N592DM – Cessna (Textron Aviation) T310R – 2004-12-08 NTSB Accident Report

HISTORY OF FLIGHT

On December 7, 2004, about 1955 mountain standard time, a Cessna T310R, N592DM, impacted an embankment adjacent to Interstate 17, about 2 miles south of the Flagstaff, Arizona, airport. The airplane had just departed the airport and was in the takeoff initial climb phase. Distribution Management Corporation, Inc., d.b.a. Aero Charter and Transport, Albuquerque, New Mexico, operated the airplane as an on-demand charter flight carrying bank and medical cargo under the provisions of 14 CFR Part 135. The airplane was destroyed. The commercial pilot, the sole occupant, sustained fatal injuries. The cross-country flight departed Grand Canyon National Park, Arizona, airport at 1736, en route to Flagstaff, and the flight was scheduled to continue on to Phoenix. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed and an instrument clearance received for the flight. The wreckage was at 35 degrees 06.480 minutes north latitude and 111 degrees 40.877 minutes west longitude.

The airplane was not equipped for, nor certified to conduct, flight into known icing conditions.

The operator indicated that the airplane had been chartered to haul bank material, and, blood and specimen samples for local hospitals. The operator further stated that the airplane's scheduled route of flight was from Phoenix Sky Harbor International Airport (PHX), to Payson Airport (PAN), Page Municipal Airport (PGA), Grand Canyon, Flagstaff, and Payson with a return to Phoenix. The flight would have departed Phoenix that day about 0700, and was scheduled to terminate back at PHX about 2000. The operator reported that the pilot had called in from Page and reported that Payson was "iced in." The pilot was instructed to fly Grand Canyon and call the company if he was not able to make it into Flagstaff. The company became aware of the airplane accident after the airplane dropped off the company's tracking system shortly after takeoff from Flagstaff.

According to the aircraft log sheet recovered in the wreckage, the pilot departed Phoenix at 0714, arriving at Page at 0856. The flight departed Page at 1646, and arrived at Grand Canyon at 1733. The flight departed Grand Canyon at 1736, and arrived at Flagstaff at 1829.

Recordings of telephone and radio conversations and other records from the Federal Aviation Administration (FAA) were reviewed. At 1540, the pilot contacted the Albuquerque Automated Flight Service Station (AFSS) to file "canned" company flight plans and to receive a weather briefing. Flight plans were filed for flights from Page, Arizona (PGA), to Grand Canyon (GCN); GCN to Flagstaff (FLG); FLG to Payson (PAN); and PAN to Phoenix (PHX). During the weather briefing, the pilot was advised, "across the majority of that route for you this evening, I do have advisories for mountain obscuration and icing, Phoenix is about the only airport uh, not included in the advisories and the icing is forecasted light to moderate from the freezing level up to eighteen thousand feet." The briefer then asked the pilot if he had any "way to deice." The pilot responded, "No," and the controller stated, "You can't go." The pilot said, "I know, technically I can't go," but continued to receive the rest of the brief that included a pilot report for moderate rime ice near Prescott, Arizona.

The pilot again spoke with Albuquerque AFSS between 1836 and 1840, and changed the last leg destination to PHX, in lieu of PAN. The briefer asked the pilot if he was aware of the Airmet for icing and mountain obscuration, to which the pilot answered, "Yeah." The pilot agreed with the briefer that the ceilings at FLG were approximately 300 feet agl. The pilot then stated, "it's disgusting here, don't tell me what the weather is, cause I get scared." He said light snow was falling, and when asked again if he had the Airmet for icing, responded "Oh yeah, it's all over my airplane." Earlier in the conversation, the pilot did state he was "wanting to get a guy to deice my airplane."

The line service person that works for Wiseman Aviation at Flagstaff-Pulliam Airport, deiced the accident airplane prior to departure. He holds FAA airframe and power plant mechanic and private pilot certificates. He had also been with the United States Air Force for 4 years, and the reserves for 1 year. He indicated he had over 5 years experience deicing aircraft from KC-135 aircraft to more recently corporate and smaller civilian aircraft. He indicated that the pilot of the accident airplane requested to have the aircraft deiced at approximately 1855 and upon arriving at the aircraft he noticed that the aircraft had "a considerable amount of ice build up" from landing at the airport. He sprayed approximately 5 gallons of Glycol mix 50/50 to remove the ice and snow that was attached to the leading edges of the wing, spinner, and the snow that had accumulated on the top of the fuselage. The pilot monitored the deicing procedure and when asked if he was satisfied with the deicing procedure indicated that it "looked good." He also indicated that he had completed deicing another aircraft, a Piper Chiefton, which had also made a quick turn and also had landed a considerable time after the accident airplane's arrival. That aircraft also had a considerable amount of ice built-up, compared to the accident airplanes. He used 15 gallons of deicing fluid to deice the Chiefton.

At 1937, the mishap pilot received an IFR clearance from Prescott AFSS.

According to witnesses at the airport, who watched the airplane takeoff, either one or both of the engines were "very rough sounding." After the airplane departed runway 21, it made a shallow left turn, and then disappeared into the clouds. One witness indicated that the airplane rotated approximately 5,000 feet down the nearly 7,000-foot-long runway. About 5 minutes later, phone calls started to come into the airport reporting an airplane crash. At 1943, a person aboard Lifeguard N842DS, a Beechcraft King Air 100, reported to Prescott AFSS the "aircraft that just departed Flagstaff having trouble, I don't hear his engines anymore. He had controllability problems. He had engine problems."

A truck driver was driving on Interstate 17 and witnessed the airplane fly from east- to-west directly across his path and impact a hillside.

Aero Charter's chief pilot reported that they had a truck standing by at Flagstaff to take the pilot's load of cargo to Phoenix in case the pilot could not fly the route for weather or mechanical reasons.

The weather conditions recorded at Flagstaff, at 1944, reported wind from 230 degrees at 9 knots; visibility 1.5 miles with light snow and rain; overcast ceiling at 300 feet; temperature -1 degree Celsius; dew point -2 degrees Celsius; altimeter setting 30.03 inches of mercury (inHg). Weather at 1956 was recorded as wind from 220 degrees at 11 knots; visibility 2 miles with light snow and rain; overcast ceiling at 300 feet; temperature -1 degree Celsius; dew point -2 degrees Celsius; altimeter setting 30.03 inHg. Weather conditions observed at 2010 were wind from 220 degrees at 10 knots; visibility 1.5 miles with light snow and rain; overcast ceilings at 300 feet; temperature -1 degree Celsius; dew point -2 degrees Celsius; altimeter setting 30.03 inHg.

PERSONNEL INFORMATION

A review of FAA airman records revealed the pilot held a commercial pilot certificate with ratings for airplane single and multiengine land and instrument airplane. The pilot also held a mechanic certificate with ratings for airframe and power plant.

A second-class medical certificate was issued to the pilot on January 5, 2004, without limitations or waivers.

An examination was conducted of the pilot's logbook that was found on scene. The last entry was dated September 28, 2004. At that time the pilot reported a total flight time of 1,692.9 hours. For the month of September he logged 27.2 hours.

According to his current employer, Aero Charter and Transport, Albuquerque, New Mexico, the pilot was hired in October 2004. He completed the 14 CFR 135.293, 14CFR 135.297, and 14 CFR 135.299 check rides on October 11, 2004.

A history of the pilot's activities and sleep schedule, and potential for sleep, was constructed from aircraft log sheets, the pilot's hand written journal, and from information obtained during an interview with the accident pilot's widow. All times are converted to the pilot's local time zone, mountain standard time.

On Friday, December 3, 2004, the pilot's duty day began at 0700. He flew two flights, PHX to YUM, and YUM to PHX. He had approximately 9 hours layover between flights. The total flight time was 2.4 hours, and his duty day ended at 2200. He departed Phoenix for California at 2230, by automobile, and arrived at his home the following morning at 0430. Another pilot, the manager of the Phoenix operation for Aero Charter, who also lived in California, accompanied him. He would have had the opportunity for a maximum of 4 hours sleep, and woke up at 0830 on Saturday, December 4, 2004.

On Saturday, December 4, 2004, the pilot framed the deck of his house with a friend, followed by dinner with his wife, and went to bed between 2200 and 2300. On Sunday morning, December 5, 2005, he woke up at approximately 0930. This would have allowed for a maximum period of sleep of about 10 hours.

On Sunday, December 5, 2005, the pilot cleaned the house in preparation for a visit from a potential buyer, and left the house for the return trip to Arizona at 1730. He first picked up the other pilot, and they arrived in Phoenix at 2345. He reported receiving 4 hours sleep that night in a hotel.

On Monday, December 6, 2004, the pilot flew a series of approaches in a Cessna 402 in adverse weather conditions, with snow and slippery runways. One of his intended stops, the Payson airport, was closed due to poor weather conditions. He reported being tired all day, and forgot one of the pickups at Flagstaff. He was discouraged by this, and after several conversations with his wife, went to bed at approximately 2200. A duty start time is not included on the aircraft log for the day of the accident, Tuesday, December 7, 2004. However, 30 minutes between duty start time and aircraft engine start time is usual. The engine start time was 0714, which puts the duty start time at 0645. Allowing 45 minutes for preparation and arrival at PHX, the pilot would have had approximately 8 hours of time available for sleep that night.

On Tuesday, December 7, 2004, the pilot completed three successful flights prior to the accident flight. He departed PHX at 0714 and arrived at PGA at 0859, with a layover of 7 hours 47 minutes. The first flight was originally scheduled for PHX to PAN, although this route was not flown due to icing conditions at PAN. He departed PGA at 1646 and arrived at GCN at 1835, with an immediate turn-around. He departed GCN at 1836 and arrived at FLG at 1932. The accident occurred at 1955, 5 minutes after his departure from FLG.

AIRCRAFT INFORMATION

The airplane was a Cessna T310R, serial number 310R0681. A review of the maintenance records revealed a total airframe time of 5,032 hours at the time of the accident. The aircraft was being maintained on an approved continuous airworthiness inspection program. The most recent inspection, an "Operation 4" was endorsed as completed on November 9, 2004, at a total airframe time of 4,988 hours. The left tachometer read 1,550 at the accident scene, the right tachometer was destroyed and displayed no numbers; the Hobbs hour meter read 2,346.3 at the accident scene.

According to Cessna Aircraft Company, this airplane was not certified for flight into known icing conditions. It was not equipped with wing or tail deice boots.

The airplane was equipped with an inboard left wing locker fuel tank. The fuel tank was placarded with a DO NOT PUT FUEL IN. According to the operator, the fuel tank was not used because they had had problems with it in the past, and had placed the placard on it.

A Teledyne Continental Motors factory remanufacturered TSIO-520-B engine, serial number 176843-R, was installed on the left position on December 4, 2003, and had accumulated a total time since remanufacture of about 700 hours. The most recent inspection, an "Operation 4" was endorsed as completed on November 9, 2004, at a total airframe time of 4,988 hours.

A Teledyne Continental Motors factory remanufacturered TSIO-520-B engine, serial number 176844-R, was installed on the right position on December 4, 2003, and had accumulated a total time since remanufacture of about 700 hours. The most recent inspection, an "Operation 4" was endorsed as completed on November 9, 2004, at a total airframe time of 4,988 hours.

Fueling records at Classic Aviation in Page, Arizona, established that the airplane was last fueled on December 7, 2004, with the addition of 57.3 gallons of 100LL aviation fuel.

The Aero Charter & Transport aircraft log sheet and associated load manifest documents were found in the wreckage. For the Flagstaff to Phoenix leg of the flight, the pilot had computed a gross takeoff weight of 4,950 pounds with a center of gravity of 39.0. The limits were listed as a gross takeoff weight of 5,680 pounds with a center of gravity range between 34.2 and 43.6. While the cargo was not weighed, the appearance of the cargo and aircraft contents during examination of the wreckage did not give investigators reason to question the weights listed by the pilot on the load manifest.

Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure.

METEOROLOGICAL INFORMATION

A staff meteorologist for the Safety Board prepared a factual report, which is included in its entirety in the docket for this accident.

The synoptic or large scale migratory weather systems influencing the area were documented using standard NWS charts issued by the National Center for Environmental Prediction (NCEP) located in Camp Springs, Maryland.

The southwest section of the NWS Surface Analysis Chart for 0300Z on December 8, 2004, depicted a low-pressure system with an associated occluded front off the northwest Pacific coast with a steep pressure gradient. A stationary front was located from British Columbia southeastward across Montana and South Dakota, where two low-pressure systems were located with central pressures of 1004 millibars (mb). Another low pressure system with a central pressure of 1008 mb was located over eastern Colorado, with a trough of low pressure extending from the low in eastern Montana to the low in Colorado, and then southward into New Mexico parallel and to the east of the Rocky Mountains. A ridge of high pressure extended from a high-pressure system off the southern California northeastward across southern California, Arizona, into New Mexico and western Colorado. The accident site was located on the northern side of the ridge of high pressure and on the cold airside of the low-pressure system to the west-northwest over Colorado.

The southwest section of the NWS Weather Depiction Chart for 0100Z depicted the general flight conditions prior to the accident. An area of instrument flight rule (IFR) conditions was depicted by a shaded contour extending over northern Arizona northward into Utah. Surrounding the IFR area was a larger area of marginal visual flight rules (MVFR) conditions indicated by an unshaded contour over most of northern Arizona, Utah, Nevada, and portions of southern California. Visual flight rule (VFR) conditions were depicted over southern Arizona, southeast California, New Mexico, and Colorado. The station model at Flagstaff indicated IFR conditions, with an overcast ceiling at 300 feet above ground level (agl). Further to the south, Phoenix reported VFR conditions with overcast clouds at 4,800 feet.

The southern section of the NWS Radar Summary Chart for 0218Z depicted a band of light-to-moderate intensity echoes extending from northwest to south-central Arizona associated with rain with a small area of intense-to-extreme intensity echoes embedded in the southern section of Arizona. The light-to-moderate echoes were in the vicinity of the accident site, with the stronger intensity echoes in the vicinity of Phoenix. The maximum echo tops identified with the light-to-moderate echoes over northern Arizona ranged from 17,000 to 19,000 feet. No echo tops were identified with the stronger echoes in the vicinity of Phoenix.

The NWS Constant Pressure Charts for 700 mb and 500 mb for 0000Z on December 8, 2004, depicted conditions at approximately 10,000 feet, and the 500-mb chart conditions at approximately 18,000 feet. The constant pressure charts depicted an upper level trough of low pressure extending from Nevada, Southern California, into western Arizona.

The station model on the 700-mb chart for the Flagstaff area depicted a wind from the west at 20 knots, with the station indicating saturated conditions with a temperature of -7 degrees Celsius (C), and a temperature-dew point spread of 1-degree C. Further south near the Phoenix area an aircraft report indicated at 8,000 feet a wind from the west at 10 knots and a temperature of -2 degrees C. On the 500-mb chart the station model for Flagstaff indicated a wind from the west at 40 knots, saturated conditions, a temperature of -18 degrees C, and a temperature-dew point spread of 2 degrees C. Over Phoenix another aircraft report indicated at 17,000 feet a westerly wind at 40 knots, and a temperature of -17 degrees C.

The nearest weather reporting facility to the accident site was from Flagstaff-Pulliam Airport (KFLG), Flagstaff, Arizona, located 4 miles south of the city and less than 2 miles north of the accident site at an elevation of 7,014 feet msl. The airport has an Automated Surface Observation System (ASOS). The Meteorological Aerodrome Reports (METARs) and Specials (SPECIs) in narrative form from the standard code surrounding the period of the accident are included below, with cloud heights are reported agl.

KFLG special weather observation at 0133Z, automated, wind from 220 degrees at 7 knots; visibility 9 miles; ceiling overcast at 300 feet; temperature -1 degree C; dew point temperature -2 degrees C; altimeter 30.01 inHg. Remarks: automated observation system; ceiling 200 variable 700 feet; thunderstorm sensor not operating.

KFLG routine weather observation at 0156Z, automated, wind from 230 degrees at 10 knots; visibility 2 1/2 miles in light snow and mist; ceiling overcast at 300 feet; temperature -1 degree C; dew point temperature -2 degrees C; altimeter 30.03 inHg. Remarks: automated observation system; visibility 1-mile variable 4 miles; snow began at 0148Z; sea level pressure 1016.6-mb; hourly precipitation less than 0.01 inches; temperature -1.1 degree C; dew point -2.2 degrees C; thunderstorm sensor not operating.

KFLG special weather observation at 0204Z, automated, wind from 230 degrees at 8 knots; visibility 1 1/4 miles in mist; ceiling overcast at 100 feet; temperature -1 degree C; dew point temperature -2 degrees C; altimeter 30.03 inHg. Remarks: automated observation system; snow ended at 0200Z; hourly precipitation less than 0.01 inches; thunderstorm sensor not operating.

KFLG special weather observation at 0226Z, automated, wind from 220 degrees at 10 knots; visibility 2 miles in light snow and mist; ceiling overcast at 300 feet; temperature and dew point temperature -2 degrees C; altimeter 30.03 inHg. Remarks: automated observation system; hourly precipitation less than 0.01 inches; thunderstorm sensor not operating.

KFLG special weather observation at 0244Z, automated, wind from 230 degrees at 9 knots; visibility 1 1/2 miles in light snow and mist; ceiling overcast at 300 feet; temperature -1 degree C; dew point temperature -2 degrees C; altimeter 30.03 inHg. Remarks: automated observation system; ceiling 200 variable 700 feet; hourly precipitation less than 0.01 inches; thunderstorm sensor not operating.

KFLG routine weather observation at 0256Z, automated, wind from 220 degrees at 11 knots; visibility 2 miles in light snow and mist; ceiling overcast at 300 feet; temperature -1 degree C; dew point temperature -2 degrees C; altimeter 30.03 inHg. Remarks: automated observation system; sea level pressure 1016.5-mb; hourly precipitation less than 0.01 inches; 3-hour precipitation less than 0.01 inches; temperature -1.1 degrees C; dew point -1.7 degrees C; 3-hour pressure tendency fallen 0.3-mb; thunderstorm sensor not operating.

KFLG special weather observation at 0310Z, automated, wind from 220 degrees at 10 knots; visibility 1 1/2 miles in light snow and mist; ceiling overcast at 300 feet; temperature -1 degree C; dew point temperature -2 degrees C; altimeter 30.03 inHg. Remarks: automated observation system; hourly precipitation less than 0.01 inches; thunderstorm sensor not operating.

IFR conditions and light snow were reported at Flagstaff from 1327Z on December 7 through 1649Z on December 8, 2004, with only a few periods of MVFR conditions and/or breaks in the light snow. The ASOS system does not report snow accumulation or depth.

The closest upper air sounding or rawinsonde observation (RAOB) was from the NWS Flagstaff (KFGZ), site number 72376, located approximately 9 miles west-northwest of the accident site at an elevation of 7,149 feet msl. The 0000Z sounding on December 8, 2004, from KFGZ, had the Lifted Condensation Level (LCL) at the surface and Convective Condensation Level (CCL) at 724-mb or 1,959 feet agl. The surface temperature was -1.7 degrees C with the temperature remaining below freezing through the depth of the sounding, even through a low-level temperature inversion located above 700-mb to 781-mb or from 3,100 to 3,728 feet agl (10,250 to 10,877 feet msl). The sounding had a relative humidity greater than 75 percent from the surface to the top of this inversion, and then between 12,500 to approximately 20,000 feet msl. The sounding was characterized as stable with a Lifted Index of 8.1.

The wind profile indicated surface wind from the southwest at 5 knots with wind speeds increasing to 25 knots within 3,000 feet of the surface with little directional variation. The maximum wind was located 35,000 feet with winds from 245 degrees at 88 knots. At 10,000 feet msl, the wind was identified from 250 degrees at 22 knots, with a temperature of -7 degrees C.

Based on the temperature and moisture profiles, the sounding indicated a probability of icing from the surface to approximately 18,000 feet. The RAOB analysis program indicated a 95 percent probability of moderate intensity clear to mixed icing between 9,000 and 10,800 feet, where the relative humidity was greater than 93 percent. In this layer the liquid water content (LWC) was between 0.516 to 0.670, and indicated significant super-cooled liquid droplet (SLD) potential. Above 10,800 feet the relative humidity decreased with a shallow dry layer and an inversion.

The Geostationary Operations Environmental Satellite number 10 (GOES-10) data was obtained from the National Climatic Data Center (NCDC), and the satellite imagery surrounding the time of the accident from 0200Z to 0300Z, at 15-minute intervals, were reviewed. The images depict a synoptic scale comma cloud system with an "S" shape situated over Arizona with the high clouds highlighted by various shades immediately bordering the accident site and KFLG to the east. Low- to mid-level cloud cover extend over the accident site with a radiative cloud top temperature of 245.40 degrees Kelvin or -27.76 degrees C, which corresponded to cloud tops near 22,000 feet based on the KFGZ sounding. The higher clouds east and northeast of the accident site indicated cloud tops near 30,500 feet.

The closest NWS Weather Surveillance Radar-1988, Doppler (WSR-88D) radar was located at Flagstaff (KFSX), with the antenna located 40 miles to the southeast of the accident site at an azimuth of 144 degrees. The archive level II data was obtained from the NCDC and displayed on the Safety Board's McIDAS system utilizing the motif-iras software. The accident site is located at the center of the grid. The image depicted an area of echoes less than 20 dBZ or VIP Level 1 "very light" intensity extending immediately east and north of the accident site, with the route of flight from the airport to the accident site clear of any echoes.

Several pilot reports (PIREPs) were recorded over northern Arizona surrounding the time of the accident. The reports are in standard format but in narrative form versus standard code and abbreviations. The reports are as follows:

Prescott (PRC) routine pilot report (UA); Over - 7 miles northeast of Prescott VOR (DRK); Time - 2203Z; Flight level - 8,000 feet; Type aircraft - Piper Cherokee single engine airplane (PA28A); Sky cover - broken clouds at 7,000 feet; Icing - moderate rime icing; Remarks - 1/8 to 1/4 accumulation.

Prescott (PRC) routine pilot report (UA); Over - 3 miles east of Prescott VOR (DRK); Time - 2241Z; Flight level - 9,800 feet; Type aircraft - Cessna Skylane single engine airplane (C182); Icing - moderate rime icing.

Flagstaff (FLG) routine pilot report (UA); Over - FLG; Time - 2300Z; Flight level - 8,000 feet; Type aircraft - Cessna Skyhawk single engine airplane (C172); Icing - moderate rime icing; Remarks - encountered icing between 8,000 and 10,500 feet.

Grand Canyon (GCN) routine pilot report (UA); Over - GCN; Time - 2315Z; Flight level - 10,000 feet; Type aircraft - DeHavilland Twin Otter multiengine turboprop (DHC6); Icing - light mixed icing; Remarks - from Los Angles Center Weather Service Unit (CWSU).

Winslow (INW) routine pilot report (UA); Over - route between Cortez (CEZ) to Winslow (INW) to 30 miles southeast of INW, Time - 0000Z; Flight level - VFR; Type aircraft - Cessna Skyhawk single engine airplane (C172); Remark - unable VFR to Phoenix (PHX) diverted to Holbrook (P14).

The Area Forecast (FA) valid for this accident was issued at 2049Z on December 7, 2004, and was valid until 0900Z on December 8, 2004. The header warned users to see AIRMET Sierra for IFR conditions and mountain obscuration information.

The forecast for northern Arizona was for ceilings broken to overcast at 8,000 feet msl with tops to 20,000 feet with scattered light rain showers or light snow showers. The outlook from 0900Z to 1500Z for northern and central Arizona was for MVFR conditions to prevail, elsewhere VFR conditions to prevail.

The NWS had a series of AIRMETs current for portions of Arizona. AIRMET Zulu update 5 was issued at 2051Z for icing conditions and was valid until 0300Z. The advisory covered portions of Wyoming, Nevada, Utah, Colorado, and Arizona. The advisory warned of occasional moderate rime to mixed icing-in-clouds and in-precipitation below 18,000 feet. The conditions were expected to move south-southeast and continue beyond 0300Z through 0900Z. The accident site was located within the boundaries of this advisory.

AIRMET Sierra update 4 for IFR conditions and mountain obscuration conditions was issued at 2045Z and was valid until 0300Z. The advisory covered portions of Idaho, Montana, Wyoming, Nevada, Utah, Colorado, Arizona, Washington, Oregon, and California. The advisory warned that mountains were occasional obscured by clouds, precipitation, and mist. Conditions were expected to slowly improve over southern and central California and continue elsewhere beyond 0300Z through 0900Z. The accident site was located within the boundaries of this advisory.

AIRMET Tango did not expect any significant turbulence outside of convective activity over Arizona.

Immediately prior to the accident, at 0245Z, the AIRMETs Sierra series was updated and valid until 0900Z on December8, 2004. AIRMET Sierra for IFR conditions and mountain obscurations over portions of Wyoming, Utah, and Arizona. The advisory warned of occasional ceiling below 1,000 feet and/or visibilities below 3 miles in clouds, precipitation, mist, or fog. The conditions were expected to continue beyond 0900Z through 1500Z. The accident site was located within the boundaries of this advisory.

AIRMET Sierra for mountain obscuration over portions Idaho, Montana, Wyoming, Nevada, Utah, Colorado, Arizona, Washington, Oregon, and California. The advisory warned of mountains occasionally obscured by clouds, precipitation, mist, and fog. The conditions were expected to continue beyond 0900Z through 1500Z. The accident site was also located within the boundaries of this advisory.

There were no Convective SIGMETs, Severe Weather Forecast Alerts, SIGMETs, or Center Weather Advisories issued for Arizona on December 7 and 8, 2004.

The Albuquerque (ZAB) Center Weather Service Unit (CWSU) issued no Center Weather Advisories for any hazardous conditions surrounding the period. After the accident at 0430Z, the ZAB CWSU issued a Meteorological Impact Statements (MIS) number 1, which was valid from 0431Z to 1600Z. The advisory warned of occasional mountain obscuration and IFR conditions over northern Arizona, with occasional moderate rime to mixed icing between the freezing level and 18,000 feet over Arizona and western New Mexico. The advisory advised users to see the latest NWS AIRMETs and advised that there would be no further updates until after 1330Z.

The forecast issued by the NWS for Flagstaff was issued at 2330Z, and valid from 0000Z through 2400Z on December 8, 2004. Beginning at 0000Z, wind from 240 degrees at 8 knots; visibility better than 6 miles with showers in the vicinity, scattered clouds at 800 feet agl, ceiling overcast at 1,400 feet, with temporary conditions from 0000Z to 0200Z of visibility 1-mile in light snow showers and mist, ceiling broken at 600 feet. From 0200Z, wind from 240 degrees at 6 knots; visibility 3 miles in light snow, a few clouds at 900 feet, ceiling broken at 1,500 feet, overcast at 3,000 feet, with a temporary condition between 0200Z and 0600Z of visibility 1/4-mile in heavy snow and freezing fog, ceiling broken at 700 feet. From 0600Z, wind variable at 5 knots; visibility 4 miles in light snow and mist, a few clouds at 500 feet, ceiling broken at 1,000 feet, overcast at 2,000 feet, with a temporary condition between 0600Z and 1000Z of visibility 1/2-mile immoderate snow and freezing fog, ceiling broken at 500 feet. From 1000Z, wind variable at 3 knots; visibility 4 miles in light snow showers, ceiling broken at 1,500 feet, with temporary conditions between 1000Z and 1400Z of visibility 1-mile in light snow showers, and ceiling broken at 800 feet. From 1400Z, wind variable at 5 knots; visibility better than 6 miles, ceiling broken at 1,500 feet. From 1800Z, wind from 230 degrees at 7 knots; visibility better than 6 miles, scattered clouds at 2,000 feet.

The forecast was amended at 0210Z. The KFLG forecast from 0200Z was for wind from 240 degrees at 8 knots; with visibility better than 6 miles with showers in the vicinity, scattered clouds at 300 feet, ceiling overcast at 900 feet, with a temporary conditions between 0200Z and 0600Z of visibility 1-mile in light snow showers and mist, ceiling overcast at 100 feet.

The NWS Current Icing Product (CIP) images for the period were recreated on the Safety Board's McIDAS system. The products valid at 0300Z on December 8, 2004, for 10,000 feet (the lowest available over the region) and 11,000 feet are included as figures 12 and 13, respectively. The images depict a band of icing conditions across extreme southern California, central and southern Arizona, into western New Mexico, with a maximum near Phoenix (KPHX) and to the west of Truth or Consequences (KTCS), New Mexico. The icing conditions were depicted over the accident site (KFGZ sounding site 72376).

The U.S. Naval Observatory located in Washington D.C. provided the following astronomical conditions for Flagstaff on December 7, 2004.

Sunset: 0014Z (1714 MST)

End of civil twilight: 0042Z (1742 MST)

Elevation of Sun: more than 15 degrees below the horizon

Elevation of Moon: more than 15 degrees below the horizon

Moonrise: 0924Z (0224 MST December 8, 2004)

Phase of Moon: waning crescent with 23 percent of the disk illuminated

AIRPORT INFORMATION

The Airport/ Facility Directory, Southwest U. S., indicated runway 21 at the Flagstaff airport was 6,999 feet long and 150 feet wide. The runway surface was composed of asphalt.

WRECKAGE AND IMPACT INFORMATION

Investigators from the Safety Board, the FAA, and Cessna, who was a party to the investigation, examined the wreckage at the accident scene.

The airplane struck an east-facing embankment that forms part of the highway about 50 feet from Interstate 17. The airplane came to rest upright on the flat part of the embankment at an elevation of 6,798 feet (about 200 feet lower than the airport's elevation). The airplane was 1.95 miles south of FLG. The embankment, on a 50-degree slope, was identified as the first point of impact (FIPC). The FIPC contained an imprint of both engines and the fuselage about halfway up the embankment. The geometry and dimensions of the imprint were observed to be consistent with the airplane in a wings level attitude. A propeller blade from the right engine was found in the crater relative to the right engine. The pitot static tube was found at the FIPC relative to the fuselage imprint. The debris path was along a magnetic bearing of 262 degrees. From the FIPC to the main wreckage was 91 feet. The main wreckage was on a magnetic heading of 270 degrees. An oxygen bottle was located 170 feet from the FIPC. About 6 inches of snow covered the ground. The emergency locator transmitter (ELT) was found in the ARMED position and turned to the OFF position by the Safety Board investigator-in-charge.

Recovery personnel retrieved about 1-gallon of fuel from the right auxiliary tank.

A portion of the red light lens from the left wing tip was found in the crater that was relative to the left engine. A potion of the nose landing gear linkage was found in the center crater relative to the fuselage. The pilot's seat had separated from the rails and was found forward of the main wreckage. The pilot had been ejected from the airplane and was found 30 yards forward of the main wreckage.

The top of the cabin separated from the cockpit and came to rest next to the main wreckage propped against a tree. The right wing had collided with a tree, and the right wing tip separated. A portion of the right wing folded over and came to rest on top of the left wing. The right engine separated from the right wing and remained in its normal relative position. The left wing remained attached at the carry through wing spar, and the left engine remained attached to the left wing. The empennage came to rest propped up against a tree; however, it was deformed and twisted. The leading edges of the elevators were partially crushed aft. About 2/3 of the left elevator separated from its attach point and was found in the main wreckage. The right elevator remained attached. The vertical stabilizer was relatively undamaged except near the top where deformation was noted.

The propeller blades for the right engine had separated from the hub. One propeller blade was located at the FIPC. The other two were located along the debris path. The tip of one blade had separated and was not recovered. A search of the area was conducted. The blade tip separation was angular and granular in nature. All of the blades showed extensive chordwise scratching, S-bending the full length of the blades, and heavy leading and trailing edge gouging.

The propeller blades for the left engine remained attached to the hub. However, the propeller assembly separated from the engine at the crankshaft flange. The propeller assembly was located about 10-feet away from the main wreckage in an upright position with two of the three blades stuck in the ground. Two of the twelve crankshaft flange bolts remained attached; however one had a portion of it sheared off with angular marks present. The other 12 had been sheared off. Four the retaining holes were deformed and oval in shape. The aft portion of the flange was gouged. All three blades had extensive chordwise scratching, S-bending the full length of the blades, and heavy leading and trailing edge gouging.

No deice or anti-ice equipment was observed on the aircraft's aerodynamic surfaces. The leading edges were painted black in the area deice boots would normally occupy.

All flight controls were found at the wreckage site. All flaps except the left outboard flap were retracted. The ailerons and portions of the elevators had separated. Control continuity was not established. Aileron cable connections were verified at the three aileron bellcranks and control column chains. The rudder cables were attached at the surface and the rudder tubes. The elevator cables were attached at the forward and aft bellcranks. The aft bellcrank was found separated from its assembly. The wings were part of the main wreckage and came to rest upright between two trees. The left wing was fractured along its chord at the outboard edge of the outboard flap. The outboard wing section, including the main tank hoop, was folded up onto the left engine nacelle and cabin. The structure forward of the aft spar was destroyed by impact on the section of wing between the aforementioned separation and the nacelle. The main tank skins and fairing were found at the top of the hill above the initial impact site. The aileron was located adjacent the main wreckage. The wing exhibited some fire damage.

The right wing also remained attached to the fuselage. A section of the right wing, including the main tank, came to rest against a tree and was partially burned. The aileron was not attached to the wing, but was found along the wreckage path.

The empennage did not exhibit any fire damage and remained attached to the main wreckage by control cables. No damage was noted on the vertical fin. The rudder was attached to it and the trim tab was in an over-travel condition to the left. The top of the rudder, including the counterweight, appeared to be crushed downward and bent to the right.

The horizontal stabilizer remained attached the aft fuselage. The left side of the stabilizer exhibited the most damage with wrinkled skins and a leading edge tapering crush and 45-degree fold in the skin at the tip. The 45-degree fold extended inboard and forward from the aft end of the outboard closeout rib. About 2/3 of the left elevator had separated from the inboard section and the horizontal stabilizer.

Five fuel caps were identified in their ports. All the gaskets had some cracking, but remained pliable. The main and aux fuel tanks were breached.

MEDICAL AND PATHOLOGICAL INFORMATION

The Coconino County Sheriff-Coroner completed an autopsy on the pilot. The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens from the pilot. The results of analysis of the specimens were negative for carbon monoxide, cyanide, volatiles, and tested drugs.

TESTS AND RESEARCH

The airframe and engines were examined in detail at at Air Transport, Phoenix, Arizona, on December 11, 2004, following recovery of the wreckage from the accident site. A manufacturer's representative from Teledyne Continental Motors was a party member to the investigation.

Airframe

The fuel selector valves are in the wings and are actuated by cables that are driven by the cockpit selector handles. The cockpit fuel selector handles were not in operating positions and were found in positions inconsistent with the actual valves in the wings; the left control was in the 7 o'clock position near the OFF position, while the right one was at 11 o'clock near the left auxiliary tank. The actuating arms on the valves were found with the left in the OFF position and the right hyper extended beyond off.

The manufacturer's representative determined the landing gear actuators were in the up position, which corresponded to the cockpit landing gear control. The representative measured the left flap actuator and found that it corresponded to the full up, while the left one was destroyed. The elevator trim actuator measured 1.0-inch of extension, which corresponds to a tab down deflection of 17 degrees. The rudder trim tab actuator measured 0.7-inches of extension, which the representative said equated to 15 degrees of left tab deflection.

Engines

Left Engine

The left engine, a TSIO-520-B engine, serial number 176843-R, was visually examined. The fuel pump, oil filter, both magnetos, starter, vacuum pump, turbocharger, and alternator were broken off. The propeller governor sustained impact damage and the control arm was destroyed. The top spark plugs were RHB32E's and all six exhibited a light gray color, heavily eroded electrodes, and wide gapping. All spark plugs were clean with no mechanical deformation. The spark plug electrode coloration corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. Crankshaft rotation established mechanical continuity throughout the engine and compression in each cylinder. Both magnetos were rotated by hand and each produced strong sparks at each electrode. The turbocharger compressor exhibited smearing and broken blades that were bent opposite the direction of normal rotation.

Right Engine

The right engine, a TSIO-520-B engine, serial number 176844-R, was visually examined. Both magnetos, the starter, vacuum pump, turbocharger, and alternator were broken off. The No. 6 cylinder head sustained impact damage. The fuel pump contained fuel; the drive coupling was intact and the shaft turned freely by hand. The top spark plugs were of the fine wire type with a near new appearance. All six spark plugs exhibited a light gray color, were clean with no mechanical deformation, and the spark plug electrode coloration corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. Crankshaft rotation established mechanical continuity throughout the engine and compression in cylinders 1 through 5. No compression was developed in cylinder No. 6 due to the impact damage breeching the head. The No. 6 cylinder piston was visually examined and found to be intact, and moved normally with crankshaft rotation. Both magnetos were rotated by hand and each produced strong sparks at each electrode. The turbocharger compressor exhibited smearing and broken blades that were bent opposite the direction of normal rotation.

ADDITIONAL INFORMATION

The IIC released the wreckage to the owner's representative.