# NTSB LAX95FA077: Cessna 208B, N754FE, Pleasanton, CA, January 13, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 12, 1995, 17:47 local (Jan 13, 1995, 01:47 UTC) - Place: Pleasanton, CA - Coordinates: 37.649593, -121.849716 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.6496&lon=-121.8497&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 19, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28907 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95FA077 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28907/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=28907 - Page: https://openairdocs.org/ntsb/LAX95FA077 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, descent - normal - terrain condition - high terrain - descent - initiated, pilot in command (contributing factor) - weather condition - clouds (contributing factor) - altitude - not maintained, pilot in command (cause) - light condition - dark night (contributing factor) - flight into adverse weather - performed, pilot in command - vfr procedures - not followed, pilot in command (cause) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N754FE-1995-04-14), registration cancelled 1995-04-14, S/N 208B0249 (OpenAirDocs) - Reported make and model: CESSNA 208B - Registry model: [Cessna 208B](https://openairdocs.org/model/cessna-208b) (registry code 2073701) (OpenAirDocs) - Category: Airplane - Serial number: 0249 - Airframe hours: 2073 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; 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 ## 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 19950112000339A](https://openairdocs.org/incident/19950112000339A), Jan 12, 1995: Cessna 208B, Oakland, CA, Destroyed, 1 fatal. Saw airport through hole in clouds. Descended for same. Struck trees 14MI from oak. Hole must have closed up. ## Docket (40 files) The files NTSB released with the investigation on December 5, 1995, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=28907. 4.9 MB in all. - Supplement C (item 1, .PDF, 325 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038013&FileExtension=.PDF&FileName=Supplement%20C-Master.PDF - Supplement D (item 2, .PDF, 399 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038014&FileExtension=.PDF&FileName=Supplement%20D-Master.PDF - Supplement K (item 3, .PDF, 317 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038015&FileExtension=.PDF&FileName=Supplement%20K-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 (item 4, .PDF, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381623&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 5, .PDF, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038017&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Weather Reports and Records (item 6, .PDF, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381624&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Redacted.PDF - Transcript of Radio Communications (item 7, .PDF, 253 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381625&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - Drawings (item 8, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038020&FileExtension=.PDF&FileName=Drawings-Master.PDF - FAA Controllers Statements (item 9, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381627&FileExtension=.PDF&FileName=FAA%20Controllers%20Statements-Redacted.PDF - FAA Form 8020-6 (item 10, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381628&FileExtension=.PDF&FileName=FAA%20Form%208020-6-Redacted.PDF - Reports of Service from ATC (item 11, .PDF, 217 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381630&FileExtension=.PDF&FileName=Reports%20of%20Service%20from%20ATC-Redacted.PDF - Extract from Alameda County Sheriff's Dept. (item 12, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381631&FileExtension=.PDF&FileName=Extract%20from%20Alameda%20County%20Sheriff%27s%20Dept.-Redacted.PDF - Report from Pratt & Whitney Canada, Inc. with 13 Photos (item 13, .PDF, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381640&FileExtension=.PDF&FileName=Report%20from%20Pratt%20%26%20Whitney%20Canada,%20Inc.%20with%2013%20Photos-Redacted.PDF - Photo 1. Engine as received, left hand side. (item 14, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038026&FileExtension=.PDF&FileName=Photo%201.%20%20Engine%20as%20received,%20left%20hand%20side.-Master.PDF - Photo 2. Engine as received, right hand side. (item 15, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038027&FileExtension=.PDF&FileName=Photo%202.%20%20Engine%20as%20received,%20right%20hand%20side.-Master.PDF - Photo 3. Engine as received, accessory gearbox mounted accessories. (item 16, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038028&FileExtension=.PDF&FileName=Photo%203.%20%20Engine%20as%20received,%20accessory%20gearbox%20mounted%20accessories.-Master.PDF - Photo 4. Reduction gearbox and accessory gearbox chip detectors. (item 17, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038029&FileExtension=.PDF&FileName=Photo%204.%20%20Reduction%20gearbox%20and%20accessory%20gearbox%20chip%20detectors.-Master.PDF - Photo 5. Oil filter. (item 18, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038030&FileExtension=.PDF&FileName=Photo%205.%20%20Oil%20filter.-Master.PDF - Photo 6. Combustion chamber liner and compressor turbine downstream side, in situ. (item 19, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038031&FileExtension=.PDF&FileName=Photo%206.%20%20Combustion%20chamber%20liner%20and%20compressor%20turbine%20downstream%20side,%20in%20situ.-Master.PDF - Photo 7. Compressor turbine downstream, detail. (item 20, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038032&FileExtension=.PDF&FileName=Photo%207.%20%20Compressor%20turbine%20downstream,%20detail.-Master.PDF - Photo 8. Power turbine guide vane ring and interstage baffle, upstream side. (item 21, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038033&FileExtension=.PDF&FileName=Photo%208.%20%20Power%20turbine%20guide%20vane%20ring%20and%20interstage%20baffle,%20upstream%20side.-Master.PDF - Photo 9. Power turbine guide vane ring and interstage baffle, upstream side, detail. (item 22, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038034&FileExtension=.PDF&FileName=Photo%209.%20%20Power%20turbine%20guide%20vane%20ring%20and%20interstage%20baffle,%20upstream%20side,%20detail.-Master.PDF - Photo 10. Power turbine guide vane ring and interstage baffle, downstream side. (item 23, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038035&FileExtension=.PDF&FileName=Photo%2010.%20%20Power%20turbine%20guide%20vane%20ring%20and%20interstage%20baffle,%20downstream%20side.-Master.PDF - Photo 11. Power turbine guide vane ring and interstage baffle downstream side, detail. (item 24, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038036&FileExtension=.PDF&FileName=Photo%2011.%20%20Power%20turbine%20guide%20vane%20ring%20and%20interstage%20baffle%20downstream%20side,%20detail.-Master.PDF - Photo 12. Power turbine upstream side, in situ. (item 25, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038037&FileExtension=.PDF&FileName=Photo%2012.%20%20Power%20turbine%20upstream%20side,%20in%20situ.-Master.PDF - Photo 13. Power turbine upstream side, detail. (item 26, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038038&FileExtension=.PDF&FileName=Photo%2013.%20%20Power%20turbine%20upstream%20side,%20detail.-Master.PDF - West Air Flight Record (item 27, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381633&FileExtension=.PDF&FileName=West%20Air%20Flight%20Record-Redacted.PDF - Pilot Resume (item 28, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381635&FileExtension=.PDF&FileName=Pilot%20Resume-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 29, .PDF, 239 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381636&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 30, .PDF, 348 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381637&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 31, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381639&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1. Aerial view of wreckage site to the west. (item 32, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038044&FileExtension=.PDF&FileName=Photo%201.%20%20Aerial%20view%20of%20wreckage%20site%20to%20the%20west.-Master.PDF - Photo 2. Wreckage path. (item 33, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038045&FileExtension=.PDF&FileName=Photo%202.%20%20Wreckage%20path.-Master.PDF - Photo 3. Left main landing gear gouge and fuselage crater. (item 34, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038046&FileExtension=.PDF&FileName=Photo%203.%20%20Left%20main%20landing%20gear%20gouge%20and%20fuselage%20crater.-Master.PDF - Photo 4. Left wing tip in tree. (item 35, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038047&FileExtension=.PDF&FileName=Photo%204.%20%20Left%20wing%20tip%20in%20tree.-Master.PDF - Photo 5. Closeup of left wing tip. Note: shape of compression buckle conforms to size of tree trunk. (item 36, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038048&FileExtension=.PDF&FileName=Photo%205.%20%20Closeup%20of%20left%20wing%20tip.%20%20Note%3A%20%20shape%20of%20compression%20buckle%20conforms%20to%20size%20of%20tree%20trunk.-Master.PDF - Photo 6. View of fuselage and cargo. Note: papers and cardboard are wet. (item 37, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038049&FileExtension=.PDF&FileName=Photo%206.%20%20View%20of%20fuselage%20and%20cargo.%20%20Note%3A%20%20papers%20and%20cardboard%20are%20wet.-Master.PDF - Photo 7. Right wing and roof. Note: wet cargo. (item 38, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038050&FileExtension=.PDF&FileName=Photo%207.%20%20Right%20wing%20and%20roof.%20%20Note%3A%20wet%20cargo.-Master.PDF - Photo 8. Propeller blades. (item 39, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038051&FileExtension=.PDF&FileName=Photo%208.%20%20Propeller%20blades.-Master.PDF - Photo 9. Nose gear. Note: aft bending is parallel to axis of wheel axle. (item 40, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40038052&FileExtension=.PDF&FileName=Photo%209.%20%20Nose%20gear.%20%20Note%3A%20%20aft%20bending%20is%20parallel%20to%20axis%20of%20wheel%20axle.-Master.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.