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On September 26, 1998, at 0830 hours Pacific daylight time, a Beech 95-B55 airplane, N554MB, collided with mountainous terrain following the loss of engine power approximately 10 miles northwest of Hawthorne, Nevada. The aircraft, owned and operated by High Performance Aircraft, Incorporated, was destroyed in the collision sequence and post crash fire. The pilot, the sole occupant, sustained fatal injuries. The personal flight originated at Red Bluff Municipal Airport, Red Bluff, California, at an unknown time.
According to family members, the pilot told his wife that he was going to leave Red Bluff approximately 0530-0600 to depart for St. George, Utah. He was going to St. George to run in a marathon race.
According to records from the Rancho Murietta AFSS, the pilot called the flight service station at 0635 and obtained a full weather briefing. He told the briefer that he planned to fly visual flight rules (VFR) from Red Bluff to Sacramento to Reno at 11,500 feet, with a planned departure time of 0730. The briefer told the pilot that VFR flight was not recommended. The pilot asked about flying from Red Bluff south to the Fresno/Bakersfield area, then eastward across the Sierra Nevada Mountains to St. George, Utah. The briefer told the pilot that VFR was not recommended due to mountain obscuration, icing, and turbulence along his proposed route of flight.
The pilot took off from the airport at an unknown time, activated his VFR fight plan, and began to talk with air traffic control (ATC).
The aircraft was on VFR flight following with Oakland Air Route Traffic Control Center (ARTCC). At 0824:44, the pilot told the controller that he was "going to climb up to fifteen five (15,500 feet), or climb to fifteen to catch a hard IFR." The controller asked him, "November four mike bravo roger and do you want your IFR at this time?" At 0824:55, the pilot replied "if it's possible we'll take it now." The controller verified that the pilot's destination was St. George, and then at 1825:24, cleared the pilot to St. George Airport via "direct Tonopah direct climb and maintain flight level, correction climb and maintain one five thousand (15,000)."
At 0827:52, the pilot called the controller and said that he had a system failure. The controller asked him what type of system failure he had, and the pilot replied that he had lost control of the airplane. At 0828:15, the pilot informed the controller that he was "losing altitude two thousand feet a minute."
The following section is a verbatim transcript of recorded conversations with the pilot and ATC. The recorded conversation contains references to direction, which are incorrect given that the airplane was traveling in an easterly direction. The pilot asked the controller if he could get a heading for the closest airport. The controller told him that the closest airport was behind him on a heading of zero seven zero (070 degrees). The controller issued a terrain alert for the pilot at 11,000 feet at 0829:18. He asked the pilot if he could hold that altitude. The pilot replied that he was holding nine five (9,500 feet). The controller asked him if he had the terrain and ground in sight and the pilot replied "I do not."
The terminal control facility at NAS Fallon recorded conversations with the pilot on the emergency guard frequency of 121.5/243.0. At 0831:09, the pilot reported, "121.5, Baron 554MB, I've got an engine out in the clouds." He then reported that he was holding 9,500 feet. At 0832:10, he said "mayday mayday."
The pilot replied to a query by a passing Northwest Airlines airplane, that attempted to contact him at the controller's request, by stating, "I'm descending through 9,500 . . . can't hold altitude, terrain is around me . . . I could sure use a radar vector somewhere . . ."
The controller asked the Northwest airplane the Baron's location. The Northwest Airlines pilot advised the controller that it sounded like N554MB had said that he was descending out of 9,500 feet over Tonopah on a heading of 090 degrees, direct west.
NAS Fallon FACTS radar data was reviewed. At 0823:43, the accident airplane flight path showed the airplane at 13,700 feet on a ground track of 101 degrees with an estimated ground speed of 190 knots. Approximately 3 minutes later at 0826:34, the flight path indicated it was at 14,600 feet with a ground track of 079 degrees, and an estimated ground speed of 130 knots. At 0827:47, the radar data indicated it was at 13,700 feet with a ground track of 237 degrees, and an estimated ground speed of 110 knots. The last confirmed radar hit on the airplane was at 0829:42, and indicated it was at 10,900 feet with a ground track of 247 degrees, and an estimated ground speed of 120 knots.
The pilot held a commercial pilot certificate with airplane single and multiengine land and instrument airplane ratings. His most recent flight review located in his logbook was dated December 2, 1995. No other entries were found to indicate a more recent flight review. A review of the pilot's logbook indicated that he had logged 21.5 hours of flight time during 1998. The 21.5 hours were logged as pilot-in-command, cross-country, and actual instrument time. All the flights were completed in the accident aircraft, which he was a co-owner. His most recent logbook entry was dated August 18, 1998. A review of his medical certificate information supplied by the Federal Aviation Administration (FAA) indicates he had approximately 1,800 hours of total flight time as of the date of his last medical examination dated December 1, 1997. His most recent medical certificate was a second-class with a restriction that he must wear corrective lenses.
The operator of the aircraft told Safety Board investigators that he had flown with the pilot (referred to by the operator as "Danny") numerous times. He said that the pilot was a very conservative pilot, and a good "stick and rudder pilot." He said that the pilot would fly "mild layer" IFR, but he had never seen him fly "hard" IFR flights. He said that if the weather were really bad, Danny would drive to the location by car. He also mentioned that he had never seen him fly over the mountains, instead he would fly up a valley to his location; and he had never seen him fly over mountainous terrain in IFR conditions. He mentioned that he wasn't sure if Danny would know what to do if he was picking up ice. He said to the best of his knowledge, Danny had never flown into actual icing conditions in the airplane. The pilot of the accident airplane had been a 50 percent owner in the accident airplane for 3 years prior to the accident date.
A review of the pilot's credit card statement, and review of the truck fuel slip indicate that the pilot purchased fuel at the Red Bluff Airport after he arrived on September 25, 1998. The truck fuel slip indicates a purchase of 92.8 gallons of Avgas 100LL for a total purchase price of $181.80.
The aircraft was not equipped with any ice protection on the leading edges of the wings, horizontal stabilizer, or vertical stabilizer; therefore, according to Raytheon Aircraft, this aircraft was not equipped to fly into known icing conditions.
Under the section entitled "Normal Procedures" of the Pilot's Operating Handbook (POH), it lists various equipment that when installed and operable will provide the pilot a degree of protection when icing conditions are inadvertently encountered. It states that since this equipment has not been demonstrated to meet current requirements for flight into known icing conditions, the pilot must exit such conditions as soon as possible if ice accumulates on the airplane. The equipment required for icing conditions is appended to this report.
Section X of the POH states that pilot's must carefully review the POH and FAA approved airplane flight manual in order to ascertain the required operable equipment needed for flight into icing conditions. In addition, they must ascertain from the same source the limits of approval or certification of their airplane for flight into icing conditions and plan the flight accordingly, if icing conditions are known or forecast along the route.
The POH also states that "an airplane which is not approved or certified for flight in icing conditions, or which does not have all critical areas protected in the required manner by fully operational anti-icing equipment must not be exposed to icing encounters of any intensity."
The POH also states that if a minimum speed for flight into icing conditions is not specified in the manual, the following minimum indicated airspeeds must be maintained:
All Baron and Travel Air Models - 130 KIAS
The pilot must remain aware of the fact that if he allows his airspeed to deteriorate below this minimum speed, he will increase the angle of attack of his airplane to the point where ice may build up on the under side of the wings. Due to distortion of the wing airfoil, increased drag and reduced lift, stalling speeds will increase as ice accumulates on the airplane. Ice buildup on unprotected surfaces will increase drag, add weight, reduce lift, and generally adversely affect the aerodynamic characteristics and performance of the airplane. It can progress to the point where the airplane is no longer capable of flying.
A review of the tape of the FSS briefing that the pilot received from Rancho Murietta AFSS revealed that the pilot initially told the briefer that he was going to fly from Red Bluff to St. George, and he was trying to pick out the best route. The pilot asked the briefer what the Red Bluff-Sacramento-Reno route looked like for VFR flight. The pilot told the briefer he was planning to fly the route at 11,500 feet and estimated 3 1/2 hours time en route. The briefer told the pilot that "VFR flight is not recommended." He told the pilot that there was an AIRMET in effect for IFR conditions near Reno and the first part of his route, and also an AIRMET in effect for mountain obscurations for the entire route of flight. He concluded, "VFR flight is not recommended all day."
The pilot then asked about routing from Red Bluff south, heading toward Fresno across to Las Vegas and cutting over to St. George. The briefer told the pilot again that "VFR flight was not recommended." The pilot again changed his routing and said he'd head down toward Bakersfield and cut over toward Las Vegas and over to St. George. The briefer said there was an AIRMET in effect for southern Utah for occasional moderate turbulence in effect below 18,000 feet, an AIRMET for icing from Modesto-Wilson Creek Line northward and Modesto-Red Bluff eastward for occasional moderate rime/mixed icing in clouds and precipitation from 8,000 feet to 18,000 feet. He told the pilot that there were thunderstorms over the Sierra's, southern California, and throughout Nevada and Utah. He said there was "a weakening cold front moving through northern California at this time." The briefer told the pilot that the forecast for the Sacramento Valley and northern portion of the valley was 4,000 feet scattered/broken, 8,000 feet broken, isolated moderate rain showers, tops to 15,000 feet, occasional ceilings 1,000 feet broken, visibility 3-5 miles in mist.
The forecast for the southern Sierra's was 12,000 feet broken; occasional ceilings 8,000 feet broken; isolated moderate rain showers with tops 20,000 feet and cumulonimbus tops to 30,000 feet. The forecast for the southern portion of Nevada was 12,000 feet scattered, between 1000 and noon local time, gradually becoming 10,000 to 12,000 feet scattered to broken, isolated moderate rain showers and thunderstorms and moderate rain. Cumulonimbus tops to 30,000 feet.
A Safety Board meteorological factual report is appended to this file. According to the report, a surface analysis chart prepared by the National Weather Service (NWS) National Centers for Environmental Prediction (NCEP) for 0800 September 26 showed a large area of low pressure over Nevada and eastern California. The chart indicated mostly overcast cloud conditions over California and central/northern Nevada.
According to an eyewitness, the U.S. Navy Search and Rescue H-60 helicopter, which was launched to attempt to locate the missing airplane, flew "through the clouds" and went down on the east side of the mountain. The eyewitness reported that he heard a "loud metallic crash and could no longer hear the motor."
The Surface Aviation Weather Observations were from Fallon Naval Air Station (KNFL), Nevada. This was the closest weather observing facility to the accident site. The field elevation of Fallon is 3,934 feet mean sea level (msl), located about 005 degrees at 54 nautical miles from the accident location.
Time 0726; type METAR; (aviation routine weather report) wind 360 degrees at 8 knots; visibility 10 miles, present weather none; sky condition scattered 900 feet broken, 1,500 feet broken, 5,500 feet cumulonimbus broken 7,000 feet overcast, 10,500 feet; temperature 9 degrees Celsius; dew point 8 degrees Celsius; altimeter setting 29.79 inHg; remarks cumulonimbus distant northeast dissipated cumulonimbus distant southwest move northeast.
Time 0814; type METAR; wind 010 degrees at 9 knots; visibility 10 miles; present weather none; sky condition scattered 1,200 feet broken 2,200 feet overcast 4,200 feet cumulonimbus; temperature 9 degrees Celsius, dew point 8 degrees Celsius; altimeter setting 29.80 inHg; remarks cumulonimbus overhead move northeast.
Pilot Reports (PIREP's) for California and Nevada archived at the National Climatic Data Center (NCDC), Asheville, North Carolina, were obtained for the period from 0200 to 1200, inclusive. They indicated that there were reports of icing in the area from other general aviation aircraft. The PIREP's indicated both light clear, and rime icing between 10,000 feet and 14,000 feet.
A review of the Aviation Area Forecast's (FA) for the Pacific Coast and Rocky Mountain Areas issued September 26, 0345, indicated at 0300 cold front reached from western Wyoming across extreme northern Utah and northern Nevada to northern California. By 2200, the cold front will lie from northwestern Colorado across southern Utah to central California. Upper level low was over northeastern California with trough to western Montana. By 2200, upper low will move to central California with trough to southeastern Montana.
A review of the FA forecast for the Rocky Mountain Area issued September 26, 0345, indicated at 0300 cold front reached from western Wyoming across extreme northern Utah and northern Nevada to northern California. By 2200, cold front will lie from northwestern Colorado across southern Utah to central California. Upper level low was over northeastern California with trough to western Montana. By 2200, upper low will move to central California with trough to southeastern Montana.
AIRMETS issued by the AWC and pertinent to N554MB's route of flight, in part follow:
Airmet ZULU, issued September 26, 0045 occasional moderate rime/mixed icing in clouds in precipitation between 8,000 feet to FL 180 (Flight Level 18,000 feet.) AIRMET SIERRA contained information for mountain obscuration in clouds and precipitation along the route of flight.
The Safety Board Meteorologist concluded that there were no convective SIGMETs, nonconvective SIGMETS, or Center Weather Advisories that were issued for the accident area.
WRECKAGE AND IMPACT INFORMATION
The airplane impacted a rock outcropping in mountainous terrain at the juncture of two ridgelines. The area was above the timberline and was vegetated by grasses and occasional clusters of small trees. Site elevation was approximately 8,900 feet above mean sea level (msl) at coordinates 38 degrees 31.11 minutes north latitude and 118 degrees 48.42 minutes west longitude. Hawthorne Municipal Airport was on a magnetic bearing of 064 degrees at 8 nautical miles.
The debris field was scattered along a magnetic bearing of 140 degrees. All of the debris found was within 180 feet of the initial impact point except the left propeller and hub assembly, which was located about 255 feet away. The fuselage came to rest in an upright position on a magnetic heading of 070 degrees.
The first identifiable ground disturbance consisted of ground scaring, broken bushes, disturbed rocks, paint flecks along with the aircraft tail tie down hook, and an antenna. Red glass lens fragments, the pitot tube, and a piece of the left wing from the wing tip inboard which included a portion of the left aileron, were found in front of a large rock formation whose vertical face was perpendicular to the path of the debris field. The left wing piece exhibited crush damage back to the spar. The face of this rock formation had a line of blue and white paint transfer marks and smears to approximately 20 feet from the centerline of the debris field. The paint transfers showed that the angle of bank of the airplane was about a 10- to 15-degree angle up from the horizontal. A disturbed section of dirt in the forward center region of the initial impact area had contours similar to those of a nearby boulder which measured 6 x 2 x 3 feet, if the boulder was turned over and spun 180 degrees from it's observed position.
A 40-feet-wide and 70-feet-long charred area began 20 feet from the initial impact point. This area contained the left main wheel assembly with melted remnants of tire bead, the inverted left wing and engine with flap and a portion of the aileron attached, and the upright right wing with the aft nacelle section, aileron, and a section of flap attached. Twenty feet outboard of the right wing was the remainder of the right flap. Broken Plexiglas was found in an area of heavy ground scaring 90 to 120 feet into the debris field. Near the centerline of the debris path, between 120 and 140 feet, was the nose wheel, the entire instrument glare shield, wet compass, and one eyeglass lens. At 135 feet and approximately 10-15 feet right of the main ground scars were the charred right engine with the propeller attached, and the right elevator counterweight horn.
A charred area surrounded the immediate area around the fuselage except for an extended area abeam the left side of the cockpit area. The cabin area, including the radios and aircraft instruments, was consumed by fire with melting and thermal damage noted to large aluminum castings. The right horizontal stabilizer and right elevator were attached except for the previously noted elevator counterweight horn. The rear-indented section of the right horizontal stabilizer had been impinged by an object consistent with the dimensions of the right elevator counterweight horn. Also attached were the vertical stabilizer, rudder, left horizontal stabilizer, and a portion of the left elevator. The rotating beacon on top of the vertical stabilizer had been torn off. External surfaces on the empennage were clean with no evidence of blistering or charring; however, the inside surfaces were sooty. The bottom of the empennage was crushed. Thirty feet right of the main centerline of the debris field and 10 feet beyond the fuselage was the remainder of the left elevator with the trim tab and actuator attached. The left elevator counterweight horn was found an additional 10 feet beyond this point. This piece of wreckage was located farther from the initial impact point than any other component except the left propeller. The right hand cabin door was located 10 feet beyond the nose of the fuselage and it was outside the charred area. The cabin door exhibited minor crush damage and no fire damage. The front cabin door was found with the pin extended, except that the upper latch hook was missing. The nearby baggage door was found latched to its adjacent nose section fragment. A charred bag with burned clothing and toiletries was located midpoint on the right side of the fuselage. The second eyeglass lens was found in an area not charred that was approximately 1 foot away from the fuselage near the right front side of the cabin area. The instrument glareshield, Plexiglas fragments, cabin door, baggage door, right flap piece, and other debris found outside of the charred area were clean and free from soot and their surfaces were void of any blistering.
The windscreen was shattered and scattered throughout the center of the debris field. The right outboard portion of the main spar carry through structure exhibited aft and upward deformation and the lower right bathtub fixture separated. Left wing separation from the fuselage occurred several inches outboard of the wing attachment fitting. The main landing gear actuator was observed to be over center, which according to the Raytheon is consistent with a fully retracted landing gear position. The right wing flap actuator extension was 1 7/8 inches, which is consistent with a fully retracted flap position. The left flap actuator extension was not obtained due to fire consumption of the actuator casing. Two center seat frames were out of the cabin in the charred area on the left side of the fuselage and resting on their backs. Seat material and seat belt webbing had been consumed by fire. Each seat had a latched seat belt buckle near it. Two seat frames were found in the charred fuselage. One seat belt buckle was found unlatched; another was found with the latch engaged and exhibited molten metal around the shoulder harness engagement pin. Aft attach points were observed on the cabin floor but no attachment mechanisms were observed. A charged fire extinguisher, which functioned normally, was found outside the charred fuselage area. A Narco ELT 10 emergency locator transmitter was found properly installed in the empennage. Some melting of the case had occurred, but the unit functioned properly when the antenna cable was disconnected and the unit was tested at the crash site.
Rudder and their elevator control cable continuity was established from the cockpit area to respective control bellcrank in the empennage. Left and right aileron control cables exhibited breaks in the control cables. The measurements equate to the following: the trim tab rudder was found to be deflected right 3 3/4 inches, which is consistent with a 5-degree right trim tab deflection (nose left trim). The left elevator trim tab actuator was extended 1 3/8 inches, which is consistent with 17-degree tab down deflection. The right elevator trim tab actuator was 11/16 inch, which is consistent with 10 degrees tab up deflection. Measurement of the left wing flap actuator was not possible as its outer casing was consumed by fire; however, the exposed piece measured 2 inches.
The fuel control quadrant was badly charred and damaged. Left and right fuel selector valves handles were examined and found to be positioned approximately 40 degrees from the 9 and 3 o'clock position (off), respectively. Both main fuel strainers were charred. The setscrew in the right main fuel strainer was in an intermediate position between main and off. The setscrew in the left main fuel strainer was in the middle of the jackscrew, which is consistent with an on condition and matches the fuel selector valve.
According to the aircraft maintenance records, Teledyne Continental Motors IO-470-L engines' serial numbers 468284 and 468287 were installed on the left and right sides, respectively. Neither engine exhibited cracks or holes in the outer cases. A review of the maintenance logs on both engines revealed no discrepancies, which would have affected the operation of either engine.
The left engine had separated from the engine mount but was in a position relative to its wing, both which were inverted and charred. The oil pan was found crushed and it exhibited longitudinal scratches. The exhaust pipe exhibited longitudinal scratches, crush damage, and some fractures. The ground under the engine was moist and saturated by a dark, viscous fluid. The propeller-mounting flange was bent and cracked, and the propeller had separated from the engine. The aft engine accessory case was partially consumed by the fire. Examination of the dry vacuum pump revealed partial melting of the plastic drive coupling, thus the pump would not turn. All carbon rotors and their associated vanes were intact and the inside of the housing was free of scoring. The left engine-driven fuel pump was removed and the driveshaft was found to be intact.
The right engine separated from its engine mount and was displaced almost 70 feet from the right wing. Soot covered the right engine and the heaviest deposit was on the aft accessory case area. The top cowling was sooty on the inside and the outside paint was charred and blistered. The oil pan exhibited upward crushing. The exhaust was flattened and twisted with a small crack at the apex of one twist. Examination of the right vacuum pump coupling revealed the plastic gear was in one piece but was melted. All carbon rotors and their associated vanes were intact and the inside of the housing was free of scoring.
The right propeller was attached to the engine. All three blades exhibited aft bending and chordwise scratching, and two of the three blades exhibited leading edge twists toward the low pitch position. Blade A was bent over the engine and its back was sooty; blade B and C were soot free. The spinner exhibited minor crushing. The left propeller separated and was located 225 feet from the initial impact point. The left propeller was located the furthest from the initial impact point. Extensive longitudinal scratching was evident on the flattened portion of the spinner between blades A and B. An open area in the aft portion of this flattened area exposed the adjacent portion of the hub assembly, which was cracked and exhibited impact marks. All three blades showed forward bending towards the cambered side and were attached to their hubs. Blade A was free to rotate in the hub and was found impaled in the ground to within 3 inches of the hub. Blades B and C exhibited an angle consistent with the feather position.
TESTS AND RESEARCH
Both of the aircraft engines were recovered and sent to the Teledyne Continental Motors (TCM), plant in Mobile, Alabama for inspection and teardown. The engines were received at TCM on October 21, 1998. The crates remained unopened until the examination, which took place on November 2, 1998, under the supervision of the Safety Board. A complete report of the teardown and photographs is appended to this report. At the conclusion of the teardown, both engines were released to the Safety Board and shipped to Aircraft Recovery Services, Compton, California.
According to aircraft maintenance records, the left engine, IO-470-L, serial number 468284, was removed from the crate and mounted on an engine stand for disassembly. Copies of the engine logbook show that this engine was overhauled by Western Cylinder on March 23, 1993. At 163.5 hours since major overhaul, the cylinders were removed and top overhauled. The last entry in the logbook indicated time on the engine was 703 hours SMOH on September 24, 1998. According to the TCM inspection report, the engine exhibited extensive fire and impact damage. Additionally, both magnetos were broken off the engine and returned loose in the bottom of the engine crate. The engine crankshaft propeller flange was bent from impact. The number 6 cylinder had extensive head fin damage from impact. The vacuum pump was off the engine and returned disassembled. The engine driven fuel pump was removed from the engine and loose in the crate. The starter motor was broken off the starter adapter. The engine throttle was removed and loose with the engine. The engine oil sump was smashed flat with the crankcase sump rails from impact. All the engine mount legs were broken from impact. The induction tubes were damaged from impact. The exhaust runner was off the right side and smashed.
The report noted that all the cylinder overhead components were intact and appeared operational. The cylinders had some rust in the barrels from unpreserved storage. The hone pattern was visible and appeared fresh. Combustion deposits were normal for color and content. All valves appeared to be seating properly.
The report also noted that the piston rings were all free in their respective groves. The crown deposits were normal for color and content. All the piston pins exhibited normal operational signatures. The piston skirt color was dark indicating some possible blowby during operation.
The crankcase main bearings exhibited normal operational signatures. The babbit overlays were intact. No bearing movement was observed. The crankcase parting surfaces were free of any fretting signatures. The crankcase exhibited massive impact damage to nose breaking the case structure at the front main bearing. According to the report, this damage was all from impact.
The crankshaft main journals exhibited normal polishing signatures. All connecting rods were removed and their bearing babbit overlays were intact. Crankshaft main and connecting rod journals exhibited normal lubrication signatures. The crankshaft propeller flange was bent from impact. The oil slinger and oil transfer collar were broken also from impact. Crankshaft counterweights movements were free and unrestricted, indicating minimal counterweight pin and bushing wear. The camshaft and lifters exhibited normal operational signatures. No lifter spalling or camshaft lobe wear was observed.
The left magneto was placed on the magneto test stand and functionally tested. It produced a bright spark across a 7MM spark gap. The right magneto would not produce a spark on the magneto test stand. The magneto was disassembled. The primary wire insulation, from the points to the coil, was melted from the postaccident fire. The vent plugs were also melted. The engine driven fuel pump had all the fittings broken off during impact, except the fuel return fitting. Its drive coupling was intact and the pump would turn.
The throttle/fuel metering unit throttle and mixture levers were bent from impact. The fuel screen was removed and except for a small amount of lint, was unobstructed.
The report concluded that this engine exhibited normal operational signatures throughout, with exception to the fire and impact damage. All internal components appeared well lubricated. This engine did not exhibit any condition that would have caused an operational problem.
According to aircraft maintenance records, the right engine, serial number 468287, was removed from the crate and mounted on an engine stand for disassembly. Copies of the engine logbook indicated that this engine was overhauled on March 23, 1993 by Western Cylinder. On September 11, 1994, all the cylinders were removed and top overhauled. Time at this repair was 144.8 hours since major overhaul. The last entry in the logbook was on September 24, 1998, showing 684.3 hours SMOH. Observations noted were that the engine oil sump was crushed upward nearly flat and ripped open at the right rear. Dirt and debris from the accident site entered into the sump. The inside color was normal. No metallic debris was present. The engine oil pump gears and their respective cavities exhibited normal operational signatures.
All cylinder overhead components were intact and appeared operational. The hone pattern was visible and appeared fresh. Combustion deposits were normal for color and content. All valves appeared to be seating properly.
The TCM report noted that the piston rings were all free in their respective ring grooves. The crown deposits were normal for color and content. Piston skirt color was normal with some minor scratches observed. All piston pins exhibited normal operational signatures. Crankcase main journals exhibited normal polishing signatures. All connecting rods were removed and their bearing babbit overlays were intact. Crankshaft main and connecting rod journals exhibited normal lubrication signatures. Crankshaft counterweights movements were free and unrestricted, indicating minimal counterweight pin and bushing wear.
Camshaft and lifters exhibited normal operational signatures. Both magnetos were inspected and they received considerable postimpact fire damage. Both magnetos would rotate. All ignition harness leads were mostly consumed in the post impact fire. The engine driven fuel pump was charred form the postimpact fire. The pump drive coupling was intact. All link rods were intact.
TCM concluded that this engine exhibited normal operational signatures throughout, except for the impact and fire damage. All internal components appeared well lubricated. This engine did not exhibit any condition that would have caused an operational problem.
The propellers from the accident aircraft were torn down on October 19, 1998 at Aircraft Recovery Services, Compton, CA., by the Safety Board with assistance by Hartzell Propeller's technical staff. The propellers were identified by maintenance records and the engines that they were attached to.
According to Hartzell, the accident propeller is a 3-bladed single acting, hydraulically operated constant speed, full feathering model. Oil pressure from the propeller governor is used to move the blades to the low pitch (blade angle) direction. Blade mounted counterweights, air charge, and feathering spring are used to move the blades to the high pitch/feather direction in the absence of governor oil pressure.
According to the aircraft logbooks, the left propeller, model PHC-C3YF-2UF, Hub Serial Number EB1415, was found to have numerous indications to suggest that it was feathered prior to impact: 1) mild bends to the blades with no rotational scoring; 2) impact markings on two of the blade preload plates at the feather blade angle; 3) the spinner had large dents on one side with no signs of rotational scoring; and 4) bending of the pitch change rod that could have occurred only at a very high blade angle." The left propeller had broken free from the engine-mounting flange. Three mounting studs had been pulled out. The other three were bent and had stripped threads. The blade orientation was 1-2-3 clockwise as viewed from the rear of the propeller. The pitch change rod was broken into four pieces. It was broken on both sides of the fork and at the piston oil hole.
According to the Hartzell representative, the preload plates had impact markings from the fork and knob of the opposing blade. These markings were used to estimate a blade pitch angle position as follows:
The marks from the preload plates on the No. 1 blade equates to blade angles of 60 degrees and 71 degrees respectively.
The marks from the preload plates on the No. 2 blade equates to blade angles of 85 degrees.
The marks from the No. 3 blade equates to a blade angle of 85 degrees.
The left propeller, s/n EB1415, was manufactured July 25, 1980.
According to the propeller manufacturer's representative, the right propeller, Hub Serial Number EB1411, the spinner dome was intact with only a small dent in the cap. The spinner bulkhead was intact and unremarkable. The engine/propeller-mounting flange was intact and unremarkable. The pitch change rod was broken on both sides of the fork. The fork itself was intact and unremarkable. The preload plates had impact markings from the fork and knob of the opposing blade. These markings were used to estimate a blade angle position as follows:
The marks from the preload plates on the No. 1 blade equates to a blade angle of 41 degrees.
The marks from the preload plates on the No. 2 blade equates to a blade angle of 34 degrees.
The marks from the preload plates on the No. 3 blade equates to a blade angle of 24 degrees.
The manufacturer's representative noted that all three propeller blades on the right propeller were bent aft and twisted toward low pitch. Blades No. 2 and 3 had sharp bends/twisting in the tip area. There were signs of rotational scoring in the paint on the camber side of all three blades.
The right propeller, serial number EB1411, was manufactured July 21, 1980. Both propellers retained their original blades. The representative concluded that the right propeller had indications of rotation on impact with very little damage to the spinner. A complete copy of the Hartzell report is appended to this report.
An attempt was made to perform an inspection of a Shadin digital fuel flow indicator, which was onboard, the accident aircraft. The inspection was performed on November 5, 1998 under the guidance of the FAA Flight Standards District Office in Minneapolis, Minneapolis. The inspector stated that after unpacking the unit it appeared to have been in a fire and was very corroded. The main circuit board revealed that fire had melted the solder from the pins of the various components. In the process of removing the IC chip, No. 28C17, it cracked in half, thus concluding any attempt at retrieving data from the chip, which normally stores various inputs from sending devices.
Air Traffic Control Recording:
A certified analog copy of the air traffic control (ATC) transmissions recorded on September 26, 1998 at the Oakland Air Route Traffic Control Center was sent to the audio laboratory of the Safety Board for analysis. The recording was examined to document any warning tones or engine sounds that could be heard during the radio transmissions of the accident aircraft. A sound spectrum study was completed on all radio transmissions. The transmissions were examined on an audio spectrum analyzer to identify any background sound signatures that could be associated with aural cockpit warning tones or with either of the engines or propellers. The frequency response of the pilot's headset, the aircraft's radios, and the tower's recording system were such that there were no background signatures recorded on the ATC tape.
MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed on the pilot by the Washoe County Medical Examiner's office in Reno, Nevada, with tissue and fluid samples retained for toxicological examination. The samples were submitted to the FAA Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma. Separate toxicological studies were conducted by order of the Washoe County office.
According to the Manager, Toxicology and Accident Research in Oklahoma City, the samples from the pilot were negative for all screened drug substances.
According to the second toxicological examination performed in Las Vegas, Nevada, the sample from the pilot was negative for all screened drug substances.
SEARCH AND RESCUE
The Mineral County Sheriff's Office (MCSO) said they received a telephone call from the Reno Flight Service Station (FSS), on Saturday September 26, at 0848 advising them that there may be a possible downed aircraft in Mineral County. FSS told them that according to the pilot's transmissions, the aircraft was experiencing equipment problems, and the pilot was requesting a location to land the airplane. At the time of the transmission, FSS said the airplane was approximately 5 miles northwest of the Hawthorne airport. The MCSO deputies confirmed that the airplane had not landed at the Hawthorne airport and stated that after a brief search, the plane could not be located. They noted in their report that the weather conditions were "inclimate and unfavorable, particularly in the area of the mountain range of Mt. Grant, the last known position of the aircraft."
The MCSO search and rescue units were advised by NAS Fallon that the last contact with the aircraft was at 0830. At that time the aircraft was traveling in a west direction, ascending then turned to an east direction when the aircraft descended to the last known elevation of approximately 10,900 feet according to their radar.
MCSO notified the Nevada State Emergency Management coordinator at 1013, and advised that the weather was not favorable flying conditions for the Civil Air Patrol. At 1048, NAS Fallon advised that they would be launching a H60 helicopter to assist in the search.
According to the incident report filed by the State of Nevada, Division of Emergency Management, the Air Force Rescue Coordination Center said they received a first alert of the ELT at 0904, at coordinates 38 degrees 30.3 minutes north latitude and 118 degrees 32.7 minutes west longitude.
At 1311, Carson City Sheriff's office advised that they received a telephone call from a citizen who said he was on the west side of Mt. Grant. He reported seeing a gray-blue colored helicopter fly over the area through the clouds and banked down on the east side of the mountain. When the helicopter was out of view, he reported hearing a loud metallic crash and stated he could no longer hear the motor.
At 1648, a helicopter rescue unit advised that they were on the scene with the downed helicopter, (the H-60 helicopter launched to aid in the search and rescue mission for the airplane), and the search for the missing airplane was being suspended due to nightfall.
At 0750, on Sunday September 27, The State of Nevada, Division of Emergency Management called the National Weather Service to get an update on the weather for the Mt. Grant, Rose Peak area of Mineral County. According to Emergency Management records, they were reporting "solid cloud cover, showers, snow level 7,500 feet, snow advisory for the Hawthorne area, South East winds 5-15 mph below 9,000 feet, above 9,000 feet winds 20 knots, possible thunder storms in the late afternoon."
At 1535, NAS rescue unit Longhorn 2 (helicopter air unit) advised they had located the wreckage of the missing airplane. The airplane wreckage was located at Lappen Meadows, which is on the west side of Mt. Grant.
The aircraft was released Kern and Wooley, representing the registered owner High Performance Aircraft of San Diego, California on March 17, 1999.
Additional parties to the investigation not included on page 5 are:
Tom McCreary Hartzell Propeller Piqua, OH
John Mitchell Little Teledyne Continental Motors Mobile, AL
William G. Roebuck Teledyne Continental Motors Mobile, AL
Fred Fihe Teledyne Continental Motors Mobile, AL
Jerry Staab Raytheon Aircraft Company Wichita, KS