San Jose, CA, USA
N444JV
Cessna 425
The aircraft was on an IFR clearance and climbing through a cloud layer when it broke up in flight following an in-flight upset. The weather conditions included multiple cloud layers from 4,000 to 13,000 feet, with a freezing level around 7,000 feet msl. An AIRMET was in effect for occasional moderate rime to mixed icing-in-clouds and in-precipitation below 18,000 feet. As the airplane began to intercept a victor airway, climbing at about 2,000 feet per minute (fpm), and passing through 6,700 feet, the airplane began a series of heading and altitude changes that were not consistent with its ATC clearances. The airplane turned right and climbed to 8,600 feet, then turned left and descended to 8,000 feet. The airplane then turned right and climbed to 8,500 feet, where it began a rapidly descending right turn. At 1034:33, as the aircraft was descending through 7,000 feet, the pilot advised ATC "four Juliet victor I just lost my needle give me..." No further transmissions were received from the accident airplane and the last radar return showed it descending through 3,200 feet at about 11,000 fpm. Analysis of radar data shows the airplane was close to Vmo at the last Mode C return. Ground witnesses saw the airplane come out of the clouds in a high speed spiral descent just before it broke up about 1,000 feet agl. Examination of the wreckage showed that all structural failures were the result of overload. The aircraft was equipped with full flight instruments on both the left and right sides of the cockpit; however, the flight director system attitude director indicator and horizontal situation indicator were only on the left side. The aircraft was also equipped for flight into known icing conditions, with in part, heated pitot tubes (left and right sides), static sources, and stall warning vanes. During the on-scene cockpit examination, except for the pitot heat switches, the cockpit controls and switches were found to be configured in positions consistent with the aircraft's phase of flight prior to the in-flight upset. The right pitot heat switch was found in the ON position, while the left switch was in the OFF position. The left pitot heat switch toggle lever was noticeably displaced to the left by impact with an object in the cockpit. With the exception of the left pitot heat, the anit-ice and deice system switches were all configured for flight in icing conditions. The pitot heat switches, noted to be of the circuit breaker type (functions as both a toggle switch and circuit breaker), were removed from the panel and sent to a laboratory for examination and testing. Low power stereoscopic examination of the switches found that the right switch was intact, while the toggle lever mechanism of the left switch was broken loose from the housing. Microscopic examination of the left switches housing fracture surface revealed imbedded debris and wear marks indicative of an old fracture predating the accident. The broken left switch could be electrically switched by physically holding the toggle lever mechanism in the appropriate ON or OFF position. The electrical contact resistance measurements of the left switch varied between 0.3 and 1.4 ohms, and was noted to be intermittently open with the switch in the ON position. Both switches were then disassembled. While particulate debris was found in both switches, the left one had a significant amount of large coarse fibrous lint-like debris. The flexible copper conductor of the left switches circuit breaker section had several broken strands, and the electrical contacts were dirty. The laboratory report concluded that the left switches toggle was bent to the left in the impact sequence; however, the housing fracture predated the accident and allowed an internal build-up of large coarse fibrous lint-like debris. The combined effects of the broken housing, the resulting misalignment of the toggle mechanism, the dirty contacts, and the large coarse lint debris prevented reliable electrical switching of the device and presented the opportunity for intermittently open electrical contacts. Continuity of the plumbing from the pitot tubes and static ports to their respective instruments was verified. Electrical continuity was established from the bus power sources through the circuit breakers and switches to the heating elements of the pitot tubes and static sources. The heating elements were connected to a 12-volt battery and the operation of the heating elements verified.
1.1 HISTORY OF FLIGHT On March 6, 2002, at 1035 Pacific standard time, a Cessna 425, N444JV, experienced a loss of control and a subsequent in-flight breakup at San Jose, California. The aircraft descended to ground impact in an area of rolling, hilly pasture land. The aircraft was owned and operated by the pilot under the provisions of 14 CFR Part 91 of the Federal Aviation Regulations. The aircraft was destroyed in the accident sequence. The instrument rated private pilot and two passengers sustained fatal injuries. Instrument meteorological conditions prevailed at the altitude where the loss of control occurred. The flight departed the Reid-Hillview airport in San Jose at 1029, and was en route nonstop to La Paz, Mexico. An instrument flight rules flight plan was filed, and the pilot had received an instrument clearance prior to departure. According to a review of recorded air-to-ground communications tapes and radar data obtained from the Federal Aviation Administration (FAA) Bay Terminal Radar Approach Control facility, the aircraft was initially cleared after takeoff to climb to 13,000 feet msl on radar vectors to Victor airway 485. The controller issued a heading of 110 degrees, then told the pilot to intercept the airway and proceed on course. The communications tapes, along with recorded radar data, disclosed that the airplane was climbing at about 2,000 feet per minute (fpm) through 6,700 feet when it began a series of heading and altitude changes that were not consistent with its ATC clearances. The airplane turned right and climbed to 8,600 feet, then turned left and descended to 8,000 feet. The airplane then turned right and climbed to 8,500 feet, where it began a rapidly descending right turn. At 1034:33, as the aircraft was descending through 7,000 feet, the pilot advised ATC "four Juliet victor I just lost my needle give me..." No further transmissions were received from the accident airplane and the last radar return showed it descending through 3,200 feet about 11,000 fpm. A ground witness to the accident was riding a horse about 1.5 miles from the impact site and was attracted to the airplane by a loud "screaming" jet sound. She looked up and saw the aircraft descend out of the clouds "in a cork-screw pattern." As the airplane got close to the ground, the flight path changed from a descent to a climb while still in the corkscrew turn, with the ascending corkscrew turns much tighter than the descending ones. The airplane then seemed to level off momentarily before it began an arcing and spiraling turn until it disappeared behind a hill. Additional witnesses on a golf course about 0.5-miles from the impact location heard a loud sound they characterized as like an explosion or gunshot. The airplane then rolled level, and continued in an arcing horizontal spin until it disappeared behind a hill. These two witnesses reported that they saw parts falling from the airplane and that it was "smoking." Other ground witnesses located on a nearby golf course reported that they saw parts falling from the aircraft as it descended to the ground. 1.2 PERSONNEL INFORMATION The pilot's FAA Airman and Medical Records files were reviewed and they disclosed that he held a US private pilot certificate with land airplane ratings for single, multiengine, and instruments. The certificate was most recently issued as a replacement for a lost certificate on April 24, 2001. The US certificate was issued on the basis of Canadian pilot certificate number WGP 9287, and the records noted that the US certificate was valid only when accompanied by the Canadian certificate. Detailed review of the airman record files disclosed that he first applied for a US private pilot certificate on the basis of his Canadian certificate on November 3, 1967. A US multiengine land practical test was passed on April 3, 1979, and that class rating was added to his certificate. The pilot applied for and passed the US written and practical tests for an airplane single engine instrument rating on October 11, 1988. On April 18, 1989, the pilot passed the US practical instrument rating test for multiengine airplanes; this test was taken in a Beech 90. The application for this practical test listed a total flight time of 1,956 hours, with 247 in the Beech 90. The pilot held a third-class medical certificate, which was issued on August 2, 2000, with limitations that he wear corrective lenses and possess glasses for near and intermediate vision. At the time of the medical examination, the pilot reported a total flight time of 4,556 hours. The pilot's most recent personal flight record book covering the period from November 2000 to the date of the accident was recovered in the wreckage and showed a total pilot time of 4,987 hours, with 2,471 hours in multiengine airplanes. The log recorded 636 hours of actual instrument flight time, with 138 hours of simulated instrument experience. The pilot purchased the airplane on October 10, 2000, and he logged about 400 hours in it prior to the accident. The logbook showed a pattern of flight activity that was consistent at about 35 hours per month. On January 5, 2002, a biennial flight review was endorsed in the logbook, with the entry noting a total flight of 2.7 hours, with 1.9 hours in actual instrument conditions. An entry dated January 6, 2002, endorsed the completion of an instrument competency check. That entry listed a flight time of 3.4 hours, with 2.1 flown in simulated instrument conditions. The numbers of approaches flown are not delineated in the entry. In the 90 and 30 days prior to the accident, the logbook records a total hours flown of 86 and 29, respectively. A search of the FAA airman records database disclosed no record that the passenger who occupied the right front seat had ever held any grade of pilot certificate. 1.3 AIRCRAFT INFORMATION The maintenance records were obtained from the facility, which performed the maintenance on the aircraft, Turbine Air, Inc., Hayward, California. In addition, information was obtained from Cessna Aircraft and Pratt & Whitney of Canada manufacturing records, and the official FAA Aircraft and Registry files. According to the records examined, the aircraft, serial number 425-0013, was manufactured in December 1980, and was purchased by the pilot in October 2000. At the time of the accident, the airframe had accumulated a total time in service of 4,315 hours. The aircraft was equipped with full flight instruments on both the left and right sides of the cockpit; however, the flight director system attitude director indicator and horizontal situation indicator were only on the left side. The aircraft was also equipped for flight into known icing conditions, with in part, heated pitot tubes (left and right sides), static sources, and stall warning vanes. The aircraft was maintained on the Cessna Continuous Airworthiness Inspection Program for the model 425. The program consists five inspection phases, with varying flight hour intervals between phases depending on the phase number. A chart detailing the inspection requirements is appended to this report. According to the records, the most recent Phase 2 inspection (100-hour/annual equivalent) was completed on March 5, 2002, 2 hours prior to the accident. The most recent pitot-static system test and certification in accordance with 14 CFR 91.411 was accomplished on September 28, 2001. In September 2000, the original Pratt & Whitney of Canada PT6A-112 engines and Hartzell 3-bladed propellers were removed from the airplane. Factory new PT6A-135A engines, serial numbers PZ0040 and PZ0041, were installed in the respective left and right positions. In addition, factory new 4-bladed McCauley 4HFR34C762-1 propellers were installed, serial numbers 992818 on the left side and 000463 on the right position. This work was accomplished in accordance with Supplemental Type Certificate 5786SW. The engines and propellers had accumulated a total time in service of 337 hours at the time of the accident. Comparison of maintenance records with the FAA listing of Airworthiness Directives applicable to the airframe, engines, and propellers by serial number disclosed that all AD's were complied with. During the review of the maintenance records, two major repairs were found for structural elements in the airframe. The first concerned the replacement of the left horizontal stabilizer leading edge skin due to bird strike damage sustained in October 1998. This repair was accomplished in accordance with Cessna Engineering Order 425-0663. The second repair was the installation of reinforcement kits (Cessna kit numbers SK-425-44-1 and SK425-44-2) to the right wing forward lower spar cap. These kits were installed in response to a crack that was detected in the spar cap during an inspection for compliance with AD 91-25-08. Details of these repairs are included in the maintenance records appended to this report. In an interview, the pilot's son noted that he had spoken with his father 3 or 4 days prior to the accident flight. The pilot was satisfied with the airplane in general, and had not mentioned any chronic or unresolved problems. At the request of the National Transportation Safety Board investigators, an airworthiness inspector from the San Jose Flight Standards District Office went to the Reid-Hillview airport on the afternoon of March 6 to determine the recent fueling on the accident aircraft. He determined that Nice Air had fueled the airplane on the day before the accident (03-05-02) at the pilot's request. He obtained a sample of fuel from the truck used to refuel the airplane and also interviewed the refueling technician. According to records at Nice Air, the pilot had requested that the airplane be refueled to capacity (a total of 186 gallons in each of the left and right tanks). The fueling technician stated that he had put 107 gallons of Jet A into the left tank when the truck ran out of fuel during the processing of filling the airplane. Nice Air only has jet fuel in a tank/pumper truck and there is no underground storage or other source of Jet A on the airport. No other Fixed Base Operator on the airport carries Jet A, and fuel for the truck has to be brought in by a delivery truck. The fueling technician said the pilot arrived later that afternoon and was very upset that 107 gallons had been placed into the left tank, with none added to the right, and had ordered the technician to take 50 gallons from the left tank and place it in the right. The pilot then got in his car and left the airport. The technician reported that he took a hand pump and a 5-gallon plastic container, put the suction end of the pump hose into the left tank and transferred 50 gallons to the right tank, 5 gallons at a time. The technician could not provide an estimate as to how much fuel was in the left tank at the beginning of the fueling process, or, when the truck ran out of fuel. At the time of the interview by the FAA inspector, the technician could not identify the specific plastic container used for the fuel transfer. The FAA inspector examined the truck used to refuel the airplane. During this process he got on top of the tank and opened the cover. The interior of the tank was clean without debris of any kind. Only a small residual quantity of what appeared to be clean fuel remained in the tank. After closing the cover, he actuated the power takeoff and took the sample from the dispensing nozzle. Approximately 1 pint of fuel was dispensed into a clean sample container he brought with him before the flow stopped. Safety Board investigators attempted to reconstruct the aircraft takeoff gross weight and center of gravity. Beyond the uncertain fuel quantity discussed above, the investigators found that fire department personnel who initially responded to the accident site had removed most of the baggage from the rear baggage areas and from the forward nose bays without documenting what bags came from what location. Investigators interviewed the fire personnel and identified the baggage that was believed to have come from each location. Based on this reconstruction, the aircraft could not have had more than 266 gallons of fuel, with 133 gallons distributed in each of the left and right tanks. The total baggage area contents were estimated at about 150 pounds, with 20 pounds in the avionics bay, 30 pounds in the nose baggage compartment, and 50 pounds each in rear baggage area bays A and B. The occupant weights were determined from either official state and/or federal identification records, or from the medical examiners determination of post mortem weight. Using this reconstruction, the takeoff gross weight was estimated to be 7,804 pounds (maximum allowable takeoff gross weight is 8,600 pounds), with a center of gravity at 158.8 inches (the envelop range at 7,800 pounds is from 154.5 to 160 inches). A sheet detailing the computations is appended to this report. 1.4 METEOROLOGICAL INFORMATION 1.4.1 Witness Reports A pilot witness who was airborne at the time of the accident in the vicinity of the crash site was interviewed. He holds a commercial pilot certificate, with airplane ratings for single engine, multiengine, and instruments. As part of his employment, he flies traffic reporter(s) for two San Francisco Bay area stations. On the morning of the accident, he was airborne in the vicinity of San Jose with a traffic reporter on board. He remembered hearing the transmission from the pilot of N444JV to the effect that he had "lost his needle." Shortly after that, the Bay TRACON controller vectored him to the vicinity of the last observed radar target for N444JV and asked him to look for the airplane on the ground. The reporter in his aircraft was the first one to spot the wreckage. Neither he nor the reporter actually saw the airplane crash. The witness was asked to summarize the weather conditions he observed at the time. He said he was at 1,500 feet, roughly 1,000 feet above ground level. He reported that the lowest cloud layer was scattered at 1,600 msl, with a higher overcast layer he estimated at 2,000 feet. The visibility beneath the clouds was good, and in the range of 10 miles. No rain was falling. The atmospheric turbulence conditions consisted of light chop. He experienced no ice accumulation and noted that the temperature was well above freezing, though he could not remember an exact number. He was asked about any rain shafts, funnel clouds, or other unusual meteorological phenomenon in the area. He stated that he observed none. Review of the recorded air-to-ground communications tapes disclosed that two air carrier flights departing the Oakland International Airport during the time frame of the accident flight reported the tops of the clouds to be 9,500 feet. One flight requested a deviation left of course from Bay TRACON to avoid a cell build-up. Based on the Standard Instrument Departure routings out of Oakland, the area of concern for that flight would have been 15 to 20 miles northeast of the accident site. 1.4.2 Safety Board Meteorological Study A Safety Board staff meteorologist conducted a study of the weather conditions in the vicinity of the accident site. The full report is contained in the docket for this accident. The closest weather observation to the accident site was from San Jose International Airport (KSJC), located approximately 14 miles northwest of the accident site at an elevation of 58 feet. The airport has an Automated Surface Observation System (ASOS) and was augmented by NWS Certified weather observers. The following conditions were reported surrounding the time of the accident: KSJC weather at 0953, wind from 100 degrees at 7 knots; visibility 10 statute miles; a few clouds at 900 feet, scattered clouds at 2,500 feet, second scattered clouds layer at 9,000 feet; temperature 14 degrees Celsius; dew point 13 degrees Celsius; altimeter 29.98 inches of Mercury (Hg). Remarks: automated observation system, rain began at 1705Z and ended at 1750Z, sea level pressure 1015.2 mb, precipitation last hour 0.03 inches, 6-hour rainfall 0.04 inches, 3-hour pressure tendency steady at 0.00 mb
the pilot's loss of control and resulting exceedence of the design stress limits of the aircraft, which led to an in-flight structural failure. The pilot's loss of control was due in part to the loss of primary airspeed reference resulting from pitot tube icing, which was caused by the internal failure of the pitot heat switch. Factors in the accident were the pilot's distraction caused by the airspeed reading anomaly and spatial disorientation.
Source: NTSB Aviation Accident Database
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