CHI02FA074
CHI02FA074

HISTORY OF FLIGHT

On January 30, 2002, at 1359 central standard time, a Cessna 441, N441AR, was destroyed when it impacted terrain in a pasture near Winfield, Kansas. The private pilot and passenger received fatal injuries. The 14 CFR Part 91 personal flight departed the Springdale Municipal Airport (ASG), Arkansas, at 1314 en route to the Garfield County Regional Airport (RIL), Rifle, Colorado, on an instrument flight plan.

The pilot received two weather briefings from the Jonesboro Automated Flight Service Station (AFSS) on the day of the accident. The first weather briefing occurred between 0622 and 0632 and the second between 1130 and 1140. During the first weather briefing, the AFSS briefer provided the pilot with the current in-flight weather advisories concerning instrument flight (IFR) conditions, mountain obscuration, icing, and turbulence. The pilot was advised of the rain, freezing rain, and snow along the proposed route of flight. The pilot inquired about the cloud tops and was briefed that the forecast cloud tops were 25,000 feet. The pilot filed an IFR flight plan with a cruise flight level of 28,000 feet (FL 280).

At 1133, the pilot called AFSS for a weather update. The AFSS briefer reported the current weather included a mixture of precipitation that ranged from moderate rain to freezing rain, snow, and an area of freezing rain that extended about 70 miles along the route, and then changed over to snow. The pilot asked about the location of the freezing level and cloud tops. The briefer reported that the freezing level was at 12,000 feet across Oklahoma, but there were freezing conditions at the surface with freezing rain. The briefer indicated the only pilot report he had over northwestern Arkansas was over a hour old and it indicated the top of the first layer was at 8,000 feet, with a higher overcast layer at 9,500 feet with tops 11,000 feet with higher cirraform clouds above. Over central Oklahoma the clouds tops were in the 11,000 feet - 13,500 feet range based on pilot reports, with cirraform clouds above.

A witness reported that the pilot had checked the weather on the morning of the accident. He reported that the pilot was aware of the en route weather conditions. He reported the pilot had said the cloud tops were at 22,000 feet and that he would be flying at 29,000 feet.

N441AR departed ASG at 1314. At 1326:38, N441AR was cleared to climb to FL 280. Radar data indicated that N441AR leveled off at FL 280 at 1331:57 on a direct heading of about 288 degrees to RIL.

At 1345:58, N441AR reported to the FAA's Kansas City Air Route Traffic Control Center (ARTCC), "Uh yeah I'm an attitude gyro problem I'm hand flying um might be a few hundred feet deviation here and there."

At 1346:05, The ARTCC position R27 controller asked, "November one alpha romeo roger and you you'll be able to maintain flight level two eight zero correct?"

At 1346:10, N441AR responded, "Yeah I'll be able to maintain it just might be there's nothing wrong here I just want to let you know I might be off a hundred feet here and there."

At 1346:16, R27 stated, "November one alpha romeo roger if you need a block altitude you'll need to advise me if not uh you need to maintain flight level two eight zero."

At 1346:24, N441AR asked, "Two eight zero do you have any blocks?'

At 1346:28, R27 responded, "November one alpha romeo maintain flight level two seven zero through flight level two eight zero."

Radar data indicated that N441AR's altitude remained at FL 280 +/- 100 feet between 1345:58, when N441AR first indicated he was hand flying the airplane, and 1352:30, when R27 asked, "November one alpha romeo you are doing okay with the block altitude there correct?"

At 1352:34, N441AR responded, "I think that will work for me I'm just hand flying it so far it works (laughing).

At 1352:37, R27 stated, "November one alpha romeo roger contact Kansas city center one three three point two and they're uh they're aware that your auto pilot's out."

At 1352:46, N441AR reported, "An four four one alpha romeo I got uh an emergency here." Radar data indicated that N441AR's had descended to 27,300 feet, but had maintained a northwesterly heading.

At 1352:51, R27 responded, "November one alpha romeo understand you do have an emergency?"

At 1352:53, N441AR reported, "Uh it came back on nevermind." Radar data indicated that N441AR was in a left turn and its altitude was approximately 27,000 feet."

At 1353:17, N441AR reported, "And uh four four one alpha romeo I need to get to uh anywhere I can get a visual." Radar data indicated that N441AR's altitude was about 26,500 feet.

At 1353:26, R27 stated, "And November one alpha romeo let me see if I can get a tops report right quick for you there you want to go down."

At 1353:33, N441AR responded, "I'll go up." Radar data indicated N441AR's altitude was about 26,400 feet and it had turned back to a northwest heading.

At 1353:34, R27 asked, "One alpha romeo you want to go up sir?"

At 1353:36, N441AR responded, "Where it's visual."

At 1353:37, R27 stated, "Okay I think we're blocking each other November one alpha romeo do you wish to climb sir?"

At 1353:42, N441AR responded, "Uh unless there is any vfr below anywhere."

At 1353:51, R27 stated, "I'm not aware of any here just a second."

At 1353:51, R27 stated, "One alpha romeo climb and maintain flight level three one zero."

At 1353:56, N441AR responded, "Three one zero alpha romeo." Radar data indicated N441AR's altitude was about 27,000 feet.

At 1354:44, N441AR transmitted, "What's my airspeed?"

At 1354:46, N441AR transmitted, "I got to pull up I got to pull up baby." Radar data indicated that N441AR's altitude was approximately 19,000 feet.

At 1354:56, N441AR transmitted, "I need to go up need to go up." Radar data indicated that N441AR's altitude was approximately 18,000 feet.

At 1354:58, N441AR transmitted, "What do I do?"

At 1354:59, N441AR transmitted, "You're okay you're okay."

At 1355:00, N441AR transmitted, "We're headings headings okay now."

At 1355:03, N441AR transmitted, "Our heading up just pull it up."

At 1355:29, radar data indicated that N441AR's altitude was about 21,300 feet.

At 1355:34, R27 stated, "November one alpha romeo are you doing okay now?"

At 1355:37, N441AR responded, "I'm gonna I'm having trouble maintaining this level here." Radar data indicated that N441AR's altitude was approximately 18,000.

At 1355:43, R27 stated, "November one alpha romeo can you give me your altitude now sir?"

At 1355:45, N441AR responded, "Teen thousand."

At 1355:47, R27 stated, "Eighteen thousand."

At 1356:19, R27 asked, "November one alpha romeo are uh you still with me?" Radar data indicated that N441AR's altitude was about 15,000 feet.

At 1356:21, N441AR stated, "Yep."

At 1356:22, radar data indicated that N441AR's altitude was about 14,500 feet.

At 1356:29, N441AR transmitted, "We're back up."

At 1356:33, N441AR stated, "No gyro for one alpha romeo quickly no gyro headings for alpha romeo." Radar data indicated that N441AR's altitude was about 16,800 feet.

At 1356:38, R27 stated, "November one alpha romeo."

At 1356:40, N441AR stated, "Give me a no gyro for one alpha romeo quickly."

At 1356:43, R27 stated, "Okay November one alpha romeo just fly your present heading present heading will be just fine."

At 1356:47, N441AR stated, "Left or right."

At 1356:51, R27 stated, "November one alpha romeo just present heading uh no turns now just present heading." Radar data indicated that N441AR's altitude was about 13,700 feet.

At 1356:58, N441AR stated, "Okay now I got it."

At 1357:40, R27 asked, "November one alpha romeo how do you hear center?" Radar data indicated that N441AR's altitude was about 7,600 feet.

At 1358:08, N441AR stated, "Romeo give me." There were no further recorded radio transmissions from N441AR. Radar data indicated that N441AR's altitude was about 6,800 feet.

At 1358:14, a flight crew from Northwest Airlines flight NWA 406 stated, "Alpha romeo is trying to call you again."

At 1358:15, R27 stated, "Okay November one alpha romeo how do you hear center."

At 1358:29, radar data indicated that N441AR's final altitude readout was about 2,500 feet.

At 2000:03, R27 asked, "NWA406 did you hear any more calls from November one alpha romeo?"

At 2000:06, NWA406 stated, "Uh no sir we overheard him looking for a heading and say he was in a spin."

At 2000:12, R27 stated, "Okay I heard the same thing thank you."

Several witnesses on the ground reported hearing the airplane's engines while the airplane was still in the clouds, and then they saw the airplane descending out of the low cloud layer and impact the terrain. One witness reported that the airplane's right wing was up and rolling to the left, and the nose was pitched down about 60 degrees. He reported the airplane was intact and no smoke or fire was coming from the airplane prior to impact. The airplane burst into flames upon impact.

PERSONNEL INFORMATION

The pilot, age 60, held a private pilot with single engine land, multi-engine land, and instrument airplane ratings. He held a Third Class medical certificate issued on June 13, 2000. The pilot reported his total flight time was 1,500 hours during his last medical examination. The pilot's flight logbooks were not recovered during the course of the investigation.

Pilot training records indicated the pilot received initial ground school and flight training in the Cessna 441 in August 1998. He attended refresher flight training in the Cessna 441 in 1999, 2000, and 2001. On August 1, 2001, the pilot attended pilot refresher training and he reported a total flight time of 1,800 hours, with 260 flight hours in the Cessna 441. He reported he had a total of 350 hours in turboprop airplanes, and had flown 30 hours of instrument time in the last 6 months.

A witness, who was a professional pilot, reported he attended initial Cessna 441 flight training with the pilot and was hired by the pilot to fly the pilot's airplane on an on-call, day-to-day basis. He flew for the pilot after about one year. He reported another pilot was hired to fly the airplane for the next 1.5 years. The witness reported he started flying the airplane again within 12 months of the accident when his schedule permitted. The last flight he had flown in the airplane was August 4, 2001, and he reported everything on the airplane was working properly, including the pilot's attitude gyro and autopilot. The witness reported he had flown with the pilot about 10 times. He reported the pilot was proficient at using the autopilot, but he reported the pilot would have had a hard time flying the airplane without an attitude indicator and autopilot in the weather conditions encountered during the accident flight.

Another witness, who was a business associate of the pilot's and who held a private pilot's certificate and an airplane instrument rating, reported the pilot had been trying to sell the airplane for about six months prior to the accident. He reported the pilot flew the airplane approximately twice a month in the last six months. He reported that the pilot routinely flew with the autopilot on. He reported that as soon as the airplane was off the ground, the pilot turned the autopilot on. He reported, it was, "Gear up, flaps up, autopilot ON." He reported he never saw the pilot hand-fly the airplane in instrument conditions. The witness also reported that the pilot's wife, who was the passenger on board the airplane, had been taking flying lessons and had flown about 35 hours in a Cessna 182, which included about 9 hours of pilot-in-command time.

AIRCRAFT INFORMATION

The airplane was a twin engine Cessna 441, serial number 441-0148. The airplane seated 8 and had a maximum gross weight of 9,925 pounds. The engines were Honeywell (formerly Garrett) TPE-331-1ON engines, flat rated to 635 shaft horsepower. The last continuous airworthiness maintenance inspection was conducted on May 13, 2001. The airplane had flown 54.8 hours since the last inspection and had a total time of 3,529.9 hours.

A witness reported the pilot had stated in a conversation in December 2001, that the airplane's attitude gyro had an intermittent problem.

A witness who worked at an avionics repair shop reported the pilot had talked to him two days prior to the accident. The pilot stated he was having problems with the airplane's primary attitude gyro. The witness reported that he told the pilot that the attitude gyro needed to operate or else the autopilot would disconnect. He reported that the pilot did not bring the airplane in to get the attitude gyro fixed prior to the accident.

METEOROLOGICAL INFORMATION

At 1354, the observed weather at Winfield (WLD), Kansas, was: winds 00000 knots (not reported), visibility 4 sm, freezing rain, mist, sky conditions 100 feet, 1,300 feet overcast, temperature -1 degree C, dew point -2 degrees C, altimeter 30.01.

At 1356, the observed weather at Wichita (ICT), Kansas, was: winds 010 degrees at 15 knots, visibility 1 3/4 sm, light freezing rain ice pellets, mist, sky condition 1,400 feet overcast, temperature -5 degrees C., dew point -6 degrees, altimeter 30.04.

The National Weather Service (NWS) issued Area Forecasts that were available for preflight planning. The forecasts expected cloud bases overcast at 1,000 to 2,000 feet with tops from 20,000 feet, visibility restricted to 3 miles in light freezing rain and ice pellets, with isolated thunderstorms and moderate rain to snow. The NWS issued an amended Area Forecast at 1345 for southern and eastern portions of Kansas and Oklahoma for overcast ceilings at 1,000 to 2,000 feet with clouds layered to 25,000 feet, with visibilities 3 - 5 miles in light freezing rain, snow, and mist. Across the southeast quarter of Kansas isolated embedded thunderstorms were expected with light freezing rain and snow, and cumulonimbus cloud tops to 30,000 feet.

The NWS's Aviation Weather Center (AWC) issued a full series of AIRMET bulletins at 0844 for IFR conditions, icing, and turbulence. The AIRMETs were valid until 1500 and encompassed the accident site. AIRMET Sierra was current for IFR conditions with occasional ceilings below 1,000 feet and/or visibilities below 3 miles in light snow, freezing rain, ice pellets, and mist. AIRMET Zulu was for frequent moderate rime to mixed icing in-clouds and in-precipitation between the freezing level and 25,000 feet. AIRMET Tango was for occasional moderate turbulence below 18,000 feet with another area identified between 18,000 feet and 39,000 feet to the west and north of the accident site associated with the jet stream. [See the National Transportation Safety Board's (NTSB) Meteorology Factual Report]

The pilot of NWA 406 reported that they were flying at 33,000 feet and were "barely on top" of the clouds.

WRECKAGE AND IMPACT INFORMATION

The NTSB on-site investigation of the accident began approximately 1100 on February 1, 2002. The airplane wreckage was located in a pasture about 5 miles southeast of Winfield, Kansas, at coordinates N 37 degrees 08.522 minutes, W 096 degrees 54.119 minutes.

The airplane impacted the ground on about a 280 degree heading in about an 80 - 90 degree nose down attitude. The airplane's wings, engines, fuselage, and tailcone were located at the initial impact site. The cockpit, the right inboard wing and engine nacelle, fuselage, and tail control surfaces were destroyed by post-impact fire. The nose cone of the airplane was found crushed in a nearly symmetrical pattern back to the cockpit's pressure bulkhead. The cockpit controls and instruments were destroyed by impact forces and fire damage. The main landing gear remained attached to the wings and were found in a near retracted position.

The leading edge of the right wing was found flattened along its span outboard of the right engine nacelle. The upper skin of the right wing was found about 29 feet in front of the main wreckage. The lower skin of the right wing was found about 63 feet aft of the right wing.

The leading edge of the left inboard wing was found crushed and buckled. The upper skin of the left outboard wing had separated from the wing and was found lodged in trees two feet in front of the left wing. The lower skin of the outboard wing was found about 52 feet aft of the left wing.

The left flap was found separated from the wing and was lying behind the left wing. The right inboard flap was found lying 10 feet aft of the right wing. The hydraulic actuator common to the left and right flaps had both its fluid lines separated at the actuator by the post-impact fire, and about 3 inches of the actuator was exposed. The left and right outboard flaps remained attached to the wings and were found in the up position.

The left aileron remained attached to the left wing. The left aileron trim tab at the left aileron trim actuator was out 1.5 inches, approximately 5 degrees up position. The right aileron had separated from the right wing and was found lying in the debris next to the right engine. Aileron cable control continuity was confirmed from each control cable end to the forward cockpit area.

The tailcone and vertical stabilizer were located to the front and right of the cockpit and fuselage. Cable control continuity was established to the elevators and rudder control cable ends to the forward cockpit area. The outboard segment of the left horizontal stabilizer and elevator was burned and found aft of the right wing. The right horizontal stabilizer was burned and found forward of the cockpit. The rudder was destroyed by fire.

The left engine and nacelle were found partially attached to left wing. The left propeller remained attached to the left engine. The propeller blades exhibited S-shaped bending, leading edge damage, and chordwise scratching. One of the propeller blades separated about 6 inches inboard of the blade tip.

The right engine was found near the right engine nacelle but had separated from its engine mounts. The right propeller and engine gearbox had separated from the engine and was found near the right engine. The propeller blades exhibited S-shaped bending, leading edge damage, and chordwise scratching. The left and right engines were sent to the engine manufacturer for engine teardown examinations.

The copilot's attitude indicator's gyro was examined. The attitude gyro and the gyro housing had rotational scoring marks on their surfaces. The copilot's directional gyro was examined. The directional gyro and the gyro housing had rotational scoring marks on their surfaces. The pilot's gyro horizon indicator and the pilot's horizontal situation indicator were sent to the NTSB Materials Laboratory for examination.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed on the pilot and student-pilot rated passenger at the Sedgwick County Regional Forensic Science Center, Wichita, Kansas, on February 2, 2002.

Fatal Toxicology Fatal Accident Reports were prepared by the FAA Civil Aeromedical Institute. The report concerning the pilot indicated the following results:

Carbon Monoxide: Not Performed

Cyanide: Not Performed

Volatiles:

No ethanol detected in kidney.

37 (mg/dL, mg/hg) ethanol detected in muscle.

1 (mg/dL, mg/hg) N-Propanol detected in muscle.

Note: The ethanol found in this case is from postmortem ethanol formation and not from the ingestion of ethanol.

Drugs

Bupropion detected in kidney.

Bupropion detected in liver.

Bupropion metabolite detected in liver

Diphenhydramine detected in kidney.

Diphenhydramine detected in liver.

Tramadol detected in muscle.

Tramadol detected in liver.

Amlodipine present in kidney.

Amlodipine present in liver.

Bupropion is a prescription medication used for the treatment of depression and attention deficit hyperactivity disorder. It is also used in smoking cessation. Diphenhydramine (commonly known by the trade name Benadryl) is an over-the-counter antihistamine with sedative effects, often used to treat allergy symptoms. Tramadol is a prescription narcotic-like pain killer used for the management of moderate to severe pain.

The toxicology report prepared on the student-pilot rated passenger was negative for all tests conducted.

TESTS AND RESEARCH

The NTSB Materials Laboratory examined the pilot's gyro horizon indicator, Honeywell Model GH-14 Gyro Horizon Indicator, and the horizontal situation indicator gyro. The report stated the gyro horizon indicator was severely impact and fire damaged, and the gyro rotor was severely fire damaged. Due to the fire damage, no rotational marks could be seen on the gyro rotor.

The inspection of the horizontal situation indicator's gyroscopic rotor and the rotor housing revealed rotational scoring marks on the rotor and on the inside of the housing. (See NTSB Materials Laboratory Factual Report)

The pilot's gyro horizon indicator was re-inspected at the laboratory of Fowler, Inc., in Gardena, California, on November 13, 2002. The teardown and inspection of the gyro horizon indicator revealed that the type and degree of damage was indicative of gyro rotation at the time of impact with the ground. (See Honeywell Teardown of Gyro Horizon Indicator, December 9, 2002)

The engines were inspected at Honeywell Engines & Systems, Phoenix, Arizona, on February 19, 2002. The inspection revealed that the type and degree of engine damage was indicative of engine rotation and operation at the time of impact with the terrain. No pre-existing conditions were found on either engine that would have interfered with normal operation. (See Honeywell Teardown Report of Two TPE331-10N Turboprop Engines, August 8, 2002)

ADDITIONAL INFORMATION

Parties to the investigation included the FAA, Cessna Aircraft Company, and Honeywell.

The aircraft wreckage was released to Kern and Wooly, Los Angeles, California.
































































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