Friday, January 22, 2021

Aerodynamic Stall/Spin: Cessna 414, N727RP; fatal accident occurred August 05, 2018 near John Wayne Airport (KSNA), Santa Ana, Orange County, California

 

Floria Hakimi posted this picture to Instagram two hours before the plane crashed with the caption, 'Flying out to LA'.


 Nasim Ghanadan

Lara Shepherd and pilot husband Scott.

Navid Hakimi



Aviation Accident Factual Report - National Transportation Safety Board

The National Transportation Safety Board traveled to the scene of this accident. 

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Long Beach, California
Continental Aerospace; Mobile, Alabama
Textron Aviation;  Wichita, Kansas 

Investigation Docket - National Transportation Safety Board:


Location: Santa Ana, California 
Accident Number: WPR18FA211
Date & Time: August 5, 2018, 12:29 Local
Registration: N727RP
Aircraft: Cessna 414
Aircraft Damage: Destroyed
Defining Event: Aerodynamic stall/spin 
Injuries: 5 Fatal
Flight Conducted Under: Part 91: General aviation

On August 5, 2018, about 1229 Pacific daylight time, a Cessna 414 airplane, N727RP, was destroyed when it was involved in an accident near Santa Ana, California. The pilot and four passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight.

A review of the John Wayne-Orange County Control Tower (SNA) Air Traffic Control Tower (ATCT) audio revealed that the pilot contacted SNA tower at 1225, and reported the airplane was at an altitude of 1,700 ft. The controller instructed the pilot to make right traffic for runway 20R. The pilot acknowledged the instruction and the controller then asked the pilot if he could accept runway 20L and informed him the runway was 2,850 ft long. The pilot responded that he was unable to land on runway 20L. Subsequently, the pilot was instructed to hold over the South Coast Plaza, a local VFR holding point, and to conduct left 360 turns for sequencing. Less than a minute after denying the original response to land on runway 20L, the pilot responded that he could accept runway 20L for landing. The controller then instructed the pilot to accomplish a left 270° turn and cross directly over the tower at or above 1,300 ft, for left traffic to runway 20L. The pilot acknowledged the instruction.

About 23 seconds later, the controller instructed the pilot to “climb back up to 1,300 ft or above.” Four seconds after the instruction the pilot stated, “emergency, emergency, emergency.” A review of audio transcripts, flight data, and a discussion with an ATCT who witnessed the event, were all consistent with the pilot’s emergency transmissions being made during the start of the steep nose-down descent. No further transmissions were received by the pilot.

A review of flight data provided by the airplane’s Appareo Stratus 2S ADS-B device showed at 1929:10 (all times given as Coordinated Universal Time (UTC), the airplane was at 96 knots and an altitude of 960 ft msl. Shortly thereafter, the airplane began a left turn. Initially, the airplane’s left bank increased to about 15°; about 10 seconds later, the left bank increased to about 30°. At 1929:15, the airspeed was 91 knots, and the altitude was 955 ft msl. At 1929:20, the airspeed was 85 knots and the altitude was 950 ft msl. The airplane continued the left turn and at 1929:25, the airspeed was 73 knots, the altitude was 894 ft msl, and the roll rate was increased to over 40° of bank; over the next few seconds, the bank increased to nearly 90°. The airplane began to descend, and the vertical speed was about -1200 ft per min (fpm). From this time forward, the airplane’s descent rate increased rapidly. At 1929:27, the airspeed was 62 knots, the altitude was 765 ft msl, and the vertical speed was about -2,300 fpm. At 1929:30, the airspeed was 66 knots, the altitude had decreased to 499 ft msl, and the vertical speed was about -4,400 fpm. The last recorded data point was at 1929:33, when the airspeed was 59 knots, the altitude was 292 ft msl, and the vertical speed about -5,250 fpm.

Multiple witnesses, near the accident site, observed the airplane enter the left bank turn and shortly thereafter, they observed the bank increase and the airplane descend towards the ground at a steep angle.An Air Force pilot said that it looked “like the onset of a spin.” Another pilot holding on the taxiway at SNA, said that this “was the classic stall and spin.”

The airplane came to rest in a shopping mall parking lot and struck several vehicles before coming to rest upright about 35 ft from the entrance of a store.

Observation of online video of the accident airplane showed it in a steep vertical nose down descent, while rotating to the left.

Pilot Information

Certificate: Private
Age: 53,Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane 
Second Pilot Present: No
Instructor Rating(s): None 
Toxicology Performed: Yes
Medical Certification: Class 3 With waivers/limitations 
Last FAA Medical Exam: October 20, 2017
Occupational Pilot: No 
Last Flight Review or Equivalent:
Flight Time: (Estimated) 980 hours (Total, all aircraft), 120 hours (Total, this make and model)

Passenger Information

Certificate: 
Age: Female
Airplane Rating(s): 
Seat Occupied: Unknown
Other Aircraft Rating(s): Restraint Used: Unknown
Instrument Rating(s):
Second Pilot Present: No
Instructor Rating(s):
Toxicology Performed: No
Medical Certification:
Last FAA Medical Exam:
Occupational Pilot: No 
Last Flight Review or Equivalent:
Flight Time:

Passenger Information

Certificate: 
Age: Female
Airplane Rating(s): 
Seat Occupied: Unknown
Other Aircraft Rating(s):
Restraint Used: Unknown
Instrument Rating(s): 
Second Pilot Present: No
Instructor Rating(s): 
Toxicology Performed: No
Medical Certification:
Last FAA Medical Exam:
Occupational Pilot:
Last Flight Review or Equivalent:
Flight Time:

Passenger Information

Certificate: 
Age: Male
Airplane Rating(s):
Seat Occupied: Unknown
Other Aircraft Rating(s): 
Restraint Used: Unknown
Instrument Rating(s):
Second Pilot Present: No
Instructor Rating(s):
Toxicology Performed: No
Medical Certification:
Last FAA Medical Exam:
Occupational Pilot: 
Last Flight Review or Equivalent:
Flight Time:

Passenger Information

Certificate:
Age: Female
Airplane Rating(s): 
Seat Occupied: Unknown
Other Aircraft Rating(s): 
Restraint Used: Unknown
Instrument Rating(s):
Second Pilot Present: No
Instructor Rating(s): 
Toxicology Performed: No
Medical Certification: 
Last FAA Medical Exam:
Occupational Pilot:
Last Flight Review or Equivalent:
Flight Time:

The pilot began flying the accident airplane in January 2017. In the 6 months before the accident, the pilot flew the accident airplane on 14 flights (not including the accident flight) for a total flight time of about 43 hours.

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N727RP
Model/Series: 414 Undesignated
Aircraft Category: Airplane
Year of Manufacture: 1973
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 414-0385
Landing Gear Type: Retractable - Tricycle 
Seats:
Date/Type of Last Inspection: November 26, 2017 Annual 
Certified Max Gross Wt.: 6350 lbs
Time Since Last Inspection: 
Engines: 2 Reciprocating
Airframe Total Time: 3963.6 Hrs as of last inspection
Engine Manufacturer: Continental
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: TSIO-520-NB
Registered Owner: 
Rated Power: 325 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

The airplane was modified in accordance with Supplemental Type Certificate (STC) SE4327SW, which allowed for operation of 325 horsepower at 38 inches manifold pressure at 2,700 rpm. The airplane was also modified IAW STC SA09971SC-D by installation of Hartzell three-bladed constant speed PHCC3YF-2UF propellers.

Airplane Stall Speeds:

The airplane’s Pilot’s Owner’s Manual (POH) listed the stall speeds. The speeds were listed in mph and were converted to knots for a better comparison with the flight data. At the gross weight of 6,350 pounds, with gear and flaps up, and no bank angle, the stall speed is 81 knots, at 20° of bank, 84 knots, at 40° of bank, 96 knots and at 60° of bank, 121 knots. With the gear extended, 15° of flaps, and no bank angle: the stall speed is at 80 knots, at 20° of bank, 83 knots, at 40° of bank, 91 knots, and at 60° of bank, 114 knots. (Note: The Airplane Flight Manual Supplement for the STC only listed stall speeds for a gross weight of 6,510 pounds. For stall speed at and below 6,350 pounds, the original Pilot’s Operating Manual would be referenced).

The airplane’s POH landing performance table indicated that the landing distance with wing flaps 45° would be sufficient for the use of runway 20L. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: KSNA,56 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 12:53 Local
Direction from Accident Site: 136°
Lowest Cloud Condition: Clear
Visibility 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 10 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 210°
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 29.86 inches Hg 
Temperature/Dew Point: 27°C / 18°C
Precipitation and Obscuration: No 
Obscuration; No Precipitation
Departure Point: Concord, CA (CCR) 
Type of Flight Plan Filed: None
Destination: Santa Ana, CA (SNA) 
Type of Clearance: Unknown
Departure Time: 10:20 Local 
Type of Airspace: Class C

Airport Information

Airport: JOHN WAYNE AIRPORT-ORANGE COUN SNA
Runway Surface Type: Asphalt
Airport Elevation: 56 ft msl
Runway Surface Condition: Dry
Runway Used: 20L IFR
Approach: None Runway
Length/Width: 2887 ft / 75 ft VFR 
Approach/Landing: Traffic pattern
Runway 20L was 2,887 ft long and 75 ft wide.

Wreckage and Impact Information

Crew Injuries: 1 Fatal 
Aircraft Damage: Destroyed
Passenger Injuries: 4 Fatal
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 5 Fatal 
Latitude, Longitude: 33.696109,-117.884445(est)

The airplane impacted a parking lot about 1.6 miles northwest of SNA. The wreckage was contained within an approximate 150 ft debris trail. The first piece of identified wreckage was the left-wing tip which was located about 90 ft from the main wreckage. The last piece of identified wreckage was the right-wing tip which was located about 60 ft from the main wreckage.

The initial impact point (IIP) was a depression in the asphalt. About 12 ft from this depression was a crater about 3 ft long, 2 ft wide and 6 inches deep. A propeller blade from the left engine was separated from the hub and found in the crater. Several left-wing fragments were found near the IIP. The aileron trim actuator, which was located in the left wing, separated from the wing upon impact, and was observed in the parking lot near the IIP. The aileron trim cables were observed separated, consistent with tension overload.

The main wreckage consisted of the fuselage, right engine, right wing, and empennage. The fuselage was slightly canted to the left. The empennage was mostly separated from the fuselage but remained attached by the control cables. The front of the aircraft and cabin area was destroyed during impact. The cabin door remained attached.

The inboard section of the left wing was separated from the fuselage at the wing root. Furthermore, the left engine, left flap and left main landing gear, remained attached to this inboard wing section.

The right wing remained partially attached to the fuselage. The right wing section outboard of the nacelle was separated and was found within the debris path. The right aileron remained attached at the inboard connection.

The right engine impacted into an unoccupied parked vehicle. The vehicle was then displaced by about 65 ft from its original location. The right propeller separated at the hub and was found inside the aft section of the vehicle. Additionally, a few other unoccupied vehicles were struck by the airplane debris.

The empennage remained partially attached to the fuselage. The vertical stabilizer remained attached to the empennage and was relatively intact. The rudder remained attached to the vertical stabilizer and the rudder trim was near the neutral position. The leading edge of the left horizontal stabilizer sustained impact damage. Both elevators remained attached to their respective horizontal stabilizer. The elevator trim was observed near the neutral position.

Flight control continuity was established from the cockpit area to each respective flight control surface, except for the left aileron, which had separated. Aileron flight control cable continuity was confirmed from the cockpit to the control surfaces bell crank through cable separations that exhibited tensile overload. Rudder and elevator flight control cable continuity was confirmed from the cockpit to the control surface bell cranks, through cable separations that exhibited either tensile overload or were cut by investigators to facilitate recovery.

Examination of the flap motor revealed that the left and right flap chains had 7.5 links from the sprocket, consistent with about a 10° flap setting.

The landing gear actuator was observed in the extended position. Brake assembly parts were observed in one of the impact craters. Additionally, impact markings and damage sustained to the main landing gear assemblies were consistent with the gear in the extended position.

The airplane was configured with the following fuel tanks: left and right main tanks (located at the wing tips), left and right auxiliary tanks (located in the wings outboard of the nacelles), and right wing locker (located in the right nacelle behind the engine).The left fuel selector handle was observed between the left main and left auxiliary tanks, and the right fuel selector handle was observed between the right main and right auxiliary tanks. The pointer tip of the left fuel handler selector was fractured. The left and right fuel selector cables were stretched during the separation of the wings outboard of the nacelles and the left and right control arms were pulled beyond the off position. The fuel selector valves were substantially damaged by impact and unable to be functionally tested. The only fuel tank not breached
was the right auxiliary tank.

During the examination, about 2.5 gallons of fuel were drained from the tank. The fuel was observed to be blue in color and clear of contaminants. The airplane was refueled on the morning of the accident flight; the main tanks were topped off and the right auxiliary tank was not refueled since it was full, and the left auxiliary tank received about 15 gallons. The fuel load was sufficient for the flight.

Left Engine

Impact damage to Cylinder’s Nos. 2, 4, and 6 were noted. Cylinder’s Nos. 4 and 6 rocker box covers were separated. Manual rotation was attempted by using a hand tool but was unable to be accomplished. A borescope inspection of the cylinders revealed normal operational conditions. Both magnetos were separated from the engine but remained attached to the ignition harness. The magnetos sustained impact damage but when manually rotated, spark was observed at all leads. The oil sump sustained extensive
crush damage. The top spark plugs were removed and exhibited normal worn out wear signatures when compared to the Champion Check-A-Plug comparison chart. The fuel flow divider lines were attached at all cylinder fuel injectors.

Examination of the fuel pump revealed no anomalies. The turbocharger remained attached to its respective housing. The turbocharger blades were observed bent.

Cylinder Nos. 1 and 3 were removed and eventually rotation was confirmed. The remaining cylinders were also removed, and the crankcase was disassembled. No thermal damage was observed, and all bearings displayed normal wear. The crankshaft and camshaft were also removed, and no anomalies were noted.

The oil filter was removed and cut open. The filter folds were clear of contamination.

Right Engine

The No. 6 cylinder sustained impact damage. The No. 6 rocker cover was separated. Both magnetos were separated from the engine but remained attached to their respective ignition harness. All spark plugs were removed and exhibited normal worn out wear signatures when compared to the Champion Check-A-Plug comparison chart. The fuel flow dividers lines remained attached at all cylinder fuel injectors. Examination of the fuel pump revealed no anomalies. 

Both magnetos were manually rotated, and spark was observed at all leads. The turbocharger remained attached to its respective housing. The turbocharger blades were observed bent. 

All six cylinders, crankshaft, and camshaft were removed, with no anomalies noted.

The oil filter was removed and cut open. The filter folds were clear of contamination.

The crankcase was disassembled, and no thermal damage was observed. The bearings displayed normal wear and no anomalies were noted.

Propeller examination

The propeller examination revealed that both propellers showed signs of rotation and there were no indications that either propeller was at or near the feathered position. Leading edge gouging, chordwise/rotational scoring, blade bending, and twisting were observed on both propellers, which is consistent with rotation. Overall, the damage to both the left and right propellers was similar and consistent with a power on, symmetric condition, at the time of impact.

Cockpit/Cabin Observations

The cockpit area sustained substantial impact damage and most instrumentation was damaged and unreadable. The throttles were near the idle/aft position and the mixture and propeller controls were full forward.

Postaccident examination of the airframe and engines revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation.

Medical and Pathological Information

Orange County Sheriff-Coroner, Santa Ana, California, conducted an autopsy of the pilot. The pilot’s cause of death was multiple traumatic blunt force injuries.

Toxicology testing performed at the FAA's Forensic Sciences Laboratory was negative for carbon monoxide, ethanol, and drugs.









































21 comments:

  1. Replies
    1. Uh, no:

      "Overall, the damage to both the left and right propellers was similar and consistent with a power on, symmetric condition, at the time of impact."

      Care to try again?

      Delete
    2. So let me see if I can follow your logic... as long as props are turning failure to maintain minimum controllable airspeed can’t happen? Airfoils don’t care what the propulsion state is.

      Delete
    3. You used the term, "Vmc". Are you familiar with the definition?
      "VMC—minimum control speed with the critical engine inoperative—marked with a red radial line on most airspeed indicators. The minimum speed at which directional control can be maintained under a very specific set of circumstances outlined in 14 CFR part 23, Airworthiness Standards. Under the small airplane certification regulations currently in effect, the flight test pilot must be able to (1) stop the turn that results when the critical engine is suddenly made inoperative within 20° of the original heading, using maximum rudder deflection and a maximum of 5° bank, and (2) thereafter, maintain straight flight with not more than a 5° bank."

      Delete
    4. Texas Buzzard appears incapable of following anyone's logic

      Delete
    5. Trust me on this, "Texas Buzzard" is a filthy-mouthed troll.

      Delete
  2. I don't think this was a VMC event. Clearly they were well below VMC ... and that was not the least bit helpful. But I believe both engines were making power and so VMC might not factor in directly.

    Instead I think this was a plain ol' stall. Can't allow an airplane to get that slow and bank the airplane into a turn and expect things to work out well. Gotta keep your speed up in the pattern, and especially on turns from base to final.

    Again, being well below VMC was not the least bit helpful. But the main lesson here is to maintain speed in the pattern and avoid over-banking the airplane. That lesson applies to twins, singles ... anything with wings.


    ReplyDelete
  3. I have some time in a modified 414. Never once did we ever get below 110 knots in the VFR pattern until final or ILS approach over the outer marker. There was a reason for that: allowance for margin of engine loss power and control. Book numbers and Vref mean everything in a high performance twin with very little margin for error (Vref in this aircraft being 96 knots if I remember correctly). The 400 series Cessna twin pistons need to be flown more like jets and turboprops than light pistons. They are a handful. So the question is why did this guy get so behind the aircraft so quickly in rapid airspeed loss while still in controllable flight.

    ReplyDelete
  4. Too much airplane, not enough Pilot...

    ReplyDelete
    Replies
    1. Which, at the core, is the root cause of most of these accidents.

      Most private pilots think flying airplanes is like flying a car. They never think: "What if..." They don't have, or maintain, the skill to fly around in circles holding for a time slot, then maneuvering for a landing in high-density traffic where you have to have a certain amount of instrument scan skill to look outside while maintaining safe airspeed/power.

      Delete
    2. "Most private pilots think flying airplanes is like flying a car."
      Spoken like a true non-pilot and utter nonsense.

      "They never think: "What if..."
      More nonsense.

      "They don't have, or maintain, the skill to fly around in circles holding for a time slot..."
      Nonsense x3. You can't take this accident, which appears at this point to be loss of control pilot error and apply it to most pilots.

      Delete
  5. Too much airplane, not enough fuel? 2.5 gallons doesn't sound like much room for error. When he realizes he's going to have to make 360's, he's suddenly willing to accept 20L. He wants to land and quick.

    ReplyDelete
    Replies
    1. ATC " instructed the pilot to accomplish a left 270° turn.
      cross directly over the tower at or above 1,300 ft,
      for left traffic to runway 20L.
      The pilot acknowledged the instruction.
      About 23 seconds later,
      "the controller instructed the pilot to
      “climb back up to 1,300 ft or above.”
      one thousands one
      one thousands two
      one thousands three
      one thousands four
      the pilot stated, “emergency, emergency, emergency.”

      turning and climbing after turning and desending = a plain ol' stall

      Delete
  6. Please read more carefully before making comments.

    "The only fuel tank not breached was the right auxiliary tank. During the examination, about 2.5 gallons of fuel were drained from the tank" (meaning all other fuel tanks had damage which would not allow fuel to measured.
    "On the morning of the accident flight; the main tanks were topped off and the right auxiliary tank was not refueled since it was full, and the left auxiliary tank received about 15 gallons." NTSB determined, "The fuel load was sufficient for the flight."

    ReplyDelete
    Replies
    1. There are several ways an aircraft can lose fuel in flight, fuel caps not installed after fueling (just set in place until fuel hose put away), cap not tightened, and torn gasket, all of which will cause fuel to be siphoned out during flight - and many times from more than one tank. I've seen all of these happen. The bent props can easily occur during windmilling. I wouldn't rule out fuel exhaustion just yet even if they had sufficient fuel at the start of the mission.

      Delete
    2. "Overall, the damage to both the left and right propellers was similar and consistent with a "POWER ON", symmetric condition."

      Delete
  7. I am not a pilot .. but it appears from reading this website and all these tragic situations that 400 series piston twin Cessna's are not for the faint of heart
    There seemed to be nothing gentle or forgiving about that stall .. he got behind the airspeed and dropped straight nose down like a rock ... R.I.P. :(

    ReplyDelete
    Replies
    1. It stalls no different than any other twin. There are videos of Barons and other small piston twins departing controlled flight into a spin during takeoff or landing maneuvers as the pilots didn't manage their airspeed. FYI I have time in a 414 - if flown properly (IE: not sloppily like you can get away with in a single engine 172) it is a fine flying aircraft. Anyone who has "faint of heart" when flying something probably shouldn't be flying at all except at home on a desktop computer with Microsoft Flight Simulator or X-Plane.

      Delete
    2. Ah, the "seat of the pants feel."
      "there is the "Cessna 421C Level 6 Flight Training Device. The obvious difference between a Flight Training Device (FTD) and a Full Flight Simulator (FFS) is motion, but the FTD provides good aerodynamic modeling for control inputs, systems accuracy and exterior visuals. The downside is that all aircraft motion is indicated either through instrument changes or the visual clues from outside, so there is no “seat of the pants” feel to flying the aircraft.
      Unfortunately, replication of emergencies when attempted at the limits of aircraft performance or pilot proficiency in an actual aircraft has proven dangerous, and sometimes fatal. Thus flight simulators and flight training devices have become the norm in enabling pilots to face emergency situations and practice their responses. Regulatory requirements, insurance demands, and pilot training costs have also contributed to the use of simulators by all facets of aviation including the airlines, corporate flight departments, and the GA community. But the bottom line is that simulator training enhances safety." https://www.simulator.com/wp-content/uploads/2018/04/twin-cessna-dec-2015.pdf

      Delete
  8. all pilots must have spin training so they no what happens if you get too slow and sloppy with your controls. in 50 years of flying have never come close too losing control or even a rough landing.you need to control the plane and not the other way around before one takes any passengers up.

    ReplyDelete