NTSB Factual Report

HISTORY OF FLIGHT

On November 6, 2000, about 0400 hours Pacific standard time, a Cessna 340A, N12273, operated by Air San Luis of San Luis Obispo, California, was destroyed during collision with terrain while on approach to land at Selma, California. The airline transport rated pilot was fatally injured, and the passenger received serious injuries. The flight was operating as an on-demand air taxi under 14 CFR Part 135, and a company flight plan was filed. The flight originated at Paso Robles, California, about 0320.

The pilot obtained two abbreviated weather briefings from the Federal Aviation Administration (FAA) Hawthorne, California, Flight Service Station on the morning of the accident. The airplane departed the company base at San Luis Obispo, about 0235, for the passenger pickup at Paso Robles. According to charter load manifest paperwork recovered at the accident site, the airplane landed at Paso Robles at 0250. The pilot was to return an organ transplant nurse/passenger to Selma, where her car was parked.

En route to Selma, the pilot was receiving visual flight following from Oakland, California, Air Route Traffic Center. In the vicinity of Selma the pilot reported twice, when asked, "do you have the airport in sight" that he might not be able to see the airport until he was over the top of it. Subsequently the airport was reported to be in sight and the VFR service was cancelled.

According to local area witnesses, the airplane made two attempts to land on runway 28, and the final approach to runway 10. Witnesses, including the airport manager, reported that ground fog was obscuring the airport, with the manager's estimate of approximately 500 feet of horizontal visibility. The manager stated that you could look up and see stars.

The airplane collided with a grape vineyard pole, and then the west embankment of a canal running northeast across the approach end of runway 10. All three landing gear were severed from the airplane. It then collided with the east embankment, about 250 feet short of the runway 10 threshold. There are no lights prior to the threshold green/red lights.

PILOT INFORMATION

According to information obtained from the operator, the pilot had accumulated over 19,000 flight hours, with 2,600 night hours and 1,500 hours of actual instrument flight time. His most recent second-class flight physical occurred on January 6, 2000, with a requirement for corrective lenses to be worn for flight. The pilot successfully performed an Airman Competency/Proficiency Check on August 9, 2000. The positioning flight from San Luis Obispo to Paso Robles originated about 0235, after obtaining two abbreviated weather briefing/forecasts at 0040 and 0158.

AIRPLANE INFORMATION

The airplane was maintained on a continuous airworthiness program, with the last inspection occurring on October 16, 2000, about 22.3 hours prior to the accident. The most recent altimeter, transponder, and static system functional testing occurred on October 13, 1999, at 4,592.3 hours.

According to the airplane checkout form for November 6, 2000, the pilot took possession of the airplane for the positioning flight at Hobbs recording meter time of 4,936.3 hours. The Hobbs meter reading at the accident site was 4,937.2 hours, about 54 minutes for the approximate 98-mile trips.

METEOROLOGICAL INFORMATION

The nearest weather reporting facility at 15 miles was Fresno, California. At 0356, the Fresno hourly surface observation was reporting: wind 050 degrees at 3 knots; visibility 2.5 statute miles with mist, clear; temperature 48 degrees Fahrenheit, dew point 46 degrees; and altimeter 29.87 inHg.

Another weather reporting facility is located at Hanford, California, about 16.5 miles from the accident site. At 0403, Hanford was reporting: wind calm; visibility 1 3/4 mist; scattered clouds at 8,000 feet above ground level; temperature 46 degrees Fahrenheit, dew point 46 degrees Fahrenheit; and altimeter 29.87 inHg.

WRECKAGE AND IMPACT INFORMATION

A Safety Board investigator examined the wreckage on scene and during a post accident examination at Compton, California. The main wreckage was found straddling the northeast embankment of a drainage canal. The forward half of the fuselage, wings, and engines were on top of the embankment. All three landing gear imprints were found on the first or southwest embankment. The assemblies were broken from the airframe structure and separated from it. The nose landing gear was located on the southwest or first embankment that exhibited physical contact.

The aft section of the fuselage and entire empennage were detached and hanging down the embankment into the dry canal connected by the control cables. Both main fuel wing tip tanks were separated from the wings. The right tip tank was located ahead of the wreckage about 30 feet. The left tank was on the ground near the wing tip; both exhibited fuel spillage around the tanks.

The right propeller assembly was detached from the engine crankshaft and located about 30 feet ahead of the right engine. The wings were covered with embankment sand. The engine cowlings were disrupted and open. The wing flaps were extended, and measured 45 degrees.

The fuselage nose/baggage section was broken and rotated from the main forward fuselage bulkhead revealing an open and empty baggage section.

The cabin area and cockpit were examined. On the instrument panel glare shield area were found Jeppesen instrument approach charts for Visalia, Fresno, and San Luis Obispo, sandwiched between the windshield and glare shield.

Instrument panel instrumentation appeared to be undamaged with some indications noted. The left altimeter indicated 544 feet, with the Kollsman window set at 29.95 inHg. The right altimeter was indicating 350 feet and 29.98 inHg. The left attitude indicator was 2 degrees right and 15 degrees up; the right was 20 degrees right and 15 degrees down. The magnetic compass indicated 110 degrees; the HSI "Bug" was 132 degrees. The directional gyro was indicating 118 degrees. The transponder was set at code 1200. The autopilot was off and the altitude alert was set at 3,300 feet. The alternator switches were on, as were the master, magnetos, and aux fuel pumps on low. The beacon, strobe, navigation light, and taxi light switches were on. No circuit breakers were found popped. The main fuel tanks were selected. The wing flap selector handle was full down. The instrument panel lighting rheostat was dimmed an estimated 50 percent.

The pilot's seat box structure was found collapsed at the forward and side locations, allowing the seat to tilt forward. The passenger seat was found collapsed at the forward end with seat stop pin disengagement.

Both landing lights were in the retracted position with no element stretch. The nose landing gear taxi light was destroyed. The right navigation light lamp was recovered revealing element stretch.

The engines and accessories were examined for catastrophic failures and operational signatures. The propellers were examined and found to be in the normal governing range and not feathered.

MEDICAL AND PATHOLOGICAL INFORMATION

On November 7, 2000, the Fresno County Medical Examiner performed a post mortem examination and toxicology analysis of the pilot. The analyses were negative for alcohol and other drugs. Toxicology samples were obtained and forwarded to the Federal Aviation Administration (FAA) Civil Aeromedical Institute in Oklahoma City, Oklahoma for toxicological examination. The toxicology report was negative for carbon monoxide, cyanide, ethanol, and drugs.

AIRPORT INFORMATION

According to information obtained from the FAA Airport Master Record form 5010,

The Selma Aerodrome, Inc. (0Q4) is a private airport consisting of runways 10 and 28; both have displaced thresholds equaling 301 feet and a runway length of 2,490 feet, and a combined total of 2,791 feet of asphalt surface. The record lists the elevation as 305 feet above sea level. The runways were lighted with nonstandard low intensity runway edge lighting lit from dusk to dawn. The runway end identifier lights green/red were in four positions at the runway thresholds. The combination green/red lights were mounted atop reflective traffic cones and indexed to wood platforms. At the time of the accident, the runway had recently been repaved with asphalt and remarked with runway numbers, displaced thresholds, and runway centerline. The last airport site inspection performed by FAA personnel occurred on February 27, 1998.

ADDITIONAL INFORMATION

The wreckage was released to the insurance company representative on October 18, 2001.

NTSB Probable Cause

The pilot's improper decision to attempt a visual approach and landing in instrument meteorological conditions and his failure to follow instrument flight rules procedures.