CHI99FA177
CHI99FA177

HISTORY OF FLIGHT

On June 8, 1999, about 1235 central daylight time (all times herein are central daylight time unless otherwise specified), a Cessna 340A, N1372G, piloted by a private pilot, was destroyed during a collision with the terrain while on a visual final approach for landing on runway 13 at the Phillipsburg Municipal Airport (PHG), Phillipsburg, Kansas. The pilot and one passenger were fatally injured. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 personal flight was operating on an IFR flight plan. The flight departed Wheeling, Illinois, about 0912.

The evening before the accident, at 2040, the pilot of N1372G called the Kankakee Automated Flight Service Station (AFSS) preflight one position via telephone and requested an outlook weather briefing for an I-F-R flight from the Chicago Palwaukee Municipal Airport (PWK) to the Pueblo Memorial Airport (PUB) leaving around 1400Z. The specialist then provided the pilot with an outlook weather briefing. The pilot then stated he would call again the next morning.

At 0700 on the morning of the accident, the pilot of N1372G called the Kankakee AFSS preflight five position via telephone and requested a weather briefing for an IFR flight from PWK to PUB airport leaving around 1400Z. The specialist provided the pilot with a standard weather briefing. The pilot then stated that he was ready to file an IFR flight plan, which was received and filed by the specialist.

0907 - N1372G requested IFR clearance to Pueblo, CO. Ground control issued the clearance and received a readback.

0912 - N1372G called tower holding short of runway 30 ready to roll.

0912 - N1372G was instructed to hold short of runway 30 awaiting release.

0912 - N1372G was instructed to fly the runway heading runway 30 cleared for takeoff.

0918 - N1372G was instructed to contact departure.

0919 - N1372G checked on North Satellite off the ground at Palwaukee. Radar contact was established. N1372G was instructed to maintain 3,000 and to say the altitude leaving. Pilot acknowledged out of 1,000.

0921 - North Satellite instructed N1372G to turn left heading 270. Pilot acknowledged.

0923 - N1372G checks on with South Departure at 4,000.

0924 - South Departure instructs N1372G to turn left heading 250, climb and maintain 6,000. Pilot acknowledged.

0925 - South Departure instructs N1372G to climb and maintain 10,000. Pilot acknowledged.

0927 - South Departure instructs N1372G to turn right heading 270. Pilot acknowledged.

0931 - South Departure instructs N1372G to contact Chicago Center on 127.07.

0931 - N1372G reported on the Chicago ARTCC MALTA Sector frequency, leaving 9,200 feet for 10,000.

0933 - The MALTA Radar Controller issued N1372G a clearance direct DBQ VOR

0934 - The MALTA Radar Controller issued N1372G a clearance to climb to 12,000 feet.

0938 - The MALTA Radar Controller issued N1372G a clearance to climb to 16,000 feet.

0940 - Communication with N1372G transferred to Chicago ARTCC DBQ Sector frequency 133.95. N1372G reported on the DBQ Sector frequency, leaving 13,600 feet for 16,000 feet.

0947 - The DBQ Radar Controller issued N1372G a clearance to climb to FL180 and direct destination of PUB.

1025 - Communication with N1372G transferred to Chicago ARTCC OTM Sector frequency 132.8.

1026 - N1372G reported on the OTM Sector frequency, level at FL180.

1041 - Communication with N1372G transferred to the Minneapolis ARTCC Sector 27 frequency 125.65

1041 - The pilot of N1372G checked in with Minneapolis Center Sector 27 and reported level at Flight Level 180. The Sector 27 specialist acknowledged.

1121 - Sector 27 instructed N1372G to contact Minneapolis ARTCC on 128.75. N1372G acknowledged.

1121 - N1372G checked in with Sector 26 on 128.75, level at Flight Level 180. Sector 26 acknowledged and advised N1372G that the Omaha, NE, altimeter was 29.92. Sector 26 also advised N1326G that the altimeters to the west were too low for FL180. N1372G acknowledged.

1142 - Sector 26 asked N1372G if he wanted Flight Level 200 or 16,000 feet. N1372G requested 16,000. Sector 26 cleared N1372G to maintain 16,000 and issued the Lincoln, NE, altimeter 29.90. N1372G acknowledged.

1151 - Sector 26 instructed N1372G to change to his frequency 119.4. N1372G acknowledged.

1152 - Sector 26 issued N1372G the Hastings, NE, altimeter 29.88. N1372G acknowledged.

1211 - Sector 26 instructed N1372G to contact Denver ARTCC on 132.5. N1372G acknowledged.

1211 - N1372G checked on frequency and reported level at 16,000 feet. The Sector 19 Radar Controller (ZDV19R) acknowledged and issued the Hill City, KS (HLC) altimeter setting of 29.83.

1221 - N1372G advised ZDV19R of a fuel problem with one engine and requested vectors to land.

1222 - ZDV19R advised N1372G that the Phillipsburg, KS (PHG) airport was south of his position and asked if he was able to maintain altitude. N1372G said affirmative. ZDV19R asked N1372G if he was out of fuel. N1372G said that he was not out of fuel, but was having a fuel transfer problem with one engine and that the fuel transfer was not working properly. ZDV19R advised N1372G that PHG was 12 miles south of his position and the McCook, NE (MCK) airport was at 12 o'clock and 40 miles. ZDV19R asked N1372G if he intended to land as soon as practical. N1372G did want to land as soon as he could and requested the runway length for PHG. ZDV19R advised N1372G that the runway length for PHG was 3,800 feet. N1372G said that he could land at PHG.

1223 - ZDV19R acknowledged N1372G, vectored him for PHG, then issued the HLC altimeter of 29.83.

1224 - N1372G asked ZDV19R if PHG was in Kansas. ZDV19R acknowledged that it was in Kansas and then spelled PHG for him. ZDV19R advised N1372G that PHG had a radio beacon and advised him the frequency was 368. N1372G asked for the identification of PHG again so that he could program it into his GPS. ZDV19R told him it was papa hotel golf.

1225 - ZDV19R instructed N1372G to turn left heading 150. ZDV19R informed N1372G that the main runway for PHG was 13 and 31 then stated its length as 3,800 feet. ZDV19R advised N1372G that PHG was at 11 o'clock and 8 miles.

1226 - N1372G asked ZDV19R what his heading should be for PHG. ZDV19R advised N1372G that PHG was at 11 o'clock and 5 miles. N1372G reported descending out of 14,000 feet. ZDV19R cleared N1372G to maintain at or above 6,000 feet. N1372G acknowledged.

1227 - ZDV19R advised N1372G that PHG was at 9-10 o'clock and a mile then asked N1372G if he had the airport in sight. N1372G said that he was not sure. ZDV19R asked N1372G again if he had PHG in sight. N1372G said that he did not believe so.

1228 - ZDV19R informed N1372G that he had just passed over PHG, that the airport should be off to his left, and instructed N1372G to turn right heading 320 for a vector to PHG. ZDV19R asked N1372G if he had the ground in sight and if he was VFR. N1372G said that he was VFR, but did not have PHG in sight. ZDV19R informed N1372G that PHG was now at 6 o'clock and 3 miles and instructed him to fly heading 320. N1372G acknowledged that he was turning right.

1229 - N1372G reported PHG in sight. ZDV19R informed N1372G of PHG's unicom frequency of 122.8, advised him that there was no observed traffic in the area, and then explained the radar limitations around PHG below 6,000 feet. ZDV19R advised N1372G that the minimum safe altitude within a 25-mile radius of PHG was 3,800 feet and N1372G acknowledged. N1372G advised ZDV19R that he would change over to PHG unicom then report back on ZDV19R's frequency. ZDV19R cleared N1372G for a visual approach to PHG and issued the HLC altimeter of 29.83. No response.

1231 - N1372G advised ZDV19R that he was unable to talk to anyone on PHG unicom and requested the winds for the area. ZDV19R advised N1372G that the appropriate altimeter setting for PHG would be Hayes, KS (HYS) airport and issued the HYS altimeter of 29.91. ZDV19R explained to N1372G that HYS was 80 miles south of PHG then issued the HYS winds as 19018G25. ZDV19R then explained that HLC was 35 miles southwest of PHG then issued the HLC winds as 19012G25. ZDV19R advised that MCK was north of PHG then issued the MCK winds as 20010G21. ZDV19R summarized for N1372G that the winds for the area appeared to be gusting out of the south to the southwest.

1232 - N1372G acknowledged and said that the runway at PHG was a southeast runway. ZDV19R confirmed that the southeast runway for PHG was runway 13. N1372G asked for the field elevation. ZDV19R advised N1372G that the correct field elevation for PHG was 1,907 feet. N1372G acknowledged PHG's elevation then told ZDV19R that he would try PHG unicom again, but asked ZDV19R what is the name of the airport. ZDV19R replied that the airport was PHG then N1372G said that he would try the PHG unicom again.

1233 - N1372G advised ZDV19R that he was unable to get a response on PHG unicom and would remain on ZDV19's frequency. ZDV19R asked N1372G if he was able to maintain altitude. N1372G replied that he was descending out of 5,000 feet.

1234 - Sector 19 Sector Controller (ZDV19RD) called Sector 12 and requested that TWA429 change to Sector 19's frequency to allow for continued communications with N1372G as he descended. ZDV19R advised N1372G that the minimum safe altitude for the area was 4,000 feet and that within 25 miles of PHG it was 3,800 feet. ZDV19R advised N1372G that he had already been cleared for a visual approach to PHG and if he was going to make an approach into PHG. N1372G said affirmative and advised ZDV19R that he was commencing a visual approach 4 miles north of PHG. ZDV19R advised N1372G that if he was unable to contact ZDV19R, to report his down time or cancellation time through Wichita Radio. N1372G acknowledged. ZDV19R advised N1372G to continue to monitor ZDV19R's frequency and that TWA429 would relay further radio transmissions due to anticipated radio coverage problems on his descent into PHG. N1372G acknowledged.

1235 - TWA429 checked on frequency. ZDV19R advised TWA429 that N1372G was low on fuel or having a fuel problem and planned to land at PHG. ZDV19R instructed TWA429 that he would relay communications to N1372G through TWA429. ZDV19R requested a down time at PHG from TWA429. TWA429 established communications with N1372G.

1237 - ZDV19R reminded N1372G to report his down time on ZDV19's frequency and that no reply was needed.

1238 - ZDV19R attempted contact with N1372G with no response. ZDV19R then asked TWA429 to attempt contact with N1372G. TWA429 had no response from N1372G.

1239 - TWA429 attempted contact with N1372G, again with no response.

1240 - ZDV19R asked TWA429 to attempt contact with N1372G one more time.

1241 - TWA429 attempted contact with N1372G twice, with no response. ZDV19R advised TWA429 that he understood N1372G had landed short of PHG and that personnel on the ground were now investigating.

1239 through 1312 - Wichita AFSS notified various offices and organizations of N1372G accident. A records search determined that the Wichita AFSS and the DUATS vendors had no contact.

WITNESSES

The first call received by the Phillips County Sheriff from a local witness was a 911 call at 1237 in which the dispatcher recorded in their log: "said an airplane had just nosed into the ground just south of West G. Street somewhere - went straight down - maybe west or by airport/said I'd get someone out there". There were several other 911 calls between 1237 to 1240. The PHILLIPS COUNTY CALL LOG for these calls is an attachment to this Factual Report.

A number of witnesses saw the aircraft just before the accident and describe hearing engine variances and observing the aircraft roll and impact the ground nose first. All witness statements are attached to this factual report. A witness location chart depicting witness locations relative to the accident location is also an attachment to this factual report.


PILOT INFORMATION

The pilot held a private pilot certificate with single and multi-engine, land, and instrument ratings. His third class medical was issued in March 1998. Inspection of the pilot log book found in the aircraft indicated he had total time of about 3015 hours, 2852 hours as PIC, and 2356 multi-engine time. He had a current biennial flight review on June 6, 1999.

AIRCRAFT INFORMATION

The aircraft was a 1976 manufactured Cessna 340A, Serial Number 340A0071. The aircraft was equipped with two Continental Motors TSIO-520 engines. The aircraft and engines had current annual inspections.

The Fuel System inspection at the annual inspection consisted of:
1. Check all tanks for leaks and security of mounting.
2. Drain sumps, clean fuel strainers and bowls.
3. Check all fuel lines for leaks at connections and security of mounting.
4. Check fuel tanks vents, tank caps, and gaskets.
5. Check conditions and operation of fuel tank selector valves.
6. Check placard at fuel tank filler caps.
7. Check seal of fuel tank filler neck to internal structure.

All items above were signed off as having been inspected and completed per the periodic aircraft inspection check list which is an attachment to this Factual Report.

METEOROLOGICAL INFORMATION

At 1153, Hill City, Kansas (HLC), 32 nm southwest of PHG, reported sky clear, visibility 10 miles, winds from 190 degrees magnetic at 17 knots gusting to 25 knots, temperature 32 degrees Celsius, dew point 17 degrees Celsius, altimeter setting 29.83 inches of mercury.

COMMUNICATIONS

The ATC transcripts are attached to this factual report.

WRECKAGE AND IMPACT INFORMATION

The aircraft was located in a wooded ravine on the southwest side of the runway 13 extended centerline, about three quarters of a mile from the approach end. The GPS coordinates were: North 39 degrees 44.96 minutes, and West 99 degrees, 19.92 minutes. The elevation of the site was about 1880 feet mean sea level (MSL). The fuselage was found on an approximate 040 degree magnetic heading. The nose section was crushed and the engines were partially imbedded in the ground. The front of the right wing tip tank was broken off and located about 9 feet ahead of the aft portion of the fuel tank.

The left wing tip fuel tank and outboard section of the left wing were entangled in multiple tree trunks. The front cockpit and cabin area of the fuselage was burned or consumed by fire. There was some fire damage on the left tip tank. The entire right wing had burned. The empennage of the aircraft was burned off from the cabin door aft. The tail section was resting on the ground.

Flight control continuity was confirmed to all control surfaces.

The rudder tab was deflected to the left about 45 degrees. The rudder tab actuator was extended about 1 inch, which equates to about five degrees right tab. The elevator trim tab measured externally about 2.6 degrees tab down. The elevator trim actuator extension was about 1.35 inches which equates to a seven degree tab down. The aileron trim tab was up about 35 degrees. The Aileron tab actuator extension was measured at 1.8 inches which equates to five degrees tab up.

The main landing gear was in the down and locked position. The right main tire was burned. The nose gear was broken off. The landing gear actuator was in the gear down position. The unburned inner right flap section was extended about 40 degrees per measurement with a protractor. The left inner flap section was extended about 45 degrees as measured with a protractor. The position of the flap actuator chain drive was consistent with the noted flap positions.

The right main (tip) tank was separated at the forward bulkhead. The aft portion was fire damaged. The right auxiliary tank was fire damaged, with the rubber bladder consumed by fire. The right side wing structure, outboard of the nacelle to the aileron inboard end, was consumed by fire. The right locker tank was burned out with the rubber bladder consumed. The left main (tip) tank was fire damaged and was deformed with impact marks. The left auxiliary wing tank contained about one quart of blue liquid and the tank was not fire damaged. The left locker tank was not fire damaged and had a hole about six inches in diameter in the front wall. The tank was empty.

The left auxiliary tank fuel outlet screen and the left locker tank outlet screens were inspected. They were both clean and clear. The right auxiliary tank and the right locker tank fuel outlet screen were destroyed by fire. The fuel screens on the left and right main (tip) tank boost pumps were open, with a small amount of debris noted on the right screen.

The left side fuel lines were blown through and confirmed they were clear. The left locker tank check valve was open and the left side vapor return line check valve operated. The right side fuel lines and check valves were consumed by fire.

The fuel selector handles and selector valves were removed and inspected. The left handle was between the auxiliary and main position. The left selector valve was in the off position, and could be rotated. The main, aux, and crossfeed ports were clear to the engine feed when tested by blowing through as the various positions were selected. The right handle was on the left main (cross feed) position. The right selector valve was fire damaged. Both selector valves were sent to the NTSB Metallurgical laboratory for further examination. See "Tests and Research" section later in this report.

Eight fuel pumps were removed and tested. There were two main boost pumps (left and right), two auxiliary boost pumps (left and right outer nacelle area, in the wings), wing tip transfer pumps (left and right located in aft wing tip tanks), and the locker fuel transfer pumps (left and right near the auxiliary boost). All left side pumps expelled water when operated at 28 volts DC current. None of the right pumps, which exhibited varying degree of fire damage, would operate. The right side pumps were disassembled under the supervision of the NTSB Investigator in Charge and no evidence of pre-impact malfunction was found.

The right engine had fire damage at the rear. No fire damage was noted on the left engine. Both propellers were attached at the crankshaft flanges. Both propellers were removed for later teardown and inspection as noted in the "Tests and Research" section of this factual report below.

The engines were inspected at a local hangar under the supervision of the NTSB IIC and the following was noted:

All spark plugs exhibited light gray burning coloration except the 6 top spark plugs on the right engine that had been exposed to fire suppression at the accident scene.

The crankshafts on both engines were rotated by hand. Mechanical continuity to the valves and accessories was confirmed. There was compression in all cylinders.

There was continuity to the engine driven fuel pump drive coupling.

All four magnetos were sparked.

Both engine's fuel distributor manifolds contained fuel that was free of contamination and the manifold screens were clean.

Both oil filters were clean.

The burnt cockpit area was inspected and the following readings taken:

Throttles: Left, full forward. Right, one half knob from full forward.
Continuity confirmed.
Mixtures: Left, one inch aft of slot, Right, one half inch aft of slot.
Continuity confirmed.
Propellers: Both together, one half inch aft of forward slot. Continuity
Confirmed.
Left engine magnetos: Left, on, Right, off.
Right engine magnetos: Left, off, Right, damaged.
Auxiliary pumps: Both off.
Starter prime switch: Destroyed
Battery switch: Destroyed
Avionics: Destroyed



MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot at the Sedgwick County Kansas Regional Forensic Science Center on June 10, 1999.

A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute. The report found no carbon monoxide, no cyanide and 24 mg/dl ETHANOL detected in Blood, no ethanol detected in kidney, no ethanol detected in lung, and 6 mg/dl acetaldehyde detected in blood. The report states: "The ethanol found in this case may potentially be from postmortem ethanol formation and not from the ingestion of ethanol".

FIRE

The aircraft burned post crash. See attached photographs.

TESTS AND RESEARCH

The fuel capacity of N1372G was 203 gallons of useable fuel. Each main (tip) tank held 50 gallons, each wing auxiliary tank held 31.5 gallons, and each locker tank held 20 gallons.

The propellers from the left and right engines were disassembled and inspected at the Phillipsburg Airport under the supervision of the NTSB IIC on June 11, 1999. No evidence of any pre-impact failure or malfunction of the propellers was found. A report of the propeller examination is an attachment to this factual report.

Portions of the Cessna 340A Manual from Section 7, "Airplane and Systems Descriptions", Section 3, "Emergency Procedures", and Section 2, "Limitations" are attachments to this factual report. These sections describe the fuel system, engine and fuel system emergency procedures, and airspeed limitations in various flight regimes.

The Pilot's Operating Handbook for the Cessna 340A describes the fuel selectors under the section titled "FUEL SELECTORS" as:

"Two fuel selectors, one for each engine, are provided on the floor between the pilot and copilot seats. The selectors allow selection of main fuel, auxiliary fuel, crossfeed and no fuel.

The MAIN position of each selector allows fuel to flow from the main tank through the fuel selector to the engine-driven fuel pump. The AUXILIARY position allows fuel to flow from the auxiliary tank through the fuel selector to the engine-driven pump. The crossfeed position allows fuel to flow from the opposite engine main tank to the engine-driven fuel pump. The crossfeed position is used for balancing asymmetric fuel loads and supplying the engine-driven fuel pump from the opposite main tank. When the OFF position is selected, no fuel is allowed to flow to the engine-driven fuel pump.

The fuel selector handles form the pointers for the selectors. The ends of the handles are arrow-shaped and point to the position on the selector placard which corresponds to the valve position."

ADDITIONAL DATA/INFORMATION

The left and right fuel selector valves were inspected and disassembled by the NTSB Material Laboratory in Washington, D.C. The factual report of this inspection is an attachment to this factual report.

The left fuel selector could be operated through all of the six detent positions with no apparent high force required.

The right fuel selector had been in the post crash fire and complete details of the examination are in the NTSB Material's Laboratory Report.

Parties to the investigation were the Federal Aviation Administration, Cessna Aircraft Corporation, Teledyne Continental Motors, and McCauley Propeller Systems.

The aircraft wreckage was released to the executor of the pilot's estate on July 1, 1999.

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