N642BD

HISTORY OF FLIGHT

On November 14, 2006, about 1013 Pacific daylight time, a Cessna 421B, N642BD, collided with terrain near Big Bear Lake, California. The owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The airline transport certified pilot and two passengers were killed; the airplane was destroyed. The cross-country personal flight departed Big Bear Municipal Airport about 1000, with a planned destination of Las Vegas, Nevada. Visual meteorological conditions prevailed, and no flight plan had been filed.

A friend indicated that this was to be the first flight together for the owner and his new pilot. The airplane had recently been relocated to its new home base at Apple Valley, California. The pilot flew from Apple Valley to Big Bear to pickup the owner and a friend for an overnight trip to Las Vegas. The friend said that the pilot landed at 0920. He observed the airplane as it landed and taxied to the ramp; he noted no anomalies. He talked briefly with the pilot, and the pilot did not indicate that he encountered any difficulties with the airplane on the flight. The friend left prior to the airplane's departure.

A mechanic witness stated that the airplane departed runway 26. He was familiar with the airplane, and watched it take off. The airplane rotated about 3,000 feet from the departure end of the runway, and the flaps appeared to be up. He noted nothing unusual until the airplane rotated. Just after liftoff, he said that the sound of one engine changed. It didn't sound "right," but it didn't backfire. The airplane had a positive rate of climb, but then immediately yawed extremely to the left. It veered to the left, which is a standard maneuver at Big Bear to avoid overflying a school. As the airplane approached a causeway that was just west of the end of the runway, the mechanic became concerned that it might not clear 30-foot-high power lines that were perpendicular to the flight path. The airplane was still yawed to the left. The landing gear was still down, and remained down as long as the mechanic could observe the airplane. It was about 2 miles from the runway when he noted dark smoke coming from the left engine, and the smoke increased significantly as the flight continued. The airplane got far enough away that he could barely see it, but he could still follow the smoke trail. The airplane began a right turn by Windy Point. He temporarily lost sight of it behind another point of land as it continued the right turn. When he acquired it again, he could see it in a platform view. Seconds after it disappeared behind trees, he observed an explosion.

Witnesses further down the lake observed the airplane. They saw puffs of smoke coming from an engine, and the airplane appeared to be banked about 30 degrees to the right. A couple of witnesses estimated that the altitude was no more than 175 feet above ground level (agl). Some reported that the wings were rocking; others thought that the tail of the plane was wagging left and right. One thought that the landing gear was down; another thought that the gear was up. The airplane drifted toward the north side of the lake, and then made a hard left turn with the wings perpendicular to the ground. The roll continued until the nose went straight down; one witness said that the airplane hit the water and the shoreline at the same time.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed that the 52-year-old pilot held an airline transport pilot certificate with a rating for airplane multiengine land and a commercial pilot certificate with a rating for airplane single-engine land. The pilot held a certified flight instructor (CFI) certificate with ratings for airplane single-engine land, multiengine land, instrument airplane, and basic ground.

The pilot held a second-class medical certificate issued on January 24, 2005. It had the limitations that the pilot must wear corrective lenses and possess glasses for near and interim vision.

No personal flight records were located for the pilot. The IIC obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. The pilot reported on his medical application that he had a total time of 4,700 hours.

AIRCRAFT INFORMATION

The airplane was a Cessna 421B, serial number 421B0658. It is believed that the logbooks were in the airplane, and burned. A review of maintenance work orders indicated that the total airframe time was 4,556.2 hours at the last annual inspection on May 25, 2006. The hour meter read 1,112.4 hours at the last inspection.

The left engine was a Teledyne Continental Motors GTSIO-520H, serial number 600468. Total time recorded on the engine at the last inspection was 2,545 hours, and time since major overhaul was 744 hours.

The right engine was a Teledyne Continental Motors GTSIO-520H, serial number 600340. Total time recorded on the engine at the last inspection was 2,553 hours, and time since major overhaul was 744 hours.

AIRPORT INFORMATION

The Airport/ Facility Directory, Southwest U. S., indicated that Big Bear City Airport had an Automated Weather Observation System (AWOS)-3, which broadcast on frequency 132.925. The Big Bear City runway 26 was 5,850 feet long and 75 feet wide. The runway surface was asphalt.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest on the shoreline, which was about a 4-foot rocky slope that angled up from the water an estimated 20 degrees. The right wing outboard of the nacelle and the right propeller were in the water. The nose was on the rocky shoreline; the fuselage and left wing were on the shore. The fuselage was upright and oriented 240 degrees. The empennage partially separated, and the leading edges of the horizontal and vertical stabilizers were pointing toward the ground. The right engine was nose down 90 degrees to the wing with the propeller flange in the water. Both propellers separated; the left propeller was in the rocks on the shoreline. Its hub shattered and liberated all three blades.

Fire consumed the left aileron, the cabin interior, part of the rudder, and part of the vertical stabilizer.

MEDICAL AND PATHOLOGICAL INFORMATION

The San Bernardino County Coroner completed an autopsy. The FAA Forensic Toxicology Research Team, Oklahoma City, performed toxicological testing of specimens of the pilot.

Analysis of the specimens contained no findings for carbon monoxide, volatiles, and tested drugs.

The report contained the following finding: 1.3 (ug/ml) cyanide detected in blood.

TESTS AND RESEARCH

On Scene Examination

During the wreckage examination, investigators removed the top spark plugs from the right engine. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.

Investigators removed the top spark plugs from the left engine. All spark plugs had no mechanical deformation. All of the spark plugs were black and sooty.

The left turbo compressor partially turned, but the turbine was loose and rocked when manually manipulated.

Follow-up Examination

Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on December 14, 2007.

Airframe

Investigators established control continuity from the control surfaces to the deformed cockpit area. The landing gear were down; the landing gear actuators were in the extended position. The left and right flaps were in the up positions; the controls and indicators were destroyed. The fuel selector valves were cable operated; mechanical distortion to the wings and fuselage prevented determination of the valves positions.

Factory Examination of Engines and Turbochargers

TCM personnel examined the engines under the supervision of the IIC at the factory in Mobile, Alabama, on January 29 and 30, 2007. TCM submitted a written report, and the IIC concurred with the facts in the report. Kelly Aerospace personnel examined the turbochargers under the supervision of the IIC at the TCM factory on January 29, 2007. Kelly Aerospace prepared a written report, and the IIC concurred with the facts in the report.

Left engine

TCM personnel cut away the exhaust assembly in four places to facilitate removal. The risers had sooty black deposits. The induction manifold intercooler attachment flange had impact damage. The induction risers were undamaged. The crankshaft to camshaft timing was verified by the alignment of the gear's timing marks. TCM personnel installed the magnetos onto a test bench, and both magnetos produced spark at all posts through a full range of revolutions per minute (rpm).

The oil filter housing was breached, and the oil filter adapter exhibited thermal damage. TCM personnel cut the oil filter housing open, and cut the filter element from the canister. They examined the oil filter element, and noted that it contained flakes and slivers from what appeared to be from the number four crankshaft main bearing. They noted no anomalies within the oil pump. The oil sump was crushed and breached. The oil pick-up tube was crushed. The oil suction screen was unrestricted.

The fuel pump sustained thermal and mechanical damage. The fuel manifold cover was sheared from the body leaving three of the retaining screws fractured at the body mating surface. The plunger assembly was fractured in two at the inlet ports. The lower portion of the plunger with the needle valve, spring, and spacer remained in the manifold body. The diaphragm spring was intact and undamaged. The upper portion of the plunger assembly (including the diaphragm) exhibited mechanical damage. The fuel nozzles were unrestricted, and exhibited normal operating signatures. They noted that a mixture of "B" and "C" nozzles was installed, b...