LAX95FA077

NTSB accident investigation · Cessna 208B · Pleasanton, CA · January 13, 1995

Accident · FatalField investigationFinal report
Date
January 12, 1995, 17:47 local (Jan 13, 1995, 01:47 UTC)
Place
Pleasanton, CA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N754FECessna 208B
Weather
Night/dark
Status
Completed · report December 19, 1995
Report
Approved by Office Director
FAA report
19950112000339A
Case key
28907

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

failure of the pilot-in-command to maintain visual contact with terrain and sufficient altitude for terrain clearance. Factors in the accident were the pilot's decision to initiate a descent 14 miles from the airport, and weather, specifically cloud conditions and darkness.

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 collision with objectDescent - normal
Terrain condition - high terrain
Descent - initiatedPilot in commandFactor
Weather condition - cloudsFactor
Altitude - not maintainedPilot in commandCause
Light condition - dark nightFactor
Flight into adverse weather - performedPilot in command
Vfr procedures - not followedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

A Cessna 208B struck a ridge line about 14 miles from the destination airport. The pilot reported to ATC he had the airport in sight from 7,000 feet MSL more than 30 miles away. A weather reporting station located 5 miles east of the accident site was reporting two cloud layers; a scattered layer at 1,500 feet AGL, and a broken layer at 5,000 feet AGL. The airplane was descending after the pilot was cleared for a visual approach. The airplane collided with a tree and the ground in a wings level attitude at an elevation of 1,500 feet MSL. There was no evidence of mechanical failure or malfunction found with the airplane.

Factual narrative

On January 12, 1995, at 1747 hours Pacific standard time, a Cessna 208B, N754FE, collided with terrain 4 miles west of Pleasanton, California, while approaching the Metropolitan Oakland International Airport (OAK), Oakland, California. The airplane was destroyed. The airline transport pilot received fatal injuries. The airplane was operated by West Air, Inc., Fresno, California, as a on-demand air cargo flight under 14 CFR Part 135. The flight originated in Visalia, California, at 1638 hours. Night visual meteorological conditions prevailed at the time and an IFR flight plan was filed.

At 1738 hours, the pilot contacted Bay Approach Control, reported the airplane's altitude of 7,000 feet, and requested runway 27. The Bay Approach radar sector controller informed the pilot the VOR 9R approach was in use at the time; he could get a visual approach once the airport was in sight; and to fly a 300-degree heading and maintain 7,000 feet. According to the transcript of communications, 12 seconds later the pilot indicated he had the airport in sight. According to radar data, the airplane was more than 30 miles from the airport at the time of the pilot's radio transmission.

At 1745 hours, the pilot was cleared for a visual approach to runway 27 at Oakland, and was instructed to stay north of the localizer approach course. At 1747 hours, the sector controller requested the pilot maintain "maximum speed on approach," and the pilot acknowledged.

This was the last recorded radio transmission from the pilot. Radar and radio contact was lost with the airplane at a position 14 miles east of the airport at an altitude of 1,800 feet above mean sea level (msl). The aircraft wreckage was located about .4 nautical miles west of the last radar contact on the east slope of a ridge line at an elevation about 1,500 feet msl.

Pilot Information

The pilot held an airline transport pilot certificate which was issued on December 15, 1959. The most recent first-class medical certificate was issued to the pilot on April 11, 1994, and contained the limitation that correcting lenses be worn while exercising the privileges of his airman certificate.

No personal flight records were located for the pilot, and the aeronautical experience listed on this report was obtained from information supplied from the airplane operator's accident report and a review of the pilot's resume.

According to the operator, the pilot's total aeronautical experience consists of about 25,500 hours, of which 516 were accrued in the Cessna 208. In the preceding 90 and 30 days before the accident, the operator listed a total of 151.9 and 61 hours, respectively, flown in the Cessna 208B. The pilot also completed a 14 CFR Part 135 Airman Competency Check on December 29, 1994, in a Cessna 208B.

Meteorological Information

The closest official weather observation station is Livermore Municipal Airport, Livermore, California, which is located 5 nautical miles northeast of the accident site. The elevation of the weather observation station is 397 feet above sea level.

At 1646 hours, a record scheduled surface observation was reporting in part: sky condition and ceiling 1,500 scattered, estimated 5,000 broken; visibility 7 statute miles; winds calm; altimeter 30.06 Hg.

Wreckage and Impact Information

The initial impact point was with trees located on the east slope of Sunol Ridge at 37-38.94 degrees north latitude and 121-56.71 degrees west longitude, at an elevation approximately 1,500 feet msl. The left wing topped two trees and left 6-foot of the left wing tip in a third tree. The airplane then struck the ground leaving gouges from the main landing gear and a crater 10 feet in diameter and about 1-foot deep. The crater and main landing gear gouges were found holding water at the time of arrival of the investigative team.

The wreckage path progressed up a 20-degree slope on a 240-degree magnetic bearing for about 90 feet to the tail of the airplane. The wreckage came to rest at the base of a tree. The engine and the right wing, along with the cockpit roof, separated from the fuselage and were found several feet up slope under the tree branches. The fuselage, along with the remainder of the left wing, was separated from the tail and came to rest inverted with the main landing gear up. The vertical stabilizer and rudder, and the horizontal stabilizers and elevator remained attached to the fuselage by means of the control cables and was under the fuselage. The control cables were traced to the cockpit area and found to be continuous.

The fuselage was also split circumferentially aft of the pilot's seat. The cockpit was twisted about 30 degrees left, and the firewall was crushed aft to the instrument panel.

All three propeller blades were found separated from the engine. Two blades were found up slope of the engine and a third was found in the crater still attached to a fractured piece of the hub. All three blades were twisted, exhibited forward bending at the tips, leading edge nicks and gouges, and chordwise scoring.

The crater was excavated further to reveal portions of the cargo pod with tie downs, wheel chocks, engine cowling plugs, pitot tube cover, and the nose gear. Examination of the nose gear revealed the oleo strut was bent aft parallel to the wheel axle.

Another ground scar was noted protruding about 20 feet, about 90 degrees to the wreckage path from the ground crater. The right aileron was found lying next to the scar with its longitudinal axis parallel to the axis of the ground scar.

The airplane's cargo was ejected from the fuselage and found up slope under the branches of trees. Most of the cargo was packed in cardboard containers. The cardboard was found wet.

Medical and Pathological Information

A post mortem examination was conducted by the Alameda County Coroner's Office on January 15, 1995, with specimens retained for toxicological examination. No preexisting conditions were noted during the post mortem examination which would have adversely affected the decedents abilities to pilot an airplane. The results of the toxicological analysis revealed negative results for routine drug and alcohol screens. Propranolol was detected in the liver by gas chromatography and was quantitated at 2.2 mg/kg.

Tests and Research

Engine Exam

The engine was examined on February 14, 1995, at an aircraft salvage yard in Sacramento, California. The engine was partially disassembled to view the internal compressor and turbine components. Circumferential rubs were present in the compressor and the turbine. According to the engine manufacturer, the rubs were a result of radial contact with the stationary shrouds or baffles inside the engine during the impact sequence. There was no evidence found during the engine exam that would have contributed to a loss of engine power.

Additional Information

Wreckage Release

The wreckage was released to the owner's representatives on February 14, 1995.

Aircraft

Registration
N754FE
Reported as
Cessna 208B
Category
Airplane
Serial number
0249
Airframe hours
2,073
Engine
P&W PT6A-114A, 675 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Operator
West Air, Inc., doing business as Federal Express
Registered owner
Federal Express Corporation
Airworthiness certificate
Special, Provisional (Special); Standard, Normal
Last inspection
AAIP · January 11, 1995 · 4 hours before
Departed
VIS · Visalia, CA
Destination
OAK · Oakland, CA
Flight plan
IFR
Airport
OAK · Oakland International Arp, runway 27R, 5,453 × 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
63
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
25,500 total · 516 in this make and model · 20,508 as pilot in command · 151 in the last 90 days · 61 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Night/dark
Wind
Calm
Visibility
7 statute miles
Lowest ceiling
5,000 ft overcast
Altimeter
30.00 inHg
Observed at
LVK, 5 nm away

Docket · 40

The files NTSB released with the investigation on December 5, 1995, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.9 MB in all.

Supplement CItem 1 · .PDF · 325 KBSupplement DItem 2 · .PDF · 399 KBSupplement KItem 3 · .PDF · 317 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2Item 4 · .PDF · 306 KBMaps or Charts of Accident Area, Wreckage DiagramsItem 5 · .PDF · 349 KBWeather Reports and RecordsItem 6 · .PDF · 130 KBTranscript of Radio CommunicationsItem 7 · .PDF · 253 KBDrawingsItem 8 · .PDF · 43 KBFAA Controllers StatementsItem 9 · .PDF · 85 KBFAA Form 8020-6Item 10 · .PDF · 141 KBReports of Service from ATCItem 11 · .PDF · 217 KBExtract from Alameda County Sheriff's Dept.Item 12 · .PDF · 81 KBReport from Pratt & Whitney Canada, Inc. with 13 PhotosItem 13 · .PDF · 374 KBPhoto 1. Engine as received, left hand side.Item 14 · .PDF · 49 KBPhoto 2. Engine as received, right hand side.Item 15 · .PDF · 51 KBPhoto 3. Engine as received, accessory gearbox mounted accessories.Item 16 · .PDF · 62 KBPhoto 4. Reduction gearbox and accessory gearbox chip detectors.Item 17 · .PDF · 25 KBPhoto 5. Oil filter.Item 18 · .PDF · 40 KBPhoto 6. Combustion chamber liner and compressor turbine downstream side, in situ.Item 19 · .PDF · 49 KBPhoto 7. Compressor turbine downstream, detail.Item 20 · .PDF · 41 KBPhoto 8. Power turbine guide vane ring and interstage baffle, upstream side.Item 21 · .PDF · 37 KBPhoto 9. Power turbine guide vane ring and interstage baffle, upstream side, detail.Item 22 · .PDF · 45 KBPhoto 10. Power turbine guide vane ring and interstage baffle, downstream side.Item 23 · .PDF · 40 KBPhoto 11. Power turbine guide vane ring and interstage baffle downstream side, detail.Item 24 · .PDF · 43 KBPhoto 12. Power turbine upstream side, in situ.Item 25 · .PDF · 52 KBPhoto 13. Power turbine upstream side, detail.Item 26 · .PDF · 49 KBWest Air Flight RecordItem 27 · .PDF · 85 KBPilot ResumeItem 28 · .PDF · 70 KBStatement of Party Representatives to NTSB InvestigationItem 29 · .PDF · 239 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 30 · .PDF · 348 KBToxicological ReportItem 31 · .PDF · 114 KBPhoto 1. Aerial view of wreckage site to the west.Item 32 · .PDF · 23 KBPhoto 2. Wreckage path.Item 33 · .PDF · 45 KBPhoto 3. Left main landing gear gouge and fuselage crater.Item 34 · .PDF · 65 KBPhoto 4. Left wing tip in tree.Item 35 · .PDF · 53 KBPhoto 5. Closeup of left wing tip. Note: shape of compression buckle conforms to size of tree trunk.Item 36 · .PDF · 51 KBPhoto 6. View of fuselage and cargo. Note: papers and cardboard are wet.Item 37 · .PDF · 65 KBPhoto 7. Right wing and roof. Note: wet cargo.Item 38 · .PDF · 57 KBPhoto 8. Propeller blades.Item 39 · .PDF · 52 KBPhoto 9. Nose gear. Note: aft bending is parallel to axis of wheel axle.Item 40 · .PDF · 58 KB

FAA reports on this event · 1

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