LAX06FA131
LAX06FA131

HISTORY OF FLIGHT

On March 28, 2006, about 1655 Pacific standard time, a Cessna 208B, N208WE, departed controlled flight and descended into mountainous terrain while maneuvering near Oak Glen, California. Cessna Aircraft Company was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. Both the commercial pilot and private pilot on board were killed. The airplane was destroyed. The cross-country business flight departed Jacqueline Cochran Regional Airport (TRM), Thermal, California, about 1635, with a planned destination of Ontario International Airport (ONT), Ontario, California. Instrument meteorological conditions (IMC) prevailed, and an instrument flight rules (IFR) flight plan had been filed; however, the flight plan had not been activated.

Cessna Aircraft Company owned and operated the accident airplane, which was being piloted by an independent regional aircraft sales distributor/pilot (RSD) and a Cessna Caravan Sales Manager/pilot (CSM). The CSM pilot, flying the accident airplane, departed Wichita, Kansas, on March 27, 2006. The purpose of the trip was to market the airplane to prospective customers. The CSM pilot flew the airplane to North Las Vegas, Nevada, where he met with the RSD pilot.

After staying overnight in North Las Vegas, both pilots flew to Kingman, Arizona, then on to Thermal (TRM). In the area of TRM, the two pilots conducted a demonstration flight for a prospective customer. The demonstration flight lasted about 1 hour. After the demonstration flight, and prior to departing TRM, the airplane was serviced with 100 gallons of Jet-A fuel. The CSM pilot requested and received an abbreviated weather briefing from the Riverside Flight Service Station, which included an airman's meteorological information notice (AIRMET) for occasional moderate rime ice. He then filed an IFR flight plan from TRM to ONT via Airway V388 through the 'DEWAY' intersection and to the Paradise (PDZ) VOR, with a planned en route altitude of 10,000 feet.

The CSM pilot listed himself as the pilot-in-command. Witnesses at TRM saw the CSM pilot get into the right front seat of the airplane and the RSD pilot seat himself in the left front seat. The airplane took off in visual meteorological conditions and subsequently received VFR (Visual Flight Rules) flight following. The filed IFR flight plan was not activated.

At 1636:03, the crew received a transponder code (4711) from the Palm Springs Approach Control, and one of the pilots replied by stating, "400 feet off of thermal, ah VFR through the pass and then it's gonna be, ah I'd like to pick up a IFR after the pass to Ontario."

At 1649:52, Palm Springs Approach Control handed the flight off to Southern California Terminal Radar Approach Control TRACON (SCT). During the handoff, the Palm Springs controller told the crew that SCT was aware of their request to pickup an IFR clearance to Ontario after the pass.

At 1651:50, just after passing the 'DEWAY' intersection, radar data shows the airplane at a point north of Banning Airport (BAN), Banning, California, approximately 7 nm east of the boundary line for the SCT class "E" airspace, and making a right turn on a west/northwest track heading toward the rising terrain of the San Bernardino mountain range.

At 1654:03, radar return data shows the airplane continuing a climb, crossing 7,900 feet mean sea level (msl) and beginning a more aggressive turn, to the right, toward rising terrain.

At 1653:44 and 1654:16, the crew makes two identical calls to SCT, "So Cal Approach caravan two zero eight whiskey echo." The radar return data shows the airplane at this point in a climb starting at 7,300 feet msl and still heading towards rising terrain.

At 1654:48, SCT gave the crew an altimeter setting "29.86" and asked them to ident. After the ident, the SCT controller said, "November two zero eight whiskey echo, you're turning north into higher terrain uh, you're radar contact ten miles uh, north of Banning, mode C indicates eight thousand five hundred, do you have uh the terrain in sight sir?"

The pilot did not answer the question, but instead, at 1655:03, the pilot replied, "Uh, eight whisky echo, we're uh, maneuvering away from the terrain right now."

At 1655:07, the controller said "Roger uh, continue on a southwesterly heading please, radar contact." There was no other communication heard from the mishap airplane.

At 1655:18, the controller noticed the flight had disappeared off ATC radar and made two calls to the mishap airplane stating that radar contact was lost. According to the ATC radar track, the last location of the airplane was approximately 1 nm south of the 8,900-foot San Bernardino mountain range.

At a point north of BAN, recorded radar data showed that the airplane made a right-hand turn toward rising terrain while continuing to climb to an approximate altitude of 8,800 feet msl. The last minute of radar data showed the airplane at mode C reported altitudes of 8,000 feet msl at 1654:01; 8,800 feet msl at 1655:03; and 8,600 feet msl at 1655:08. The last radar return was at 1655:12, at a mode C reported altitude of 7,300 feet msl.

At the time of the accident, three residents at the Oak Glen Conservation Camp reported that while walking to the dining hall, they heard the sound of an aircraft overhead. They said they could not see it because the clouds were too low. The Oak Glen Conservation Camp is based in the San Bernardino National Forest at an elevation of 5,500 feet. When they first noticed the sound of the aircraft, two of the witnesses described the sound as similar to a "fluid starved power steering pump - whining." The other witness described the sound as a continuous "real, real, real" sound. According to a Cessna representative, these sounds are consistent with the sound the accident airplane would make in a cruise climb. While the witnesses were commenting amongst themselves about what they had heard, the sound suddenly changed to a high-pitched rpm (revolutions per minute) sound that continued to increase in pitch. All three witnesses looked up to the right and saw the accident airplane coming out of the clouds almost straight down. The witnesses also described the weather as cold and drizzling rain, with reduced visibility due to the clouds. Within minutes after the accident, the witnesses said that the weather worsened and it started to sleet and snow.

Search and rescue personnel were notified, but before they could locate the accident site, the weather deteriorated in the intended search area. The search was suspended until the following morning.

Los Angeles Air Route Traffic Control Center (ZLA ARTCC) issued an alert notice (ALNOT) at 1937 on March 28, 2006. There was no Emergency Locator Transmitter (ELT) signal reported. The airplane wreckage was subsequently located the following morning about 0920 by personnel from the San Bernardino County Sheriff's Department search and rescue team. The wreckage was located about 3/4-mile north of the Oak Glen Conservation Camp. The elevation at the accident site was 6,073 feet.

PERSONNEL INFORMATION

LEFT SEAT PILOT-RSD Pilot

A review of Federal Aviation Administration (FAA) airman records revealed that the RSD pilot held a private pilot certificate with ratings for airplane single engine land, and instrument airplane.

The pilot, age 45, held a third-class medical certificate issued on July 19, 2005. It had no limitations or waivers.

No personal flight records were located for the pilot. The IIC obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City. The pilot reported on his medical application that he had a total time of 2,300 hours.

RIGHT SEAT PILOT-CSM Pilot

A review of FAA airman records revealed that the CSM pilot held a commercial pilot certificate with ratings for airplane single engine sea, multiengine land, and instrument airplane, with private pilot privileges for single engine land.

The pilot, age 53, held a first-class medical certificate issued on December 19, 2005. It had the limitation that the pilot must wear corrective lenses.

An examination of the pilot's logbook indicated an estimated total flight time of 1,792 hours. He logged 48.3 hours in the last 90 days, and 15.1 in the last 30 days. He had an estimated 741.7 hours in this make and model. He completed a biennial flight review on September 9, 2004.

AIRCRAFT INFORMATION

The Cessna Aircraft Company owned the airplane, and the Cessna Aircraft Company, Air Transportation Department (ATD), operated the airplane as a marketing flight demonstrator.

The airplane was a Cessna Caravan 208B, serial number 208B1171, and received its airworthiness certificate on January 26, 2006.

Since the airplane's first flight, on January 13, 2006, there were five maintenance transaction record (MTR) entries for the airplane. An entry on January 16, 2006, (MTR, Book 1, Page 3) complied with Airworthiness Directive (AD) 2006-01-11; requiring the installation of a pilot assist handle, deicing boots on the cargo pod, landing gear fairings, and appropriate changes to the Pilot's Operating Handbook (POH). MTR, Book 1, Page 4 and 5 were not found. It is believed that pages 4 and 5 were completed by Yingling Aviation. According to Yingling's Quality Manager, Page 4 was for the Avionics installation, and page 5 had to do with the interior installation completed on February 17, 2006.

After the airplane had accumulated 33.2 hours, there was another entry on March 15, 2006, (MTR, Book 1 Page 6), which removed and replaced the Radar Altimeter, the Pitch Servo, and the Flap Actuator Assembly with new components. The last maintenance entry was on March 25, 2006, at 52.0 total hours; (MTR, Book 1, Page 7) this maintenance record showed compliance with the Icing Limitations AD, 2006-06-06, to place a placard onto the instrument panel and into the POH.

Pages 5, 6, and 7 of the Aircraft Flight Records were also not found (this is the time between February 28, 2006, thru March 17, 2006). The last recorded flight was on Book 1, Page 10, on March 28, 2006; the airplane total flight time after this flight was: 50.1 hours.

The engine was a Pratt & Whitney PT6A-114A, serial number PC1257.

Fueling records at TRM established that the airplane was last fueled on March 28, 2006, with the addition of 100 gallons of Jet-A fuel. Examination of the maintenance and flight department records revealed no evidence of unresolved maintenance discrepancies against the airplane prior to departure.

METEOROLOGICAL CONDITIONS

A staff meteorologist for the Safety Board prepared a factual report, which included the following weather for the departure area, route of flight, and destination.

The closest official weather observation station was March Air Reserve Base, Riverside, California (RIV), which was located 19.6 nautical miles (nm) southwest of the accident site. The elevation of the weather observation station was 1,535 feet msl. An aviation routine weather report (METAR) for RIV was issued at 1655. It stated: winds from 170 degrees at 8 knots; visibility 20 miles; skies 1,200 feet scattered, 2,300 broken, 3,500 broken, 9,000 overcast; temperature 12 degrees Celsius; dew point 05 degrees Celsius; altimeter 29.87 inHg.

A twin Cessna model 421, which was being flown on a 14 CFR Part 135 charter flight from Bermuda Dunes, California, to Torrance, California, via the airway V388, passed just south of the accident site about 20 minutes after the accident occurred. Investigators contacted the pilot, who, in a written statement, reported that the clouds around Palm Springs, California, (PSP) were 7,000 to 9,000 feet msl. He stated that the Banning pass looked like it had low clouds, which were dark and ragged. The pilot encountered moderate and occasionally severe turbulence; the worst was from the PSP VOR at 4,500 feet through 9,000 feet. He crossed the DEWAY navigation fix at 10,000 feet. The turbulence had diminished, and he was then between two layers of clouds. He stated that between PSP VOR and DEWAY he was in instrument meteorological conditions and only picked up a "trace" of rime ice. The pilot reported his total flight time was more than 12,000 hours, and he was very familiar with flight conditions around the accident site.

For further meteorological information, see the Meteorology Factual Report available in the public docket for this accident.

WRECKAGE AND IMPACT INFORMATION

The elevation at the accident site was 6,073 feet. The slope of the mountainside terrain was approximately 40 degrees. The airplane was located approximately 200 feet below a fire road and on the east side of the mountain ridge approximately 1,000 feet below the top of the ridge. The ridgeline to the north of the accident site rises to an elevation of 8,900 feet. The wings were oriented on a 040-degree and 220-degree heading. From the center fuselage, the left wing was upslope and on a 220-degree magnetic heading, and the right wing was downslope on a 040-degree magnetic heading. The fuselage was in a near vertical position, and the wreckage debris path was on a heading of approximately 115 degrees.

Trees and branches were damaged only in the immediate area of the main wreckage; the tree trunks exhibited scraping, scratching, and broken branches consistent with a near vertical descent of the airplane through the trees. One tree trunk, approximately 8 inches in diameter, was completely cut through approximately 15 feet above the base of the tree.

FUSELAGE

The airframe was heavily fragmented by the collision forces. All flight control cable separations were identified with tension overloads or shear separation consistent with the impact forces. The fuselage structure was pushed aft along the longitudinal axis to approximately the main landing gear trunnion mounts. An approximately 8-foot by 4-foot section of the aft lower fuselage structure was attached to the floor structure. The airplane cabin sidewall structure was heavily fragmented, fractured, and scattered throughout the wreckage site. The composite cargo pod structure was separated from the bottom of the airframe structure, fractured into multiple pieces, and scattered throughout the mishap site.

ENGINE

The majority of the engine cowling structure was crushed, fractured, and not identified in the wreckage. All of the engine accessories were separated from the core structure of the engine, and the engine was imbedded in the earth approximately 6 feet. The engine was heavily damaged and compressed through the longitudinal axis, to approximately 2 feet in length. The exhaust manifold (located on the right side of the engine) was separated from the engine and exhibited aft crushing damage at the forward section and ductile deformation around the base of a tree.

PROPELLER

The propeller was separated from the engine and imbedded in the ground. The propeller hub was fractured, and the three propeller blades were separated from the propeller hub. Each of the propeller blades exhibited leading edge damage. Two of the three were found in the same vicinity under the engine; one of the two had its tip curled aft approximately 90 degrees. The third propeller blade was found broken midspan, and located approximately 50 feet from the main impact location.

MEDICAL AND PATHOLOGICAL INFORMATION

LEFT SEAT PILOT (IRSD)

The San Bernardino County Coroner completed an autopsy. The cause of death was determined to be massive blunt force trauma. The FAA Civil Aeronautical Medical Institute (CAMI), Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, volatiles, and tested drugs.

RIGHT SEAT PILOT (CSM)

The San Bernardino County Coroner completed an autopsy. The cause of death was determined to be massive blunt force trauma. The FAA Civil Aeronautical Medical Institute (CAMI), Oklahoma City, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, and tested drugs.

The report contained the following findings for volatiles: 34 (mg/dL, mg/hg) ethanol detected in muscle. The report stated that the ethanol found in this case may potentially be from postmortem ethanol formation and not from the ingestion of ethanol.

TESTS AND RESEARCH

Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on April 2, 2006.

Investigators examined the engine after recovery; there were no anomalies noted during the examination that would have precluded normal engine operation.

Investigators examined the airplane fuselage and flight controls; there were no anomalies noted that would have precluded normal operations.

On April 3, 2006, four instrument gyros recovered from the wreckage, were taken to Otto Instrument Service, Inc., laboratory, Ontario, California, for examination. These include the gyros from the Standby Attitude Indicator (electric), Flight Director (pneumatic), Directional Gyro (electric), and the Autopilot Rate Gyro (electric). All four gyros exhibited evidence of rotational scoring.

The Standby Attitude Indicator gyro housing showed rotational scoring. The instrument face was stopped by the impact damage and had an indication >= 40 degrees left bank and full nose down attitude.

The Flight Director displayed a full nose down attitude on the display and rotational scoring of the gyro housing with gyro bucket vane impact imprints in the housing.

The Directional Gyro (DG) exhibited rotational scoring in the housing. The DG face card was destroyed.

The Autopilot Rate Gyro rotor showed rotational scoring, but the housing was destroyed.

The Flight History Data was successfully downloaded from the Honeywell EGPWS (Enhanced Ground Proximity Warning System); KMH880/820, Multi-Hazard Awareness System unit, P/N: 965-0702-001, S/N: SPE1216 at the Honeywell Laboratory in Redmond, Washington, on April 21, 2006. The data recorded in the EGPWS Flight History Database can be viewed in the Docket. The timeline is shown in MM:SS format starting 00:00 at the beginning of the recording for the event.

According to Honeywell, and the system data extracted from the EGPWS unit, the "TERR INHB" function was not selected; meaning, the terrain warning feature was active. This is indicated in column "S," titled "TADinh," from the data that was recovered. The zero digit indicates that the "TERR INHB" was not selected, which was the case for the last 37 seconds of recorded data. However, the data extracted also indicated the Terrain Display page was not the page the pilots were viewing on the 850 (Multi Function Display) during the later portion of the flight, but that the page changed to the terrain screen when the alert notice "Pop-Up" feature occurred at t=00:19 seconds during the final event sequence.

The KMD 850 Multi Function Display (MFD) displays the KMH 880 Integrated Hazard Awareness System data (data within the KMH 820 box circuit cards) along with weather radar data display information. According to Honeywell, data depicting the actual pages that were being viewed on the 850 is not captured; only that a "Pop-Up" event occurred across the screen. Time capture in the unit is "operational time" recorded during events. Global Positioning System (GPS) date and time information is not captured.

A staff Aircraft Performance Specialist for the Safety Board prepared a performance report, which utilized data from the Airport Surveillance Radar data, Enhanced Ground Proximity Warning system, and incorporated ATC transmissions. The results indicate that the bank angle steadily increased during the final turn, until a very abrupt change in pitch occurred, and the airplane departed controlled flight and descended very steeply into terrain.

ADDITIONAL INFORMATION

Four employees of Cessna who personally knew the CSM pilot reviewed the ATC transmission recordings between the accident airplane and controllers. All four identified the voice of the pilot making the radio calls as that of the CSM.

An individual, who works at Signature, recalled that the airplane had arrived with two people onboard. A third person got onboard, and the three people went out for about a 45-minute flight. The airplane returned to drop off the third person and took on the above mentioned fuel. He also stated he had a casual conversation with the CSM pilot about the Cessna Caravan because he had never seen one before. They had no conversation about the weather, but the last words he remembered from the CSM, before they departed for the mishap flight, were that "he (CSM) was going to let the RSD "drive" the plane, and he (CSM) was going to do paperwork."

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