NTSB Factual Report

HISTORY OF FLIGHT

On January 23, 2009, about 0655 mountain standard time, a Cessna 205, N8298Z, impacted a hill shortly after departing from Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona, killing the two pilots. The private pilots, one of which was the owner, were operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The airplane sustained substantial damage. The cross-country business flight was originating from Flagstaff with a planned destination of Yuma, Arizona. Instrument meteorological conditions prevailed in the area surrounding the accident site; no flight plan had been filed.

The National Transportation Safety Board investigator-in-charge (IIC) interviewed both of the pilots' spouses several days after the accident. They reported that the pilots had been planning to fly to Yuma to attend a business meeting.

PERSONNEL INFORMATION

Left-seated Pilot (owner)

A review of the airmen records maintained by the Federal Aviation Administration (FAA) disclosed that the left-seated pilot, age 47, held a private pilot certificate with airplane ratings for single-engine. His most recent third-class medical certificate was issued on March 12, 2007, with a limitation that he “must wear corrective lenses.” On his last application for a medical certificate, he reported a total flight time of 1,550 hours.

The Safety Board IIC reviewed copies of the left-seated pilot’s personal flight logbooks. The last entries in the flight section were labeled as being complete in 2002, with a total flight time indicated of 960.9 hours. In the endorsement section of the logbook the last biennial flight review (BFR) was signed as being completed on February 06, 2006. Another entry was entered as the pilot having completed an instrument proficiency check on February 28, 2008; the same certificated flight instructor signed both these entries. The left-seated pilot did not hold an instrument rating.

The left-seated pilot's spouse stated that her husband would take her on flights often and classified him as a very conservative and conscientious pilot; this was the second airplane he owned. He had planned this trip to Yuma with the right-seated pilot as they had an important meeting. He was excited about the meeting, as he had recently had numerous stressors about the financial health of his company with a downturn of the economy.

The left-seated pilot's spouse further stated that her husband and the right-seated pilot had flown together before. On several occasions they also teamed up on different work related projects. Her husband had spoken highly of the right-seated pilot's flying ability. She noted that when flying with her husband to the south or west of Flagstaff, they would normally be to the east of Interstate 17.

Right-seated Pilot

According to the FAA airmen records, the right-seated pilot, age 57, held a private pilot certificate with airplane ratings for single-engine land and instrument flight. His most recent third-class medical certificate was issued on May 06, 2008 with the limitation that he must have glasses available for near vision.

The pilot's personal flight records were not recovered. On his last application for a medical certificate, he reported a total flight time 2,500 hours.

The right-seated pilot's souse stated that her husband was a seasoned pilot, with lineage of aviators in his family. He regularly flew in the harsh conditions of Alaska where they owned another home, although he frequently operated out of Flagstaff. She flew with him often and classified him as a conscientious pilot, always willing to cancel a flight for any reason, including poor weather conditions. Her husband had relayed to her that he was excited about the Yuma project. He had spent many years working on the job and the meeting was of high importance. The night prior to the accident he received about 6 hours of sleep, which was shorter than normal. She added that although he had his instrument rating, he rarely flew instruments, as he did not like to conduct such operations.

AIRCRAFT INFORMATION

The Cessna 205, serial number 205-0298, was manufactured in 1963. A review of the logbooks revealed that the most recent annual inspection was performed on May 16, 2008, at a total airframe time of 5,017.1 hours.

The powerplant, a Teledyne Continental Motors IO-470-S, serial number 102781-3-S-1, last underwent a major overhaul on April 30, 2008; during the last annual inspection this engine was installed on the airframe. The maintenance records listed the last maintenance as occurring on July 08, 2008, where the owner performed preventative maintenance items, which included an oil change.

The last known fueling occurred on January 13, 2009, where the owner added 48 gallons of fuel in Sedona, Arizona, filling the tanks to their full capacity. The flight time between the fueling and the accident is unknown.

An Arizona Department of Public Safety commander was making a traffic stop near the accident site and radioing to dispatch when the accident airplane passed overhead. The audio recording was sent to the National Transportation Safety Board Vehicle Records Laboratory in Washington D.C., for examination. Based on the recording, it was estimated that the engine rpm was about 2,000 and the airplane was traveling at an airspeed of about 130 knots.

METEOROLOGICAL INFORMATION

The first officer of a Horizon Air flight 2497 recalled that on the morning of the accident he was preparing to fly from Flagstaff en route to Prescott, Arizona. Prior to departure, and while waiting for a clearance, he witnessed an airplane taxiing to runway 21. He subsequently observed the airplane depart off of runway 21, which he noted to be similar appearance to a Cessna 172. He further stated that around 0700 he departed from runway 03, complying with company procedures. The airplane entered the cloud layer before the facility-observed 1,600 feet, somewhere around 1,000 feet above ground level (agl). He added that the cloud layer and visibility seemed to be lower to the south of the airport. During the entire flight there was continuous light turbulence and light rime ice, until they eventually broke out of the cloud layer just before Prescott.

At 0656, the weather observation facility at FLG reported calm wind; 10 statute miles visibility; scattered cloud layer at 800 feet; broken cloud layer at 1,500 feet; and an overcast layer at 2,200 feet; temperature 04 degrees Celsius; dew point 04 degrees Celsius; and an altimeter setting of 30.23 inches of mercury. At 0659, 3 minutes later, the same facility updated the cloud conditions to a broken cloud layer at 800 feet; an overcast layer at 1,500 feet; remarking that a cloud ceiling varied between 700 feet and 1,100 feet.

An audio recording was provided by the Lockheed Martin Prescott Automated Flight Service Station (AFSS), of the owner requesting and receiving an outlook weather briefing at 1951 the night prior to the accident. He stated that he intended on departing from Flagstaff to Yuma at 0630 the next morning. The owner stated that the flight would take about 2 hours at an en route altitude of 8,500 feet mean sea level (msl). Immediately following his announcement of the planned altitude, he relayed that "we may have to go IFR (Instrument Flight Rules) in which case the altitude would change."

The briefer informed the owner that from 2200 that night to 1900 the next day, the Flagstaff weather was forecasted with the following conditions: light rain showers; mist; visibility 2 miles; scattered clouds at 500 feet; and an overcast layer at 1,000 feet. He added that around Flagstaff there would be snow and mixed precipitation as well as other areas along the intended route. The briefer stated that for northern Arizona "outlook marginal VFR for ceilings, rain showers, and mist."

The owner called the AFSS at 0611 the morning of the accident. He requested a "standard briefing for [a] VFR (Visual Flight Rules) flight from Flagstaff to Yuma in about 30 minutes." The briefer then queried him if he could, "go IFR if necessary?" The owner replied, "we may end up filing IFR if we have to." The briefer then continued with the weather conditions stating that there was an Airmen's Meteorological Information (AIRMET) for IFR conditions in the Flagstaff area. The AIRMET included mountain obscurations from the departure point to Prescott.

The briefer stated "VFR flight not recommended," as there was a low pressure system moving over the area and bringing in moisture. He read Flagstaff's current conditions as: 1,300 feet broken; 1,800 feet overcast; visibility 10 miles; temperature 5 degrees Celsius; and dewpoint 4 degrees Celsius. The pilot then asked for the terminal forecast for Flagstaff at 1900. The briefer stated that there was to be a scattered ceiling at 2,400 feet and 4,000 feet broken with showers in the vicinity. He added that there was a 30 percent chance of 2,500 feet broken, with light rain showers.

AIRPORT INFORMATION

The Airport/Facility Directory, Southwest U. S., indicated runway 03/21 was 8,800 feet long and 150 feet wide with an airport elevation of 7,014 feet. The air traffic control tower at the airport is open from 0700 to 1900.

WRECKAGE AND IMPACT

The accident site was located on a hill about 700 feet west of Interstate I-17 and about 10 miles south of Flagstaff. The debris stretched over 200 feet from the first impact marking to the farthest debris found (shards of glass) on a bearing of 280 degrees; the main wreckage was situated near the middle of the path. In character, the hill was comprised of wet hard dirt and snow, populated by scattered Ponderosa pine trees typical of the Northern Arizona region. The main wreckage elevation was about 6,850 feet msl.

The first identified points of contact consisted of a broken tree top located at the far east end of the debris field, about 83 feet downslope from the main wreckage. The main wreckage came to rest on an east facing slope of about 40 degrees and suffered major crush deformation. The main wreckage consisted of the left wing (in sections), empennage and engine, as well as the heavily deformed cabin area. The inboard left wing remained affixed to the fuselage by the aft attach bolt; a portion of the outboard section was folded back over the tail section and resting on a tree. The empennage was found partially intact and "scorpioned" forward toward the fuselage, just aft of the baggage door where the airframe had an "accordioned" appearance. The rudder was attached to the vertical stabilizer and intact. The horizontal stabilizer and elevator control surfaces remained attached. All control surfaces were accounted for at the accident site.

A detailed wreckage and impact report with accompanying pictures is contained in the public docket for this accident.

MEDICAL AND PATHOLOGICAL INFORMATION

The Coconino County Sheriff-Coroner completed autopsies on both pilots. Additionally, the FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens from both pilots. The results of analysis of the specimens of the right-seated pilot were negative for carbon monoxide, cyanide, volatiles, and tested drugs. The results for the left-seated pilot were negative for ethanol; Cyclobenzaprine was detected in the liver and Diphenhydramine was found in the liver and kidney.

TESTS AND RESEARCH

Investigators from the Safety Board, FAA, Cessna Aircraft Company, and Teledyne Continental Motors (TCM) examined the wreckage on January 26, 2008, at the facilities of Air Transport, Phoenix, Arizona.

An external visual examination of the engine revealed that it had broken from its mounts, consistent with impact damage. There were several cracks in the crankcase and crush damage was noted to the cylinder cooling fins. Numerous areas of damage were found on the cylinder rocker box covers. The oil sump was crushed up into the engine; the propeller spinner was bent back over the crankshaft flange. The bottom of all the exhaust tubing was crushed and sections had separated.

All of the cylinders’ rocker box covers were removed and noted a light oil film on the rocker arms and valve assemblies. The upper spark plugs were all removed and photographed. The spark plug faces and electrodes were all light gray and similar in appearance, with the exception of the number 2 and number 6 spark plugs, which had a light oily residue on the face and some debris imbedded near the electrodes.

The cylinders’ combustion chambers were examined through the upper spark plug holes utilizing a lighted borescope. The combustion chambers remained mechanically undamaged, and there was no evidence of foreign object ingestion or detonation. There was no evidence of valve to piston face contact observed. The gas path and combustion signatures observed at the spark plugs, combustion chambers, and exhaust system components displayed coloration that the TCM representative said was consistent with normal operation. There was no oil residue observed in the exhaust system gas path.

Manual manual rotation of the crankshaft was achieved by rotation of the crankshaft propeller flange. Thumb compression was established in all cylinders, but the number 6 cylinder. Valve train continuity was observed, with approximately equal lift action at each rocker assembly. The accessory gears were undamaged and had a light residue of oil.

The number 6 cylinder was removed. Areas in the crankcase were cracked, consistent with impact damage. No evidence of mechanical malfunction was found; the piston oil rings were intact. The exhaust valve spring assembly had damage consistent with impact, with one of the valve keepers missing. The exhaust valve was removed from the cylinder and appeared bent with impact.

The propeller blades were in the immediate vicinity of the wreckage. One blade was found partially imbedded in a crater just downslope of the main wreckage. The blade was still attached to the hub and remained intact; slight forward bending was noted. The other blade came to rest near the engine and was missing the blade tip. The leading edge contained numerous gouges and the blade had s-bending.

A detailed tests and research report with accompanying pictures is contained in the public docket for this accident.

NTSB Probable Cause

The pilot's loss of situational awareness and failure to maintain clearance from hilly terrain while flying in an area of a low cloud ceiling. Contributing to the accident was the pilot's decision to continue flight due to a self-induced pressure.