# NTSB WPR09FA258: Cessna 320D, N320KP, Fallon, NV, May 23, 2009

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: May 22, 2009, 19:35 local (May 23, 2009, 02:35 UTC)
- Place: Fallon, NV
- Coordinates: 39.503887, -118.738052
- Nearby events: https://openairdocs.org/map.md?lat=39.5039&lon=-118.7381&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-VFR pattern downwind: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Fatal
- Injuries: 4 fatal
- Status: Completed, report March 8, 2012
- Report: Approved by Office Director
- NTSB office: Western Pacific Region
- Parties: Federal Aviation Adminstration, Teledyne Continental Motors, Cessna Aircraft Company
- NTSB case key (mKey): 73890
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09FA258
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73890/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73890
- Page: https://openairdocs.org/ntsb/WPR09FA258

## Probable cause

The pilot’s inadequate airspeed, which resulted in an aerodynamic stall.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Response/compensation; cases with it: [Cessna 320D, 1 case](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=2074512), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 320D, 4 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2074512), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 320D, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=2074512), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md)
- [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 320D, 2 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2074512), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach-VFR pattern downwind: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 320D, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2074512), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Approach-VFR pattern downwind: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cessna 320D, 2 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2074512), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 320D, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2074512), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

Witnesses reported seeing the airplane approach the airport from the southwest and cross near mid-field to enter the left traffic pattern for landing. Witnesses observed the airplane make a right 270-degree turn to enter on the downwind and, after becoming established on the downwind, make a sharp left turn and descend out of sight near a point consistent with a turn to a close-in base leg. Witnesses then reported seeing a fireball erupt in the area of the accident site. On the downwind leg, at a radar-recorded ground speed of 93 to 106 knots, the airplane's indicated airspeed could have been between 71 and 81 knots, which is in the range of potential stall speeds. Ground scar and wreckage signatures were consistent with a nose-low and left-wing-low ground impact. The witness observations and the impact attitude could be consistent with a stall and loss of control. No anomalies or other conditions were found with either engine that would have precluded normal operation.

## Factual narrative

HISTORY OF FLIGHT On May 22, 2009, about 1935 Pacific daylight time (PDT), a Cessna 320D, N320KP, impacted terrain during landing at Fallon Municipal Airport (FLX), Fallon, Nevada. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot and three passengers were fatally injured; the airplane was substantially damaged by impact forces and post crash fire. The cross-country personal flight departed Fresno, California, about 1830, with a planned destination of Fallon. Visual meteorological conditions prevailed, and no flight plan was filed. Witnesses to the accident reported seeing the airplane approach the airport from the southwest and cross mid-field to enter the downwind leg for landing on runway 21. The airplane was observed making a right 270-degree turn to the downwind leg. At a base turn point, the airplane made a sharp left turn and descended out of sight. Witnesses then reported seeing a fireball erupt in the area of the accident. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the 44-year-old pilot held a commercial pilot certificate with ratings for airplane multi engine land and instrument airplane. The pilot held a second-class medical certificate issued on September 14, 2007, with no limitations or waivers listed. At the time of the accident, the pilot was a U.S. Naval aviator, and was current and qualified in the F/A-18, which is a multi engine jet with centerline thrust. An examination of the pilot's flight records as of September 12, 2008, indicated the pilot had accumulated a total flight time of 3,235 hours, with an estimated 204 hours in the accident make and model. A biennial flight review was completed on July 23, 2008. The investigation team was unable to recover any records, or witnesses, that indicated the pilot had obtained any recent flight training involving the make and model of the accident airplane, or for any multi engine airplane with differential thrust. The pilot’s total civilian flight time at the time of the accident could not be determined. The pilot utilized the accident airplane to facilitate roundtrip flights between Fallon and Fresno to pickup family members. He would depart from Fallon and fly to Fresno, where he would fill the main fuel tanks. He would then fly back to Fallon. On his trip retuning to Fresno he would again fill the main fuel tanks for his return to Fallon. No records of the pilot buying fuel at Fallon were located. The FBO at Fresno was contacted and reported that the accident pilot would fly in and only obtain fuel in the main fuel tanks, and had no record of him ever having the auxiliary fuel tanks fueled. AIRCRAFT INFORMATION The airplane was a Cessna 320D, serial number 0070. A review of the airplane’s logbooks revealed that the airplane had a total airframe time of 5,667.8 hours at the last annual inspection. The logbooks contained an entry for an annualinspection dated September 23, 2008. The tachometer read 4452.3 at the last inspection. The last maintenance entry was on January 22, 2009, with a total airframe time of 5,687.1 hours, and the tachometer read 4471.6, reflecting the replacement of two new Gill 25 batteries. The left engine was a Teledyne Continental Motors TSIO-520-B, serial number 176347-R. Total time recorded on the engine at the last 100-hour inspection was 1,481.3 hours, and time since major overhaul was 1,481.3 hours. The right engine was a Teledyne Continental Motors TSIO-520-B, serial number 145061-5-B. Total time recorded on the engine at the last 100-hour inspection was 4,452.3 hours, and time since major overhaul was 108.5 hours. Fueling records at Fresno Yosemite International Airport (FAT) established that the airplane was last fueled on May 22, 2009, with the addition of 62.5 gallons of 100-octane aviation fuel. The lineman reported that on the several occasions when he fueled the airplane, he always filled the main fuel tanks to capacity. He could not remember ever putting fuel in the auxiliary fuel tanks. Examination of the maintenance records revealed no unresolved maintenance discrepancies against the airplane prior to departure. According to the Cessna 320D Owner's Manual, the power-off stall speed at maximum gross weight with the landing gear down and 15 degrees of flaps extended at 20 degrees of bank is 82 miles per hour (71 knots); at 40 degrees of bank is 92 miles per hour (79 knots). METEOROLOGICAL INFORMATION Official weather observations were not available at FLX. Weather observation taken from Naval Air Station Fallon (NFL), which is 5.5 nm south of FLX, at 1856 was: wind 250 degrees at 25 knots gusting to 32 knots; peak winds of 230° at 36 knots were recorded at 1922; visibility 10 statute miles (sm), few clouds at 12,000 feet, ceiling 16,000 feet broken, and 25,000 feet overcast. The temperature was 25 degrees Celsius; dew point was 2 degrees; and the altimeter was 29.88 inches of mercury. Airport elevation for FLX was 3,963 feet. COMMUNICATIONS On May 22, 2009, about 1830, the airplane departed Fresno Yosemite International Airport (FAT), Fresno, under visual flight rules (VFR), en-route to FLX. Air traffic control services provided by FAT, Oakland Center (ZOA), and Reno Approach Control were unexceptional. At 1927, the pilot informed the Reno approach controller he had FLX in sight and was switching frequency. There were no further communications with the pilot. Radar data indicated the airplane was approximately 25.5 statute miles southwest of FLX when the pilot reported the airport in sight. A factual report was completed by a NTSB Air Traffic Control Specialist on October 23, 2009. The complete report is attached to the docket. A review of the radar data for the accident flight revealed that the airplane approached FLX from the southwest and crossed the runway centerlines just south of the airport heading in a northeasterly direction about 700feet agl. Once the airplane was on the east side of the airport, the airplane made a right descending 270-degree turn to enter the downwind leg for landing on runway 21. The last three radar returns indicated that the airplane was about 240 feet agl. At 1935:35, the radar return revealed the airplane completed a 270-degree turn and had a ground speed of 93 knots, and was headed in a northeasterly direction. The last radar return was recorded at 1935:47, and the ground speed was 106 knots approximately 1/2 mile southeast of the approach end of runway 21. The wreckage was located approximately .3 statute miles north of the last radar return. AIRPORT INFORMATION The Fallon Municipal Airport was located approximately 2 miles northeast of Fallon. The airport had two runways: runway 3/21 was asphalt, and runway 13/31 was dirt. The airport elevation was 3,963 feet. Approach and departure service was provided by ZOA when Navy Fallon Approach Control was closed for operations. The official weather observation at the airport was provided by the Naval Aviation Forecasting Component - Weather (NAFCOMP), Naval Air Station, Fallon. WRECKAGE AND IMPACT INFORMATION Investigators examined the wreckage at the accident scene. The first identified point of contact (FIPC) was a ground scar. The debris path was along a magnetic heading of 294 degrees. The orientation of the fuselage was 310 degrees. The airplane impacted the flat terrain in a left wing low, and nose-low attitude. The approximate 124-foot-long debris path extended along an approximate 338-degree heading with the majority of the airplane on a berm along the south side of Enterprise Way, approximately 1/3 SM east of Indian Lakes Road. The accident site is located approximately 1 SM east of the FLX runway 21 threshold. The wreckage burned extensively where it came to rest. The cockpit, cabin, right wing, aft fuselage, and tail cone were mostly consumed by fire. Parts of the nose and left wing were fire damaged. All major components of the airplane were accounted for on site. The landing gear system gearbox and linkage were in the gear extended position. The flap actuation linkage indicated the flaps were extended to approximately 12 degrees. The left propeller assembly separated from the engine and was found near the initial impact point. The propeller hub had damage at the flange mount area, and interior components had separated and were found nearby. The spinner had crushing and ripping at the tip and blade areas. -Blade A had a slight S-bend near the tip and chordwise scratches on the chambered face near the tip. The blade had a slight decreased pitch twist. -Blade B had leading edge and span-wise scratches from the mid-section to the tip and chordwise at the tip. A portion of the deice boot separated from the blade. The blade had S-bending from the shank to the tip with a decreased pitch twist. -Blade C was loose in the hub and had scuffing at the tip on the chambered face. The blade had leadingdamage and chordwise scratches on the chambered face. The blade had aft bending from the mid-section to the tip and a decreased pitch twist. The right propeller assembly was found near the main wreckage forward of the right engine. The propeller hub had damage at the flange mount area. A small portion of the propeller flange remained attached to the hub. The spinner had crushing and ripping at the tip and blade areas. -Blade A was loose in the hub and was bent aft near the shank and at the midsection. The chambered face had chordwise scratches from the mid-section to the tip. The blade face had span-wise scratches and scuffing near the tip. The blade had a decreased pitch twist from the mid-section to the tip. -Blade B was loose in the hub and was bent aft at the mid-section. The chambered face had chordwise scratches at the tip and multi directional scratches from the mid-section to the tip. The face of the blade was undamaged. -Blade C had leading edge damage and chordwise scratches from the mid-section to the tip. The face of the blade had light scratches at the tip. The blade had a slight forward bending from near the shank to the tip. Examination of the fuel system revealed that the left fuel selector valve was selected to the left main fuel tank. The right fuel selector valve was selected to cross-feed, which would draw fuel for the right engine from the left main fuel tank. The POH calls for the left and right main fuel tanks to be selected for takeoff and landing. The right main and right auxiliary fuel tanks were consumed by post impact fire. The left main fuel tank was fire and impact damaged and did not contain fuel. The left auxiliary fuel tank was not compromised and contained approximately 2.5 gallons of blue fuel, which tested negative for water contamination. Unusable fuel for one auxiliary fuel tank is 3 gallons. A strong smell of aviation gasoline permeated the area around both fuel tanks. MEDICAL AND PATHOLOGICAL INFORMATION The Washoe County Coroner completed an autopsy on May 24, 2009. The FAA Civil Aerospace Medical Institute (CAMI), Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. Analysis of the specimens for the pilot contained no findings for volatiles or tested drugs. They did not perform tests for carbon monoxide or cyanide. TESTS AND RESEARCH Teledyne Continental Motors (TCM) personnel examined the engines under the supervision of the National Transportation Safety Board investigator at the factory in Mobile, Alabama, on June 15, 2009. TCM submitted a written report, and the IIC Safety Board investigator who observed the inspection concurred with the facts in the report. The left engine was noted to have impact damage to the front of the engine cases. It was determined that with minor repairs to the engine cases the engine could be run in the test cell. The engine was successfully run in the engine test cell. No anomalies were noted that would affect normal operation. The rightengine was thermally damaged, which prevented running the engine in the test cell. The right engine was disassembled and examined. No mechanical anomalies were noted that would prevent normal operation.

## Aircraft

- Registration: [N320KP](https://openairdocs.org/deregistered/N320KP-2017-06-21), registration cancelled 2017-06-21, S/N 320D0070, built 1966 (OpenAirDocs)
- Reported make and model: CESSNA 320D
- Registry model: [Cessna 320D](https://openairdocs.org/model/cessna-320d) (registry code 2074512) (OpenAirDocs)
- Registry engine: [Continental GTSIO-520-C](https://openairdocs.org/engine/continental-gtsio-520-c) (registry code 17035, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 320D0070
- Airframe hours: 5668
- Engines: CONT MOTOR TSIO-520-B 340 horsepower reciprocating; CONT MOTOR GTSIO-520-C 340 horsepower reciprocating
- Damage: Substantial damage
- Fire: On-Ground
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, September 23, 2008
- Departed: FAT, Fresno, CA
- Destination: FLX, Fallon, NV
- Airport: FLX, Fallon Municipal Airport

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 44; injuries: fatal; commercial; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review July 21, 2008; seat: left; toxicology performed; flight hours: 3,235 total, 204 in this make and model

## Weather

- Conditions: Visual (VMC), Dusk
- Wind: 250° at 28 knots, gusting 36
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 77 °F, dew point 36 °F
- Altimeter: 29.80 inHg
- Observed at: NFL, 58 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 20090522013509A](https://openairdocs.org/incident/20090522013509A), May 22, 2009: Cessna 320D, Fallon, NV, Destroyed, 4 fatal. (-23) Cessna 320D, N320KP, impacted terrain during landing. The airplane was destroyed by impact forces and post crash fire. The flight departed fresno,…

## Docket (21 files)

The files NTSB released with the investigation on January 18, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73890. 24.6 MB in all.

- ATC 3 - Factual Report of Group Chairman (item 1, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360739&FileExtension=.PDF&FileName=ATC%203%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- ATC 3 - FAA Accident Report - N320KP - FAA Form 8020 (item 2, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320501&FileExtension=.PDF&FileName=ATC%203%20-%20FAA%20Accident%20Report%20-%20N320KP%20-%20FAA%20Form%208020-Redacted.PDF
- ATC 3 - Daily Record of Facility Operation (item 3, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320504&FileExtension=.PDF&FileName=ATC%203%20-%20Daily%20Record%20of%20Facility%20Operation-Redacted.PDF
- ATC 3 - Controller Statement (item 4, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320505&FileExtension=.PDF&FileName=ATC%203%20-%20Controller%20Statement-Redacted.PDF
- ATC 3 - Partial Transcript Reno TRACAB (item 5, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320509&FileExtension=.PDF&FileName=ATC%203%20-%20Partial%20Transcript%20Reno%20TRACAB-Redacted.PDF
- Wreckage Diagram- Debris Field (item 6, .PDF, 338 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360430&FileExtension=.PDF&FileName=Wreckage%20Diagram-%20Debris%20Field-Master.PDF
- Witness Statement - Hilpert (item 7, .PDF, 609 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361610&FileExtension=.PDF&FileName=Witness%20Statement%20-%20Hilpert-Redacted.PDF
- Witness Statement- Boehm (item 8, .PDF, 460 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360416&FileExtension=.PDF&FileName=Witness%20Statement-%20Boehm-Redacted.PDF
- Witness Statement - Madraso (item 9, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361611&FileExtension=.PDF&FileName=Witness%20Statement%20-%20Madraso-Redacted.PDF
- Record of conversation- Holladay (item 10, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361517&FileExtension=.PDF&FileName=Record%20of%20conversation-%20Holladay-Redacted.PDF
- Fuel Valve Diagram (item 11, .PDF, 644 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360427&FileExtension=.PDF&FileName=Fuel%20Valve%20Diagram-Master.PDF
- Final Report - Cessna (item 12, .PDF, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361576&FileExtension=.PDF&FileName=Final%20Report%20-%20Cessna%20-Redacted.PDF
- Final Report- TCM Right Engine Exam (item 13, .PDF, 107 photos, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360425&FileExtension=.PDF&FileName=Final%20Report-%20TCM%20Right%20Engine%20Exam-Redacted.PDF
- Final Report- TCM Left Engine Run (item 14, .PDF, 13 photos, 633 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360426&FileExtension=.PDF&FileName=Final%20Report-%20TCM%20Left%20Engine%20Run-Master.PDF
- Toxicological Report- Hook (item 15, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360428&FileExtension=.PDF&FileName=Toxicological%20Report-%20Hook-Master.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 16, .PDF, 533 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361582&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF
- Statement of Party Representatives to NTSB Investigation (item 17, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360584&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Insurance Application - Hook (item 18, .PDF, 201 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361583&FileExtension=.PDF&FileName=Insurance%20Application%20-%20Hook-Redacted.PDF
- N320KP Aircraft Logbook Entries (item 19, .PDF, 575 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360583&FileExtension=.PDF&FileName=N320KP%20Aircraft%20Logbook%20Entries-Redacted.PDF
- Excerpts from Cessna 320D Owner's Manual (item 20, .PDF, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360767&FileExtension=.PDF&FileName=Excerpts%20from%20Cessna%20320D%20Owner%27s%20Manual-Master.PDF
- Fuel Invoices - N320KP (item 21, .PDF, 6.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361584&FileExtension=.PDF&FileName=Fuel%20Invoices%20-%20N320KP-Redacted.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.

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