NTSB Factual Report

HISTORY OF FLIGHT

On April 20, 2005, about 1850 Pacific daylight time, a Lockheed P-3B air tanker airplane, N926AU, registered to and operated by Aero Union Corporation, Chico, California, impacted terrain while maneuvering about 12 nautical miles north of the Chico Municipal Airport (KCIC). The three crewmembers on board, the airline transport rated captain, the commercial rated copilot and the operator's chief pilot, who was providing flight instruction, were fatally injured, and the airplane was destroyed by impact forces and fire. The training flight was being conducted under 14 CFR Part 137. Day visual meteorological conditions prevailed, and a company flight plan was filed. The flight departed KCIC at 1838.

According to Aero Union Corporation records, prior to the accident flight, the airplane had flown 9 times on April 20, for a total flight time of 5 hours and 46 minutes. The purpose of the flights was to provide recurrent training for pilots scheduled to conduct fire-fighting operations for the United States Department of Agriculture Forest Service (USFS) during the upcoming fire season.

The accident captain flew the first two training flights of the day. In an interview conducted by Safety Board investigators, the copilot on those flights stated that although the accident captain had a lot of time in P-3s, he did not have much time in the low level environment. On flights 1 and 2, they dropped 2 loads of water. The accident captain briefed the copilot well regarding the drop area and escape routes. Normal drop speed was between 130 and 140 knots, and the mission was flown at an altitude about 200 feet above ground level (AGL). There were no open minimum equipment list (MEL) items and no "abnormals" were encountered during the flight.

On flight 1, they climbed out of Chico to an altitude of 3,500 feet. The Chief Pilot assumed the role of Attack Captain and selected a simulated spot fire area that needed the first portion of the drop across the head of the fire. The Chief Pilot noted that the accident captain never called for the Before Drop checklist. When conducting a drop, basically, they are trying to simulate a landing pattern with the landing gear retracted. They were at 120 knots approaching a "saddle" (between two peaks) before the push over to make the drop across the simulated head of the fire. The second part of the drop was to be made down the left or right flank; therefore, the accident captain attempted to do the drop out of a right hand turn. They had to go around because they were not lined up on the target. The copilot stated that the go-around decision was made late. The accident captain then decided to do the drop from a left hand pattern. The third drop was also made from a left hand pattern. When they departed the drop area and headed back to Chico, the accident captain faked a heart attack as a cue for the copilot to take over and land the airplane.

On flight 2, the Chief Pilot selected a drop area that was along a road that curved. The accident captain selected a right hand pattern for the drop but had to make a go-around. He then selected a left hand pattern and made the drop while in a turn. The Chief Pilot did not like that the accident captain made the drop while in a turn and briefed him accordingly, stating the dangers of possibly hitting a snag or other hazards. The copilot stated that he did not remember the accident captain making a go-around call but he did remember him saying "check flaps approach" as the go-around was initiated. The copilot waited for a minimum of 140 knots before retracting flaps beyond Takeoff/Approach setting.

The copilot stated that they try not to exceed 30 degrees of bank angle. The accident captain got close to that at times but did not exceed it. Final approach entails a constant descent to a level altitude. On these runs, the lowest altitude was perhaps 200 feet above terrain, but certainly not less than 150 feet. In case of a go-around, there is no lag in power; power is available right away.

The copilot stated that the accident captain was not as comfortable in the low level environment as he was in the normal flight regime, but the accident captain was confident. The copilot stated that he believed that the accident captain was task saturated in the low level environment, but that was not uncommon for other captains, as well. There was not much talk on final approach and the copilot stated that he did not think there should be. There were no simulated emergencies during the drop. They had already done a lot of simulated emergences at other times during training.

In an interview conducted by Safety Board investigators, the captain of flights 3 and 4 on the day of the accident stated that they took on a load of water and did three drops in a triangular area with a simulated boxed-in area of fire. They normally train in the area where the accident occurred, using a variety of different targets in that general area. The captain does all the flying during the actual fire-fighting activity. There were no mechanical problems with the airplane; it was a good flying airplane. He wrote up a couple of light bulbs after the flight but there were no other problems noted.

Flight 7 was a type rating check ride. The accident captain occupied the copilot seat on the flight and the Chief Pilot was conducting the check from the center seat. According to company records, the flight lasted for 1 hour and 56 minutes.

In an interview conducted by Safety Board investigators, the captain of flights 5, 6, 8 and 9 on the day of the accident stated that he flew the accident airplane for a total of 2 hours and 2 minutes on these four flights. The captain did not report any anomalies with the airplane.

The accident airplane had been fueled to 22,500 pounds just prior to flight 9. After flying for 28 minutes, flight 9 returned to KCIC at 1815. After returning to KCIC, no additional fuel was added but the airplane's retardant tank was loaded with 2,550 gallons of water.

The accident flight, the tenth flight of the day, taxied out for takeoff at 1834 and departed at 1838. As was the mission for other flights that day, the accident flight was a training flight to conduct practice drops of water over an area of rugged mountainous terrain located north of the airport. Aboard the flight were the captain, the copilot, and the Chief Pilot. The Chief Pilot had been on board all 10 flights that day.

According to radar plots of data provided by the U. S. Navy, the flight departed the airport and proceeded north while climbing to and maintaining between 3,000 and 3,500 feet msl. The airplane turned northeast and approximately 10.5 nautical miles from the airport, descended to between 2,700 and 2,900 feet msl and executed a left-hand 270-degree turn. The airplane then executed a second level left-hand turn of about 270 degrees coming out of the turn on a southwest heading. While on the southwest heading, the airplane descended to 2,300 feet msl and then began climbing. The airplane continued to climb to an altitude of 3,200 feet msl as it executed a right-hand race track pattern oriented northeast-southwest. In the race track pattern, as the airplane returned to a southwest heading, it again descended to an altitude of 2,300 feet msl and then began climbing. As the airplane continued to follow the race track pattern and turned from the southwest to the northeast it climbed to 2,700 feet msl. The last minute of radar data showed the airplane continuing to head northeast with its altitude varying as follows:

Time Mode C Altitude

18:49:55 2,700 feet

18:50:07 2,500 feet

18:50:19 2,500 feet

18:50:31 2,700 feet

18:50:43 2,600 feet

18:50:55 2,900 feet

The airplane had completed approximately 1.75 circuits of the racetrack when the data ended at 1850:55 with the airplane at 2,900 feet msl, heading northeast. The initial impact point was located about 2,150 feet northwest of the last radar data point at an elevation of about 2,450 feet msl.

No distress calls were received from the airplane. According to local authorities, witnesses observed a "fire ball" at the time of the accident. When the airplane did not return to the airport, a search was initiated. The wreckage was spotted from the air on the evening of April 20, and ground search and rescue personnel reached the site early on the morning of April 21. The main wreckage was located at 39 degrees 59.241 minutes North latitude and 121 degrees 47.208 minutes West longitude at an elevation of 2,359 feet.

PERSONNEL INFORMATION

The Captain

The captain held an airline transport pilot certificate with the ratings and limitations of airplane multiengine land; commercial privileges for airplane single-engine land; and type ratings for the B-737 and the L-188. He obtained his L-188 type rating on August 30, 1993, on the basis of military competence. Additionally, he held flight engineer and mechanic certificates. His most recent FAA first-class medical certificate was issued on April 18, 2005, with the limitation that he must have available glasses for near vision.

According to Aero Union Corporation records, the captain had accumulated 4,937 total flying hours, of which 2,915 were in the L-188/P-3. He had flown 12, 12, and 135 hours in the past 30 days, 90 days, and 1 year, respectively. His most recent L-188/P-3 competency/proficiency check was completed May 2, 2004.

The captain's date of hire with Aero Union Corporation was March 31, 1995. He was employed as a P-3 pilot for the U. S. Navy Reserves from June 1993 until the time of the accident. Before that, he was employed as a P-3 flight engineer and P-3 pilot for the U. S. Navy from December 1975 until June 1993.

The Copilot

The copilot held a commercial pilot certificate with the ratings and limitations of airplane single- and multiengine land, instrument airplane, and an L-P2V type rating. Additionally, he held flight instructor and mechanic certificates. His most recent FAA second-class medical certificate was issued on April 15, 2005, with no limitations or restrictions.

According to Aero Union Corporation records, the copilot had accumulated 4,317 total flying hours, of which 192 hours were in the L-188/P-3. He had flown 15, 27, and 251 hours in the past 30 days, 90 days, and 1 year, respectively. His most recent FAR 61.55 second-in-command qualification check was completed January 28, 2005.

The copilot's date of hire with Aero Union Corporation was April 1, 1997. He was employed as an air tanker copilot for TBM, Inc., from April 1996 until December 1996. Prior to that he was the owner of an air conditioning and heating business from April 1992 until April 1996.

The Chief Pilot

The chief pilot held an airline transport pilot certificate with the ratings and limitations of airplane multiengine land; commercial privileges for airplane single-engine land; and type ratings for the DC-4, L-188, L-382, and L-P2V. The chief pilot obtained his L-188 type rating on April 18, 1996. Additionally, he held flight instructor and mechanic certificates and was a designated pilot examiner. His most recent FAA second-class medical certificate was issued on January 3, 2005, with no limitations or restrictions.

According to Aero Union Corporation records, the chief pilot had accumulated 6,527 total flying hours, of which 902 were in the L-188/P-3. He had flown 34, 88, and 232 hours in the past 30 days, 90 days, and 1 year, respectively. The chief pilot's most recent FAR 61.58 pilot-in-command proficiency check was completed November 14, 2002.

The chief pilot's date of hire with Aero Union Corporation was May 1990. He was employed as an instructor/charter pilot for Flight Operations, from July 1989 until May 1990. Prior to that he was employed as a DHC-4 copilot for Union Flights from March 1989 until July 1989. Before that he was a flight instructor for various companies from 1987 to June 1989.

AIRCRAFT INFORMATION

The Lockheed P-3B Orion is a low-wing, 4-engine anti-submarine warfare airplane originally developed from the Lockheed L-188A Electra passenger airplane. The airplane is 106 feet long, has a wingspan of 99 feet, 8 inches and a height at the tip of the vertical stabilizer of 33 feet, 8.5 inches. It is constructed primarily of aluminum alloy with a semi-monocoque fuselage design. The empennage is of the conventional design utilizing a single elevator on each horizontal stabilizer each with a trim tab and a force link tab. There is a single rudder on the vertical stabilizer with an attached trim tab. Each wing is equipped with an aileron and attached trim tab and a one-piece fowler flap. The flaps are each actuated by two jackscrews and the motion is defined by five flap tracks. The nose and two main landing gear are installed in a tricycle configuration.

The airplane was manufactured by Lockheed around February 1966 in Los Angeles, California for the United States Navy. The United States Navy took delivery of the airplane on March 10, 1966. According to military records, the airplane had accumulated 13,751 total hours since new and 10,293 total landings. Aero Union purchased the airplane from the General Services Administration on January 14, 1997. A special ferry flight permit was issued by the FAA on January 23, 1997 to ferry the airplane from MacDill Air Force Base, Florida to Chico, California. On May 3, 1999, the airplane was converted to a tanker configuration using Aero Union Supplemental Type Certificate (STC) STC00792LA and Master Drawing List Number 11700 Rev F dated September 3, 1998. The FAA issued a restricted category airworthiness certificate for the airplane on May 5, 1999. The airplane had accumulated 15,614.1 total hours at the time of the accident. Aero Union had flown the airplane 1,863.1 hours since purchasing the airplane from the military.

The airplane was equipped with four Rolls-Royce T56-A10W turbo propeller engines. The T56-A10W engine features a power reduction gearbox, 14-stage axial flow compressor, a can-annular combustor with 6 combustion chambers, and a 4-stage turbine. The T56-A10W engine has a takeoff power rating of 4,591 shaft horsepower (shp). The airplane was also equipped with four Hamilton Sundstrand 54H60-77 propellers. The 54H60-77 propeller is a four-bladed, hydraulically actuated, variable pitch, constant speed propeller.

Aero Union Corporation maintained its P3 fleet in accordance with an FAA Approved Inspection Program, signed and dated May 6, 2004. The most recent inspection was accomplished on April 11, 2005 in Chico, California. This inspection was a "Special" inspection, which is the equivalent of an annual inspection. At the time of the inspection, the airplane had accumulated 15,583.0 hours. The inspection consisted of a detailed airframe inspection, lubrication of the entire airplane, inspection of the retardant tank and its systems, a check of FAA and USFS requirements, and a discrepancy review and corrective action. Review of the airplane's maintenance records by Safety Board investigators revealed no significant issues, trends, or findings.

The airplane's weight and balance were estimated for the time of the accident. The estimated gross weight of 73,292 pounds and center of gravity of 586.5 inches were within the manufacturer's Airplane Flight Manual (AFM) limits (105,000 pounds and 577.95 to 598.20 inches). The estimated weight was based on the assumption that all retardant (water) was jettisoned. The actual amount of retardant that was jettisoned could not be determined.

According to the AFM Supplement, Lockheed P3A/P3B STC ST00792LA, the maximum drop speed is 150 KIAS and the minimum flap setting for retardant drop is TAKEOFF/APPROACH.

The airplane was equipped with neither a cockpit voice recorder (CVR) nor a flight data recorder (FDR) and 14 CFR Part 137 did not require the airplane to be so equipped.

METEOROLOGICAL INFORMATION

The closest operating weather reporting station was located at Red Bluff Municipal Airport (KRBL), Red Bluff, California, about 25 miles northwest of the accident site at an elevation of 349 feet msl. The

NTSB Probable Cause

Terrain clearance was not maintained while maneuvering for undetermined reasons. Mountainous terrain was a factor.