Bee Caves, TX, USA
N729DM
Cessna 421C
The 14,000-hour airline transport pilot was hired to fly the owner of the airplane and his mother on a cross country flight. Approximately 3 hours and 15 minutes into the flight, the pilot reported that he had a rough running engine and declared an emergency. A review of ATC voice communications revealed that the pilot had changed his mind several times during the emergency about diverting to a closer airport or continuing to the intended destination. Prior to his last communication, the pilot informed ATC that he, "was not gonna make it." The sole survivor of the accident reported that the flight was normal until they approached their destination. He said, "all of a sudden the engines did not sound right." The right engine sounded as if the power was going up and down and the left engine was sputtering. The airplane started to descended and the pilot made a forced landing in wooded area. The cockpit, fuselage, empennage, and the right wing were consumed by post-impact fire. A review of fueling records revealed that the pilot had filled the main tanks prior to the flight for a total of 213.4 gallons; of which 206 gallons were usable (103 gallons per side). During the impact sequence, the left wing separated at the wing root and did not sustain any fire damage. No fuel was found in the tank, and there was no discoloration of the vegetation along the left side of the wreckage path or around the area where the wing came to rest. The left fuel selector was found set to the LEFT MAIN tank, and the right fuel selector valve was set between the LEFT and RIGHT MAIN tanks. This configuration would have allowed fuel to be supplied from each tank to the right engine. A review of the airplane's Information Manual, Emergency Procedures-Engine Failure During Flight (speed above air minimum control speed) instructed the pilot to re-start the engine, which included placing both fuel selector handles to the MAIN tanks (Feel for Detent). If the engine did not start, the pilot was to secure the engine, which included closing the throttle and feathering the propeller. The propellers were not feathered. Examination of the airplane and engine revealed no mechanical deficiencies.
HISTORY OF FLIGHT On September 23, 2004, approximately 1619 central daylight time, a Cessna 421C twin-engine airplane, N729DM, was destroyed when it impacted terrain following a loss of engine power to the left engine during descent near Bee Caves, Texas. The airline transport rated pilot and a passenger were fatally injured, and the other passenger was seriously injured. The airplane was registered to and operated by N729DM LLC of Ingram, Texas. An instrument flight rules (IFR) flight plan was filed for the cross-country flight that originated at the Angel Fire Airport (AXX) near Angel Fire, New Mexico, at 1304, and was destined for the Austin-Bergstrom International Airport (AUS) near Austin, Texas. Visual meteorological conditions prevailed for the personal flight conducted under 14 Code of Federal Regulations Part 91. On September 23, 2004, the pilot, the owner of the airplane, and his assistant departed Texas, about 0930, and flew to Angel Fire, New Mexico. The purpose of the flight was to pick up the owner's mother, who spent her summers in Angel Fire, and then bring her back to her home in Austin, Texas. The owner's assistant was going to drive the owner's mother's car and personal belongings back to Austin. When they arrived in Angel Fire, the owner's mother met them at the airport and she had a picnic lunch prepared for them. The group had lunch, after which, the pilot excused himself and tended to the airplane. The pilot was reported to have purchased 94 gallons of 100 LL aviation fuel, which filled the main tanks of the airplane. The pilot, the airplane owner, and his mother departed Angel Fire around 1200. The pilot was occupying the front left (pilot's) seat, the owner sat in the left rear seat, and his mother sat in the right rear seat. According to the owner, the flight was uneventful and they cruised at an altitude of 18,000-20,000 feet mean sea level (msl). Prior to their arrival into Austin, the owner stated that all of a sudden, the engines did not sound right. He could not recall if it was just one engine, and believed it to be both engines. The right engine sounded as if the power was going up and down and the airplane was yawing. He added that the pilot had quickly applied full left aileron, and the control yoke was positioned with the right side of the yoke facing up towards the roof of the airplane. At one point, the owner thought the plane was going to stall. He said the pilot appeared busy in the cockpit, but not "harried". The owner could also hear the pilot talking to ATC. The owner added that the pilot never spoke directly to the passengers during the emergengy; however, the owner did hear the pilot say out loud, "Oh God, I don't think we're going to make it!" During this time, the airplane was descending and the owner noted that they were getting closer to the ground. He told his mother to tighten her seat belt and they held hands. Also during this time, the owner heard the left engine sputtering but could not recall if it ever quit. He did recall that the right engine "came back on line" (though he was not sure if it ever completely stopped producing power), and the airplane yawed. After the engine came back up to power, he recalled hearing the pilot tell ATC that they could make Austin. The owner stated that he remembered seeing the pilot move his right hand down toward the floor where the fuel selector handles were located, but could not recall seeing him turn the handles. He thought he might have been reaching for a chart. The owner also recalled (but wasn't completely sure) that the mixture controls were full rich; the propeller controls were at low rpm and the throttles were in the mid rpm position. He did not recall what any of the engine instruments indicated. The owner further stated that he did not recalled the impact, but remembered the left side of the airplane hitting tree limbs. When the airplane touched down, the impact broke his seat from the mounts and he was thrown to the right side of the airplane. He did not recall if he was unconscious, but woke up with the left side of his face pressed against a window and it was burning his face. The owner looked at his mother and she was lifeless, and there was no movement or sound from the pilot. Smoke started filling the cabin and he could see heat waves building. With the left side of his body broken, the owner lunged toward the aft cabin door and it opened. He fell down the stairs and dragged himself about 15-20 feet away from the burning airplane. When he exited the left side of the airplane, there was no fire on that side. The fire was burning the right side of the airplane. The owner said there had been no previous mechanical problems with the airplane or engines. A review of air traffic control (ATC) communications revealed that the pilot made initial contact with Austin Approach Control at 1608:09 and reported that he was descending from an altitude of 10,000 feet to 6,000 feet and he had the current airport information "Charles." Between 1608:20 and 1612:29, the pilot communicated with ATC regarding instructions for an approach to runway 35R at AUS. During this time, the pilot complied with all ATC instructions, had descended to 4,000 feet, and was on a heading of 155 degrees. At 1616:08, the pilot reported to ATC, "And delta mike, I'm having a rough running engine, I'd like to declare an emergency." ATC replied, "Okay nine delta mike, uh, roger, you also have Lakeway Airport just off to your right there if you want to." At 1616:15, the pilot responded, "No sir, I want to go in to Austin, just help me out." At 1616:24, ATC instructed the pilot to turn 10 degrees to the left, maintain 3,000 feet, and report the airport in sight. ATC then asked the pilot for the number of souls on board and the amount of fuel remaining. At 1616:40, the pilot replied, "Okay, I've got three people on board and I've got plenty of fuel. I've got two hours of fuel left." ATC then instructed the pilot to report when the airport was in sight and informed him that he would be number one for a visual approach to runway 35L. The pilot acknowledged. Four seconds later, the pilot reported to ATC, "may have to go to Lakeway," and ATC responded by informing him that it was four miles west of his position. Approximately 30 seconds later, at 1617:44, ATC informed the pilot that Lakeway Airport had one runway that was aligned with 16/34 and was 4,000 feet long. At 1617:50, the pilot contacted ATC and stated, "Sir, I'm gonna keep trying to come to Austin, my, ruh, engines cutting in and out." ATC acknowledged. At 1617:58, the pilot stated, "no sir, I guess I have to go to Lakeway, give me a vector." ATC responded, "okay, turn right heading, uh, two eight zero," and the pilot acknowledged. At 1618:20, ATC informed the pilot that the surface winds at Austin were from 040 degrees at 6 knots. At 1618:33, the pilot reported to ATC, "not gonna make it." ATC responded at 1618:36, "nine delta mike, the airport one o'clock and four miles." The pilot did not respond, and there were no further communications with him. A review of radar data revealed the last radar return was received at 1618. At that time, the airplane was at an altitude of 1,100 feet mean sea level (msl), and on a northwesterly heading. A witness, who was in his front yard, reported hearing a sputtering noise. He looked around and saw the airplane coming from the west. He reported that it appeared to be shaking and oscillating vertically. The airplane then disappeared over the trees and the witness did not see or hear anything else. A second witness, who was practicing football at a near-by middle school, stated that he observed the white, twin-engine airplane pass from his left to right in a fast, descending, right-hand turn. He noticed that one of the engines (he could not recall which) was sputtering, and he could see smoke coming from the back of that engine. A third witness, who was walking around in a church parking lot, reported hearing a sputtering noise and saw the airplane circling at approximately 200-300 feet above ground level (agl) near a church construction site across the street from him. He reported that the plane went silent and then gradually descended until it disappeared behind the trees to the west of the construction site. Then, almost simultaneously, the witness heard the impact and explosion. A fourth witness, who worked at an office near the site of the accident, heard a sputtering noise and saw the airplane directly above him. He reported that one of the engines was going "off and on" and the airplane was "losing altitude fast." A fifth witness, who was working as a land steward at the nature conservancy where the airplane crashed, was in a pasture when he "heard the plane noise, loud and low, it was revving and uneven." The sound came from behind a cliff to the south of him. The witness then began to run toward the cliff, and the airplane "came into view about 100 feet up from the cliff and about 100-200 yards to the southeast" of the witness. He reported that "the plane wobbled a bit, then straightened, and it was flying in a really shallow, downward glide." He also reported that the engine was "revving and popping" before he lost sight of it. After the explosion, the witness saw a thick plume of smoke rising from the trees and a fire on the lawn. The accident occurred during daylight hours approximately 30 degrees, 18 minutes north latitude, and 97 degrees, 53 minutes west longitude. PERSONNEL INFORMATION The pilot held an airline transport pilot (ATP) certificate with a rating for airplane multi-engine land. The pilot also held a commercial certificate with ratings for airplane single-engine land, airplane single-engine sea, and rotorcraft-helicopter. The pilot, a retired airline pilot, was type-rated in a B-727, CE-500, L-1011, and MD-11. His most recent Federal Aviation Administration (FAA) first class medical certificate was issued on December 9, 2003, during which time the pilot reported a total of 14,000 hours of civilian flight time. A logbook was located in the wreckage; however, according to his wife, this was a supplemental logbook. The pilot had recently started using this supplemental logbook and would later transfer the flight to his master logbook, which he kept at home. A review of the supplemental logbook revealed that he had accrued a total of approximately nine hours in make and model. AIRCRAFT INFORMATION A review of the aircraft maintenance logbooks revealed that the aircraft had undergone an annual inspection on September 7, 2004, in Waco, Texas, at an aircraft total time of 5,328.8 hours. The airplane had accrued approximately 12 hours since the inspection. The airplane's fuel system consisted of two main tanks, two auxiliary wing locker tanks, two fuel selectors, and emergency cross feed shutoff valves. The main fuel tanks supplied their respective engine with fuel for normal operations, including takeoffs and landings. The left auxiliary tank was intact, but was not used during the flight. The fuel quantity sending unit was disconnected, and approximately one cup of blue aviation fuel was found in the tank. The right auxiliary fuel tank was destroyed by fire. Two fuel selectors, one for each engine, were located on the floor between the pilot and co-pilot seats. The selectors allowed selection of main fuel, cross feed, and off. According to the airplane's Operation Manual, it stated that during normal flight operations, the pilot was to position the left fuel selector to LEFT MAIN and the right fuel selector to RIGHT MAIN. With the selectors set to these positions, fuel would flow from each main tank, through the fuel selector, to the respective engine driven fuel pump. Additionally, fuel could also be cross-fed from the left main tank to the right engine and vice versa. If the pilot elected to cross-feed the fuel, then both engines would be supplied with fuel from the right main tank when both fuel selectors are positioned to the RIGHT MAIN tank. Conversely, both engines would be supplied with fuel from the left main tank when both fuel selectors were positioned to LEFT MAIN tank. The cross-feed function is used to balance asymmetric fuel loads and to supply the engine-driven fuel pump from the opposite main tank. WRECKAGE AND IMPACT INFORMATION The wreckage was examined at the accident site on September 24-25, 2004. All major components of the airplane were accounted for at the scene. The airplane impacted wooded terrain and came to rest upright at an elevation of approximately 780 feet mean sea level (msl) on a magnetic heading of 260 degrees, at an elevation of approximately 780 feet msl. The point of initial impact appeared to be along a line of several trees that ran parallel to the wreckage path. The tops of the tree limbs were severed and impact marks were evident at points progressively closer to the ground along the wreckage path prior to the airplane's first contact with the ground. The first ground impact mark was noted approximately 50 feet beyond initial impact with the trees, and the main wreckage came to rest approximately 50 feet beyond the first ground impact mark. The main wreckage included the cockpit, fuselage, empennage, tail section, inboard section of the right wing and the right engine. The cockpit, fuselage, empennage, and inboard section of the right wing were consumed by post-impact fire. The right engine sustained fire and impact damage. The propeller remained attached to the engine. Scattered along the wreckage path were the left wing and engine. The engine had separated from the nacelle and was found forward of the left wing and was embedded in trees. The propeller remained attached to the engine. Both the wing and the engine sustained impact damage and were not damaged by fire. The left wing came to rest adjacent to a large cedar tree that exhibited an impact mark near the base of the trunk. Examination of the wing revealed that the flap and aileron sustained impact damage, but remained attached to the wing. The fuel tank was breached, and there was no evidence of fuel in the tank. There was also no evidence of a fuel spill and vegetation around the wing was not discolored. The wing locker fuel tank was intact, and approximately one cup of fuel was observed in the tank. The fuel strainer was intact and disassembled. Approximately one cup of light blue colored fuel was drained from the bowl, and the filter was absent of debris. Also found along the wreckage path was the outboard section of the right wing, which was located at the base of a small tree. This section of wing was consumed by fire. The fuel strainer was intact and the bowl was empty. The filter was absent of debris. The left wing fuel selector handle located in the cockpit was found set to the left tank, and the right wing fuel selector was found positioned in-between the left and right fuel tank. The left wing fuel selector valve located in the wing was found in the "off" position, and the right wing fuel selector valve was set "in-between" the left and right fuel tanks. This configuration would have allowed fuel to be supplied from each tank to the right engine. The engines were examined at Teledyne Continental Motors (TCM), Mobile, Alabama, on November 30- December 3, 2004, under the supervision of the Safety Board. Examination of the left engine revealed that the propeller shaft was bent and bulged. This damage precluded the opportunity to test run the engine and a subsequent examination and teardown were initiated. The propeller flange was manually rotated and continuity to the rear accessories was established. Valve train continuity was also established. A compression check was conducted via a compression gauge and compression was established on each cylinder. Both magnetos were removed and placed on a test bench. Spark was noted on each ignition lead at various power settings. Engine timing was found to be within limits. The top and bottom spark plugs were removed and appeared to be light gray in color. The fuel pump housing for the inlet fitting
The pilot's improper positioning of the fuel selector valves, which resulted in a loss of power to the left engine due to fuel exhaustion. After the power loss, the pilot failed to follow checklist procedures and did not secure (feather) the left propeller, which resulted in a loss of altitude and subsequent forced landing.
Source: NTSB Aviation Accident Database
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