Creede, CO, USA
N777GY
CESSNA 320E
The commercial pilot and crew were conducting aerial photography work under contract with the U.S. Department of Agriculture. Shortly after departure, the pilot noticed an engine vibration coming from the airplane's right side and returned to the departure airport to have a mechanic inspect the engine. The pilot called the company operator to notify the company's owner of the engine anomaly; the operator and the crew agreed that they would stop aerial photography work and return to the operator's base in Longmont, Colorado but that they would call the operator's base to provide an update on the mechanics' findings before departing; however, the operator received no further communications from the crew. GPS data showed the airplane departing AEJ and then heading south in the opposite direction of the operator's base and overflying one aerial survey point near C24. The airplane maintained an altitude of between 11,300 and 13,000 ft mean sea level (msl) with a ground speed between 120 to 169 knots for most of the flight. The last two minutes of flight showed the airplane circling around C24 while decreasing in altitude and fluctuating in airspeed between 140kts and 98kts. During the last 3 minutes of the flight, the airplane was descending, and the groundspeed decreased from 141 knots to 98 knots, before increasing to 128 knots and then rapidly decreasing to 99 knots during a sharp, 90º left turn to the north. The last recorded parameter showed the airplane at 8,665 ft msl with a groundspeed of 99 knots. Witnesses stated that the airplane was on a left base for the runway but did not appear to be correctly positioned or high enough for the pattern into the airport. One witness stated that the airplane appeared to yaw and then return to wings level while descending to the ground. One witness stated he saw the propellers turning; however, two witnesses reported that they did not hear engine sounds. Flight control continuity was established from all control surfaces to the cockpit input controls. Left and right engine test-runs and examinations revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation. However, examination of the left and right propellers indicated that the engines were likely operating with low to no power at the time of impact. Additionally, both propellers had several indications consistent with operating near their low-pitch position and they were not in the feathered position, consistent with the engines not being shut down by the pilot. The flaps were set to the 10º position and the gear was up, consistent with an approach configuration. The pilot's autopsy findings revealed that he had an enlarged heart and moderate coronary artery disease, which slightly increased his risk of impairment from a cardiovascular event. However, there was no evidence of recent or old ischemic damage to the heart muscle or evidence of pilot impairment or incapacitation. Therefore, it is unlikely the pilot's cardiovascular disease contributed to the accident. Given the evidence, it is likely the engines experienced a loss of power and that the pilot subsequently lost airplane control during the descent to the airport for landing, which resulted in impact with terrain. The reason for the dual loss of engine power could not be determined based on available evidence.
HISTORY OF FLIGHT On June 15, 2016, about 1409 mountain daylight time, a Cessna 320E airplane, N777GY, was destroyed when it impacted terrain near Mineral County Memorial Airport (C24), Creede, Colorado. The commercial pilot and two passengers were fatally injured. The airplane was registered to Left Hand Financial, Inc., and was being operated by Rocky Mountain Aerial Surveys (RMAS) under contract with the U.S. Department of Agriculture (USDA) as a Title 14 Code of Federal Regulations Part 91 aerial photography flight. Day visual meteorological conditions prevailed, and no flight plan had been filed for the flight, which departed Central Colorado Regional Airport (AEJ), Buena Vista, Colorado, about 1307. According to an RMAS employee, about 1240, the pilot called the RMAS base in Longmont, Colorado, to provide a mid-day briefing. The pilot reported that the airplane had performed "fine" for the first 2.5 hours of surveying. However, he added that, after they had lunch at AEJ and departed about 1307, the airplane experienced an engine vibration that felt like it was coming from the right side and that the airplane seemed slow. According to the AEJ manager, about 15 minutes after takeoff, the pilot called AEJ to report that he had an issue and would be returning to the airport. After the pilot landed the airplane at AEJ, he and a local mechanic inspected it to determine what was causing the vibration. The pilot called the RMAS base, and the RMAS employee and the pilot agreed that he would fly to Rocky Mountain Metropolitan Airport (BJC), Longmont, Colorado, for maintenance but that he would call the RMAS base to provide an update on the mechanics' findings before departing AEJ. The RMAS base received no further communications from the pilot. A Garmin GPSMAP 396 was found near the wreckage and was submitted for examination by the NTSB Vehicle Recorders Division for pertinent data for the accident flight. The data started at 1307:41 and ended at 14:09:27. The data showed that the airplane departed AEJ about 1307 and followed highways, first traveling south away from the operator's base (93 miles northeast), then turning west over Del Norte, Colorado, and then turning northwest toward Creede. Approaching C24, the airplane overflew one aerial survey point just north of the airport. The airplane was between 11,300 to 13,000 ft above mean sea level (msl) and at a groundspeed of between 120 to 169 knots for much of the approximate 1-hour flight. However, during the last 2 minutes of the flight, the airplane passed north of C24, then circled around to the south side of the airport. During this time, the airplane was descending, and the groundspeed decreased from 141 knots to 119 knots to 98 knots, before increasing to 128 knots and then rapidly decreasing to 99 knots during a sharp, 90º left turn to the north. The last recorded data were at 1409:27, at which time the airplane was at a GPS altitude of 8,665 ft with a ground speed of 99 knots. Due to data buffering on the GPS unit, the data recording may have ended before the accident event. Figures 1 and 2 are graphical overlays showing about the first hour and the last 3 minutes of the airplane's flightpath, respectively. Figure 1. A graphical overlay showing the accident flightpath. (GPS Time recorded in UTC (MDT +6 hours)) Figure 2. A graphical overlay showing the last 3 minutes of the airplane's flightpath. (GPS Time recorded in UTC (MDT +6 hours)) One witness reported seeing the airplane making a left base turn for approach to runway 25 at C24. Another witness stated that the airplane was at a "very low altitude for his position in the pattern," that the propellers were turning, and that the airplane then yawed, returned to a wings-level position, and continued to descend until impacting the ground. Another witness stated that the airplane did not appear to be "far enough out to line up appropriately with the runway." Two witnesses stated that the landing gear were up. One witness, who lived near the accident location, reported that the airplane flew about 10 ft above her house, that it then veered left, and that it was making "loud revving noises." However, two other witnesses located about 1/4 mile west of the accident site reported that they did not hear engine noise. The accident site was located 0.7 miles from east of runway 25 at C24; which was southwest of AEJ, while BJC was located northeast of AEJ. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with airplane single- and multiengine land and instrument ratings. The pilot's most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on June 22, 2015, with the limitation that he "must have available glasses for near vision." On his medical certificate application, the pilot reported that he had about 1,591 total hours of flight experience, with 230 hours in the previous 6 months. The pilot reported no significant medical conditions and no use of medications to the FAA. According to the pilot's logbook, his first flight in a Cessna 320 was in the accident airplane on August 20, 2015. The pilot accumulated 28.9 hours of experience in the airplane between August 20 and September 16, 2015. He accumulated an additional 71.5 hours in the airplane between April 12 and May 5, 2016, for a total of 100.4 hours of experience in the Cessna 320. The pilot had 1,985.1 hours total flight experience, with 295.1 hours in multi-engine airplanes. His last flight review was completed on July 7, 2014, in a Cessna 182. AIRCRAFT INFORMATION According to FAA records, the low-wing, turbocharged, twin-engine airplane, serial number 320E0027, was issued its original airworthiness certificate on September 3, 1966, and was registered to the operator on September 6, 2011. The airplane had been reconfigured from its original six-seat configuration to a three-seat configuration to allow space for the use of an aerial camera and survey equipment. According to the airplane's maintenance records, Western Plains Aviation, LLC (WPA), completed the last annual inspection on March 23, 2016, at a recorded Hobbs time of 572.7 hours. The last maintenance entry for the airframe was on June 6, 2016, at a Hobbs time of 789.6, after the operator reported a vibration in the airplane during flight. WPA found the left and right main gear doors were loose and repaired the gear doors and engine nacelle lower skins. Also completed during this maintenance was installation of a Heli-Coil in the left engine oil drain pan, as described below, and replacement of an inoperative left-hand gear indicator switch. On March 21, 2016, at a time since major overhaul (TSMOH) of 1,059.3 hours and a Hobbs time of 572.7 hours, Aircraft Cylinders & Engines, Inc. (ACE), disassembled and repaired the right engine after the mechanic found spalled lifters during a top overhaul. The engine was reinstalled on the airplane using the existing engine mounts, hoses, and turbocharger components. The last maintenance entry for the right engine was dated April 1, 2016, at a Hobbs time of 573.5 hours and indicated that the right engine cowl flaps had been adjusted. On June 19, 2013, at a Hobbs time of 2,698.1 hours and a TSMOH of 1,703.7 hours, ACE removed, repaired, and then reinstalled the left engine's Nos. 2 and 4 cylinders. According to the records, a new Hobbs meter was installed sometime in 2014; an entry dated December 12, 2014, listed the Hobbs time as 0, the engine total time as 6,698.5 hours, and the TSMOH as 2,051.5 hours. On March 15, 2016, at a Hobbs time of 572.7 hours, ACE overhauled the left engine and installed overhauled turbocharger components. The engine was installed in the left nacelle with new hoses and new engine mounts on March 23, 2016. The last maintenance entry was dated June 6, 2016, at a Hobbs time of 789.6, and it reported WPA installed a Heli-Coil in the left engine oil drain pan. The airplane was equipped with two Hobbs meters (one that recorded total flight operations and another that recorded revenue flight operations). The airplane Hobbs meter was missing after the accident, only the revenue Hobbs meter was observed after the accident; it indicated 770.6 hours. After the right and left engine were overhauled in March 2016, an RMAS pilot ferried the airplane back to its base at BJC. During the ferry fight, the pilot noticed a vibration in the airplane, which he later determined was coming from the left side after landing. The pilot ferried the airplane back to WPA the following day where maintenance personnel determined that the fuel manifold valve was leaking. The fittings on the fuel divider were tightened, and according to the RMAS pilot, the return ferry flight to BJC on June 13, 2016, was "smooth and vibration free." Two days later, on the day of the accident, after takeoff from BJC, an RMAS pilot asked the accident pilot how the airplane was performing. The accident pilot reported that it was operating "real smooth." WRECKAGE AND IMPACT INFORMATION The airplane struck willow bushes and then the ground about 3,500 ft east-southeast of runway 25 at C24. Based on airplane deformation and impact signatures, the airplane impacted in a slightly nose-low, left-wing-low attitude. The outboard 5 ft of the left wing separated from the inboard wing during impact. The fuselage had slid right and came to rest with the right wing folded underneath the fuselage. The aft fuselage was observed compromised just forward of the empennage section. No fire was observed at the wreckage site. Airframe Flight control and trim continuity were established from the control surfaces to the forward cabin and cockpit controls. The rudder balance weight had separated from the top of the rudder and was found at the initial ground contact location. The rear flap actuator chain remained on the sprocket and was observed with eight pins on the lower chain, which indicated that the flaps were extended about 15°. The elevator trim actuator indicated a 10º tab-down position, the rudder trim actuator indicated a neutral position, and the aileron trim actuator indicated a 10º tab-up position. The landing gear actuator was found in the retracted position, and the landing gear was stowed. The fuel tank system in the Cessna 320F consist of the 2 each main fuel tanks (tip tanks), 2 each auxiliary tanks (in the wing), 2 each fuel valves located outboard of the left and right engines respectively and 2 each fuel selector valve handles located in the cockpit between the pilots and copilots seats. The fuel selector handle for the left engine has 4 positions; Left Main, Left Aux, Right Main, or Left Engine Off. The fuel selector handle for the right engine also has 4 positions; Left Main, Right Aux, Right Main, or Right Engine Off. The fuel selector handles are connected to the fuel selector valves, located outboard of the engines in the wings, by a push-pull cable. The fuel selector valve handles for both the left and right engines, were found in the "Left Main" position. Both fuel selector valves in the wings were found positioned between the main tank position and the auxiliary tank position. The right fuel selector handle position is consistent with the push-pull cable being compromised during impact. The deformation to the left wing would have also compromised the left fuel selector valve position. The left main fuel tip tank remained largely intact and attached to the outboard section of the wing. The baffle installed at the fuel tank attachment fitting was found displaced forward, and the fuel cap was in place. The left auxiliary wing fuel tank exhibited impact damage to the outboard section, and the fuel cap was in place. The right main fuel tip tank had separated from the wing into three sections: the area forward of the fuel tank attachment fitting, the section aft of the fuel tank fitting, and the aft fairing. The baffle installed in the fuel tank attachment fitting was found displaced forward. The fuel cap was in place. The displacement of the fuel baffles in both main fuel tanks is indicative of the fuel tank containing fuel at the time of the impact. The right auxiliary wing fuel tank was intact, and the fuel cap was in place. Fuel was observed draining from both wings in the area of the auxiliary fuel tanks during the airplane recovery. The fuel strainer screens were free of debris, and the fuel strainer bowl appeared lightly corroded with no blockages present. The ELT was removed from the aircraft and found to be in the "OFF" position. None of the first responders indicated that they had turned the ELT "OFF". Left Engine The left engine remained in the engine nacelle attached to the airframe and engine mounts. The throttle, propeller, and mixture control cables remained attached to their respective control levers. The magnetos remained attached to their mounting pads, and the ignition harness remained secured to the magnetos, and the lead terminals remained attached to their respective sparkplugs. The fuel lines remained secured to their respective fittings with no signs of leakage noted. The oil lines remained attached to the engine, their controllers, and the turbocharger wastegate actuator with no signs of preaccident leakage noted. The manifold pressure and upper deck reference lines remained in place and intact. The left engine examination revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. Right Engine The right engine remained in the engine nacelle but was separated from all four engine mounts. The throttle, propeller, and mixture control cables remained attached to their respective control levers; however, the throttle and mixture control levers were deformed. Most of the oil had drained from the engine. Both magnetos were separated from their mounting pads, and portions of their flanges remained secured under the mounting hardware. The fuel lines remained secured to their respective fittings, but two of the fuel fittings were fractured, with no signs of preaccident staining or leakage. The oil lines remained attached to the engine, their controllers, and the turbocharger wastegate actuator with no signs of preaccident leakage noted. The manifold pressure and upper deck reference lines remained secured to their fittings, but some of the fittings were fractured. The right engine examination revealed no preimpact mechanical malfunctions of failures that would have precluded normal operation. Propellers The left three-bladed variable-pitch propeller remained attached to the crankshaft propeller flange. The propeller spinner remained in place over the propeller hub and exhibited deformation and crushing damage on one side. All three propeller blades remained attached to the hub; however, one propeller blade was rotated about 180° in the hub, consistent with a pitch change link fracture. That blade was bent aft near its shank with paint erosion on the leading and trailing edges in a chordwise orientation, accompanied by spanwise gouges and scrapes overlying the chordwise erosion. The other two blades were also bent aft and exhibited chordwise paint erosion and scrapes near the tip along with a deep leading-edge gouge, and the other exhibited chordwise paint erosion on the leading and trailing edges and spanwise scrapes and paint erosion in the bent area. The right three-bladed variable pitch propeller remained attached to the crankshaft propeller flange by one bolt. The other bolts were stripped form the backside of the propeller hub. The propeller flange was fractured on one side. The propeller spinner remained in place, but it was fractured and deformed over all sides of the propeller hub. The three propeller blades remained attached to the hub; however, one blade was rotated within the hub consistent with a pitch change link fracture. All three blades exhibited chordwise paint erosion and scraping, and one blade exhibited spanwise scrapes and paint erosion overlying the chordwise erosion. One blade was twisted toward low pitch and exhibited deep leading-edge gouges. MEDICAL AND PATHALOGICAL INFORMATION The El Paso County Coroner, Colorado Springs, Colorado, conducted an autopsy of the pilot and determined
The pilot's loss of airplane control during descent following a loss of engine power for reasons that could not be determined because postaccident examinations and engine test-runs of both engines revealed no evidence of any mechanical malfunctions or failures that would have precluded normal operation.
Source: NTSB Aviation Accident Database
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