Accident Details
Probable Cause and Findings
The failure of the pilot to properly configure the airplane for a one engine inoperative condition (including his failure to feather the propeller of the affected engine, retract the landing gear, and maintain minimum single engine speed). Factors related to the accident were fuel starvation of the left engine, due to an inadequate fuel supply in the left tanks, inoperative fuel transfer pumps, and the pilot's decision to takeoff with out fueling.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On May 4, 2003, at 1453 Pacific daylight time, the pilot of a Cessna 411 twin engine airplane, N1133S, lost control and collided with terrain approximately 2 miles east of the Corona Municipal Airport, Corona, California. The pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The commercial pilot, who was the sole occupant, received fatal injuries. The airplane was destroyed. Day visual meteorological conditions prevailed, and no flight plan had been filed. The flight originated from the Corona airport around 1430, and was en route to Santa Monica, California.
According to Air Traffic Control (ATC) communications, and family members, the purpose of the flight was to deliver the airplane to Santa Monica Propeller for maintenance on one of the airplane's propellers. The pilot checked in with Southern California Approach (SoCal Approach) and requested flight following to Santa Monica. Approximately 3 minutes after checking in with SoCal approach, the pilot reported having engine difficulties and was returning to Corona. SoCal approach assisted the pilot with vectors to Corona Airport. SoCal approach lost radar contact with the airplane approximately 3 miles to the east of Corona Airport. So Cal approach advised loss of radar contact then instructed the pilot to change to the airport advisory frequency, which the pilot acknowledged.
The airplane flew over several witnesses who were within 1/2 mile of the accident site. They reported to the National Transportation Safety Board investigator-in-charge (IIC) that they observed the airplane flying "very low," about 300 to 500 feet msl. The airplane was heading toward the Corona airport. The witnesses reported consistent observations of the airplane "wobbling," then going into a steep knife-edge left bank before it dove into the ground. The wreckage was immediately located by police and fire rescue crews who extinguished a fire on the right side of the airplane.
PERSONNEL INFORMATION
The pilot obtained his third-class medical certificate on March 25, 2002. His medical was valid with no limitations.
Examination of the pilot's logbook and Federal Aviation Administration (FAA) records revealed the pilot received his commercial pilot certificate, single engine land, and instrument ratings through military competency on May 4, 1960. He received his multiengine land rating on May 17, 1999. The pilot had accumulated about 4,899 total flight hours with approximately 412 hours in the Cessna 411.
In the Riverside Automated Flight Service Station re-recording of the pilot requesting a weather brief, the pilot can be heard to say in a side conversation while he was waiting for a briefer, "Thank you very much for coming and helping I,...its been four and a half months since I've been in an airplane, I can't even figure out how to put the radios back in."
AIRCRAFT INFORMATION
The twin engine, low wing airplane was powered by two Teledyne Continental GSTIO-520-C engines. The airplane's serial number was: 411-0202. The airplane and engines underwent their last annual inspection on March 19, 2003, at an aircraft total time of 4,915 hours, and 86.5 hours since the last inspection in 2002. The total time since the last engine overhaul was 503 hours on the right engine and 563 hours on the left engine.
An aircraft logbook entry dated March 19, 2003, indicated the aircraft annual inspection was completed; however, the left propeller did not comply with AD 95-24-05 RI: "The propeller must be inspected by a certified person. Completion of AD 95-24-05RI will make the aircraft airworthy."
The mechanic who performed the last annual inspection provided copies of his discrepancy notes pertaining to the accident airplane to the Safety Board IIC. In those documents it is noted that the left propeller was leaking red dye.
According to Corona Aircraft Sales, the airplane had been placed on their sales lot to be sold. The airplane had not been flown since the completion of the annual inspection.
AIR TRAFFIC CONTROL AND RADAR DATA
Review of the Air Traffic Control (ATC) communications re-recording and radar plot data revealed that the pilot had been in communications with Southern California Approach. Upon initial contact with SoCal approach the airplane was observed by the controller to be heading east, away from Santa Monica. When the controller queried the pilot, the pilot said his GPS indicated he was heading the correct direction. The controller informed the pilot that he was heading east when Santa Monica was to the west, and gave the pilot an appropriate heading towards his stated destination. Approximately 3 minutes 15 seconds after initial contact with SoCal approach, and at an altitude of 4,000 feet, the pilot reported an "engine cutting out" and intended to return to Corona airport. The SoCal approach controller observed the airplane descend in altitude, assisted the pilot with vectors to Corona Airport, and expressed concern about the airplane's ability to maintain altitude. The pilot reassured the controller that he could maintain altitude. Approximately 3 miles east of Corona airport the controller reported that radar contact was lost and to switch to the airport advisory frequency. The pilot acknowledged this last communication.
Radar and radio communication re-recordings and data files were obtained from Southern California TRACON and a plot was generated by a private vendor for the Cessna Aircraft Company. A copy of the plot and communication transcripts is attached to this report. It shows the aircraft departing Corona airport, climbing to 4,000 feet, turning back towards Corona, and continuously descending until radar contact is lost at about 700 feet agl and 85 knots ground speed.
WRECKAGE AND IMPACT INFORMATION
The airplane wreckage was located in a construction site on a small plateau approximately 30 feet above River Road to the east. The dirt plateau falls away into a drainage culvert approximately 75 feet below to the north. The construction site was barren of all trees and brush. The plateau had an approximate 20-degree slope downwards to River Road. The wreckage location was recorded with a global positioning system as latitude north 33 degrees 53.794 minutes, longitude west 117 degrees 34.275 minutes at an elevation of 590 feet.
All major components of the airplane were present at the accident site. The airplane was oriented on a bearing of 310 degrees magnetic. The airplane was laying upright with the landing gear collapsed underneath the fuselage. The nose, flight deck, and instrument panel of the airplane were completely destroyed. The engine control quadrant; throttle, propeller, and mixture control levers were all found parallel, in the full forward position. The circuit breaker panels had pulled apart. Most circuit breakers were popped or broken, posts sheared, and extended out of position.
The right wing exhibited fire damage outboard of the right engine. The entire right engine was twisted 90 degrees along its longitudinal axis so that the engine cylinders were directed vertically. The crankshaft propeller flange exhibited torsional shearing and the propeller was not attached to the engine. The right wing leading edge and fuel tip tank were crushed aft to the wing spar and thermally damaged. The right aileron was consumed by fire but the aileron spar was attached to its respective hinge points. The right aileron flight control cables were present and attached to the aileron bellcrank and push rod, which connect to the aileron.
The right side of the fuselage was split along an upper longitudinal rivet line and laying open from aft of the upper corner of the emergency exit to the leading edge of the horizontal stabilizer.
The last outboard quarter of the right horizontal stabilizer had a 20-degree bend upward. The rudder had skin wrinkles along the rivet line that extends horizontally from the upper hinge. The left horizontal stabilizer and elevator displayed no apparent damage.
The left side of the fuselage was split aft horizontally along a lower rivet line from the bottom corner of the main cabin door. The top half of the split cabin door was jarred open. The bottom half of the cabin door was detached, and found laying on the ground 3 feet in front of the doorframe location, but remained attached to the airplane by its chain handrail.
The left wing was attached to the fuselage. The engine had detached from the firewall and was laying on top of the wing with a pivot point at the outboard intersection of the nacelle and wing leading edge. The propeller remained attached to the engine. The section of the wing outboard of the nacelle exhibited leading edge crushing and deformation. This section was also twisted about the wing spar upward approximately 110 degrees and passed through the vertical plane. The wing tip fuel tank was detached and located 30 feet from the wing tip. The wing tip tank had a softball sized hole in the forward section. Dirt beneath the tip tank hole had a slight gasoline odor. Neither the wing tip tank nor the interior baffle of the tank exhibited any evidence of hydraulic deformation.
The left propeller blades exhibited aft bending and slight chordwise scratches. The spinner was crushed aft without torsional twisting and with folds that paralleled the aft face of the spinner.
The right propeller was located approximately 7 feet from the right wing tip in line with the lateral axis of the airplane. The spinner, hub, and blades were buried about 12 inches into the ground, which formed a cratered area 4 feet across. The blades exhibited chordwise scratching and trailing edge buckling, forming a sinusoidal type bend.
Witnesses reported seeing the airplane flying very low, approximately 500 feet agl, towards Corona airport
MEDICAL AND PATHOLOGICAL INFORMATION
The Riverside County Sheriff-Coroner conducted an...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX03FA147