San Dimas, CA, USA
N8145M
Cessna 310I
The airplane impacted trees, terrain, and pedestrians after the pilot declared an emergency during takeoff from a nearby airport. Witnesses observed the airplane not climbing after takeoff and air traffic controllers heard the pilot declare mayday three times. The pilot did not elaborate on the emergency situation. Witnesses observed the airplane turn left over the shoreline of a reservoir where it impacted a tree with its left wing. One witness stated the left propeller was not turning as fast as the right propeller and he heard the engines backfiring. Post-accident examination of the aircraft revealed no flight control anomalies. The left engine's top spark plugs were covered with black soot and the piston and cylinders were dark in appearance, indicative of an overly rich fuel/air mixture. The reason for the excessively rich mixture was not determined. The left engine was successfully test run twice following the accident, once utilizing the systems and plumbing in the airframe, and the second time in an instrumented test cell. Examination of the wreckage did find irregularities in the wiring circuits for both boost pumps and their associated cockpit switches; however, the relationship of these irregularities to the loss of power is uncertain. Review of the airplane owner's manual revealed the emergency procedures for a loss of engine power after takeoff called for the retraction of the landing gear and the feathering of the propeller to obtain the maximum climb performance. The landing gear was not retracted and the left propeller was not feathered. Eighteen months prior to the accident, the pilot failed his first attempt to obtain his multiengine airplane rating due to improper emergency procedures during engine failure operations after liftoff. The pilot's total time in the same make and model as the accident airplane is unclear.
HISTORY OF FLIGHT On July 4, 2002, at 1230 Pacific daylight time, a Cessna 310I twin-engine airplane, N8145M, was destroyed when it impacted terrain shortly after takeoff from the Brackett Field Airport, La Verne, California. The airplane was registered to, and operated by, the pilot. The commercial pilot and his pilot-rated passenger sustained fatal injuries. Two individuals on the ground received fatal injuries and nine individuals on the ground sustained serious injuries. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The local flight was originating at the time of the accident. The Brackett Field air traffic controllers reported that the pilot made three consecutive mayday calls during the initial climb out from runway 26L; however, the pilot did not indicate the nature of the emergency. The controllers observed the airplane "not climbing" before the airplane descended behind trees. A witness, located on a boat in the Puddingstone Reservoir, observed the airplane flying toward the west after departing Brackett Field. The witness was facing north. The airplane was approximately 100 feet above the ground. As the airplane approached the reservoir, the witness heard the engines "backfiring" and noted the right propeller was not turning as fast as the left propeller (as viewed facing the nose of the airplane). The witness also noted the landing gear were extended. The airplane turned toward the south and continued to lose altitude. The witness observed the airplane strike a tree with the right propeller (when viewed from the front of the airplane looking aft), "causing the plane to spin around." The airplane then struck a second tree, bounced back up into the air, and over the second tree. The witness then lost sight of the airplane. Another witness located on the reservoir said that the propellers were turning. He said one could normally hear the engine power when taking off, but he could not hear engine power for the accident airplane. He observed the airplane turn left toward the shore and lose altitude. The airplane clipped a tree with the port side wing about halfway up the wing, "pulling the plane into a cartwheel." The main body of the airplane hit the second tree with the starboard side and spun around until impacting a picnic area. The airplane came to rest along the shoreline of Lake Puddingstone in the Frank G. Bonelli Park, San Dimas, California. Park officials estimate that 200-400 people were at the lake near the time of the accident. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with single engine land airplane, rotorcraft helicopter, and instrument airplane and helicopter ratings. He also held a private pilot certificate with multiengine land airplane privileges, which was limited to visual flight rules (VFR) operations only. In addition, the pilot held a flight instructor certificate for single engine land airplanes, rotorcraft helicopters, and instrument helicopters. The pilot held a Federal Aviation Administration (FAA) second-class medical certificate that was issued on October 12, 2001. The medical certificate did not contain any limitations or waivers. According to the pilot's last pilot certificate application (airplane multiengine add-on rating), which was dated January 29, 2001, he had accumulated a total of 468 hours of airplane flight time and 4,396 hours of helicopter flight time. According to the application, he had accumulated a total of 13.3 hours in the Cessna 310, which is what the pilot used for the practical flight test. According to the FAA's certificate records for the pilot, he failed his multiengine add-on rating practical flight test on January 29, 2001, due to "Emergency Procedures: Engine Failure After Lift Off" and "Emergency Descent." Following the failed practical flight test, the pilot received additional flight instruction, which equated to 0.5 hours of flight time. On the 29th, the pilot was given another endorsement indicating he was "given additional instruction required for a retest after failure of the airplane multiengine land" flight test, and passed the practical flight test on the 29th. Following the January 2001 practical test, the pilot logged 1.1 hours of multi-engine flight time; however, the last logbook entry was dated September 1, 2001. The pilot completed an application for the use of another Cessna 310 aircraft; adjacent to the pilot's name, was an entry for total time in the same make and model. Penned into that entry block was "92". A date was not affiliated with this pilot experience application. The pilot-rated passenger held a private pilot certificate with single engine land airplane privileges. He also held a third-class medical certificate that was issued on November 29, 2001. The medical certificate stipulated that the airman must wear lenses for distant vision and possess glasses for near vision while exercising the privileges of his airman certificate. The passenger reported on the medical certificate application that he had accumulated a total of 180 flight hours. A review of his logbook revealed he logged a total of 153.8 hours of flight time, none of which was obtained in multiengine airplanes. AIRCRAFT INFORMATION The 1964 model airplane was issued an airworthiness certificate on July 13, 1964. The airplane was equipped with two Teledyne Continental Motors (TCM) IO-470 engines, each rated at 260 horsepower (left engine serial number 115276-4-U, right engine serial number 118267-70-U-R), and two McCauley constant speed, manually feathering, 2-bladed propellers. A bill of sale closing statement indicated the pilot and his partner purchased the airplane on February 13, 2002. An aircraft registration application for N8145M was filled out by the pilot and his partner on February 8, 2002. On February 15, 2002, a Special Flight Permit was issued for the airplane in order to transport the airplane to a maintenance facility. The airplane was officially registered to the pilot and his partner on March 15, 2002. The airframe logbooks revealed a period between February 16, 1993, and April 26, 2002, when no maintenance entries were made. According to those familiar with the airplane, it was awaiting sale during this time period. The February 1993 logbook entry was a determination of airworthiness for a ferry flight. The last entry prior to that was a July 1992 entry, which also determined airworthiness for a ferry flight. The last annual inspection prior to the ferry flights was completed on July 3, 1989, but an aircraft total time was not entered. A logbook entry dated February 11, 1976, revealed the Hobbs meter was replaced at an aircraft total time of 3,108.5 hours. A logbook entry dated July 15, 1981, stated, "For TT [total time] add 4109 to Hobbs time." A review of the aircraft maintenance records revealed complete engine histories were not available and their total times were unknown. According to separate engine entries, both dated May 7, 2002, the left engine's total time since its last major overhaul was 1,050 hours, and the right engine's total time since its last major overhaul was 850 hours. The Hobbs meter at the time of these entries was 2,052 hours. The aircraft's last static system check was completed on April 26, 2002. The last annual inspection conducted on the airplane was completed on May 7, 2002. This annual inspection entry listed both the aircraft total time and the Hobbs meter reading as 2,052.0 hours. Adding the aircraft's hour meter reading at the accident site to 4,109, as instructed to in the logbook entry dated July 15, 1981, provides an aircraft total time of 6,166.1 hours. According to those familiar with the airplane, the airplane's landing gear collapsed in June 2002. No mention of the repair work was found in the maintenance logbooks. The airplane was refueled at the departure airport on June 28, 2002, with 28.8 gallons of 100LL aviation gasoline; however, it is unknown how much fuel was onboard the airplane during the accident flight. METEOROLOGICAL INFORMATION At 1237, the weather observation facility at the Brackett Field Airport reported the wind from 250 degrees at 7 knots; visibility 5 miles in haze; sky partially obscured; and an altimeter setting of 29.96 inches of mercury. The temperature and dew point were not recorded. WRECKAGE AND IMPACT INFORMATION According to a Global Positioning System (GPS) receiver, the accident site was located at 034 degrees 05.078 minutes north latitude and 117 degrees 48.097 minutes west longitude, and at an elevation of 1,444 feet. The linear energy path from the initial tree impact to the final airplane component, which was the right engine, measured 230 feet in length. The airplane initially contacted a tree that was 30 feet tall. The airplane then contacted a second tree that was 100 feet past the first tree. The main wreckage was located 184 feet past of the initial tree impact, and adjacent to a park cooking grill (steel grill cemented in place) and picnic table. The airplane separated into four major structural sections; the left wing, right wing, the fuselage from the instrument panel forward, and the fuselage from the instrument panel aft. The second tree entered the cabin just forward of where the leading edge of the right wing meets the fuselage. The cabin floor was separated on a diagonal line starting at the point the tree entered the cabin and ending where the trailing edge of the left wing meets the fuselage. The park grill indented and ruptured the right side fuselage skin at fuselage station 132.00. The energy path was oriented on a magnetic heading of 160 degrees until the point of the second tree impact. The energy path then switched to a 130-degree heading to where the final piece of wreckage came to rest. The airplane's final resting heading was 100 degrees. The following components were found within the debris path (distances are referenced from the initial impacted tree). The front section of the left main fuel tank (tip tank) was located in the debris path approximately 65 feet past of the initial tree impact, and the tip tank displayed a semicircular indentation consistent with the shape and size of the initial tree. A section of the right wing spar came to rest at the 94-foot mark. At the 104-foot mark, the right seat and cabin section came to rest. At 120 feet, one of the right propeller blades came to rest in the tree debris. The nose landing gear door and the nose wheel were found at 124 feet and 138 feet, respectively. At 141 feet, the top section of the second tree came to rest. Three feet past the top of the tree was the front section of the right main fuel tank (tip tank). At 184 feet and 230 feet were the main aircraft wreckage and the right engine, respectively. Initial examination of the airframe accounted for all primary structural elements of the flight control surfaces. The flight control system was examined. Of the control cables that were found separated, all displayed a broom-straw appearance. Some of the flight control cables had to be cut to facilitate transport from the accident site. Continuity was established through the cables, and the broom-straw separations. The aileron trim actuator was found set to 11 degrees tab down and its position indicator was destroyed (aileron trim was located on left wing). The elevator trim actuator was found in the neutral position and its position indicator was destroyed. The rudder trim was extended 3/8 inch to the left of its trailing edge. The landing gear was in the extended position. By comparing the position of the flap drive chains of the accident airplane with an exemplar model, it was determined the flaps were in the retracted position. According to photographs taken by first responders, the throttle quadrant was found with the following settings: the left throttle control was in the mid-range setting, the left propeller control was positioned aft 1 inch, the left mixture control was pulled aft 1 inch; the right engine throttle, propeller, and mixture controls were in the full forward position. The left engine's fuel selector was in the left main tank position and the right engine's fuel selector was in the right main tank position. The left and right main fuel tank quantity indicators displayed a zero indication, the left auxiliary tank indicated 10 gallons, and the right auxiliary tank indicated 7.5 gallons. The left and right fuel boost pump switches were in the ON (up) position. The left engine remained attached to its mounts and in its nacelle, and the propeller assembly remained attached to the engine. The fuel line between the fuel pump and fuel metering unit was removed at the fuel metering units fitting and fuel was present. The engine's accessories all remained attached to the engine. Both propeller blades were bent aft and displayed very light leading edge damage. One of the blades was twisted toward low pitch near its tip. The other blade did not display any twisting, but displayed slight leading edge polishing. The right engine separated from its nacelle and the propeller separated from the engine. The engine crankcase displayed two cracks. The first initiated at the front top and extended aft to the rear of the No. 6 cylinder. The second crack initiated at the propeller hub and extended aft to the top of the No. 5 cylinder. The propeller hub was found split into two halves and both propeller blades were separated from the hub. One propeller blade displayed scrape marks consistent with making contact with the cement ground. The propeller blade was not twisted and did not display face polishing. The other blade was never located. The engine's accessories remained attached except for the starter and left magneto, which separated. The left magneto's drive coupling was rotated by hand and the three leads that remained attached made sparks. The pulley, which drives the alternator, was separated and no rotational scoring was noted. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on both the pilot and passenger at the Los Angeles County Medical Examiner's Office. According to the autopsy reports, the pilot and passenger both died as a result of "multiple traumatic injuries." A toxicology test conducted on the pilot revealed 0.011 ug/mL and an unquantified amount of bupropion metabolite detected in the blood and urine, respectively. Buproprion is a drug used in the treatment of depression and is used for the management of smoking cessation. It is commonly known by the trade name Zyban. TESTS AND RESEARCH On July 6, 2002, the wreckage was examined at a wreckage recovery facility located in Corona, California. The top spark plugs on the left engine were removed and were dark in color (all top spark plugs were covered with black soot) when compared to the Champion Aviation Check-A-Plug AV-27 Chart. The left engine's pistons were observed through the spark plug holes and they also appeared dark in color. A thumb compression check was performed while the propeller was manually rotated by hand. Compression was achieved on each cylinder. The oil screen and fuel screen were removed and both were free of debris. The left engine was prepared for a test run. A new propeller was installed on the left engine and it was successfully run at an idle power setting utilizing fuel from the auxiliary fuel tank. The left engine was removed from the nacelle and sent to the Teledyne Continental Motors (TCM) factory for an official test run. The top spark plugs on the right engine appeared normal when compared to the aforementioned spark plug comparison chart. The spark plugs were free of deposits and their electrodes were round. The right engine's main oil screen and fuel screen at the fuel metering unit were removed and both were free of debris. The damage sustained by the right engine prohibited a test run. The right engine was also shipped to the TCM factory for a more detailed examination. On September 4-6, 2002, the left and right engines were examined under the supervision of the National Tr
the pilot's failure to maintain control of the airplane following a loss of power in one engine during takeoff. The reason for the loss of power in the left engine could not be determined. Contributing factors to the accident were the pilot's failure to retract the landing gear and to feather the inoperative engine propeller.
Source: NTSB Aviation Accident Database
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