WPR10LA002

NTSB accident investigation · Cessna 421B · San Simeon, CA · October 3, 2009

Accident · No injuriesLimited investigationFinal report
Date
October 2, 2009, 17:16 local (Oct 3, 2009, 00:16 UTC)
Place
San Simeon, CA
NTSB coordinates
33.6636, -121.1986, outside the stated state
Injuries
6 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N31KTCessna 421B
Defining event
Standing-engine(s) shutdown: Ground collision
Weather
Visual (VMC) · Day
Status
Completed · report March 3, 2010
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20091003019429A
Case key
74841

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 pilot's failure to follow the manufacturer’s checklist and set the parking brake.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Parking/securing: parking/storageAircraft › Aircraft handling/service · Not specifiedCessna 421B: 1 caseAll aircraft: 5 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotCessna 421B: 1 caseAll aircraft: 336 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Ground collisionStanding-engine(s) shutdownCessna 421B: 2 casesAll aircraft: 618 casesDefining event

Analysis

The pilot taxied into the parking area, which appeared to be level from his perspective in the cockpit. Although the checklist called for setting the parking brake, the pilot elected to not use it since there were several chocks available on the ramp and no movement of the airplane was observed. He walked back to open the passenger door when the airplane began rolling backwards and impacted the windshield of a parked car. Although the parking area appeared level, the pilot indicated that later analysis showed there was a gradual slope.

Factual narrative

On October 2, 2009, at 1716 Pacific daylight time, N31KT, a Cessna 421B, rolled backwards into a parked car at the Hearst Castle Airstrip, San Simeon, California. The empennage sustained substantial damage. Western Air Charter was operating the airplane under the provisions of 14 Code of Federal Regulations Part 135. The airline transport pilot and five passengers were not injured. Visual meteorological conditions prevailed and the pilot had requested and received flight following. The pilot departed from Santa Monica Municipal Airport, Santa Monica, California, at 1600 and was at his destination when the accident occurred. The pilot reported that he had shutdown the engines and secured the airplane. The pilot indicated that although the checklist called for setting the parking brake, he elected to not use it since there were several chocks available on the ramp and no movement of the airplane was observed. He walked back to open the passenger door when the airplane began rolling backwards and impacted the windshield of a parked car. Although the parking area appeared level, the pilot indicated that later analysis showed there was a gradual slope.

Aircraft

Registration
N31KT
Reported as
Cessna 421B
Category
Airplane
Serial number
421B0011
Airframe hours
4,850
Engine
Teledyne Continental Motors GTSIO-520-H, 375 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Western Air Charter
Registered owner
Kenneth Smith
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · December 24, 2008 · 73 hours before
Departed
SMO · Santa Monica, CA
Destination
PVT · San Simeon, CA
Airport
PVT · Hearst Castle Airstrip

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
56
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
March 31, 2009
Seat
Left
Flight hours
5,612 total · 1,700 in this make and model · 5,518 as pilot in command · 59 in the last 90 days · 28 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 34 °F
Altimeter
29.80 inHg
Observed at
PRB, 30 nm away

Docket · 1

The files NTSB released with the investigation on November 23, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 698 KB in all.

FAA reports on this event · 1

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