SEA06FA147

NTSB accident investigation · Cessna 421C · Carson, WA · January 25, 2006

Accident · FatalField investigationFinal report
Date
January 25, 2006, 13:44 local (21:44 UTC)
Place
Carson, WA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N69KMCessna 421C
Weather
Instrument (IMC) · Day
Status
Completed · report January 31, 2007
Report
Approved by Office Director
Parties
FAA/FSDO, Cessna Aircraft Company, Teledyne Continental Motors
FAA report
20060125016149A
Case key
64209

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 NTSB’s determination of the probable cause, and any contributing factors.

The pilot's failure to maintain aircraft control while maneuvering. Icing conditions, clouds and the pilot's continued flight into known adverse weather were factors.

Analysis

During a cross country flight, the pilot was informed by air traffic control that adverse weather was along his route of flight for terrain obscurement in clouds, precipitation, fog or mist. Turbulence was reported below 12,000 feet and occasional moderate rime or mixed icing was reported from the freezing level to 14,000 feet. Further along the route, the pilot reported to another controller that he was at 13,000 feet and descending. The controller inquired if the pilot was aware of the center weather advisory and the reports of severe rime ice in the direction that he was heading. The pilot acknowledged the controller by reporting that he was aware of the weather and that the aircraft was "equipped." The controller continued to inform the pilot of pilot reports from commercial aircraft flight crews of the reports of icing conditions, however, the pilot continued on his routing and again reported that the aircraft was "equipped." During the last transmissions from the pilot, he reported that he was "turning on (de-ice) equipment now." The controller recommended to the pilot to stay clear of the clouds. The pilot responded, "roger." The controller then asked the pilot if he was "going to orbit there for awhile." The pilot responded, "yes," followed by a partially unintelligible transmission of "getting some weather here." The pilot's last transmissions were "Ah, I'm in a little trouble," followed by "Ah, standby 9KM." Radar tracking indicated that the aircraft had been cruising at 16,500 feet before starting a gradual descent. The aircraft descended to 12,700 feet and it began a turn to the right. During this turn, the aircraft's altitude changed rapidly beginning with an increase, followed by a rapid loss of altitude from 8,000 feet per minute descent to 10,600 feet per minute descent before radar contact was lost. The aircraft was found 6 months later in an area of mountainous terrain. On site evidence indicated that the aircraft collided with trees and terrain in a nose low attitude with the majority of the wreckage contained in a large deep crater.

Factual narrative

The factual narrative1,284 words

History of flight

On January 25, 2006, at 1344 Pacific standard time, a Cessna 421C, N69KM, registered to Sugar Financial Inc., and operated by the pilot as a 14 CFR Part 91 personal flight, was reported missing when radar contact and communications were lost over mountainous terrain about 15 nautical miles northeast of Carson, Washington. Visual and isolated instrument meteorological conditions prevailed in the area where the aircraft dropped from radar contact. A search was initiated, however, due to adverse weather conditions and rugged terrain, the wreckage was not located and the search was suspended on January 27, 2006. The pilot was presumed fatally injured. No flight plan had been filed, however, the pilot was utilizing flight following services. The flight departed from Scottsdale, Arizona, approximately 1030 mountain standard time, with a final destination to Tacoma, Washington. No emergency locator transmitter signal was detected.

On July 27, 2006, the wreckage was located by two U.S. Forest Service personnel in an area of mountainous terrain about one-half mile south of the last radar target at North 45 degrees 52.154 minutes latitude and West 122 degrees 2.465 minutes longitude. Impact damage and a post-crash fire destroyed the aircraft. The pilot was fatally injured.

Personnel information

Federal Aviation Administration airmen records indicated that the pilot was issued a private pilot certificate for airplane single engine land on July 19, 2005. At this time, the pilot indicated a total flight time of 134 hours, with 12.5 hours as pilot-in-command.

On December 21, 2005, the pilot was issued the airplane multi-engine land rating for private pilot privileges. At this time, the pilot indicated a total flight time of 350 hours, with 130 hours as pilot-in-command. The rating was attained in a Cessna 310, with a reported 12 hours total time in this aircraft.

At the time of the accident, the pilot held a second-class medical certificate, dated June 8, 2005. No waivers or limitations were identified.

The flight instructor/Designated Examiner, who signed the pilot off for the private pilot certificate in both the single and multi-engine aircraft, stated that the pilot had been working on his instrument rating since October 2005. He believed that the pilot had accumulated about 200 hours in the Cessna 421. The day before the accident, he spoke with the pilot. The pilot reported that he just accumulated 400 hours total flight time. The Examiner stated that he had flown with the pilot on several occasions, and that he had flown in the Cessna 421C with the pilot from Scottsdale to Tacoma on one of those flights.

The pilot's flight logbook was not located.

Aircraft information

Aircraft records indicated that the aircraft was manufactured in 1977. The aircraft held a standard class, normal category airworthiness certificate. The aircraft was equipped with two Teledyne Continental Motors GTSIO-520-L engines. The aircraft was also equipped with a deice boot system attached to the leading edges of the wings and stabilizers.

Federal Aviation Administration Aircraft Registration records indicated that the aircraft was registered to Sugar Financial, Scottsdale, Arizona, on October 17, 2005.

Maintenance records indicated that the aircraft was signed off for the completion of the Cessna Progressive Operation #4 Inspection on August 19, 2005. At the time of the inspection the aircraft had accumulated a total airframe time of 5,206 hours.

On November 29, 2005, Scottsdale Flyers, LLC, signed the aircraft off for the Cessna Progressive Operation #1 Inspection. At the time of the inspection, the aircraft had accumulated a total airframe time of 5,264.1 hours. On December 15, 2005, the logbook entry indicated that the aircraft was removed from the Cessna Progressive Care Inspections program. At this time the airframe total time was listed as 5,306.5 hours. The next annual inspection was due August 2006.

The last entry in the maintenance logbook was dated January 23, 2006, for the completion of a visual inspection of the exhaust system in compliance with AD 00-01-16. At this time the airframe total time was listed as 5,358.8 hours.

The engine logbooks indicated that the left engine, model GTSIO-520-L3B, s/n: 292435-R, was rebuilt/zero timed on March 31, 2000, by Teledyne Continental Motors, and installed on N69KM on April 24, 2000. The last entry in the logbook dated January 23, 2006, indicated that the engine total time since major overhaul was 1,541.8 hours. During this maintenance visit, the oil and filter were changed and the engine was serviced with 12 quarts of oil. The engine was run and a leak check was accomplished.

The right engine, model GTSIO-520-L, s/n: R-245870.R, was overhauled by RAM Aircraft on June 13, 2001, and installed on N69KM June 15, 2001. The last entry in the logbook dated January 23, 2006, indicated that the engine total time was 7,907.2 hours, with 1,207.7 hours since major overhaul.

Prior to departing from Scottsdale, the aircraft was fueled. The person who fueled the aircraft was employed with Corporate Jets. The fueler stated that he was familiar with this aircraft and had seen this pilot before, however, he stated that this was the first time that the pilot was not with another person. The fueler stated that he topped off both wing main tanks and finished with the left side wing locker tank. A total of 152.2 gallons of 100LL fuel was added. During the brief conversation the fueler had with the pilot, he did not notice anything out of the ordinary with the pilot's behavior. The fueler stated that the pilot did a pre-flight check of the aircraft. Once the fueling was complete, the fueler stated that the engines were started and the pilot taxied the aircraft out to the runway and took off. The fueler did not provide any other services to the aircraft and noted nothing out of the ordinary with the operation of the aircraft or engines.

The Cessna 421C Airplane & Systems Description section from the Pilot's Operating Handbook of the fuel system indicated that the left and right main tanks in the wings each held 103 gallons. The optional wing locker fuel tank held 28 gallons.

Meteorological information

Weather information provided by the Federal Aviation Administration indicated that the weather in the area about 35 miles south of the accident site reported moderate to occasional severe rime/mixed icing conditions in precipitation between 8,000 feet to 12,000 feet. The area of icing covered from 55 miles east of Seattle International Airport (SEA), to 70 miles south, to 40 miles west and was valid from 1324 to 1430 local time. Tacoma Narrows Airport was within this area of coverage to the southwest (15 nautical miles) of SEA.

Flight crews from commercial aircraft in the area issued pilot reports (PIREPs) to air traffic control. At 1228 local time a DeHavilland Dash-8 flight crew reported their location of 360 degrees from Battle Ground VOR at 40 miles, the flight encountered severe mixed icing from 13,000 feet descending to 11,000 feet. At 1246, another commercial flight crew reported at 340 degrees from Battle Ground VOR at 10 miles, the flight encountered moderate mixed icing climbing from 10,000 feet to 13,000 feet.

The Portland International Airport (PDX) aviation routine weather report (METAR) reported at 1255, a temperature of 07 degrees C., dew point of 06 degrees C., and wind from 170 degrees at 6 knots. The visibility was 5 statute miles, with an altimeter setting of 29.91" Hg. The clouds were broken at 600 feet and 2,500 feet, and overcast at 4,000 feet, with light rain and mist.

At 1343 a Special METAR for PDX indicated a temperature of 07 degrees C., a dew point of 06 degrees C., and wind from 170 degrees at 7 knots. The visibility was 6 statute miles, with an altimeter setting of 29.92" Hg. Th

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 weatherManeuvering
Weather condition - icing conditionsFactor
Flight into known adverse weather - continuedPilot in commandFactor
Weather condition - cloudsFactor
Loss of control - in flightDescent - uncontrolled
Aircraft control - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - mountainous/hilly

Aircraft

Registration
N69KM
Reported as
Cessna 421C
Category
Airplane
Serial number
421C0440
Airframe hours
5,363
Engine
Continental GTSIO-520-L, 375 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Operator
Martin A Ayres
Registered owner
Sugar Financial
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 1, 2005 · 95 hours before
Departed
SDL · Scottsdale, AZ
Destination
TIW · Tacoma, WA

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
42
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 2
Last flight review
December 1, 2005
Seat
Left
Toxicology
Performed
Flight hours
400 total

Weather

Conditions
Instrument (IMC) · Day
Wind
160° at 8 knots
Visibility
10 statute miles
Lowest ceiling
3,400 ft overcast
Temperature
45 °F, dew point 41 °F
Altimeter
29.89 inHg
Observed at
PDX, 29 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.