation and Warnings.

The following statement was contained in the Cessna 208B Caravan Information Manual: "Before refueling, or when the airplane is parked on a slope, turn off one of the fuel tank selectors. . . ."

The Information Manual provided pilots with the following instructions regarding fuel unbalance situations: "Fuel unbalance should b

Aircraft

Registration
N746FE
Reported as
Cessna 208B
Category
Airplane
Serial number
208B0236
Airframe hours
2,439
Engine
P&W PT6A-114A, 675 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Operator
Empire Airlines, Inc.
Registered owner
Federal Express Corporation
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · December 2, 1994 · 40 hours before
Departed
FLG
Destination
PHX · Phoenix, AZ
Flight plan
IFR
Airport
FLG · Flagstaff Pulliam, runway 21, 6,999 × 150 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
59
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land, Multi-engine sea
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
10,000 total · 2,000 in this make and model · 7,500 as pilot in command · 100 in the last 90 days · 36 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
200° at 5 knots
Visibility
0.75 statute miles
Lowest ceiling
200 ft broken
Temperature
91 °F, dew point 90 °F
Altimeter
29.00 inHg
Observed at
FLG, 2 nm away

Docket · 46

The files NTSB released with the investigation on January 25, 1996, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.0 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 437 KBSupplement CItem 2 · .PDF · 314 KBSupplement DItem 3 · .PDF · 435 KBSupplement KItem 4 · .PDF · 313 KBFactual Report of Group Chairman - MetallurgistItem 5 · .PDF · 138 KBFactual Report of Group Chairman - ATC Tape StudyItem 6 · .PDF · 86 KBPersonnel and Witness StatementsItem 7 · .PDF · 860 KBAccident Site Map and Wreckage DiagramItem 8 · .PDF · 353 KBWeather ReportsItem 9 · .PDF · 129 KBTranscript of Radio Communications and Report of Aircraft Accident, FAA Form 8020-6Item 10 · .PDF · 303 KBDrawing of Airplane Showing ELT LocationItem 11 · .PDF · 66 KBReport from FAAItem 12 · .PDF · 64 KBReport from Transportation Safety Board of CanadaItem 13 · .PDF · 43 KBReport from Pratt & Whitney CanadaItem 14 · .PDF · 263 KBReport from McCauley PropellerItem 15 · .PDF · 142 KBReport from Cessna - ELTItem 16 · .PDF · 155 KBReport from Empire Airlines - Fuel HornItem 17 · .PDF · 44 KBReport from Empire Airlines - ELT InstallationItem 18 · .PDF · 358 KBReport/Data from Empire Airlines on PAR Data and Par Operator's Manual ExtractItem 19 · .PDF · 448 KBReport from Federal Express - Flight PathItem 20 · .PDF · 403 KBReport from Pointer, Inc. on ELTItem 21 · .PDF · 125 KBWeight and Balance Calculations - CessnaItem 22 · .PDF · 47 KBFuel Request Documentation (by Empire)Item 23 · .PDF · 44 KBWeight Manifest - Federal ExpressItem 24 · .PDF · 341 KBFuel SlipItem 25 · .PDF · 167 KBFlight Record Logbook RecordItem 26 · .PDF · 61 KBLatitude and Longitude CalculationsItem 27 · .PDF · 38 KBCessna Emergency Checklist (Damaged) and Extract of New Copy - (4 pages each)Item 28 · .PDF · 880 KBExtract from Empire Airlines Deice ProgramItem 29 · .PDF · 598 KBExtract from Caravan Pilot's Operating Handbook - Supplement on Known Icing EquipmentItem 30 · .PDF · 127 KBExtract from Caravan Pilot's Operating Handbook (Information Manual) on Fuel System Malfunction/Inadvertent Fuel Flow Interruptionand AnnunciatorsItem 31 · .PDF · 775 KBExtract from Pilot's Operating Handbook on Emergency Power LeverItem 32 · .PDF · 235 KBExtract from Pilot's Operating Handbook on Fuel Tank SelectorsItem 33 · .PDF · 268 KBStatement of Party Representatives to NTSB InvestigationItem 34 · .PDF · 268 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 35 · .PDF · 88 KBToxicological ReportItem 36 · .PDF · 58 KBPhoto 1. Northeasterly view of the main wreckage.Item 37 · .PDF · 52 KBPhoto 2. Southwesterly view of the bottom of the fuselage and crushed forward cockpit.Item 38 · .PDF · 49 KBPhoto 3. Westerly view showing the fuselage bottom and right side, and the empennage tear at the ELT antenna site.Item 39 · .PDF · 58 KBPhoto 4. Close up view of the ELT antenna and downward hanging cable (photo center).Item 40 · .PDF · 55 KBPhoto 5. Upside down cockpit instrument panel, overall view.Item 41 · .PDF · 59 KBPhoto 6. Engine (photo center).Item 42 · .PDF · 53 KBPhoto 7. Engine following recovery.Item 43 · .PDF · 54 KBPhoto 8. Propeller assembly.Item 44 · .PDF · 48 KBPhoto 9. ELT antenna cable and ELT attachment bracket on separated structure.Item 45 · .PDF · 43 KBPhoto 10. Close up view of broken ELT attachment bracket.Item 46 · .PDF · 35 KB

FAA reports on this event · 1

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