Sedona Airport- Three Killed at the airport on take off on Thursday, July 26, 2012.
How many more people need to die in Sedona from this airport?
Sedona Airplane and Jet Crashes
Two Runway Accidents at Sedona, two days in a row. May 25th and May 26th 2011.
Mac McCall, the Sedona Airport General Manager speaks about the Sedona Jet Crash and the Sedona Airport.
On May 25, 2011, about 1550 mountain standard time, an Embraer-Empresa Brasileira DE EMB-500, N244MD, sustained substantial damage during a runway overrun during landing at the Sedona Airport (SEZ), Sedona, Arizona. The airline transport rated captain, who was the flying pilot, and two of the three passengers were not injured. The airline transport rated first officer and one passenger sustained serious injuries. The airplane was registered to a private individual and operated by Superior Air Charter LLC., doing business as Jet Suite, Long Beach, California, under the provisions of Title 14 Code of Federal Regulations Part 135 as an on demand air charter flight. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The cross-country flight originated from San Jose, California, about 1420 Pacific daylight time, with an intended destination of SEZ.
A witness, located in the airport terminal building reported that he had received a landing request on the common traffic advisory frequency. The witness responded to the landing request with the current automated weather observing system (AWOS) and informed the pilots that runway 3 was the uphill runway. The witness said that he attempted to transmit this information twice with no response. He further stated that he then observed the accident airplane land within the touchdown area on runway 21 and proceed to “fish tail” down the runway at a “high rate of speed” until it exited the departure end of the runway. The witness further reported that he observed the airplane strike a chain link fence and continue out of sight down an embankment.
Examination of the accident site revealed that the airplane came to rest upright on an approximate 40-degree incline, about 397 feet beyond the departure end of runway 21. All major structural components of the airplane were located within the wreckage debris path. The wreckage was transported to a secure location for further examination.
Prior to entering the traffic pattern with the intention to land on runway 21, the pilot contacted the pilot of another airplane that had just landed to inquire about the wind conditions. The pilot that previously landed reported the wind was “a little squirrelly but not bad.” The pilot elected to continue his entry into the traffic pattern and made an uneventful landing. During the landing roll, the airplane veered to the left and exited the runway colliding with a tree and substantially damaging the left wing. At the time of the accident, the airport was reporting the wind as variable from 140 degrees to 200 degrees at 13 knots, gusting 32 knots. According to the pilot operating handbook, the maximum demonstrated crosswind component of the airplane was 17 knots. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airframe or engine that would have precluded normal flight.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s failure to maintain directional control on the landing roll out. Contributing to the accident was the pilot’s decision to attempt a landing in crosswind conditions that exceeded the maximum demonstrated capability of the airplane.
The engine lost partial power during flight, and the airplane collided with a vehicle during a forced landing on a road. The pilot was performing a local for hire sightseeing flight for two passengers. Approximately 15 minutes into the flight, a loud “popping” noise was heard coming from the engine. The pilot was unable to maintain altitude and force landed on a city street. During the landing roll, the right wing impacted a car on the road. Post accident examination of the engine revealed that the number 7 cylinder exhaust valve rocker arm had failed in fatigue. The surface fracture initiation marks were consistent with a grinding operation during manufacture. The grinding operation is performed to remove any flash remaining at the mold parting line, after the casting operation, and is normally carried out by holding the part by hand and guiding it on a large grinding wheel.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
a loss of engine power due to the fatigue fracture of the number 7 cylinder exhaust rocker arm as a result of a grinding operation during manufacture.
Press Release from the Sedona Police Department
October 2, 2004
Title: Plane Crash In Sedona
Contact: Rod Johnston
Information Officer, Sedona Police Department
On 10/02/04 at approximately 10:17AM a single engine bi-plane, attempting an emergency landing on Highway 89A in Sedona, struck the rear end of a vehicle and came to rest partially in the roadway. The pilot, James Barron, was giving a bi-plane tour of Oak Creek Canyon to Paul and Bonnie Roberts from Albany, Oregon when the plan began to experience engine problems. The pilot headed back to Sedona airport, but realizing he would not make it, he chose Highway 89A as a landing alternative. Many onlookers heard the engine sputtering and backfiring as the plane approached the highway.
The plane descended westbound onto Highway 89A and touched down as it approached Coffee Pot Road. The traffic light turned red causing a car in front of the plane to slow down in preparation to stop. The driver of the vehicle, Carl Galletti of Cornville, Az., saw the plane in his rearview mirror and attempted to move to the right to stop in the hopes that the plane would pass over the vehicle, The lower right wing struck the rear of the vehicle causing the plane to veer around the vehicle and come to a stop on its left side, partially in the AM PM parking lot.
The three people in the plane appeared uninjured, but were transported to local hospitals for precautionary measures. The driver of the vehicle was uninjured. The plane was removed to the Sedona Airport, where it will be stored for further investigation by NTSB.
Photos by David Sunfellow
|Accident date||November 13, 2008|
|Aircraft type||Piper PA-32-260|
On November 13, 2008, about 1645 mountain standard time, a Piper PA-32-260, N3929W, collided with wooded terrain above a mesa near Sedona, Arizona. The pilot/owner was operating the airplane under the provisions of Title 14 Code of Federal Regulations Part 91. The certificated private pilot sustained serious injuries, and the two passengers were killed. The airplane was destroyed by post accident fire. The cross-country personal flight departed the Sedona Airport (SEZ) about 1630, with a planned destination of Hangar Haciendas Airport (AZ90), Laveen, Arizona. Visual meteorological conditions prevailed, and no flight plan had been filed.
According to relatives of the pilot and passengers, the flight had departed from the Phoenix area earlier in the day. They reported that the purpose of the trip was to conduct personal sightseeing flights in the Sedona area, with the accident flight being the return leg to Phoenix.
A witness who was located close at a viewing area adjacent to Sedona airport reported observing a light colored, single-engine airplane depart from the northbound runway approximately 1630. He observed the airplane fly at a level attitude, and begin a, “slow” right turn to the east. The airplane continued and then began a turn to the south just below the tops of the cliff faces, which overlooked the airport. The airplane continued on the southbound heading and then began a 180-degree turn to the north. The airplane continued north and then passed beyond the end of the cliffs, and turned eastward and out of his view. A short time later he observed smoke on the plateau in the vicinity of the last observed location.
A second witness, who stated that he was a pilot, reported similar observations. He stated that the airplane was of the low-wing type, and that it was flying at a low speed and altitude such that he thought it was sightseeing. He did not observe any smoke trailing from the airplane.
A witness, located in the vicinity of the accident site, submitted a written statement. He reported observing a small single-engine airplane flying to the east, away from Sedona at about 1645. Five minutes later he observed smoke rising from a distant wooded area. He immediately proceeded towards the smoke, and arrived at the accident site 20 minutes later. While at the site, he administered first aid to the pilot, who was outside of the burning airplane. The pilot relayed to the witness that the engine “sputtered” a single time and then, “shut down.” He further reported to the witness that he unsuccessfully attempted to restart the engine, and subsequently made a forced landing. The pilot stated that prior to the crash one of the passengers had “passed out.”
Operators in the vicinity of the airport reported not hearing any mayday or distress calls on the Sedona UNICOM (the common traffic advisory frequency for the airport).
The pilot succumbed to his injuries 2 months following the accident. Due to the nature of the injuries, the NTSB investigator-in-charge was unable to interview the pilot.
A review of Federal Aviation Administration airman records revealed that the pilot, age 51, was issued a private pilot certificate on May 24, 2005, with a rating for airplane single-engine land. The pilot was issued a third-class medical certificate in October 2008, with limitations that he wear lenses for distant vision and that he possess glasses for near vision.
An examination of the pilot’s flight logbook revealed that the last flight time entry was on October 18, 2008, and at that time he reported a total of 379 hours of total flight experience. An entry by a Certified Flight Instructor, dated March 8, 2008, stated that the pilot was proficient in the operation and systems of a high performance airplane.
The low-wing, fixed-gear airplane, was manufactured in 1967. It was powered by a six-cylinder, Textron Lycoming O-540 engine, and equipped with a Hartzell two blade, constant-speed propeller.
Maintenance records indicated that an annual inspection was completed on February 1, 2008, at a recorded tachometer time of 3,341.3 hours. At the time of the annual inspection, the engine had accumulated 1,484.8 flight hours since manufacture in June 1982.
Fueling records from the Sedona Airport Administration established that, prior to the accident flight, the airplane was serviced with the addition of 13.5 gallons of 100-octane low lead aviation fuel.
The closest official weather observation station was Ernest Flagstaff Pulliam Airport, Flagstaff, Arizona, located about 18 miles north of the accident site. The elevation of the weather observation station was 7,015 feet mean sea level (msl). An aviation routine weather report was issued at 1656, and it stated: wind variable between 270 and 340 degrees at 9 knots, gusting to 19 knots; visibility 10 statute miles; skies clear; temperature 16 degrees Celsius; dew point minus 5 degrees Celsius; altimeter 30.10 inches of mercury.
The approximate density altitude at the weather reporting station was 8,500 feet.
The manager of an aircraft tour operator located at Sedona airport reported that the winds at the time of the accident were calm, with temperatures of about 24 degrees Celsius with unrestricted visibility.
Sedona Airport is located on a 500-foot-high mesa that overlooks the town of Sedona. The terrain descends steeply from the airport on all sides to the valleys below. Terrain to the north and east is characterized by mesa formations that rise to about 6,500 feet within a distance of 6 miles.
The Airport/Facility Directory, Southwest U. S., indicated runway 03 was 5,132 feet long and 100 feet wide with an airport elevation of 4,830 feet.
The accident site was located at the 6,400-foot level, 6 miles northeast of Sedona Airport, on a plateau overlooking the Sedona Valley area. The site was characterized by 10 degrees downsloping rocky terrain, lightly dispersed with oak, juniper, and pine trees.
The first identified point of contact (FIPC) was located about 40 feet above ground level on a tree trunk. A section of the left wing fuel tank was located at the base of the tree. The section of wing exhibited a 30-inch diameter indentation that corresponded to the diameter of the tree trunk. The debris field continued on a heading of 340 degrees magnetic to the location of the outboard section of the left wing, 190 feet from the FIPC. The main wreckage came to rest 60 feet beyond the left wing.
The main wreckage came to rest inverted on a heading of 240 degrees magnetic. It consisted of the fuselage, right wing, left wing inboard of the aileron, vertical stabilizer and rudder, horizontal stabilator, engine, and propeller. The engine aligned with the cabin and had become separated from the firewall. The right wing was inverted and folded back at the wing root such that it was parallel with the main cabin. Fire consumed the entire fuselage structure, the center section of stabilator, and the right wing trailing edge, flaps, and aileron. The right main fuel tank sustained impact and thermal damage and was breached along the aft lower rivet line. Traces of blue colored liquid were observed in the tank. All major sections of airplane were accounted for at the site.
Review of the pilot’s medical certificate application revealed that he had indicated the use of Lisinopril and Synthroid. Additionally, he stated that his right knee was fused.
Autopsies for the passengers were conducted by the Coconino County Medical Examiner. The cause of death for both occupants was reported as the effects of thermal injuries.
A report of external examination for the pilot was issued by the Maricopa County Office of the Medical Examiner. The cause of death was reported as complications of thermal injuries.
All control cables were secure to the appropriate controls and continuous to their respective surfaces except the left aileron control cable, which was separated in a broomstraw manner just inboard of the bellcrank.
The stabilator trim wheel shaft extension was measured, and according to the Piper representative correlated to an approximately 50 percent nose up trim position. The flap torque tube was in a position that corresponded to the flaps being fully retracted.
The fire damaged fuel selector valve was in the left tip tank position.
Removal of the engine spark plugs revealed the top spark plug electrodes from cylinders two, four, and six to be oil-soaked. The remaining spark plug electrodes were light gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. The spark plugs appeared worn beyond normal service limits when compared to the Champion Aviation chart.
An inspection of the cylinders was performed via the utilization of a lighted borescope; the valves were intact, combustion chambers remained mechanically undamaged, and there was no evidence of foreign object ingestion or detonation.
The mechanical fuel pump had become separated at the diaphragm housing and displaced from the wreckage; the pump flange was securely attached to the accessory case. The diaphragm was exposed and had sustained thermal damage.
The spark plug harnesses were destroyed by fire. Both magnetos were securely attached to their mounting pads. The right magneto was partially consumed by fire. The left magneto sustained thermal damage and heavy sooting. Both magnetos were removed; thermal damage prevented rotation by hand. The flywheel was fractured and had become separated at the hub; due to its separation, ignition timing could not be confirmed.
The carburetor separated from the intake flange, was detached from its control cables, and came to rest underneath the engine. The carburetor was visually inspected, and it was noted that all parting surface bolts and locking tabs were in place. The carburetor was then disassembled. The parting surface gasket, floats, and rubber needle valve sustained thermal damage and had disintegrated. The fuel intake screen was removed, and found free of blockage.
The engine crankshaft was manually rotated utilizing the hub. The crankshaft rotated, and the valves moved approximately the same amount of lift. Valve train continuity was confirmed through to the accessory case, and thumb compression was obtained on all six cylinders. Removal of cylinder number one revealed the internal cylinder dome and piston crown to exhibit light brown combustion deposits. The piston rings were intact and residual oil was observed in the crankcase. The camshaft lobes of cylinder one and six were inspected, and found clean and free of scour marks and abrasions.
The oil sump screen was observed heat distressed, and free of blockage. The oil filter exhibited external impact damage and remained attached to the filter mount. The oil sump drains were in place and securely affixed to the sump.
The propeller separated from the crankshaft at the propeller flange. Both blades exhibited chordwise abrasions, S-bending, and leading edge gouges. The tips of both blades separated approximately 3 inches from the tip in a jagged S-pattern.
|Accident date||October 13, 2008|
|Aircraft type||Bell 407|
On October 13, 2008, at 1518 mountain standard time, an Arizona Department of Public Safety (AZ DPS) paramedic was killed after coming into contact with the main rotor blades of a Bell 407, N42AZ, while performing a mountain rescue on Doe Mountain near Sedona, Arizona. The helicopter was operated by the AZ DPS as a public-use search and rescue (SAR) flight. The pilot and two hikers were not injured; the helicopter was not damaged. The flight had departed on the SAR mission from the Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona, at 1440, to aid in the search and rescue of two stranded hikers.
According to DPS, the helicopter and flight crew are based in Flagstaff; the flight crew consists of a pilot (right seat) and a paramedic (left seat). Prior to departing FLG, the flight crew was notified of SAR mission by the Sedona Fire Department requesting assistance in locating missing hikers. The flight departed FLG and commenced the search. The flight crew radio contacted the Fire Department that they had located the hikers on a mountain northwest of Sedona. An uneventful landing was made on a large boulder near the hikers. The paramedic exited the helicopter, walked to the front of the helicopter to the hikers. The paramedic and one hiker returned to the helicopter where the hiker was secured inside. The paramedic then returned to the last hikerâ€™s position and was escorting the hiker to the helicopter when he was struck by the main rotor blades.
|Accident date||April 15, 2007|
|Aircraft type||Beech 35-B33|
THIS CASE WAS MODIFIED 11/21/2007
On April 15, 2007, at 1210 mountain standard time, a Beech 35-B33, N9556Y, impacted terrain while on a low approach for landing at Sedona Airport, Sedona, Arizona. The pilot and two passengers were fatally injured; the airplane was destroyed. The pilot-owner operated the airplane under the provisions of 14 CFR Part 91. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight originated at La Cholla Airpark, Tucson, Arizona, at 1112.
The Sedona Airport is located on a plateau, and the terrain drops off steeply at both ends of the single runway. There were high winds in the vicinity with recorded gusts up to 38 knots, and one witness reported 47-knot gusts. Witnesses reported to the National Transportation Safety Board investigator that they observed the airplane on its final approach to runway 21. All witnesses stated that the airplane appeared to get “low and slow” while on final, descending below the approach end of the runway. The airplane had a nose high attitude, and the engine sounded as if it was operating at high rpm “straining against the wind.” They said the wing tips appeared to wobble up and down starting with the right wing; the airplane rolled to the right, and impacted rising terrain short of the runway. A post impact fire erupted immediately and consumed the airplane.
The pilot of a twin Piper PA-34 made his approach and landing directly ahead of the accident pilot, and reported that the winds were 140 to 160 degrees at 23 knots gusting to 36 knots during his approach. On short final he encountered a 30-knot windshear and an abrupt negative 2.5-G drop. He radioed to the accident pilot that he had encountered a 30-plus knot windshear on final; the accident pilot responded “in a calm voice,” “ok, thank you for the heads up.”
A review of the Federal Aviation Administration (FAA) airman records revealed that the pilot held a commercial pilot certificate issued on June 26, 1968, with ratings for single engine land and instrument airplane. Investigators were unable to locate the pilot’s personal flight logbook. The pilot reported on his most recent FAA medical application form, dated July 5, 2006, that he had an estimated total flight time of 2,180 hours.
The pilot held a third-class medical certificate that was issued on July 5, 2006, with the limitation that he shall wear corrective lenses.
The airplane was a 1963 Beech 35-B33, serial number CD-561, commonly referred to as a “Debonair.” The engine was a Teledyne-Continental IO-470-K3B. Investigators were unable to locate the airplane’s maintenance logbooks. The airframe and power plant (A&P) mechanic who performed the last annual inspection for the airplane provided copies of those documents to the Safety Board investigator. The most recent airframe, engine, and propeller annual inspection had been completed on June 3, 2006. The maintenance documentation indicated that the total airframe time was 3,938.72 hours, and the time on the engine was 1,316.49 hours since major overhaul (SMOH). The airplane was configured with a short takeoff and landing (STOL) kit. The mechanic noted that the pilot had planned on having the airplane’s annual inspection performed in May.
The pilot contacted Albuquerque Flight Service on April 15, at 1009 local time, and requested a weather brief for Sedona, as well as winds aloft for 6,000 and 9,000 feet. The briefer stated that there were AIRMETS out for occasional moderate turbulence 18,000 and below, to which the pilot replied, “Yeah, it’s going to be bumpy.” The briefer then stated winds aloft for 6,000 feet in the Sedona area were 170 degrees at 25 knots, and at 9,000 feet, the winds were 210 degrees at 40 knots.
A review of weather data showed a surface cold front was passing through the Sedona area near the accident time. The front and strong low-level southerly winds caused variable gusty surface winds, low-level wind shear, and moderate turbulence over Arizona throughout the day. The Aviation Area Forecast, AIRMET TANGO for moderate turbulence, and the Flagstaff Terminal Forecast valid at the accident airplane’s departure time indicated the general en route and destination flight conditions.
At 1221, the Sedona Airport Automated Weather Observation System recorded scattered clouds at 9,000 feet; visibility 10 statute miles; winds from 270 degrees at 38 knots; temperature 18 degrees Celsius; and altimeter setting 29.75 inches of mercury.
The Sedona Airport is located on a 500-foot-high mesa that overlooks the town of Sedona. The terrain descends steeply from the airport on all sides to the valleys below. The Southwest U.S. Airport/Facility Directory, published by the U.S. Department of Transportation, stated, in the Airport Remarks section, that turbulence might be experienced in the vicinity of the airport.
The Precision Approach Path Indicator (PAPI) lights on the approach end of runway 21 are set for a 3.5-degree approach glide slope.
The wreckage was located on sloping terrain about 200 feet north of the approach end of runway 21. The airplane was completely consumed by a post impact fire. FAA inspectors examined the wreckage on scene. There was a 5-inch diameter tree that was fractured, missing its top, and a piece of fiberglass wing tip was at its base. This corresponded to an indentation to the right wing tip; the indentation was formed from the bottom up, consistent with a nose high attitude. The airplane appeared to have rotated 90 degrees to the right after the wing tip impact, and impacted the terrain in that orientation. The main wreckage was on the extended centerline of the runway. The FAA inspectors traced out the flight control system and confirmed control continuity. The entire airplane was confined to the accident location, and the wreckage was distributed such that the wings, fuselage, engine, and tail were in their normal and appropriate location/position. The propeller had sheared from the engine crankshaft, and one propeller blade was located at the approach end of the runway. The other two propeller blades were contained within the main wreckage.
The Yavapai County Medical Examiner completed the autopsy on the pilot. The FAA Forensic Toxicology Research Team performed toxicological analysis from blood and tissue specimens obtained during the autopsy. The results of the specimen analysis were negative for carbon monoxide, cyanide, and ethanol. The results were positive for Butalbital (0.101 ug/ml in blood and 0.213 ug/ml in the liver), Propoxyphene (0.046 ug/ml in blood and 0.472 ug/ml in the liver), Norpropoxyphene (0.394 ug/ml in blood and 12.265 ug/ml in the liver), and Quinine (in blood).
The Safety Board’s Medical Officer reviewed the blue ribbon copy of the pilot’s FAA medical records, medical records obtained from the pilots personal physician, and the autopsy report. The pilot had reported a long history of inflammatory bowel disease, bilateral hip replacements, and subsequent revisions for arthritis beginning more than 35 years prior to the accident. The FAA medical records documented the use of medications including folic acid and vitamin B12 shots, acetaminophen for arthritis pain, and lisinopril for high blood pressure, which was well controlled. Personal medical records noted rare use of propoxyphene and a combination medication containing butalbital, caffeine, and acetaminophen, neither of which were noted in the most recent application for Airman Medical Certificate.
Statement from the Mechanic
The A&P mechanic who regularly performed the annual inspection also holds an airline transport pilot (ATP) certificate; his primary employment was that of an airline pilot. He would routinely fly with the accident pilot during the post-inspection maintenance check flight. He noted that the accident pilot routinely flew a low and flat landing approach pattern, which he estimated to be around a 2.5-degree glide slope. The mechanic/ATP reported that his preference was for a steeper approach, around 3- to 3.5-degree glide slope. When he asked the accident pilot why he flew a flatter approach technique, the pilot said that he thought the shallower approaches were safer because of the enhanced capability the plane had with the STOL kit installation, which provided for a lower stall speed.
Windshear and Mountain Winds Discussion
The following was extracted from FAA publication AC 00-57 – “Hazardous Mountain Winds and Their Visual Indicators.”
“Aircraft that engage in low-level flight operations over mountainous terrain in the presence of strong winds (20 kt or greater at ridge level) can expect to encounter moderate or greater turbulence, strong up and down drafts, and very strong rotor and shear zones. This is particularly true for general aviation aircraft.”
“The mountain flying literature cites 20 kt as the criterion for classifying a wind as ‘strong.’ As used in the current document, this criterion refers to the large-scale (or prevailing wind in the area as opposed to a local wind gust) wind speed at the crest of the ridge or level of the mountain peaks, upwind of the aircraft’s position. Such an ambient wind flow perpendicular to a ridge will lead to substantially stronger surface winds, with the likelihood of turbulence. Similar wind enhancements can be anticipated near the slopes of an isolated peak. Forecast and actual wind speeds at ridge level can be determined from the FD (forecast winds and temperatures aloft) and UA (PIREPS) products, respectively. In contrast, downdrafts over forested areas may be strong enough to force aircraft down into the trees, even when the aircraft is flown at the best rate-of-climb speed. This effect on the aircraft is exacerbated by loss of aircraft performance because of the high-density altitude.”
The following was extracted from FAA publication FAA-H-8083, The Airplane Flying Handbook.
“WIND SHEAR – A sudden, drastic shift in wind speed, direction, or both that may occur in the horizontal or vertical plane.”
“On final approach, at a constant airspeed, the glidepath angle and rate of descent is controlled with pitch attitude and elevator. The optimum glidepath angle is 2.5 degrees to 3 degrees whether or not an electronic glidepath reference is being used. On visual approaches, pilots may have a tendency to make flat approaches.”
|Accident date||September 24, 2006|
|Aircraft type||Cessna 182K|
|Accident date||April 13, 2003|
|Aircraft type||Beech A36|
On April 13, 2003, about 1230 mountain standard time, a Beech A36, N323D, collided with a fence and then terrain during takeoff from runway 21 at Sedona, Arizona. Mesa Pilot Development, Inc., was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) pilot, the private pilot undergoing instruction (PUI), and one passenger sustained fatal injuries; the airplane was destroyed. The instructional cross-country flight was en route to Williams Gateway Airport, Phoenix, Arizona. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The primary wreckage was at 34 degrees 50.63 minutes north latitude and 111 degrees 47.69 minutes west longitude.
Several witnesses observed the takeoff roll. They all noted that the airplane did not seem to accelerate and was rolling very slowly as it passed the midfield point. Several of the witnesses noted that the flaps were partially down. The witnesses thought that the pilot would abort the takeoff. However, the airplane continued down the runway and was still on the ground about 80 percent of the way down the runway. Then the pilot rotated it to a takeoff attitude. Several witnesses thought that it retained that attitude, and if it left he ground at all, it only attained an altitude of several feet.
Several of the witnesses that heard the engine reported that it did not sound like it was producing much power. The engine tones stayed steady and the engine sounded smooth. It did not cough, sputter, or backfire, and none of them observed smoke or any indications of a problem.
Another witness on the opposite side of the airport heard clanking and banging that sounded like a thresher machine. It was definitely not smooth or sound like engines that he had previously heard. It caught his attention and he looked toward the runway. He saw the top of a tail and fuselage. He estimated that the airplane was going about 70 miles per hour. He did not hear the engine wind down and wondered why it was trying to take off. He lost sight of the airplane behind trees and did not see it rotate. He thought that it was within 1,000 feet of the end of the runway. About 5 to 10 seconds later he heard a bang, and about 10 seconds later he heard another bang.
One witness was a CFI, and an airplane mechanic with 30 years experience in general aviation. He first saw the airplane about 1/3 of the way down the runway. From the moment he saw it, he thought that something was not right. He was concerned that it was not accelerating to flying speed. The engine sounded quite different from airplanes that he had heard over his career. It sounded like it was turning very slowly, much slower than takeoff revolutions per minute (rpm). He thought that the propeller was set to cruise power rather than full rpm. It sounded like it was turning about 2,300 rpm. It sounded smooth; it did not backfire, surge, miss, or chug. It sounded the same from the time that he first saw it until it went out of sight. Other airplanes that he had observed take off had been airborne by this point. The accident airplane kept going and going. It went past the halfway point and was not accelerating. The witness kept saying, “shut down, shut down.” It broke ground about 2/3 to 3/4 of the way down the runway, maybe beyond 3/4. He left his chair to watch the airplane. He noted that the nose came up and the airplane continued down the runway about 200 yards with the nose wheel off the ground and the main gear on the ground. It might have gotten airborne about 1 or 2 feet. The airplane broke ground with an extremely nose high attitude. He lost sight of it behind a parked airplane. He thought that the stall horn had to be going off.
The operator submitted a written report.
A review of Federal Aviation Administration (FAA) airman records revealed that the CFI held a commercial pilot certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. She held a certified flight instructor certificate with ratings for airplane single engine land and instrument airplane.
The CFI held a first-class medical certificate issued on May 9, 2001. It had no limitations or waivers.
The operator reported that the CFI had a total flight time of 652 hours. She had 136 hours in the last 90 days, and 32 in the last 30 days. She had 50 hours in this make and model.
The operator reported that the PUI had a private pilot certificate with a rating for airplane single engine land. He had a total flight time of 174 hours. He had 34 hours in the last 90 days, and 14 in the last 30 days. He had 37 hours in this make and model, and was preparing for his instrument check ride.
The airplane was a Beech A36, serial number E2613. The operator reported a total airframe time of 2,249 hours. The airplane was on a manufacturer’s inspection program, and the last 100-hour inspection occurred on March 12, 2003. The tachometer read 1,748.2 and the Hobbs hour meter read 270.2 at the daily inspection prior to departure for Sedona.
The engine was a Teledyne Continental Motors IO-550-B(6) engine, serial number 296594R. Time since overhaul on the engine at the last inspection was 514 hours.
The operator indicated that the last fueling of the airplane occurred on April 12 with the addition of 36 gallons of aviation fuel. The airplane flew 0.8 hours on one flight prior to the accident flight.
The Sedona airport administration office reported the weather conditions: skies clear; winds from 170 degrees at 11 knots gusting to 24 knots; temperature 68 degrees Fahrenheit; altimeter 30.05 inches of mercury.
The Airport/ Facility Directory, Southwest U. S., indicated runway 21 was 5,132 feet long and 75 feet wide. The runway surface was asphalt, and the airport elevation was 4,827 feet.
The National Transportation Safety Board investigator-in-charge (IIC) and investigators from the FAA, Beech, and Teledyne Continental Motors (TCM) examined the wreckage at the accident site on April 14, and at the facilities of Air Transport, Phoenix, on April 15. Safety Board software determined that the airplane came to rest approximately 1,032 feet on a magnetic bearing of 213 degrees from the airport.
Sedona airport is on a plateau that is surrounded by rocky canyons about 500 feet deep that are sparsely covered by cedar trees and bushes. The airport boundary fence was a 6-foot-high chain link fence with angled barbed wire strands another foot high. The fence ran along the edge of a canyon that began at the end of the runway. The fence was about 150 feet from the end of the runway. It sustained mechanical damage about 100 feet right of the extended centerline. The top part of the fence was deformed and pieces of barbed wire and fence posts were on the ground on the side of the fence away from the runway.
The main wreckage was on the opposite side of the canyon from the airport boundary. It was several hundred feet lower than the airport boundary fence.
The first identified point of contact (FIPC) was a cedar tree with broken limbs. Another cedar tree, about 10 feet right of the FIPC as one looked toward the main wreckage, also had broken limbs. Near the base of this tree were clear Plexiglass fragments similar in shape to the wing tip recognition lights’ covers. The debris path was along a magnetic bearing of 185 degrees.
Thirty-three feet from the FIPC was the right main landing gear. Pieces of propeller, identified as prop piece 2 and prop piece 1, were 36 and 38 feet from the FIPC, respectfully.
The principle impact crater (PIC) was 46 feet from the FIPC. A scorched area about 6 feet in diameter surrounded the PIC. The left elevator counterweight separated and was just past the scorched area. It was not scorched and had scrapes along its edge and a dent along its front edge.
The main wreckage came to rest 85 feet from the FIPC. The main wreckage pointed along a magnetic bearing of 190 degrees. The separated left main landing gear was at the trailing edge of the left elevator. The left main gear had pieces of wire around it that were similar to the airport boundary fence. Fire consumed the cabin area. A scorched area extended from wing tip to wing tip, and from the nose of the engine to mid empennage. The tail area was outside of the scorched area and did not sustain thermal damage. About 6 feet of the outboard left wing bent up about 30 degrees.
About 10 feet right of the right elevator was the propeller. The propeller was outside of the scorched area and it did not exhibit thermal damage. A piece of propeller, identified as prop piece 3, was between the propeller and the main wreckage.
The engine separated from the airframe and rotated to a magnetic bearing of 235 degrees. The left side of the engine was downslope and sustained more thermal damage than the right side.
The Yavapai County Coroner completed an autopsy on both pilots. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilots.
Analysis of the specimens of the PUI contained no findings for carbon monoxide, cyanide, volatiles, or tested drugs.
Investigators established control continuity for all control surfaces. The airframe manufacturer’s representative determined that the landing gear was in the down position. The representative measured the flap actuator at 4.4 inches. He reported that this corresponded to the 15 degrees flaps down position. The left aileron trim actuator measured 1.78 inches. He reported that this equated to 4.75 degrees tab up position. The elevator trim measured 1.4 inches. He determined that this equated to 5 degrees tab down.
Investigators removed the engine, which sustained thermal damage on its left side. The engine lay canted to the left at the accident site. Investigators slung it from a hoist, and removed the top spark plugs. All spark plugs were clean with no mechanical deformation. All spark plugs exhibited a slightly oval shape and had similar gaps. The spark plug electrodes for cylinder nos. 1 and 3 were very light gray. Cylinder no. 5 was light gray. The bottom spark plugs for cylinders 1, 3, and 5 were also very light gray. The top plugs for cylinder nos. 2, 4, and 6, which were on the left side of the engine, had light soot deposits, while the bottom plugs for nos. 2, 4, and 6 were oily. According to the Champion Aviation Check-A-Plug AV-27 Chart, light gray colorization corresponded to lean operation.
Investigators manually rotated the engine. The engine rotated freely and the valves moved approximately the same amount of lift in firing order. The gears in the accessory case turned freely. Investigators obtained thumb compression on all cylinders in firing order.
Investigators manually rotated the magnetos. The left magneto was partially melted and could not be tested. The right magneto produced spark at all posts.
The vacuum pump drive gear remained unbroken, and the vacuum pump turned freely.
The oil filter material was brittle, but contained no debris.
The screens in the fuel distribution valve and fuel-metering unit were clean. The fuel nozzles were open and the injector lines were open.
The three-bladed propeller, which separated from the engine, was about 30 feet from the engine. All of the propeller’s attachment bolts were stripped. The tips of all three blades separated. Blades 2 and 3 exhibited leading edge gouges, chordwise striations, and curled toward the low pitch (high rpm) position. The tip for blade 1 split at midchord, and bent forward 90 degrees. Three pieces of propeller blades were recovered. Prop piece 1 was several inches long and curled about 180 degrees. Its fracture surface mated with the fracture surface of blade 2. Prop piece 2 was about 2 inches long and curled about 180 degrees. It had gouges on the back that were similar to the gouges on blade 2. Prop piece 3 was about 12 inches long and its fracture surfaces appeared to match propeller blade 3. Blade 3 bent forward, about 60 degrees, from the end of the shank to the tip. It had leading edge gouges and scrapes, the trailing edge buckled, and it fractured along an angular plane.
Fuel Pump Examination
A Safety Board investigator observed the teardown and examination of the altitude compensating fuel pump. After technicians cleaned the pump, they performed a satisfactory leak check. They placed it in a test stand. The aneroid reduced the fuel flow rate as they reduced the atmospheric pressure input.
Pilot Operating Handbook (POH)
The operator had two Beech A36 airplanes in its fleet. The accident airplane had an altitude compensating fuel pump installed. The second airplane did not have the altitude compensating fuel pump installed. Section VII of the POH indicated that the compensating pump automatically leaned or richened the engine’s fuel mixture as the airplane changed altitude. Without the compensating fuel pump, the pilot would have to manually adjust the mixture as the airplane changed altitude.
The before takeoff checklist in Section IV (Normal Procedures) instructed the pilot of an airplane with the compensating fuel pump to position the mixture to the full rich position. Those without the compensating pump were to adjust the mixture manually prior to takeoff as required by field elevation. The takeoff checklist in this section instructed the pilot to make a final check of manifold pressure, fuel flow, rpm, and oil pressure at the start of the takeoff run.
The manufacturer determined from the POH that, at maximum certified gross weight with the given atmospheric condition, the airplane should have had a ground roll of 1,900 feet, and would clear a 50-foot obstacle at 2,100 feet.
The FAA accident coordinator supervised examination of the takeoff performance in another of the operator’s airplanes in Gallup, New Mexico. The conditions approximated the same density altitude as the accident flight. This airplane also had the altitude compensating fuel pump installed. He observed several takeoffs. The test pilot took off using a full rich mixture setting, and also did takeoffs after leaning the mixture. The coordinator did not observe any appreciable difference in the takeoff roll or climb. The engine attained expected power settings and climb performance. They tried to simulate the power conditions that the witnesses reported. The closest configuration was with reduced manifold pressure (MP) and revolutions per minute (rpm). They reduced power to 23 inches MP and 2,300 rpm. They were not able to attain flying speed with full flaps. However, they did attain flying speed with 10-degree flaps about 500 feet further down the runway than they calculated.
The operator had a form that they used for performance calculations including weight and balance. They required pilots to complete the form prior to each flight. The form provided spaces for pilots to record pertinent data, and log computed parameters. Those parameters included takeoff weight, density altitude, runway length, rotation speed, takeoff distance, takeoff distance over a 50-foot obstacle, rate of climb, and landing distance.
The IIC interviewed other instructors from the operator who had flown with the accident instructor. The instructors all had similar practices. They indicated that they leaned engines in both airplanes prior to takeoff from high density altitude airports. One instructor and the CFI used similar leaning techniques. She would go to full power in the run up area and lean 40 degrees rich of peak prior to taking the runway. Another instructor said that she and the CFI were very thorough, and diligently followed company rules regarding takeoff and performance data on the company form. She said company procedures require a 60-knot callout, and the instructor responds,
|Accident date||August 29, 2001|
|Aircraft type||Harter Kitfox Classic|
On August 29, 2001, at 1215 hours mountain standard time, an experimental Harter Kitfox Classic, N46MH, impacted terrain while attempting to reverse course in Fox Canyon near Sedona, Arizona. The private certificated pilot, the sole occupant, was fatally injured and the amateur built aircraft was destroyed. The local area personal flight, operated by the owner under 14 CFR Part 91, departed from Sedona at 1130. Visual meteorological conditions prevailed and no flight plan was filed.
A second pilot in another Kitfox airplane flew in loose formation with the accident aircraft for the first time on the day of the accident. The second pilot would later witness the accident. He reported that the trip of the pilot involved in the accident originated on the east coast, and that he had flown to a Kitfox enthusiast’s meeting at the Kitfox factory in Caldwell, Idaho. From there he flew to Cameron Park, Placerville, and Death Valley, all in California, before continuing to Chandler, Arizona, where he spent the night of August 28th at the second pilot’s home.
The second pilot said that the accident pilot’s Kitfox was a Classic IV 1200 model (1,200-pound gross weight) and, whereas most Kitfox’s have a Rotax 912 engine, this one had a heavier Subaru EA-81 engine. He said that the Kitfox involved in the accident had a “full panel” of instruments and radios and was equipped for instrument flight. The pilot told him that, with the heavier engine and instrumentation, he was “over gross” with himself, baggage, and fuel onboard. The pilot built his Kitfox in 1999, and said he had flown it more than 1,200 hours. His total flying time was about 1,500 hours.
On the day of the accident, the two aircraft departed Chandler in loose formation about 0630. The second pilot flew at all times about 1/2 mile behind and 800 feet above the accident airplane. The second pilot said it was apparent that his Rotax-powered airplane climbed and flew faster than the accident pilot’s Subaru-powered plane. He recalled the accident Kitfox cruising about 90 knots indicated airspeed at 5,000 feet msl. The pilot was carrying camping gear (sleeping bag, tent, a small stove) and his baggage. They flew to Sun Valley Airpark and, after landing there, flew via the Prescott Valley and Cottonwood Canyon to Sedona, where they landed and had breakfast. After landing at Sedona, the pilot’s plane was leaking some engine coolant. The pilot removed the cowling and found the coolant was coming from the vent on the coolant expansion tank and was not further concerned. He reinstalled the cowling.
They next intended to fly to Marble Canyon at the northeast end of the Grand Canyon where they would camp overnight. Before taking off they discussed the route they would fly. The pilot wanted to cross the Grand Canyon, however, when the second pilot pointed out that the Special Air Traffic Rules Area “Dragon Transition” over the Grand Canyon would require them to climb above 11,500 feet, the pilot had reservations about flying at that altitude given the heavy loading of his airplane. They decided, instead, to fly a route east of the Grand Canyon airspace at 10,000 feet. After fueling their planes to capacity, they departed Sedona about 1130.
After takeoff they climbed out to the north flying up a wide canyon that parallels Oak Creek Canyon on the west side. The pilot was flying below and in front of the second pilot at an altitude that placed him below the canyon walls. The second pilot radioed to him “you should climb” and the pilot radioed back that he was taking pictures. The second pilot asked how his engine temperature was and he radioed back that it was “OK, plenty of margin.” This was about 3 minutes before the accident.
About 1 mile further, it appeared that the pilot started climbing. He was keeping even with gently upsloping terrain ahead and was in no danger at that point. The pilot then made a right turn into a narrow canyon that would take him over a ridge into Oak Creek Canyon. Flying behind him, it took the second pilot a moment to reach the entrance to the canyon and, when he did, he was immediately uncomfortable. Even from his higher altitude the second pilot was barely level with the ridgeline ahead. He radioed to the pilot that he should “do a 180 . . . there is room to your right.” At this point he had sufficient space to his right to reverse course. The pilot radioed back words to the effect that he thought he could make it and would proceed ahead. The second pilot radioed that he was turning immediately and that the pilot had plenty of spacing and was clear of terrain. When he started his climbing left turn he last saw the accident airplane below and in front of him, hugging the left canyon wall. It appeared the other pilot was setting up to make a right turn out of the canyon. He appeared to be in a climbing attitude.
When the second pilot completed his 360-degree turn, he next saw the accident airplane in a 45-degree right bank as it entered a spin to the right about 300 feet agl. The spin continued for 2 1/2 turns and the airplane impacted terrain below and a fire erupted. It appeared that the spin slowed and a partial recovery was made just before the impact. In the immediate area where the accident occurred the canyon was closing; there was rising terrain ahead and insufficient canyon width to turn around. The second pilot said there was no transmission (on the radio) of any mechanical problem and, as he watched the aircraft spin, it appeared that the airplane was structurally intact.
The density altitude at the accident site was approximately 8,000 feet.
|Accident date||June 14, 1998|
|Aircraft type||Blackmore RV-4|
On June 14, 1998, about 1145 hours mountain standard time, an experimental Blackmore RV-4, N813R, collided with mountainous terrain south of Sedona, Arizona. The aircraft was destroyed and the private pilot, the sole occupant, sustained fatal injuries. The aircraft, owned and operated by the pilot, was on a local flight conducted under 14 CFR Part 91 of the Federal Aviation Regulations. The flight originated from the Sedona airport about 1120. Visual meteorological conditions prevailed at the time and no flight plan was filed.
A Federal Aviation Administration inspector performed an on-site inspection of the aircraft wreckage. He observed that the accident site was located on the northeast side of Cathedral Rock, a tall, rock formation that stands 1,000 feet above the surrounding terrain. Cathedral Rock is formed by two main spires with a 200-foot-wide gap between them. The wreckage was located about 200 yards from the northeast side of this gap, about 100 feet below the steep terrain that angles downward about 45 to 60 degrees. According to the inspector, the aircraft was resting on a southeasterly heading. The inspector judged that, from the frontal damage to the aircraft and lack of disturbance to the surrounding vegetation, the aircraft impacted the ground on a steep angle relative to the terrain.
Retrieval of the engine tachometer, altimeter, and turn coordinator indicated the aircraft was developing 2,450 rpm’s approximately 4,400 feet msl, while in a slightly banked right turn. An inspection of the engine by the manufacturer representative, under the supervision of the Safety Board investigator, revealed no evidence of abnormalities or malfunctions prior to impact.
According to conversations with friends of the pilot, the inspector learned the pilot was planning to attend a high school reunion in the Sedona area that weekend. At the conclusion, the pilot mentioned he wanted to perform some aviation stunts for his friends who would be hiking in the Cathedral Rock area the following Sunday morning.
The inspector also spoke with a close friend of the pilot’s who had previously flown as a passenger with the pilot during a practice aerobatic flight involving a “roll” maneuver. He recalled that whenever the pilot would come out of the roll, he would “lose his centrifugal force to the outside and drop out of the maneuver.” The friend had witnessed the pilot attempting this “roll” maneuver within 15 to 20 feet of the top of the Cathedral Rock cliffs on several previous occasions. People on top of the spires at Cathedral Rock were able to see the pilot smiling and laughing as he flew by. He went on to explain that the aircraft appeared to have needed approximately 75 to 100 feet agl of additional altitude in order to complete the maneuver without contacting the ground. The friend concluded that it was the pilot’s intention to “buzz the hell out of them” (the hikers on Cathedral Rock), and that he had continuously tried to persuade him not to do so.
Several hikers were on a trail up into the Cathedral Rock area on the morning of the accident. They witnessed the aircraft fly almost one complete loop before it contacted the terrain at the base of the mountain. Hikers stated the aircraft’s engine could be heard throughout the loop. One witness encountered a person claiming to be a friend of the pilot’s who stated the pilot was “showing off for his party of friends.”
The kit manufacturer stated that increased density altitude conditions, that occur with higher than standard temperatures, degrade aircraft performance. The accident site was about 4,450 feet msl, with an altimeter setting of 30.24 inches and a current temperature of 72 degrees Fahrenheit. Density altitude was computed by a Safety Board investigator as 5,873 feet.
An autopsy was conducted by the Yavapai County Coroners Office with specimens retained for toxicological examination. The toxicological tests results were negative for alcohol and all screened drug substances.
|Accident date||December 2, 1997|
|Aircraft type||Mooney M20J|
On December 2, 1997, about 2200 hours mountain standard time, a Mooney M20J, N301JL, en route to Flagstaff, Arizona, collided with mountainous terrain after takeoff from the Sedona, Arizona, airport. The aircraft was destroyed and the pilot and his passenger received fatal injuries. The aircraft was being operated by the pilot/owner as a personal flight under 14 CFR Part 91 of the Federal Aviation Regulations when the accident occurred. The flight originated about 2158. Visual meteorological conditions prevailed at the time and no flight plan was filed.
An unidentified transient pilot reported to the airport manager that he had heard an aircraft climbing out about 2200 on December 2, 1997. There were no other witnesses identified.
There were no ground-based lighting systems in the vicinity of the accident site.
The wreckage was spotted about 0835 the next morning by a resident with a telescope who subsequently reported it to the Sedona Fire Department.
According to Federal Aviation Administration (FAA) records, the pilot did not receive a weather briefing.
No pilot logbooks were available for review by investigators.
The aircraft was equipped with an S-Tech model 0110 autopilot and a Bendix/King model KLN 90B GPS navigational system. There was no retrievable memory available from either system.
Sheriff’s deputies reported that the aircraft logbooks were given to an FAA inspector who made copies of selected entries. The inspector reported that, according to the logbook entries, the aircraft was being maintained in an airworthy condition. The sheriff reported that the logbooks were signed out of the evidence locker on December 17, 1997, by a person identified as the son of the pilot.
The aircraft logbooks were discarded by the pilot/owner’s son after he received them from sheriff’s deputies and before they could be reviewed by Safety Board investigators. The FAA inspector did not retain the logbook copies he had made on the day of the accident.
The date, location, and amount of the last fuel purchase are unknown.
There was no evidence found to indicate that the aircraft was beyond gross weight or center of gravity limitations.
The area forecast for December 3, 1997, at 1145Z was for VFR to MVFR conditions with occasional visibility down to 3 to 5 miles in mist.
The 700 mb Constant Pressure chart for December 3, 1997, at 1200Z depicted the Flagstaff station model. The indications were northwesterly winds of approximately 25 knots, a temperature of -9 degrees Celsius, and a dew point of -10 degrees Celsius at 10,000 feet msl.
There was no moon illumination at the estimated time of the accident.
There was no FAA record of the pilot receiving a weather briefing, although friends of the pilot reported that he had checked the weather several times before departing.
The accident site was located on the south side of an approximate 6,100-foot east-west ridge, at about 5,952 feet msl. A GPS indicated the position was 34 degrees 54 minutes 18.9 seconds north latitude and 111 degrees 44 minutes 17.9 seconds west longitude.
The accident site was on a 019-degree bearing, 4.3 miles from the Sedona airport. The runway is oriented toward 03 and 21. The Flagstaff airport is located on a 003-degree bearing, 21 miles from the Sedona airport.
An examination of the aircraft revealed that the right wing was separated, at the root, from the fuselage. The right wing exhibited more leading edge crushing than did the leading edge of the left wing. Control continuity was established to all flight control surfaces. The nose of the aircraft was crushed aft to within 14 inches of the leading edge of the remaining wing. The instrument panel was positioned in proximity to the back of the front seats. There was evidence of oil-canning on the top and sides of the main fuselage.
The engine initially was found at the accident site shifted aft and separated from the airframe engine mounts. There was evidence of impact damage on both the engine and engine accessories. The oil sump/plenum with the attached fuel control servo was separated from the engine, as were the engine accessory case, magneto, fuel pump, vacuum pump, and propeller governor.
An attempt to rotate the crankshaft by hand was unsuccessful. There was a gouge across the No. 1 cylinder barrel that was consistent in size and orientation to that of a propeller blade. The piston faces were viewed, with the aid of a penlight, through the spark plug holes and appeared undamaged. The rocker covers were removed and the valve components were visually inspected. The connecting rods and crankshaft at the No. 3 and 4 cylinder positions were viewed through a hole in the rear of the engine case. There was no evidence of mechanical malfunction visible. The idler gears were missing from the accessory case and were not recovered from the site. The crankshaft gear and dowel were secure and intact.
There was no evidence of metal contamination in the engine oil. The oil pump was intact and contained residual oil.
The vacuum pump drive was intact; however, the vanes were found cracked and shattered.
Half of the 8 spark plug electrodes, 1 per cylinder, were undamaged. According to the Champion Spark Plugs Check-A-Plug chart, AV-27, the undamaged electrodes displayed wear and coloration patterns consistent with normal operation.
The single drive dual magneto could not be functionally tested due to damage. The impulse coupler drive was intact and secure on the shaft.
The fuel injection servo fuel flow divider was intact and secure at its mounting bracket. Line continuity was established to each cylinder nozzle. The No. 3 nozzle was separated. The flow divider was disassembled and trace amounts of a fuel-like substance were noted.
The engine driven fuel pump was disassembled and examined. There was no evidence of internal blockage or mechanical malfunction.
The exhaust system gas path coloration was light gray. There was no evidence of internal obstructions when viewed through the ports of each pipe.
The two-bladed constant speed propeller was separated from the engine crankshaft. A portion of the propeller hub remained attached to the propeller flange. Both propeller blades’ tips, though fractured, were found at the accident site. The blades exhibited leading edge damage as well as chordwise scouring.
An autopsy was conducted on December 4, 1997, by the Coconino Medical Examiner, with specimens retained for toxicological examination. The toxicological test results were negative for alcohol and all screened drug substances.
The direct flight time from takeoff to impact was estimated by Safety Board investigators and the aircraft manufacturer’s representative to have been approximately 3.0 minutes. This was based on an average rate of climb of 980 fpm, an estimated gross weight of 2,517 pounds, surface winds from 130 degrees at 4 knots, a surface temperature of 43 degrees Fahrenheit, and an initial field elevation of 4,827 feet msl. Under the stated conditions, the expected altitude gain would have been about 2,940 feet, or 7,767 feet msl. These computations did not account for the potential effect of mountain wave conditions. That altitude is 571 feet above the highest terrain depicted on the 60th edition of the Phoenix Sectional Aeronautical Chart, for the direct route of flight between Sedona and Flagstaff.
The ELT activated when slapped against the palm of the hand.
The aircraft wreckage was released to a representative of the registered owner on May 4, 1999.
|Accident date||October 7, 1993|
On October 7, 1993, at 2038 hours mountain standard time, a Cessna 172N, N5365D, operated by Aerovision, Inc., of Sedona, Arizona, collided with a shear rock wall in mountainous terrain near Sedona, Arizona. The airplane was destroyed and the pilot received fatal injuries. Visual meteorological conditions prevailed at the departure and destination points and a VFR flight plan was filed. The accident occurred during the hours of darkness.
The pilot had just completed a 14 CFR Part 135 charter flight from Flagstaff Arizona, to Farmington, New Mexico, and back to Flagstaff where his passengers deplaned. The pilot was returning the aircraft to its Sedona base when the accident occurred.
Two witnesses, a husband and wife, were located about 2 miles north of the accident site at the time of the accident. They observed a low flying aircraft. The wife stated that her attention was first drawn to the area of the aircraft by what she first thought was lightning and then she realized that it was a bright, flashing white light reflecting off the clouds. She stated that the airplane made an abrupt turn southbound; she observed both red and white flashing lights, and reported that the engine sounded normal. Upon hearing an impact, she notified the Sedona Police.
According to the pilot’s logbook, he had accumulated about 13,205 hours of flight time with about 60 hours as a pilot examiner. The day before the accident the pilot successfully passed a 14 CFR Part 135 proficiency check ride with a Federal Aviation Administration (FAA) inspector from the Scottsdale Flight Standards District Office.
The airplane was manufactured in 1979 and had accumulated 4,325 hours at the time of the last annual inspection. The last documented annual inspection was accomplished on September 21, 1993, at a recording tachometer time of 259.5 hours. According to the records, the engine had accumulated 296.9 hours of operation since a major overhaul was performed. The recording tachometer recovered at the postcrash examination revealed a reading of 275.0 hours.
Airport fueling records at the Flagstaff and surrounding airports disclosed no evidence that N5365D was refueled on the day of the accident. The last documented fueling for the aircraft was at Farmington, New Mexico, where 10 gallons of 100LL aviation gasoline was added to the tanks.
National Transportation Safety Board investigators performed fuel consumption calculations using the known flight times, since the morning departure from Sedona to the accident site, at an average consumption rate for 75 percent power. The calculations revealed that at the time of the accident the aircraft had about 5.5 total gallons of usable fuel on board. The calculations are attached to this report.
A pilot witness stated that just prior to the accident time he noted some scattered clouds in the accident area with tops around 5,000 feet msl.
According to a National Transportation Safety Board meteorologist report, infrared satellite images taken around the time of the accident show patchy lighter shades of grey in the vicinity of Flagstaff and Sedona. These lighter colors imply temperatures consistent with colder cloud top temperatures. In addition, these features drifted to the northeast.
The wreckage was located in the Coconino National Forest. According to Arizona Department of Public Safety helicopter pilots who responded to the accident site, the airplane collided with a sheer rock wall at 5,980 feet msl, 13.6 nautical miles from the Flagstaff VOR along the 182 degree radial.
An aerial view revealed the impact site was about 1,000 below the top of the 6,900 foot mountain. There was an imprint of the aircraft on the rock wall. The majority of the wreckage was located at the base of the wall about 5,800 feet msl.
Examination of one of the propeller blades indicated chordwise scratches and leading edge gouges with spanwise twisting. The dry air vacuum pump drive and vanes were found intact.
On October 10, 1993, the Coconino County Medical Examiner in Flagstaff, Arizona, performed the autopsy on the pilot.
Samples were obtained from the pilot for toxicological analysis by the FAA Civil Aeromedical Institute in Oklahoma City, Oklahoma. The results of the toxicological analysis were negative for all screened drug substances and alcohol.
Postcrash examination of the aircraft radios revealed that the ADF was tuned to 780 KHz which is the frequency of a local radio station located about 3.0 miles west of the Sedona Airport. The Sedona nondirectional radio beacon was NOTAMed out of service October 11, 1991. The other recovered radio frequency from a navigation receiver was determined by an approved radio shop to be set on 108.2 MHz, which is the Flagstaff VOR frequency.
The aircraft wreckage was released to Mr. Bill Bertles, an insurance representative, on May 24, 1994.
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