Flagstaff, AZ, USA
N592DM
Cessna T310R
The aircraft collided with an embankment 2 miles from, and about 200 feet lower than, the airport during a takeoff attempt in icing conditions. Examination of the ground scars and wreckage disclosed that the airplane collided with the berm in near wings level controlled flight while in a slightly nose high descending flight path. Evidence showed that both engines were developing symmetrical high power at impact. The aircraft was transporting cargo and medical specimens over a route the pilot flew every day according to a company schedule. The aircraft had arrived at 1826 from the previous stop on the scheduled route. According to witnesses at the airport who watched the airplane takeoff, either one or both of the engines were "very rough sounding." After the airplane departed runway 21, it made a shallow left turn, and then disappeared into the low clouds. One witness indicated that the airplane rotated approximately 5,000 feet down the nearly 7,000-foot-long runway. While on the ground after arrival, the pilot requested that the airplane be deiced. The line service technician accomplished this at 1855, 1 hour before the accident, with the pilot observing the procedure. When the technician arrived at the aircraft he noticed that the aircraft had "a considerable amount of ice built up" from the landing. He sprayed approximately 5 gallons of Glycol mix 50/50 to remove the ice and snow that was attached to the leading edges of the wings, spinners, and the snow that had accumulated on the top of the fuselage. During the procedure, light snow continued to fall. The accident airplane was not certified, nor equipped for flight into known icing conditions. Based on an evaluation of the weather data, IFR conditions, light snow showers, and conditions highly conducive to icing from the surface to 20,000 feet existed at the airport during the aircraft's landing, stay on the ground, and departure. There was a 95 percent probability of moderate clear to mixed icing from the surface to 10,800 feet. The pilot was aware of the icing conditions both at the airport and in the local area at the time of departure, and had received multiple weather briefings where the forecasted and observed icing conditions were clearly described. The operator reported that a truck was available to take the pilot's cargo onto the final destination should weather or mechanical reasons preclude completion of the flight. According to entries in a journal the pilot kept, there is evidence that the pilot perceived a great deal of pressure to fly in icing conditions with an under-equipped aircraft, and some of this pressure involved a perceived association between doing so and maintaining employment; however, there was insufficient information to determine whether the company culture condoned or encouraged this behavior. There was insufficient information from which to determine why the pilot chose to depart in icing conditions. Fatigue was not a factor in this accident. No preimpact mechanical malfunctions or failures were identified in the wreckage examinations.
HISTORY OF FLIGHT On December 7, 2004, about 1955 mountain standard time, a Cessna T310R, N592DM, impacted an embankment adjacent to Interstate 17, about 2 miles south of the Flagstaff, Arizona, airport. The airplane had just departed the airport and was in the takeoff initial climb phase. Distribution Management Corporation, Inc., d.b.a. Aero Charter and Transport, Albuquerque, New Mexico, operated the airplane as an on-demand charter flight carrying bank and medical cargo under the provisions of 14 CFR Part 135. The airplane was destroyed. The commercial pilot, the sole occupant, sustained fatal injuries. The cross-country flight departed Grand Canyon National Park, Arizona, airport at 1736, en route to Flagstaff, and the flight was scheduled to continue on to Phoenix. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed and an instrument clearance received for the flight. The wreckage was at 35 degrees 06.480 minutes north latitude and 111 degrees 40.877 minutes west longitude. The airplane was not equipped for, nor certified to conduct, flight into known icing conditions. The operator indicated that the airplane had been chartered to haul bank material, and, blood and specimen samples for local hospitals. The operator further stated that the airplane's scheduled route of flight was from Phoenix Sky Harbor International Airport (PHX), to Payson Airport (PAN), Page Municipal Airport (PGA), Grand Canyon, Flagstaff, and Payson with a return to Phoenix. The flight would have departed Phoenix that day about 0700, and was scheduled to terminate back at PHX about 2000. The operator reported that the pilot had called in from Page and reported that Payson was "iced in." The pilot was instructed to fly Grand Canyon and call the company if he was not able to make it into Flagstaff. The company became aware of the airplane accident after the airplane dropped off the company's tracking system shortly after takeoff from Flagstaff. According to the aircraft log sheet recovered in the wreckage, the pilot departed Phoenix at 0714, arriving at Page at 0856. The flight departed Page at 1646, and arrived at Grand Canyon at 1733. The flight departed Grand Canyon at 1736, and arrived at Flagstaff at 1829. Recordings of telephone and radio conversations and other records from the Federal Aviation Administration (FAA) were reviewed. At 1540, the pilot contacted the Albuquerque Automated Flight Service Station (AFSS) to file "canned" company flight plans and to receive a weather briefing. Flight plans were filed for flights from Page, Arizona (PGA), to Grand Canyon (GCN); GCN to Flagstaff (FLG); FLG to Payson (PAN); and PAN to Phoenix (PHX). During the weather briefing, the pilot was advised, "across the majority of that route for you this evening, I do have advisories for mountain obscuration and icing, Phoenix is about the only airport uh, not included in the advisories and the icing is forecasted light to moderate from the freezing level up to eighteen thousand feet." The briefer then asked the pilot if he had any "way to deice." The pilot responded, "No," and the controller stated, "You can't go." The pilot said, "I know, technically I can't go," but continued to receive the rest of the brief that included a pilot report for moderate rime ice near Prescott, Arizona. The pilot again spoke with Albuquerque AFSS between 1836 and 1840, and changed the last leg destination to PHX, in lieu of PAN. The briefer asked the pilot if he was aware of the Airmet for icing and mountain obscuration, to which the pilot answered, "Yeah." The pilot agreed with the briefer that the ceilings at FLG were approximately 300 feet agl. The pilot then stated, "it's disgusting here, don't tell me what the weather is, cause I get scared." He said light snow was falling, and when asked again if he had the Airmet for icing, responded "Oh yeah, it's all over my airplane." Earlier in the conversation, the pilot did state he was "wanting to get a guy to deice my airplane." The line service person that works for Wiseman Aviation at Flagstaff-Pulliam Airport, deiced the accident airplane prior to departure. He holds FAA airframe and power plant mechanic and private pilot certificates. He had also been with the United States Air Force for 4 years, and the reserves for 1 year. He indicated he had over 5 years experience deicing aircraft from KC-135 aircraft to more recently corporate and smaller civilian aircraft. He indicated that the pilot of the accident airplane requested to have the aircraft deiced at approximately 1855 and upon arriving at the aircraft he noticed that the aircraft had "a considerable amount of ice build up" from landing at the airport. He sprayed approximately 5 gallons of Glycol mix 50/50 to remove the ice and snow that was attached to the leading edges of the wing, spinner, and the snow that had accumulated on the top of the fuselage. The pilot monitored the deicing procedure and when asked if he was satisfied with the deicing procedure indicated that it "looked good." He also indicated that he had completed deicing another aircraft, a Piper Chiefton, which had also made a quick turn and also had landed a considerable time after the accident airplane's arrival. That aircraft also had a considerable amount of ice built-up, compared to the accident airplanes. He used 15 gallons of deicing fluid to deice the Chiefton. At 1937, the mishap pilot received an IFR clearance from Prescott AFSS. According to witnesses at the airport, who watched the airplane takeoff, either one or both of the engines were "very rough sounding." After the airplane departed runway 21, it made a shallow left turn, and then disappeared into the clouds. One witness indicated that the airplane rotated approximately 5,000 feet down the nearly 7,000-foot-long runway. About 5 minutes later, phone calls started to come into the airport reporting an airplane crash. At 1943, a person aboard Lifeguard N842DS, a Beechcraft King Air 100, reported to Prescott AFSS the "aircraft that just departed Flagstaff having trouble, I don't hear his engines anymore. He had controllability problems. He had engine problems." A truck driver was driving on Interstate 17 and witnessed the airplane fly from east- to-west directly across his path and impact a hillside. Aero Charter's chief pilot reported that they had a truck standing by at Flagstaff to take the pilot's load of cargo to Phoenix in case the pilot could not fly the route for weather or mechanical reasons. The weather conditions recorded at Flagstaff, at 1944, reported wind from 230 degrees at 9 knots; visibility 1.5 miles with light snow and rain; overcast ceiling at 300 feet; temperature -1 degree Celsius; dew point -2 degrees Celsius; altimeter setting 30.03 inches of mercury (inHg). Weather at 1956 was recorded as wind from 220 degrees at 11 knots; visibility 2 miles with light snow and rain; overcast ceiling at 300 feet; temperature -1 degree Celsius; dew point -2 degrees Celsius; altimeter setting 30.03 inHg. Weather conditions observed at 2010 were wind from 220 degrees at 10 knots; visibility 1.5 miles with light snow and rain; overcast ceilings at 300 feet; temperature -1 degree Celsius; dew point -2 degrees Celsius; altimeter setting 30.03 inHg. PERSONNEL INFORMATION A review of FAA airman records revealed the pilot held a commercial pilot certificate with ratings for airplane single and multiengine land and instrument airplane. The pilot also held a mechanic certificate with ratings for airframe and power plant. A second-class medical certificate was issued to the pilot on January 5, 2004, without limitations or waivers. An examination was conducted of the pilot's logbook that was found on scene. The last entry was dated September 28, 2004. At that time the pilot reported a total flight time of 1,692.9 hours. For the month of September he logged 27.2 hours. According to his current employer, Aero Charter and Transport, Albuquerque, New Mexico, the pilot was hired in October 2004. He completed the 14 CFR 135.293, 14CFR 135.297, and 14 CFR 135.299 check rides on October 11, 2004. A history of the pilot's activities and sleep schedule, and potential for sleep, was constructed from aircraft log sheets, the pilot's hand written journal, and from information obtained during an interview with the accident pilot's widow. All times are converted to the pilot's local time zone, mountain standard time. On Friday, December 3, 2004, the pilot's duty day began at 0700. He flew two flights, PHX to YUM, and YUM to PHX. He had approximately 9 hours layover between flights. The total flight time was 2.4 hours, and his duty day ended at 2200. He departed Phoenix for California at 2230, by automobile, and arrived at his home the following morning at 0430. Another pilot, the manager of the Phoenix operation for Aero Charter, who also lived in California, accompanied him. He would have had the opportunity for a maximum of 4 hours sleep, and woke up at 0830 on Saturday, December 4, 2004. On Saturday, December 4, 2004, the pilot framed the deck of his house with a friend, followed by dinner with his wife, and went to bed between 2200 and 2300. On Sunday morning, December 5, 2005, he woke up at approximately 0930. This would have allowed for a maximum period of sleep of about 10 hours. On Sunday, December 5, 2005, the pilot cleaned the house in preparation for a visit from a potential buyer, and left the house for the return trip to Arizona at 1730. He first picked up the other pilot, and they arrived in Phoenix at 2345. He reported receiving 4 hours sleep that night in a hotel. On Monday, December 6, 2004, the pilot flew a series of approaches in a Cessna 402 in adverse weather conditions, with snow and slippery runways. One of his intended stops, the Payson airport, was closed due to poor weather conditions. He reported being tired all day, and forgot one of the pickups at Flagstaff. He was discouraged by this, and after several conversations with his wife, went to bed at approximately 2200. A duty start time is not included on the aircraft log for the day of the accident, Tuesday, December 7, 2004. However, 30 minutes between duty start time and aircraft engine start time is usual. The engine start time was 0714, which puts the duty start time at 0645. Allowing 45 minutes for preparation and arrival at PHX, the pilot would have had approximately 8 hours of time available for sleep that night. On Tuesday, December 7, 2004, the pilot completed three successful flights prior to the accident flight. He departed PHX at 0714 and arrived at PGA at 0859, with a layover of 7 hours 47 minutes. The first flight was originally scheduled for PHX to PAN, although this route was not flown due to icing conditions at PAN. He departed PGA at 1646 and arrived at GCN at 1835, with an immediate turn-around. He departed GCN at 1836 and arrived at FLG at 1932. The accident occurred at 1955, 5 minutes after his departure from FLG. AIRCRAFT INFORMATION The airplane was a Cessna T310R, serial number 310R0681. A review of the maintenance records revealed a total airframe time of 5,032 hours at the time of the accident. The aircraft was being maintained on an approved continuous airworthiness inspection program. The most recent inspection, an "Operation 4" was endorsed as completed on November 9, 2004, at a total airframe time of 4,988 hours. The left tachometer read 1,550 at the accident scene, the right tachometer was destroyed and displayed no numbers; the Hobbs hour meter read 2,346.3 at the accident scene. According to Cessna Aircraft Company, this airplane was not certified for flight into known icing conditions. It was not equipped with wing or tail deice boots. The airplane was equipped with an inboard left wing locker fuel tank. The fuel tank was placarded with a DO NOT PUT FUEL IN. According to the operator, the fuel tank was not used because they had had problems with it in the past, and had placed the placard on it. A Teledyne Continental Motors factory remanufacturered TSIO-520-B engine, serial number 176843-R, was installed on the left position on December 4, 2003, and had accumulated a total time since remanufacture of about 700 hours. The most recent inspection, an "Operation 4" was endorsed as completed on November 9, 2004, at a total airframe time of 4,988 hours. A Teledyne Continental Motors factory remanufacturered TSIO-520-B engine, serial number 176844-R, was installed on the right position on December 4, 2003, and had accumulated a total time since remanufacture of about 700 hours. The most recent inspection, an "Operation 4" was endorsed as completed on November 9, 2004, at a total airframe time of 4,988 hours. Fueling records at Classic Aviation in Page, Arizona, established that the airplane was last fueled on December 7, 2004, with the addition of 57.3 gallons of 100LL aviation fuel. The Aero Charter & Transport aircraft log sheet and associated load manifest documents were found in the wreckage. For the Flagstaff to Phoenix leg of the flight, the pilot had computed a gross takeoff weight of 4,950 pounds with a center of gravity of 39.0. The limits were listed as a gross takeoff weight of 5,680 pounds with a center of gravity range between 34.2 and 43.6. While the cargo was not weighed, the appearance of the cargo and aircraft contents during examination of the wreckage did not give investigators reason to question the weights listed by the pilot on the load manifest. Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure. METEOROLOGICAL INFORMATION A staff meteorologist for the Safety Board prepared a factual report, which is included in its entirety in the docket for this accident. The synoptic or large scale migratory weather systems influencing the area were documented using standard NWS charts issued by the National Center for Environmental Prediction (NCEP) located in Camp Springs, Maryland. The southwest section of the NWS Surface Analysis Chart for 0300Z on December 8, 2004, depicted a low-pressure system with an associated occluded front off the northwest Pacific coast with a steep pressure gradient. A stationary front was located from British Columbia southeastward across Montana and South Dakota, where two low-pressure systems were located with central pressures of 1004 millibars (mb). Another low pressure system with a central pressure of 1008 mb was located over eastern Colorado, with a trough of low pressure extending from the low in eastern Montana to the low in Colorado, and then southward into New Mexico parallel and to the east of the Rocky Mountains. A ridge of high pressure extended from a high-pressure system off the southern California northeastward across southern California, Arizona, into New Mexico and western Colorado. The accident site was located on the northern side of the ridge of high pressure and on the cold airside of the low-pressure system to the west-northwest over Colorado. The southwest section of the NWS Weather Depiction Chart for 0100Z depicted the general flight conditions prior to the accident. An area of instrument flight rule (IFR) conditions was depicted by a shaded contour extending over northern Arizona northward into Utah. Surrounding the IFR area was a larger area of marginal visual flight rules (MVFR) conditions indicated by an unshaded contour over most of northern Arizona, Utah, Nevada, and portions of southern California. Visual flight rule (VFR) conditions were depicted over southern Arizona, southeast California, New Mexico, and Colorado. The station model at Flagstaff indicated IFR conditions, with an overcast ceiling at 300 feet above ground level (agl). Further to the south, Phoenix reported VFR conditions with overcast clouds at 4,800 feet. The southern section of the NWS Radar Summary Chart for 0218Z depicted a band of light-to-moderate intensity echoes extending from northwest to south-central Arizona associated with rain with a small area of intense-to-extreme intensity echoes embedded
The pilot's decision to attempt flight into known adverse weather conditions beyond the capability of the airplane and his failure to ensure that the airplane's wings were free of ice and/or snow contamination that accumulated while the airplane was on the ground, which resulted in an attempted takeoff with upper wing contamination that induced a subsequent stall/mush and a collision with the ground.
Source: NTSB Aviation Accident Database
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