N7581F

HISTORY OF FLIGHTOn June 03, 2022, about 1347 Pacific daylight time, a Cessna 208B, modified as a Supervan Systems. LLC 900 airplane, N7581F, was substantially damaged when it was involved in an accident near Bob Maxwell Memorial Airfield, Oceanside, California. The left-seated pilot was fatally injured and the right-seated pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 skydiving flight.

On the day of the accident, the pilots were performing skydiving flights while the right-seated pilot was training the left-seated pilot on the operation. A flight consisted of two pilots taking a group of approximately 17 skydivers to an altitude of about 11,500 feet mean sea level (msl) to jump out and then returning to the airport. The flights started about 1015 and were airborne for an average of 17 minutes, with about 15 minutes on the ground between flights, during which the airplane’s engine was kept operating while a new load of skydivers boarded the airplane. The pilots completed six flights without incident and departed on the accident flight at 1331.

The right-seated pilot stated that he could not recall many of the details leading up to the accident. He remembered that, on the accident flight, everything was normal with the departure and the unloading of the skydivers. The airplane was descending as expected with the power at idle. As the airplane turned onto final approach, about 2-3 miles from the approach end of runway 25, the left-seated pilot either had her hand on the throttle or began to reach up to the throttle. The right-seated pilot thought the airplane was low and attempted to increase the power by taking the controls and slightly nudging the throttle forward. He noticed that the engine power did not appear to change in response to the movement of the lever and he moved the throttle lever further forward. The lever was still unresponsive, and he estimated the airplane was about 400 ft above ground level (agl). He aimed for an open dirt field and observed a berm in the immediate flight path. In an effort to avoid the berm, the pilot maneuvered the airplane into a right turn.

Investigators reviewed the automatic dependent surveillance – broadcast (ADS-B) flight track data covering the area of the accident during the time surrounding the accident. After departing from runway 25, the airplane made a gradual climb to 11,575 ft msl as it circled to the right, back to the airport. The airspeed was reduced to about 80 KCAS (presumably to unload the skydivers) and then the airplane made a steep, turning descent reaching 130 KTAS (110 KCAS) when transitioning to the downwind leg of the traffic pattern. The airplane was at an altitude of about 2,400 ft msl and 2.5 nautical miles (nm) from the approach end of runway 25 when it turned onto final approach. When the airplane was about 2 nm from the runway, it made a 360° right-turn which was about 0.5 nm in diameter (see Figure 1 below).

Figure 1: Accident Flight Path

At 1346:10, about 1,025 ft msl, the airplane rolled out of the 360° turn and continued west toward the runway. For the remainder of the flight (one minute), the airplane was roughly following Highway 76 making a gradual descent toward the runway (see Figure 2 below).

Figure 2: Flight Path on Final Approach

The last recorded ADS-B point was at 1347:10 about 975 feet east of the accident site. At that time, the data indicated that the airplane was at 230 msl (190 feet above ground level) at a ground speed of 68 kts (76 KCAS). Witnesses stated that they observed the airplane flying at a very low altitude (see Figure 3). The airplane then pitched down in a nose-low attitude and banked to the right. The airplane impacted terrain and collided with the side of a berm. A security camera captured the airplane seconds before impact (see Figure 3 below).

Figure 3: Video Footage Showing the Airplane Before Impact PERSONNEL INFORMATIONThe right-seated pilot was employed by Desert Sand Aircraft Leasing Co. Inc., the airplane owner, and had been a pilot for the company for over 20 years. He was training the left-seated pilot how to fly the airplane and learn the operations. He stated she started about two weeks before the flight and estimated she would have needed about two more weeks before she would have been proficient to the company standards. He stated that she was doing very well and that he was comfortable with her piloting abilities.

The left-seated pilot was undergoing training; she had six days of experience flying a modified Cessna 208, equating to 25.8 hours. All the pilot’s known flight time in a Cessna 208B was accumulated in a 208B equipped with a TPE331 engine. This was her third day in the left seat. All her training in the airplane was conducted by the right-seated pilot. She had numerous photos of the airplane systems (including the throttle quadrant) on her phone and notes about the operation of the airplane. According to the pilot’s iPhone application, she was listening to music in her Bose A20 Aviation headset at about 79 decibels during the accident flight. The headset is designed such that the primary source of audio is from the airplane’s intercom and the secondary source of audio is the device connected (in this case, the iPhone). Only one source can be heard at a time and the audio from the secondary source will never override intercom communications. AIRCRAFT INFORMATIONThe airplane was modified in 2012 by the Supervan Systems, Ltd. (Texas Turbines) with a TPE331 engine and 4-blade aluminum propeller installation via Supplemental Type Certificate (STC) SA10841SC.

The airplane’s engine is managed by the pilot through the power lever and speed lever located in the cockpit center console. The engine power lever (black) connects to the propeller pitch control and the manual fuel valve. The engine speed lever (blue) connects to the propeller governor and to the underspeed fuel governor (USFG). AIRPORT INFORMATIONThe airplane was modified in 2012 by the Supervan Systems, Ltd. (Texas Turbines) with a TPE331 engine and 4-blade aluminum propeller installation via Supplemental Type Certificate (STC) SA10841SC.

The airplane’s engine is managed by the pilot through the power lever and speed lever located in the cockpit center console. The engine power lever (black) connects to the propeller pitch control and the manual fuel valve. The engine speed lever (blue) connects to the propeller governor and to the underspeed fuel governor (USFG). WRECKAGE AND IMPACT INFORMATIONThe accident site was located about 1,615 feet east of the approach end of runway 25 on flat terrain composed of soft, dry dirt. The wreckage was found distributed over an approximate 125-foot distance with the nose pointed on a heading of about 335°. The right wing was partially separated from the fuselage root and had folded forward and over upon itself, coming to rest inverted. The first identified piece of debris was a fragment of the right wingtip light lens, consistent with the right wingtip contacting the ground at the beginning of the accident sequence.

All flight control surfaces were at the main wreckage and attached at their respective fittings. The left flap was found in the retracted position, and damage at the inboard end of the right flap was consistent with it being retracted at the time of impact. Investigators established flight control continuity during the postaccident examinations. The left side of the center pedestal was crushed and a majority of the fuselage deformation was near the left pilot seat.

The engine teardown revealed that several compressor blade tips were curled in the opposite direction of rotation and there was metal splatter on the turbine discs and stators, all of which is consistent with the engine rotating and operating at the time of impact. There was no evidence of mechanical malfunctions or failures that would have precluded normal operation.

There was about 50 gallons of fluid, consistent in appearance and odor with Jet A fuel, recovered from the right wing; no fluid was recovered from the left wing, but the fuel line had separated from the connection into the fuselage, allowing fuel to drain from the left wing tank. The fuel system remained unbreached from the header tank to the engine’s fuel nozzles. Fluid was found in the header tank, in the airframe fuel filter, and in several fuel lines before and after the fuel control unit.

Seat Belts

The right-seated pilot stated that he was wearing a lap-belt, but not the shoulder harness; he could not recall if the left-seated pilot wore a seat belt. He stated that he normally does not wear a shoulder harness because he gets too hot and the belts cut into his neck. He thought that because the headrest was removed on the right seat, it was not really possible to use the shoulder harness on that side. The left seat remained in its tracks and did not show evidence of crush deformation. The left-seat belts were intact and investigators found them unbuckled; it could not be determined whether the seat belts were unbuckled during the flight or whether they were buckled and the first responders unbuckled them in order to extricate the pilot from the wreckage. The buckles functioned as expected when locked in place and then released via the release mechanism. The lap belt portion exhibited signs of stretching. The right-seat lap belt was cut in several areas consistent with post-accident first responder actions; there was no evidence of stretch. The right seat had been removed as part of the first responder efforts. MEDICAL AND PATHOLOGICAL INFORMATIONToxicology testing performed by the Federal Aviation Administration Forensic Sciences Laboratory detected ketamine in the left-seated pilot’s cavity blood and in her liver tissue consistent with it being administered post-accident for resuscitation purposes.

Body camera video footage and first responder’s reports indicate that...