# NTSB SEA99FA041: Cessna 421B, N41096, North Bend, OR, March 9, 1999 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 8, 1999, 21:45 local (Mar 9, 1999, 05:45 UTC) - Place: North Bend, OR - Coordinates: 43.479976, -124.160858 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.4800&lon=-124.1609&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report March 31, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 45891 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA99FA041 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/45891/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=45891 - Page: https://openairdocs.org/ntsb/SEA99FA041 ## Probable cause A delayed aborted takeoff for an undetermined reason. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, takeoff - aborted - terrain condition - dirt bank/rising embankment - aborted takeoff - delayed, pilot in command (cause) - 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](https://openairdocs.org/deregistered/N41096-2018-01-19), registration cancelled 2018-01-19, S/N 421B0446, built 1973 (OpenAirDocs) - Reported make and model: Cessna 421B - Registry model: [Cessna 421B](https://openairdocs.org/model/cessna-421b) (registry code 2076014) (OpenAirDocs) - Registry engine: [Continental GTSIO-520-C](https://openairdocs.org/engine/continental-gtsio-520-c) (registry code 17035, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 421B0446 - Airframe hours: 2342 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; 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 ## 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 19990308002089A](https://openairdocs.org/incident/19990308002089A), Mar 8, 1999: Cessna 421B, North Bend, OR, Substantial damage, 2 fatal. Acft crashed in a marshy area while attempting to abort take-off for unknown reasons, the pilot suffered serious injuries, the passenger suffered fatal… ## Docket (28 files) The files NTSB released with the investigation on February 22, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=45891. 3.4 MB in all. - Supplement a (item 1, PDF, 2 pages, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15126186&FileExtension=pdf&FileName=Supplement%20A-Master-Rel.pdf - Supplement b (item 2, PDF, 4 pages, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15126106&FileExtension=pdf&FileName=Supplement%20B-Master-Rel.pdf - Supplement s (item 3, PDF, 1 page, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125852&FileExtension=pdf&FileName=Supplement%20S-Master-Rel.pdf - Witness statements (item 4, PDF, 6 pages, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15126109&FileExtension=pdf&FileName=Witness%20Statements-Master-Rel.pdf - Wreckage diagram (item 5, PDF, 1 page, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125658&FileExtension=pdf&FileName=Wreckage%20Diagram-Master-Rel.pdf - Runway diagram (item 6, PDF, 1 page, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125784&FileExtension=pdf&FileName=Runway%20Diagram-Master-Rel.pdf - Transcript of radio communications (item 7, PDF, 14 pages, 323 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125855&FileExtension=pdf&FileName=Transcript%20of%20Radio%20Communications-Master-Rel.pdf - Tcm analytical inspection report (item 8, PDF, 9 pages, 601 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15126189&FileExtension=pdf&FileName=TCM%20Analytical%20Inspection%20Report-Master-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 3 pages, 774 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125621&FileExtension=pdf&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master-Rel.pdf - Release of aircraft wreckage NTSB form 612015 (item 10, PDF, 1 page, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125663&FileExtension=pdf&FileName=Release%20of%20Aircraft%20Wreckage%20%20NTSB%20Form%20612015-Master-Rel.pdf - Toxicological report (item 11, PDF, 1 page, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125965&FileExtension=pdf&FileName=Toxicological%20Report-Master-Rel.pdf - Photo 1 view facing 130 degrees from end of runway to accident site (item 12, PDF, 1 page, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125409&FileExtension=pdf&FileName=Photo%201%20%20View%20facing%20130%20degrees%20from%20end%20of%20runway%20to%20accident%20site-Master-Rel.pdf - Photo 2 view facing 310 degrees from accident site to runway (item 13, PDF, 1 page, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15126193&FileExtension=pdf&FileName=Photo%202%20%20View%20facing%20310%20degrees%20from%20accident%20site%20to%20runway-Master-Rel.pdf - Photo 3 rear view of wreckage (item 14, PDF, 1 page, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15121539&FileExtension=pdf&FileName=Photo%203%20%20Rear%20view%20of%20wreckage-Master-Rel.pdf - Photo 4 arrow points to brush with tips broken off tape on ground reflects right main landing gear ground impact (item 15, PDF, 1 page, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125859&FileExtension=pdf&FileName=Photo%204%20%20Arrow%20points%20to%20brush%20with%20tips%20broken%20off%20%20Tape%20on%20ground%20reflects%20right%20main%20landing%20gear%20ground%20impac-Master-Rel.pdf - Photo 5 left main landing gear ground impact (item 16, PDF, 1 page, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125969&FileExtension=pdf&FileName=Photo%205%20%20Left%20main%20landing%20gear%20ground%20impact-Master-Rel.pdf - Photo 6 view of broken trees from left wing impact (item 17, PDF, 1 page, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125863&FileExtension=pdf&FileName=Photo%206%20%20View%20of%20broken%20trees%20from%20left%20wing%20impact-Master-Rel.pdf - Photo 7 aft view of left wing (item 18, PDF, 1 page, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15126197&FileExtension=pdf&FileName=Photo%207%20%20Aft%20view%20of%20left%20wing-Master-Rel.pdf - Photo 8 forward view of wreckage before removal from site pole designates airport boundary fence (item 19, PDF, 1 page, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125413&FileExtension=pdf&FileName=Photo%208%20%20Forward%20view%20of%20wreckage%20before%20removal%20from%20site%20%20Pole%20designates%20airport%20boundary%20fence-Master-Rel.pdf - Photo 9 forward view of wreckage after removal from site (item 20, PDF, 1 page, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15126201&FileExtension=pdf&FileName=Photo%209%20%20Forward%20view%20of%20wreckage%20after%20removal%20from%20site-Master-Rel.pdf - Photo 10 right side view of wreckage (item 21, PDF, 1 page, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125667&FileExtension=pdf&FileName=Photo%2010%20%20Right%20side%20view%20of%20wreckage-Master-Rel.pdf - Photo 11 rear view of wreckage (item 22, PDF, 1 page, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15126113&FileExtension=pdf&FileName=Photo%2011%20%20Rear%20view%20of%20wreckage-Master-Rel.pdf - Photo 12 left side view of wreckage (item 23, PDF, 1 page, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125627&FileExtension=pdf&FileName=Photo%2012%20%20Left%20side%20view%20of%20wreckage-Master-Rel.pdf - Photo 13 view of leading edge right wing inboard of engine damage (item 24, PDF, 1 page, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15126117&FileExtension=pdf&FileName=Photo%2013%20%20View%20of%20leading%20edge%20right%20wing%20inboard%20of%20engine%20damage-Master-Rel.pdf - Photo 14 view of right engine (item 25, PDF, 1 page, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125631&FileExtension=pdf&FileName=Photo%2014%20%20View%20of%20right%20engine-Master-Rel.pdf - Photo 15 view of leading edge of right wing outboard of engine (item 26, PDF, 1 page, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15126121&FileExtension=pdf&FileName=Photo%2015%20%20View%20of%20leading%20edge%20of%20right%20wing%20outboard%20of%20engine-Master-Rel.pdf - Photo 16 view of left engine (item 27, PDF, 1 page, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125417&FileExtension=pdf&FileName=Photo%2016%20%20View%20of%20left%20engine-Master-Rel.pdf - Photo 17 view of fuel selectors (item 28, PDF, 1 page, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15125787&FileExtension=pdf&FileName=Photo%2017%20%20View%20of%20fuel%20selectors-Master-Rel.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.