SEA99FA041

NTSB accident investigation · Cessna 421B · North Bend, OR · March 9, 1999

Accident · FatalField investigationFinal report
Date
March 8, 1999, 21:45 local (Mar 9, 1999, 05:45 UTC)
Place
North Bend, OR
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N41096Cessna 421B
Weather
Visual (VMC) · Night/dark
Status
Completed · report March 31, 2000
Report
Approved by Office Director
FAA report
19990308002089A
Case key
45891

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

A delayed aborted takeoff for an undetermined reason.

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 terrain/waterTakeoff - aborted
Terrain condition - dirt bank/rising embankment
Aborted takeoff - delayedPilot in commandCause
Reason for occurrence undetermined
Misc eqpt/furnishings,seat belt - not engaged

Analysis

Witnesses reported hearing the engines start and shortly thereafter, the airplane taxied to the runway. The pilot then contacted ATC for an IFR clearance. The clearance was given with a short void time. The pilot acknowledged the clearance and began the takeoff ground roll. Witnesses reported that the night-time takeoff roll and engine sound appeared normal. Witnesses near the end of the runway reported that the airplane was observed at about 50 feet above the runway with about 1,000 feet of runway remaining when engine power was reduced on both engines. The airplane was heard to touch down, then engine power was reapplied. Shortly thereafter, the sound of the impact was heard. The airplane collided with the terrain about 600 feet from the end of the runway. During the post-accident inspection of the airplane and engines, no evidence was found to indicate a mechanical failure or malfunction. Documentation of the events indicated that from the time the aircraft began its taxi to the runway, to the time the takeoff roll began, was approximately six minutes in duration. Before the takeoff roll began, the pilot had accepted a clearance with a void time of four minutes. By the time the pilot correctly read back the clearance, less than two minutes remained before the void time. Post accident documentation of the accident site revealed that neither the pilot nor the passenger were wearing their lap belts or shoulder harnesses. It was also noted that the pilot had not yet selected the discrete transponder code as indicated by the clearance.

Factual narrative

History of flight

On March 8, 1999, about 2145 Pacific standard time, a Cessna 421B, N41096, registered to and operated by the pilot as a 14 CFR Part 91 personal flight, aborted takeoff from the North Bend Municipal Airport, North Bend, Oregon, and collided with the terrain about 600 feet from the end of runway 13. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The airplane was substantially damaged and the private pilot and his passenger were fatally injured. The flight's destination was to Aurora, Oregon.

The Operations agent located at the terminal building who was monitoring the North Bend Unicom frequency (122.7) and taking weather observations, reported that he heard the aircraft's engines start. Shortly thereafter, he saw the aircraft taxi to runway 13, at about 2135. The pilot did not make radio contact or report his position over the Unicom frequency as he was taxiing out. The agent reported that as the aircraft was positioned near the threshold of runway 13, he heard the pilot contact McMinnville Flight Service Station (FSS) at 2138, requesting an IFR clearance. After the clearance was received at 2141, the agent observed the aircraft begin its takeoff roll. The agent stated that the landing and taxi lights were on during the roll.

Witnesses located at various points along the south side of the runway reported that the engines sounded like they were developing full power, and the takeoff roll appeared normal. Towards the end of runway 13, at approximately taxiway A3, four U.S. Coast Guard mechanics were working on the ramp and heard the aircraft on the runway. The mechanics reported that the engines sounded normal and were developing full power. One of the mechanics reported that he looked up and saw the aircraft at about 50 feet above ground level over taxiway A3. The mechanics stated that, at this point, they heard a power reduction on both engines. The one mechanic lost sight of the aircraft, but reported that he heard the sound of the tires screech on the runway surface. After this sound, the mechanics heard the engine power being reapplied. Seconds later, the mechanics heard the sound of the impact and they responded to the accident site.

Personnel information

At the time of the accident, the pilot held a private pilot certificate with an instrument rating in single and multi-engine land aircraft. Only flight logbooks one and five were located and provided by a family representative for a review of the pilot's flight time. Logbook five indicated that the first flight in N41096 was on February 6, 1997. The last entry in the logbook was dated March 28, 1997, in N41096. Other flights dating back to 1995, indicated flight time in another Cessna 421. Utilizing the available flight logbooks and the maintenance logbooks for N41096, it is estimated that the pilot had accumulated a total flight time in all aircraft of approximately 1,220 hours, with approximately 287 hours in multi-engine aircraft. Approximately 135 hours had been accumulated in the Cessna 421. Total night flight or night currency could not be determined. The maintenance logbooks indicate that the aircraft had accumulated 12 hours of flight time in the 90 days preceding the accident.

Records obtained from SIMCOM Training Center, Scottsdale, Arizona, indicated that the pilot had satisfactorily accomplished an instrument competency check on February 20, 1999. No logbook entries for this training or flight time were logged in the flight logbooks that were provided for review.

Medical records obtained from the Federal Aviation Administration Airmen Records, Oklahoma City, Oklahoma, indicated that the pilot held a third class medical certificate dated October 6, 1998. A limitation indicating that the pilot shall possess glasses that correct for near vision was noted. At this time, the pilot reported a total flight time of 1,200 total flight hours.

Communications

At 1448, the pilot contacted McMinnville FSS and requested a weather briefing for an IFR flight from North Bend to Aurora State. The pilot indicated that he expected to leave in about two hours. The specialist briefed the pilot on the conditions and asked the pilot if he wanted to file the flight plan. The pilot stated that he did not, as his passenger had not yet arrived and he did not know exactly when they would be departing. The conversation ended at 1454.

At 2102, the pilot again contacted McMinnville FSS, and reported that he would be leaving North Bend in 30 minutes and requested a weather update. The specialist briefed the pilot as to the weather conditions for the route of flight. The pilot then filed the IFR flight plan. After some discussion with the specialist, the pilot filed using the published Standard Instrument Departure (SID). The SID is the North Bend Four Departure via the Rares transition. The conversation ended at 2110.

At 2138, the pilot contacted McMinnville FSS and reported that he was on the ground at North Bend and ready to copy the IFR clearance to Aurora State. The specialist contacted Seattle Center and received the clearance, which was then relayed to the pilot at 2139. The clearance read:

"Cleared from the North Bend Airport to the Aurora State Airport via the North Bend Four Departure, Rares transition, Victor 287 as filed. Maintain 6,000 feet. Squawk 4677, and contact Seattle Center on 121.4 leaving 2,000 feet. Clearance void if not off by 0543 (2143 PST)."

The North Bend Four Departure, Rares transition states that after takeoff from runway 13, turn right and climb via the North Bend 250 degree radial to 1,300 feet, then a climbing right turn direct to the North Bend VOR. The Rares transition from the VOR indicates a 005 degree heading via Victor 287 to Rares intersection, 16 Distance Measuring Equipment (DME) miles from the VOR.

The pilot correctly read back the clearance, except for the void time. The pilot stated that the clearance was void if not off in five minutes. The specialist corrected the pilot and stated that the clearance was void if he was not off in the next minute and three-quarters. The time was 2141:16. The pilot thanked the specialist, and the conversation ended at 2141:21.

At 2147, the specialist at McMinnville FSS and the controller at Seattle Center reported that they had not heard from the pilot since the last transmission. The controller at Seattle Center reported that he had someone (a Horizon Airlines flight) waiting to come inbound, and asked the specialist that if he heard from the pilot, to give him a call.

Aerodrome information

Directly off the end of the runway pavement, the terrain is level and grass covered. This grass area extends beyond the width of the runway, and is approximately 135 feet in length. The terrain then descends about 30-40 feet into a marsh area. The length of the marsh area extends approximately 465 feet to the airport boundary fence, and is approximately 300 feet wide. The terrain raises back up to approximately the runway elevation at the boundary fence.

Wreckage and impact information

The aircraft came to rest at the top of the embankment with the nose of the airplane positioned about three feet inside of the airport boundary fence. The aircraft was aligned on a magnetic bearing of approximately 130 degrees and was about 30-feet south of runway centerline. The terrain directly behind the aircraft descended about 30-feet to the bottom of the marsh. The terrain was soft, wet and covered with grass and brush.

The fuselage remained intact. The forward section of the fuselage and wings were resting on the ground. The empennage extended out over the descending terrain.

The left main landing gear and nose landing gear separated from the aircraft. The left main landing gear was found about five feet behind the left wing. The nose gear was found at the

Aircraft

Registration
N41096
Reported as
Cessna 421B
Category
Airplane
Serial number
421B0446
Airframe hours
2,342
Engine
Continental GTSIO-520-H, 375 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
John E. Hoesly
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 2, 1998 · 12 hours before
Destination
UAO · Aurora, OR
Flight plan
IFR
Airport
OTH · North Bend Muni, runway 13, 5,046 × 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
48
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,220 total · 135 in this make and model

Weather

Conditions
Visual (VMC) · Night/dark
Wind
140° at 6 knots
Visibility
9 statute miles
Lowest ceiling
1,500 ft overcast
Temperature
39 °F, dew point 36 °F
Altimeter
29.00 inHg
Observed at
OTH

Docket · 28

The files NTSB released with the investigation on February 22, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.4 MB in all.

Supplement aItem 1 · PDF · 2 pages · 241 KBSupplement bItem 2 · PDF · 4 pages · 407 KBSupplement sItem 3 · PDF · 1 page · 50 KBWitness statementsItem 4 · PDF · 6 pages · 288 KBWreckage diagramItem 5 · PDF · 1 page · 80 KBRunway diagramItem 6 · PDF · 1 page · 155 KBTranscript of radio communicationsItem 7 · PDF · 14 pages · 323 KBTcm analytical inspection reportItem 8 · PDF · 9 pages · 601 KBStatement of party representatives to NTSB investigationItem 9 · PDF · 3 pages · 774 KBRelease of aircraft wreckage NTSB form 612015Item 10 · PDF · 1 page · 72 KBToxicological reportItem 11 · PDF · 1 page · 68 KBPhoto 1 view facing 130 degrees from end of runway to accident siteItem 12 · PDF · 1 page · 11 KBPhoto 2 view facing 310 degrees from accident site to runwayItem 13 · PDF · 1 page · 16 KBPhoto 3 rear view of wreckageItem 14 · PDF · 1 page · 18 KBPhoto 4 arrow points to brush with tips broken off tape on ground reflects right main landing gear ground impactItem 15 · PDF · 1 page · 22 KBPhoto 5 left main landing gear ground impactItem 16 · PDF · 1 page · 23 KBPhoto 6 view of broken trees from left wing impactItem 17 · PDF · 1 page · 32 KBPhoto 7 aft view of left wingItem 18 · PDF · 1 page · 25 KBPhoto 8 forward view of wreckage before removal from site pole designates airport boundary fenceItem 19 · PDF · 1 page · 24 KBPhoto 9 forward view of wreckage after removal from siteItem 20 · PDF · 1 page · 20 KBPhoto 10 right side view of wreckageItem 21 · PDF · 1 page · 16 KBPhoto 11 rear view of wreckageItem 22 · PDF · 1 page · 19 KBPhoto 12 left side view of wreckageItem 23 · PDF · 1 page · 19 KBPhoto 13 view of leading edge right wing inboard of engine damageItem 24 · PDF · 1 page · 27 KBPhoto 14 view of right engineItem 25 · PDF · 1 page · 26 KBPhoto 15 view of leading edge of right wing outboard of engineItem 26 · PDF · 1 page · 27 KBPhoto 16 view of left engineItem 27 · PDF · 1 page · 25 KBPhoto 17 view of fuel selectorsItem 28 · PDF · 1 page · 25 KB

FAA reports on this event · 1

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