Friday, March 09, 2012

Cessna 320D, N320KP: Accident occurred May 22, 2009 in Fallon, Nevada

NTSB Identification: WPR09FA258 
14 CFR Part 91: General Aviation
Accident occurred Friday, May 22, 2009 in Fallon, NV
Probable Cause Approval Date: 03/08/2012
Aircraft: CESSNA 320D, registration: N320KP
Injuries: 4 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

Witnesses reported seeing the airplane approach the airport from the southwest and cross near mid-field to enter the left traffic pattern for landing. Witnesses observed the airplane make a right 270-degree turn to enter on the downwind and, after becoming established on the downwind, make a sharp left turn and descend out of sight near a point consistent with a turn to a close-in base leg. Witnesses then reported seeing a fireball erupt in the area of the accident site. On the downwind leg, at a radar-recorded ground speed of 93 to 106 knots, the airplane's indicated airspeed could have been between 71 and 81 knots, which is in the range of potential stall speeds. Ground scar and wreckage signatures were consistent with a nose-low and left-wing-low ground impact. The witness observations and the impact attitude could be consistent with a stall and loss of control. No anomalies or other conditions were found with either engine that would have precluded normal operation.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot’s inadequate airspeed, which resulted in an aerodynamic stall.

HISTORY OF FLIGHT

On May 22, 2009, about 1935 Pacific daylight time (PDT), a Cessna 320D, N320KP, impacted terrain during landing at Fallon Municipal Airport (FLX), Fallon, Nevada. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot and three passengers were fatally injured; the airplane was substantially damaged by impact forces and post crash fire. The cross-country personal flight departed Fresno, California, about 1830, with a planned destination of Fallon. Visual meteorological conditions prevailed, and no flight plan was filed.

Witnesses to the accident reported seeing the airplane approach the airport from the southwest and cross mid-field to enter the downwind leg for landing on runway 21. The airplane was observed making a right 270-degree turn to the downwind leg. At a base turn point, the airplane made a sharp left turn and descended out of sight. Witnesses then reported seeing a fireball erupt in the area of the accident.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed that the 44-year-old pilot held a commercial pilot certificate with ratings for airplane multi engine land and instrument airplane.
The pilot held a second-class medical certificate issued on September 14, 2007, with no limitations or waivers listed.

At the time of the accident, the pilot was a U.S. Naval aviator, and was current and qualified in the F/A-18, which is a multi engine jet with centerline thrust.

An examination of the pilot's flight records as of September 12, 2008, indicated the pilot had accumulated a total flight time of 3,235 hours, with an estimated 204 hours in the accident make and model. A biennial flight review was completed on July 23, 2008.

The investigation team was unable to recover any records, or witnesses, that indicated the pilot had obtained any recent flight training involving the make and model of the accident airplane, or for any multi engine airplane with differential thrust.

The pilot’s total civilian flight time at the time of the accident could not be determined.

The pilot utilized the accident airplane to facilitate roundtrip flights between Fallon and Fresno to pickup family members. He would depart from Fallon and fly to Fresno, where he would fill the main fuel tanks. He would then fly back to Fallon. On his trip retuning to Fresno he would again fill the main fuel tanks for his return to Fallon. No records of the pilot buying fuel at Fallon were located. The FBO at Fresno was contacted and reported that the accident pilot would fly in and only obtain fuel in the main fuel tanks, and had no record of him ever having the auxiliary fuel tanks fueled.

AIRCRAFT INFORMATION

The airplane was a Cessna 320D, serial number 0070. A review of the airplane’s logbooks revealed that the airplane had a total airframe time of 5,667.8 hours at the last annual inspection. The logbooks contained an entry for an annual inspection dated September 23, 2008. The tachometer read 4452.3 at the last inspection. The last maintenance entry was on January 22, 2009, with a total airframe time of 5,687.1 hours, and the tachometer read 4471.6, reflecting the replacement of two new Gill 25 batteries.

The left engine was a Teledyne Continental Motors TSIO-520-B, serial number 176347-R. Total time recorded on the engine at the last 100-hour inspection was 1,481.3 hours, and time since major overhaul was 1,481.3 hours.

The right engine was a Teledyne Continental Motors TSIO-520-B, serial number 145061-5-B. Total time recorded on the engine at the last 100-hour inspection was 4,452.3 hours, and time since major overhaul was 108.5 hours.

Fueling records at Fresno Yosemite International Airport (FAT) established that the airplane was last fueled on May 22, 2009, with the addition of 62.5 gallons of 100-octane aviation fuel. The lineman reported that on the several occasions when he fueled the airplane, he always filled the main fuel tanks to capacity. He could not remember ever putting fuel in the auxiliary fuel tanks.

Examination of the maintenance records revealed no unresolved maintenance discrepancies against the airplane prior to departure.

According to the Cessna 320D Owner's Manual, the power-off stall speed at maximum gross weight with the landing gear down and 15 degrees of flaps extended at 20 degrees of bank is 82 miles per hour (71 knots); at 40 degrees of bank is 92 miles per hour (79 knots).

METEOROLOGICAL CONDITIONS

Official weather observations were not available at FLX. Weather observation taken from Naval Air Station Fallon (NFL), which is 5.5 nm south of FLX, at 1856 was: wind 250 degrees at 25 knots gusting to 32 knots; peak winds of 230° at 36 knots were recorded at 1922; visibility 10 statute miles (sm), few clouds at 12,000 feet, ceiling 16,000 feet broken, and 25,000 feet overcast. The temperature was 25 degrees Celsius; dew point was 2 degrees; and the altimeter was 29.88 inches of mercury. Airport elevation for FLX was 3,963 feet.

COMMUNICATIONS

On May 22, 2009, about 1830, the airplane departed Fresno Yosemite International Airport (FAT), Fresno, under visual flight rules (VFR), en-route to FLX. Air traffic control services provided by FAT, Oakland Center (ZOA), and Reno Approach Control were unexceptional.
At 1927, the pilot informed the Reno approach controller he had FLX in sight and was switching frequency. There were no further communications with the pilot. Radar data indicated the airplane was approximately 25.5 statute miles southwest of FLX when the pilot reported the airport in sight.

A factual report was completed by a NTSB Air Traffic Control Specialist on October 23, 2009. The complete report is attached to the docket.

A review of the radar data for the accident flight revealed that the airplane approached FLX from the southwest and crossed the runway centerlines just south of the airport heading in a northeasterly direction about 700 feet agl. Once the airplane was on the east side of the airport, the airplane made a right descending 270-degree turn to enter the downwind leg for landing on runway 21. The last three radar returns indicated that the airplane was about 240 feet agl.

At 1935:35, the radar return revealed the airplane completed a 270-degree turn and had a ground speed of 93 knots, and was headed in a northeasterly direction. The last radar return was recorded at 1935:47, and the ground speed was 106 knots approximately 1/2 mile southeast of the approach end of runway 21.

The wreckage was located approximately .3 statute miles north of the last radar return.

AIRPORT INFORMATION

The Fallon Municipal Airport was located approximately 2 miles northeast of Fallon. The airport had two runways: runway 3/21 was asphalt, and runway 13/31 was dirt. The airport elevation was 3,963 feet. Approach and departure service was provided by ZOA when Navy Fallon Approach Control was closed for operations. The official weather observation at the airport was provided by the Naval Aviation Forecasting Component - Weather (NAFCOMP), Naval Air Station, Fallon.

WRECKAGE AND IMPACT INFORMATION

Investigators examined the wreckage at the accident scene. The first identified point of contact (FIPC) was a ground scar. The debris path was along a magnetic heading of 294 degrees. The orientation of the fuselage was 310 degrees. The airplane impacted the flat terrain in a left wing low, and nose-low attitude.

The approximate 124-foot-long debris path extended along an approximate 338-degree heading with the majority of the airplane on a berm along the south side of Enterprise Way, approximately 1/3 SM east of Indian Lakes Road. The accident site is located approximately 1 SM east of the FLX runway 21 threshold.

The wreckage burned extensively where it came to rest. The cockpit, cabin, right wing, aft fuselage, and tail cone were mostly consumed by fire. Parts of the nose and left wing were fire damaged. All major components of the airplane were accounted for on site.

The landing gear system gearbox and linkage were in the gear extended position. The flap actuation linkage indicated the flaps were extended to approximately 12 degrees.

The left propeller assembly separated from the engine and was found near the initial impact point. The propeller hub had damage at the flange mount area, and interior components had separated and were found nearby. The spinner had crushing and ripping at the tip and blade areas.

-Blade A had a slight S-bend near the tip and chordwise scratches on the chambered face near the tip. The blade had a slight decreased pitch twist.

-Blade B had leading edge and span-wise scratches from the mid-section to the tip and chordwise at the tip. A portion of the deice boot separated from the blade. The blade had S-bending from the shank to the tip with a decreased pitch twist.

-Blade C was loose in the hub and had scuffing at the tip on the chambered face. The blade had leading damage and chordwise scratches on the chambered face. The blade had aft bending from the mid-section to the tip and a decreased pitch twist.

The right propeller assembly was found near the main wreckage forward of the right engine. The propeller hub had damage at the flange mount area. A small portion of the propeller flange remained attached to the hub. The spinner had crushing and ripping at the tip and blade areas.

-Blade A was loose in the hub and was bent aft near the shank and at the midsection. The chambered face had chordwise scratches from the mid-section to the tip. The blade face had span-wise scratches and scuffing near the tip. The blade had a decreased pitch twist from the mid-section to the tip.

-Blade B was loose in the hub and was bent aft at the mid-section. The chambered face had chordwise scratches at the tip and multi directional scratches from the mid-section to the tip. The face of the blade was undamaged.

-Blade C had leading edge damage and chordwise scratches from the mid-section to the tip. The face of the blade had light scratches at the tip. The blade had a slight forward bending from near the shank to the tip.

Examination of the fuel system revealed that the left fuel selector valve was selected to the left main fuel tank. The right fuel selector valve was selected to cross-feed, which would draw fuel for the right engine from the left main fuel tank. The POH calls for the left and right main fuel tanks to be selected for takeoff and landing.

The right main and right auxiliary fuel tanks were consumed by post impact fire. The left main fuel tank was fire and impact damaged and did not contain fuel. The left auxiliary fuel tank was not compromised and contained approximately 2.5 gallons of blue fuel, which tested negative for water contamination. Unusable fuel for one auxiliary fuel tank is 3 gallons. A strong smell of aviation gasoline permeated the area around both fuel tanks.

MEDICAL AND PATHOLOGICAL INFORMATION

The Washoe County Coroner completed an autopsy on May 24, 2009. The FAA Civil Aerospace Medical Institute (CAMI), Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot.

Analysis of the specimens for the pilot contained no findings for volatiles or tested drugs. They did not perform tests for carbon monoxide or cyanide.

TESTS AND RESEARCH

Teledyne Continental Motors (TCM) personnel examined the engines under the supervision of the National Transportation Safety Board investigator at the factory in Mobile, Alabama, on June 15, 2009. TCM submitted a written report, and the IIC Safety Board investigator who observed the inspection concurred with the facts in the report.

The left engine was noted to have impact damage to the front of the engine cases. It was determined that with minor repairs to the engine cases the engine could be run in the test cell.

The engine was successfully run in the engine test cell. No anomalies were noted that would affect normal operation.

The right engine was thermally damaged, which prevented running the engine in the test cell. The right engine was disassembled and examined. No mechanical anomalies were noted that would prevent normal operation.



An enduring mystery will enshroud the May 22, 2009, plane crash that killed veteran Navy aviator Lt. Commander Luther H. Hook III and his three daughters.

In a long-awaited final report, federal investigators this week concluded Hook's plane crashed because it fatally slowed while landing amidst stiff winds at Fallon, Nev. The precise reason why, though, remains unknown.

"The pilot's inadequate airspeed...resulted in an aerodynamic stall," the National Transportation Safety Board concluded in a final report officially adopted Thursday.

Clovis, Calif., residents Kaitlyn Elizabeth Hook, 15, Rachel Katherine Hook, 12, and Mackenzie Elena Hook, 9, died in the Memorial Day weekend crash, along with the 44-year-old pilot.

The nearly three-year investigation lasted longer than most safety board probes into fatal aviation accidents, which more typically take 18 months to two years. The final report on a fatal plane crash in New Mexico that killed two on the same day as the Fallon accident, for instance, was wrapped up last June.

Despite the extended time, investigators couldn't pin down exactly how it was that one of the Navy's high-speed fighter pilots allowed his civilian plane to stall. The probable cause report made final this week simply noted the available evidence "could be consistent" with a stall and subsequent loss of control.

Investigators, moreover, avoided loaded terms such as "error" or "mistake" in their final report.

"No anomalies or other conditions were found with either engine that would have precluded normal operation," the safety board added.

Hook's fellow Navy aviators, who called him by the nickname "Meat," knew him as someone supremely prepared to handle flight risk.

A 1986 Naval Academy graduate, Hook was serving as the executive officer of Naval Air Station Fallon at the time of the accident. He had accumulated more than 3,235 hours of flight time, many of them in the Navy's screamingly fast F/A-18 Hornet, which can approach twice the speed of sound.

During his career, Hook had served at Naval Air Station Lemoore in the San Joaquin Valley and had deployed on four different aircraft carriers. He had been awarded, among other decorations, the Air Medal for his combat service in Iraq.

On the day of the accident, he had flown his twin-engine Cessna 320 from Nevada to pick up his daughters from Clovis, where they lived with their mother, Brenda Hook, and stepfather, Pat Doles. Hook was living in Fallon at the time with his second wife, Wende, and their two young daughters.

Hook and his daughters took off from Fresno Yosemite International Airport about 6:30 p.m. About an hour later, investigators found, he radioed ground controllers that he had Fallon Municipal Airport in sight. Winds were blowing about 25 knots with gusts up to about 36 knots, which is enough to make trees sway

"He was flying in a good, controlled manner, and I was thinking how much fun it would be to fly one of them," one witness, Fallon resident Hal David Boehm, told investigators.

Witnesses told investigators that they saw the plane make a right turn to establish a downwind approach, then they saw it make a sharp left turn and descend out of sight.

"(I saw) a huge amount of black smoke, and I notified two daughters at my residence to get medical equipment...and call 911," Fallon resident Louis Madraso told investigators.