Mather, CA, USA
N6814A
Cessna 402C
The airplane collided with obstructions following a loss of power in one engine during a missed approach. Following the collision sequence the airplane came to rest upright about 500 feet from the approach end of the runway and was destroyed in a post-impact ground fire. The pilot told a responding sheriff's deputy and a Federal Aviation Administration (FAA) inspector that he made the ILS approach to land and initiated a missed approach. When he added power, the left engine sputtered and the airplane veered to the left. He activated the fuel boost pump, but the airplane contacted obstructions and crashed. The responding sheriff's deputy also observed the accident. He heard an engine of an airplane making unusual sounds. The engine "seemed to get quiet and then revved higher as if to climb." He looked in the direction of the sound and saw a series of blue flashes and then an orange fireball. The deputy reported that there was a dense fog in the area at the time. At the time of the accident, the airport's weather conditions were reported as 100 feet overcast and 1/4-mile visibility in fog. The landing minimums for the ILS approach are 200 feet and 1/2-mile. According to the operator's records, when the airplane departed from Ukiah, its gross takeoff weight was about 5,909 pounds. The pilot operating handbook (POH) for the airplane lists the following items in the single engine go around checklist: 1) Throttle full forward; 2) wing flaps up; 3) when positive climb rate achieved, gear up; 4) ensure the inoperative engine is feathered. For a gross weight of 5,900 pounds, and the existing atmospheric conditions, the single engine climb performance chart shows an expected positive rate of climb of 500 feet per minute if the airplane was configured correctly. The chart also lists the following subtractions from that performance for the listed condition: 1) -400 fpm for wind milling inoperative engine; 2) -350 feet for landing gear down; 3) -200 fpm for flaps extended to 15 degrees. Examination of the wreckage disclosed that neither engine's propeller was feathered, the landing gear was down and the flaps were extended to 10 degrees. Without the airplane configured correctly for the single engine missed approach, the net climb performance would be a negative 400 feet per minute. There were no discrepancies noted with the airframe examination. The engine examination revealed no mechanical anomalies with either engine that would have precluded normal operation. 14 CFR 135.224 states that a pilot cannot initiate an approach if the weather conditions are below landing minimums if the approach is started outside of the final approach fix. The pilot can continue the landing if they are already established on the approach and the airport goes below landing minimums. According to the operator's FAA approved operating specifications, the operator had not been approved for lower than standard landing minimums.
HISTORY OF FLIGHT On January 23, 2003, about 2030 Pacific standard time, a twin engine Cessna 402C, N6814A, collided with a utility pole near the approach end of runway 22L during a single engine missed approach at the Sacramento Mather Airport (MHR), Mather, California. The airplane was owned and operated by Redding Aero Enterprises, Inc., as Boxer 465, under the provisions of 14 CFR Part 135. The airplane was destroyed in a post-impact fire. The commercial pilot, the sole occupant, received serious injuries. Night Instrument meteorological conditions prevailed for the local area cargo flight. An instrument flight rules (IFR) flight plan had been filed. The flight departed the Ukiah Municipal Airport (UKI), Ukiah, California, about 2000 the night of the accident. The flight was destined for Mather. According to a Federal Aviation Administration (FAA) inspector who interviewed the pilot, the pilot stated that he conducted a missed approach due to low weather at MHR. During the missed approach, the left engine lost power. The airplane struck a utility pole, flew over a gazebo, struck the ground, and collided with trees before going through a chain link fence and came to rest, right side up near an access road. A deputy from Sacramento County Sheriff's Department interviewed the pilot on scene. The pilot reported that he made the approach to land at Mather in the fog, and had discontinued the approach to try again. When he added power, the left engine sputtered and the airplane veered to the left. He activated the fuel boost pump, but the airplane contacted obstructions and crashed. The responding sheriff's deputy also observed the accident. He was working at the Sacramento Regional Training Facility as a driver-training instructor when he heard an engine of an airplane making unusual sounds. The engine "seemed to get quiet and then revved higher as if to climb." He looked in the direction of the sound and saw a series of blue flashes and then an orange fireball. The deputy reported a dense fog in the area at the time. The pilot contacted Northern California Terminal Radar Approach Control (NCT) for a landing clearance to Mather Airport. The controller instructed the pilot to descend and maintain 3,000 feet, cleared to Mather via vectors, and was approved for the instrument landing system (ILS) approach to runway 22L. During this time, a UPS 897 flight reported to NCT that they were on the missed approach at Mather due to the weather. The controller queried UPS 897 as to their intentions and if they want to try the approach again. UPS 897 reported that they did not believe it would do any good to go back around for another try and they wanted to contact their company to find out how the company wanted them to proceed. UPS 897 requested to continue the missed approach to COSKA and hold. The controller approved the request. NCT then instructed Boxer 465 to descend and maintain 2,500 feet and to fly a heading of 120 degrees. UPS 897 checked back in with NCT reporting that they were established in the holding pattern at COSKA. The controller issueed the time as 2028, and told the crew to expect further instructions at 2045. The approach controller contacted the Mather airport tower controller via a landline, and indicated that in the event that Boxer 465 went missed to have him maintain 2,000 feet and a 090-degree heading. The approach controller then instructed the accident pilot to turn right heading 250 degrees, descend and maintain 2,200 feet until established on the localizer, cleared ILS 22L. The pilot acknowledged the instructions. The approach controller then transferred Boxer 465 to Mather approach. During the transfer, another aircraft identified as Jetspeed 1682 checked in with NCT. Jetspeed 1682 requested extended vectors for Mather airport to wait and see if the weather cleared to 1/2 statute mile visibility. NCT approved the request and informed Jetspeed 1682 that two twin Cessna's had just made it in, but prior to that a Boeing 757 did not land due to weather. The approach controller contacted the Mather tower controller and asked to be notified as soon as the visibility went back to 1/2 statute miles. The NCT controller then asked if Boxer 465 had gone missed. The Mather tower controller replied that he did not see him on the scope, but was not sure if Boxer 465 had landed. The NCT controller indicated that he had two flights holding, waiting for the weather to clear so they could land at Mather. Jetspeed 1682 contacted NCT and requested to orbit outside of the final approach fix for a while. NCT approved the request. NCT again called the Mather tower controller, and both indicated that they were not talking to him, and that he had not reported in for either the approach or missed approach. Boxer 465 checked in with NTC; however, the audio transmission ended and there were no further transmissions provided to the National Transportation Safety Board investigator-in-charg (IIC). The FAA accident coordinator interviewed Mather Airport control tower personnel. The tower controllers reported that they could not see the airplane due to the heavy fog. A review of the radar plot for the accident airplane showed, that at 2025:16 east of Mc Clellan Airport, Boxer 465 stoped its descent at 3,000 feet. About 3 minutes later a descent is initiated, and at 2028:28, the radar return shows the airplane's altitude at 2,500 feet at the YOSHE intersection. Between 2028:28 and 2030:29, the radar target shows a wide sweeping arc turn to the south with a descent from 2,500 feet to 1,800 feet at the GADBE intersection. From 2030:29 until 2032:41, the airplane descends from 1,800 feet to 300 feet to the accident site. PERSONNEL INFORMATION A review of FAA airman records revealed the pilot held commercial pilot certificate with an airplane single and multiengine land, and instrument airplane ratings. The pilot also held a certified flight instructor certificate with airplane single and multiengine land, and instrument airplane ratings. The pilot held a first-class medical certificate issued on July 31, 2002. It contained the limitation that the pilot must wear corrective lenses. No personal flight records were made available to the Safety Board IIC, and the aeronautical experience listed in this report was obtained from the pilot's employer, Redding Aero Enterprises, Inc. These records indicated a total time of 3,400 hours; 350 hours in the accident make and model, and 270 hours in the last 90 days. AIRCRAFT INFORMATION The airplane was a Cessna 402C, serial number 402C0645. According to paperwork submitted by Redding Aero Enterprises, the airplane's total airframe time was 13,817.5 hours at the time of the last FAA approved airworthiness inspection program (AAIP), which was completed on December 2, 2002. The airplane was equipped with two Teledyne Continental Motors TSIO-520-VB engines. Engine serial number 290314-R was installed on the left side. Total time on the engine at the last inspection was 3,375.5 hours; 782.5 hours since major overhaul, and 70.5 hours since the last inspection. Engine serial number 278264-R was installed on the right side. Total time on the engine at the last inspection was 6,380.5 hours; 392.5 hours since major overhaul, and 70.5 hours since the last inspection. According to the operator's records, when the airplane departed from Ukiah, its gross takeoff weight was about 5,909 pounds. The pilot operating handbook (POH) for the airplane lists the following items in the single engine go around checklist: 1) Throttle full forward; 2) wing flaps up; 3) when positive climb rate achieved, gear up; 4) ensure the inoperative engine is feathered. For a gross weight of 5,900 pounds and the existing atmospheric conditions, the single engine climb performance chart shows an expected positive rate of climb of 500 feet per minute. The chart also lists the following subtractions from that performance for the listed condition: Inoperative engine windmilling -400 feet per minute Gear down -350 feet per minute Flaps down 15 degrees -200 feet per minute METEOROLOGICAL INFORMATION Routine aviation weather reports (METAR) issued for Mather airport surrounding the time of the accident indicated fog and an overcast layer of 100 feet. At 1945, the Mather METAR reported winds from 290 degrees at 6 knots; visibility 1 statute mile; rain and overcast cloud layer at 100 feet; temperature 54 degrees Fahrenheit; no reported dew point; altimeter 30.24 inches of Mercury (inHg). At 2000, the Mather METAR reported winds from 300 degrees at 3 knots; visibility 1/2 statute mile; fog and an overcast cloud layer at 100 feet; temperature 54 degrees; no reported dew point; altimeter 30.23 inHg. At 2030, the Mather METAR reported winds from 340 degrees at 5 knots; visibility 1/4 statute mile; fog and an overcast cloud layer at 100 feet; temperature 54 degrees; no reported dew point; altimeter 30.23 inHg. At 2120, the Mather METAR reported winds from 320 degrees at 5 knots; visibility 1/8 statute miles; fog and an overcast cloud layer at 100 feet; temperature 52 degrees; no reported dew point; altimeter 30.24 inHg. COMMUNICATIONS The airplane was in contact with NCT during the approach to Mather Airport. The Safety Board investigator-in-charge reviewed the audio transmissions between NCT and the accident pilot (the flight was using the call sign Boxer 465). Transcripts were not prepared, and the tape did not provide time stamps during the recording. However, the recording on the audiotape indcated times from 2009 through 2108. Also, at one point during the recording, United Parcel Service (UPS 897) was issued a hold time. UPS 897 checked back in with NCT reporting that they were established in the holding pattern at COSKA. The controller issueed the time as 2028, and told the crew to expect further instructions at 2045. AIRPORT INFORMATION The Airport/ Facility Directory, Southwest U. S., indicates that Sacramento Mather Airport runway 22L is 11,301 feet long and 150 feet wide. The runway surface is composed of asphalt and concrete. The ILS landing minimum for a straight-in approach to runway 22L was 296 feet mean sea level (200 feet agl) and 1/2 statute mile visibility. According to the Jeppesen approach chart, the final approach fix is at the GADBE intersection. Federal Aviation Regulation (FAR) Title 14 CFR Part 135.225 IFR titled Takeoff, approach and landing minimums: (a) No pilot may being an instrument approach procedure to an airport unless - (1) That airport has a weather reporting facility operated by the U.S. National Weather Service, a source approved by U.S. National Weather Service, or a source approved the by the Administrator; and (2) The latest weather report issued by that weather-reporting facility indicates that weather conditions are at or above the authorized IFR landing minimums for that airport. (b) No pilot may begin the final approach segment of an instrument approach procedure at an airport unless the latest weather reported by the facility described in paragraph (a)(1) of this section indicates that weather conditions are at or above the authorized IFR landing minimums for that procedure. (c ) If a pilot has begun the final approach segment of an instrument approach to an airport under paragraph (b) of this section and a later weather report indicating below minimum conditions is received after the aircraft is - (1) On an ILS final approach and has passed the final approach fix... According to the FAA approved operating specifications for the operator, the operator was not approved for lower than standard landing minimums. WRECKAGE AND IMPACT The airplane came to rest on a south westerly heading approximately 3,000 feet from the base of the Mather air traffic control tower, at Global Positioning System (GPS) coordinates of 38 degrees 33.4 minutes north latitude and 121 degrees 16.7 minutes west longitude. An FAA inspector examined the wreckage on scene and noted that the first identified point of contact (FIPC) was a utility pole about 500 feet northwest of where the airplane came to rest. He noted an impact mark on the pole about 25 feet from the bottom. After striking the pole the airplane flew over a gazebo, impacted the ground, where it turned 90-degrees from its original direction of travel, went through a chain link fence and came to rest upright near an access road. TESTS AND RESEARCH Investigators from the Safety Board, the FAA, Cessna Aircraft Company, and Teledyne Continental Motors (TCM), examined the wreckage at Plain Parts, Sacramento, California, on January 27 and 28, 2003. Investigators noted that the post-impact fire destroyed the entire fuselage with the exception of some floor area, and portions of aft fuselage. The flaps were found in the 10-degree extended position, and the landing gear actuators were in the down position. No discrepancies were noted with the airframe examination. A Safety Board investigator examined the extensively burned wreckage. No system powerplant discrepancies were identified. During the visual inspection of the left engine, investigators noted that a majority of the oil sump, and the accessory section, were thermally destroyed. The starter separated from the engine; the exhaust system was crushed and broken and the induction was broken and melted. The propeller governor was partially retained in place, with the top portion broken off. The propeller flange had separated at the crankshaft. The alternator, along with a portion of the engine case, had separated from the engine case. The turbocharger remained attached to the firewall and was thermally damaged. The compressor impeller and turbine wheel rotated freely with no binding. Investigators noted that both magnetos remained attached to the engine via their mounting pads. The magnetos were removed, and the TCM representative manually rotated the magnetos. Both magnetos produced spark at each of their respective posts. The spark plugs were removed, and when compared to the Champion Aviation Check-A-Plug chart AV-27, were normal in appearance. The TCM representative removed the fuel pump, and noted that the drive coupler was intact. When manually rotated the fuel pump's drive turned freely. The fuel pump was disassembled with no discrepancies noted. The TCM representative noted that the throttle body was in the full open position and the mixture was near the mid-point. He removed the fuel control unit and noted that the screen was covered in an identified black substance attributed to the post-impact fire. Mechanical and drive train continuity were established via manual rotation of the engine from the accessory drive. Investigators obtained thumb compression on all cylinders in firing order. The main and scavenge oil pumps were removed, and investigators noted the gears were intact with no evidence of metal flakes or chips found. The TCM representative noted that the pump walls had been scored. The oil sump was also removed with no evidence of metal debris found. The oil pickup screen was clean of debris. The TCM representative removed all of the cylinders, and noted a light deposit in the combustion chambers, and that the valves were not burned. No mechanical anomalies were noted with the valves or pistons. The piston rings were intact and could be rotated freely. The TCM representative separated the case halves. There were no abnormal or unusual wear noted with the inside of the case halves. The main bearings remained intact with no scoring or abnormal wear noted. The TCM representative further reported that the bearing tang slots were not elongated. The crankshaft was visually inspected with no discrepancies noted. The counterweights remained in place and moved freely about their pins. The connecting rods remained attached to their respective journals. The camshaft was visually inspected with no pitting observed. Investigators noted no heat discoloration inside the engine. The TCM representative reported that there were no mechanical ano
loss of engine power in the left engine for undetermined reasons. Also causal was the pilot's failure to correctly configure the airplane for a single engine missed approach, which resulted in a negative climb performance. A factor was the pilot's decision to initiate the approach when the weather conditions were below the published approach minimums.
Source: NTSB Aviation Accident Database
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