Accident Details
Probable Cause and Findings
The flight instructor's improper selection of the high boost position for the operating right engine while on base leg to land, which resulted in a loss of engine power of the right engine. Factors associated with the accident are the left engine's loss of power for an undetermined reason, the flight instructor's failure to feather the propellers of the affected engines, and his failure to maintain directional control, which resulted in an off-airport forced landing.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On January 14, 2003, at 1359 Pacific standard time, a Cessna 414, N127WW, lost engine power and made an off airport forced landing at Palm Springs, California. The owner operated the airplane under the provisions of 14 CFR Part 91. The airplane sustained substantial damage. The commercial multiengine pilot undergoing instruction (PUI) was located in the left seat, and received serious injuries. The certified flight instructor (CFI) in the right seat, and a pilot rated passenger in the passenger compartment had minor injuries. Visual meteorological conditions prevailed for the cross-country flight. An instrument flight rules (IFR) flight plan had been filed. The flight departed Zamperini Field (TOA), Torrance, California, at 1145. The flight was destined for Palm Springs International Airport (PSP). The wreckage was at a global positioning system (GPS) coordinates of 33 degrees 51 minutes north latitude and 116 degrees 29 minutes west longitude.
Responding Palm Springs Police Department officers interviewed the pilots after the accident. The CFI reported that as they turned towards final, the left engine began to surge and the airplane yawed to the right. He went through the emergency procedures but the airplane continued to lose airspeed and altitude. While maneuvering to the landing spot, the CFI noted that the fuel selectors were positioned to the MAIN fuel tanks, and the gauges showed 25 gallons in each wing.
The responding officers verified that the master switch and the magnetos were in the OFF positions, the landing gear handle was in the retracted position, and the flaps were retracted. They also noted that the fuel boost pump switches were "fully on." The fuel selector handles were in the OFF position. The officers inspected the fuel tanks and noted that the left side fuel tanks were empty, with the odor of fuel present under the damaged wing. The two outer right wing fuel tanks each had fuel remaining in them.
CFI Statement (seated in the right seat)
The CFI reported that on the day prior to the accident, during the preflight inspection, he noted that the left alternator circuit breaker had been tripped to the OPEN position, and he reset it. They started the engines and cross-fed fuel from the opposite main fuel tanks priming the engine via the emergency fuel pump ON position. Normal fuel flow was established and the engines were operating normally. They tested the airplane system per the BEFORE TAKEOFF checklist, with no discrepancies noted. As they taxied to the fueling area there was a discussion about the left alternator, which had recently been replaced. They did not know if it was on line or not. The PUI had informed him that during the ferry flight to reposition the airplane from Palomar Airport, Carlsbad, California, to TOA, the pilot noted that the left alternator was inoperative. However, during the taxi, no discrepancies were noted with the left alternator. The airplane was fueled to capacity; 100 gallons in the main fuel tanks, and 40 gallons each in the auxiliary and nacelle locker fuel tanks for a total of 80 gallons. The airplane was taxied to the hangar where they adjourned to start the ground school portion of the training. They spent the next 6 hours reviewing airplane systems.
They met the next day to complete the ground school instruction. The pilots again performed the preflight inspection, which included sampling the fuel sumps, where about 1 quart of water was removed from the right wings' innermost rear sump. The water was not "clean; it was cloudy and contained sediment." They continued to sample the fuel until "clear fuel was detected."
The airplane was started normally and they received an IFR flight plan to PSP via Thermal, California, and Blythe, California, reaching an altitude of 25,000 feet (flight level - FL250) to conduct high altitude operations. After reaching FL250, the airplane was configured for 65-percent power and the air-to-fuel mixture was adjusted to the recommend values. At that point, the CFI switched from the main fuel tanks to the auxiliary fuel tanks. Moments later, the left engine "dropped off line," and no fuel flow was evident on the fuel gauge. He then moved the left fuel selector back to the left main fuel tank. He advised Southern California Air Route Traffic Control Center (SoCal ARTCC) of the situation, and initiated a slow right circling descent towards Blythe airport. The left engine did not immediately come back on line, and it took a few minutes before the engine regained power.
The CFI reported that they stabilized the airplane's altitude at 15,000 feet and elected to continue on towards Thermal. At that point both engines were operating normally. He stated that the left fuel selector was positioned to the MAIN fuel tank, and the right fuel selector was positioned to the AUXILIARY fuel tank. The CFI reported that because the engines were operating normally, he moved the left fuel selector from the MAIN fuel tank back to the AUXILIARY fuel tank. The left engine continued to operate normally. He stated that they performed flight maneuvers that included medium and steep bank turns, unusual attitudes, and various simulated emergency conditions. During the airwork, the fuel selectors were both positioned to the MAIN fuel tanks, and they initiated the fuel transfer process from the nacelle locker tanks to the main fuel tanks.
The CFI stated that the engines were operating normally, and they continued the flight towards PSP, their original destination so they could refuel and switch pilots. At 8,500 feet, he radioed the PSP approach controller with a request to circle PSP airport, and simulate single engine operations (an engine out condition). The PSP controller acknowledged and approved their request. The flight proceeded direct to PSP at 3,500 feet and was instructed to contact tower personnel; a tower controller cleared them to land on runway 31L.
The CFI then simulated a left engine failure by reducing the power with the throttle. The PUI initiated the emergency procedures by increasing mixture to rich, propellers to high rpm (revolutions per minute), and right throttle full forward. The PUI performed a "drag check" to ensure the landing gear and wing flaps were retracted. The PUI then identified the left engine as inoperative and verified by closing the left throttle. When the PUI went to feather the left propeller the CFI blocked him, and then set power on the left engine to simulate "zero thrust and trimmed for that condition." The PUI circled the airplane to the right, towards the operating engine, and during the descent, the power on the right engine was reduced to 29.5 inches manifold pressure (MAP) and 2,400 rpm.
The CFI reported that they orbited the airplane a couple of times before establishing the airplane on the right downwind leg for runway 31L. As they turned from base to final, left wing high, the left engine started to "surge wildly, rotating the [airplane] clockwise 180 degrees from our previous heading and outbound perpendicular from the runway." They arrested the turn by leveling the wings, lowering the pitch attitude, and "bringing power up on both throttles." The CFI reported at that point he took over the flight controls. The power increased on the left engine, which continued to surge "with a higher frequency," and power on the right engine began to drop off progressively.
They attempted to stabilize the power situation on the left engine and restore power to the right engine by placing the auxiliary fuel pump switches from the LOW position to the ON position. However, there was not a noticeable change in either engine. The airplane yawed to the right towards a housing development with surface streets and power lines in their route of flight. The airplane continued to lose altitude. He had the PUI inform PSP tower that they had an actual emergency condition. The CFI was able to regain directional control of the airplane by banking towards the left engine, but "felt the power dropping off there also." He reported that his main priority was clearing the housing development and obstacles in the area. He was able to maintain a minimal descent rate by reducing the airspeed. After the airplane cleared the obstacles, he then "gave up my altitude to preserve lift over the wings." He could feel the wings were just above a stall and pushed the nose down to maintain airplane control. The CFI stated that he made a forced landing in a sand covered ravine just west of the housing development.
After landing hard, he had the PUI switch off the magnetos, alternators, and battery. The CFI selected both fuel selectors to the OFF position. The CFI further reported that fuel was pouring out of the left main fuel tank, which had broken away from its attachment point.
PUI Statement (seated in the left seat)
The pilot reported that after completing their morning ground session, they conducted a preflight of the airplane in accordance with the manufacturer's pilot operating handbook (POH). All six fuel tanks had been "topped" off with 100 low-lead octane aviation fuel by the local fixed base operator (FBO), totaling 180 gallons of useable fuel. He drained fuel sampled from all 12 fuel valve drains. Water was evident from the innermost fuel valve under the right wing. He drained about 2 cups of water from the fuel valve drain.
After starting the airplane, he obtained Torrance's current Automatic Terminal Information Service (ATIS) information and taxied to the run-up area for runway 29R. In the run-up area he obtained the IFR clearance to PSP, with a requested altitude of FL 250. After takeoff, SoCal cleared them to the Seal Beach Very High Frequency Omni-directional Range (SLI VOR), where they began a series of climbs to FL250. The PUI indicated that the climbs were done using the cruise climb settings called out on the RAM series ...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX03FA067