NTSB Factual Report

HISTORY OF FLIGHT

On January 27, 2012, about 1227 eastern standard time, a Cessna 340A, N340HF, was substantially damaged following a collision with terrain during approach to Ocala International Airport (OCF), Ocala, Florida. The certificated private pilot was fatally injured and one passenger received serious injuries. The airplane was registered to a corporation and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight originated from Middle Georgia Regional Airport, Macon, Georgia, about 1117.

An examination of recorded radar data revealed that the pilot entered a left downwind leg on a southerly heading, about 6 miles west of OCF. The airplane was abeam the approach end of runway 36, and about 1,800 feet mean sea level (msl), when a left base turn was initiated. The pilot then initiated a turn to final about 2.5 miles from the runway approach end, at an altitude of about 700 feet msl. The last radar return with an altitude readout other than zero occurred about 1.16 nautical miles south of runway 36, at 1727:27 (HHMM:SS) at an altitude of about 300 feet msl (about 210 feet above the ground).

According to recorded voice transmissions between the accident pilot and Ocala FAA Contract Tower (FCT) personnel, the pilot checked in at 1723:51. The local controller provided the pilot with the current wind information and the pilot reported turning left base at 1724:07. The local controller reported that the airplane was not in sight and issued a landing clearance to the pilot. At 1725:41, the local controlled advised the pilot that he had him in sight. At 1727:52, the local controller stated, "zero hotel foxtrot altitude altitude." No response was received from the pilot, and there were no distress calls received from the pilot.

The pilot's wife was seated in the aft cabin and reported the following after the accident. During the descent for landing at OCF, she recalled the "choppy" and "bumpy" conditions, and the "ground was coming up on them quickly." She recalled hearing two distinct warning horns in the cockpit prior to the crash. She also reported that, during the final phase of the flight, the airplane veered left noticeably two times. Prior to the crash, her husband made no comments regarding any mechanical difficulties with the airplane.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He reported a total flight experience of 1,005 hours on his latest third-class medical certificate application, dated June 10, 2011.

According to the pilot's logbook that was located in the wreckage, as of January 21, 2012, he recorded about 416 hours in single engine airplanes, about 632 hours in multi-engine airplanes, and about 828 hours as pilot-in-command. His first recorded flight in the accident airplane was on December 19, 2011, and he recorded about 14.2 hours total time in the accident airplane.

The pilot's last recorded Code of Federal Regulations (CFR) part 61.56 flight review occurred on December 28, 2009. The flight included an instrument proficiency check and was conducted in a single-engine Cessna 182. The accident pilot's last flight review in a Cessna 340A occurred on November 3, 2007. The certified flight instructor (CFI) who administered the examinations was interviewed by the NTSB investigator-in-charge following the accident. The CFI reported that he last flew with the accident pilot in 2011. The CFI also owned a Cessna 340A and asked the accident pilot to fly the airplane to Albany, Georgia for him, since the CFI was injured from a recent fall. The CFI reported that the flight from Florida to Albany was uneventful until entering the traffic pattern for landing. The accident pilot lined up on an incorrect runway, and the CFI provided verbal guidance to correct the situation. Once aligned on the correct runway, the accident pilot allowed the airspeed to decay on short final to the point where the CFI responded out loud, "power, power!" The airplane landed hard on the runway, and a hard landing inspection was accomplished after the flight with no damage found.

A friend of the accident pilot, who was also a CFI, provided dual instruction following the pilot's purchase on the accident airplane in December, 2011. The CFI was interviewed by the NTSB investigator-in-charge following the accident. He stated that he did not administer a flight review to the accident pilot. During recent dual instruction, the accident pilot flew precise, smooth approaches and landings. He stated that the accident pilot would have passed a flight review based on how he flew when they were together. The CFI and the accident pilot conversed prior to the flight, and he was aware that the accident pilot needed to be in Ocala by 12 o'clock noon on the day of the accident to meet with a realtor.

The CFR part 61 addresses certification of pilots. The following pertains to flight reviews:

Except as provided in paragraphs (d), (e), and (g) of this section, no person may act as pilot in command of an aircraft unless, since the beginning of the 24th calendar month before the month in which that pilot acts as pilot in command, that person has—

(1) Accomplished a flight review given in an aircraft for which that pilot is rated by an authorized instructor; and

(2) A logbook endorsed from an authorized instructor who gave the review certifying that the person has satisfactorily completed the review.

AIRCRAFT INFORMATION

The airplane was a twin-engine, low wing, retractable gear airplane, serial number 340A0624. It was powered by two Continental TSIO-520 engines with RAM conversions rated at 335 horsepower each.

According to the aircraft maintenance records, the last annual inspection on the airframe and engines was performed on April 18, 2011, at a total aircraft time of 5,057.4 hours.

METEOROLOGICAL INFORMATION

The 1227 surface weather observation for OCF reported wind 260 degrees at 9 knots with gusts to 15 knots, visibility 10 miles or better, few clouds at 2,800 feet, ceiling 3,400 feet overcast, temperature 19 degrees C, dew point 14 degrees C, and altimeter setting 30.00 inches of mercury.

At 1224, the Ocala FAA Control Tower local controller provided with following wind information to the accident pilot, "…wind two seven zero at nine and uh gust one four." The pilot acknowledged the transmission.

WRECKAGE AND IMPACT INFORMATION

The accident site was situated on level ground and was an active livestock pasture. The main wreckage was located about 0.65 nautical miles south-southwest of the approach end of runway 36. The airplane fuselage came to rest on a heading of 120 degrees. Small flecks of white paint and a broken portion of the left wing navigation light were found with the first ground scar along the wreckage path. The straight line distance from the initial impact scar to the main wreckage was about 86 feet and was on a heading of 300 degrees.

An initial examination of the wreckage revealed the following. The cockpit and cabin were extensively burned from a post-impact fire. The landing gear handle was found in the retracted position. The position of the landing gear actuator linkage indicated an "in transit" position and was in close proximity to the up/retracted position. The wing flaps were found extended about 15 degrees. All engine controls were found near the full-forward positions.

Control cable continuity was established from the cockpit controls to the rudder and elevators. The left aileron cables were attached to the bell crank with overload separations noted near the wing root. The right aileron cables were continuous from the wing bell crank to the wing root. The pilot and co-pilot control wheels were linked together by the chain.

The left engine remained attached to the airframe via the engine mounts and thermal damage was evident to the accessory section. The engine-driven fuel pump was removed by investigators and the drive coupling was intact. The pump did not rotate freely by hand. The fuel metering unit/mixture control exhibited thermal damage and both control arms moved freely by hand. The crankshaft rotated by hand when the propeller flange was rotated manually with a hand tool. The turbocharger compressor wheel turned freely by hand and was coupled to the turbine wheel.

The right engine remained attached to the airframe by three of the four mount legs and thermal damage was evident to the accessory section. The engine-driven fuel pump was removed by investigators and the drive coupling was intact. The pump did not rotate freely by hand. The fuel metering unit/mixture control exhibited thermal damage and both control arms moved freely by hand. The crankshaft rotated by hand when the propeller flange was rotated manually with a hand tool. The turbocharger compressor wheel turned freely by hand and was coupled to the turbine wheel.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination of the pilot was performed at the District 5 Medical Examiner's Office, Leesburg, Florida, on January 28, 2012. The autopsy report noted the cause of death as "Acute carbon monoxide poisoning and thermal injuries due to fire due to airplane crash" and the manner of death was "accident."

Forensic toxicology testing was performed on specimens of the pilot by the Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The CAMI toxicology report indicated 31 percent carbon monoxide detected in blood and 1.3 ug/ml of cyanide detected in blood. No ethanol was detected in vitreous fluid. No drugs were detected in the urine.

TESTS AND RESEARCH

The engines were shipped to the Continental Motors, Inc. (CMI) facilities in Mobile, Alabama for further examination. The investigation team reconvened on April 3 through 5 to perform the examinations. After an initial evaluation of overall condition, it was concluded that test runs of the engines would be attempted.

Left Engine

Due to impact and thermal damage, the following items were substituted or repaired prior to the test: fuel manifold valve fittings, the throttle control link rod, the induction system "Y" pipe, and the exhaust system.

The engine was fitted to the test stand and a test club propeller was installed. The engine started normally on the first attempt without hesitation or stumbling in observed RPM. The engine RPM was advanced in steps for warm-up in preparation for full power operation. The engine was advanced to 1,200 RPM, 1,600 RPM , and 2,450 RPM and held for 5 minutes at each RPM setting to stabilize. The engine throttle was then advanced to the full open position and held for an additional 5 minutes to stabilize. Throughout the test phase, the engine accelerated normally without any hesitation, stumbling, or interruption in power and demonstrated the ability to produce rated horsepower. The engine fuel system was not adjusted and was found to be set at a lean condition as compared to CMI specifications.

Right Engine

Due to impact and thermal damage, the following items were substituted or repaired prior to the test: fuel pump fittings, the induction system "Y" pipe, and the engine starter.

The engine was fitted to the test stand and a test club propeller was installed. The engine started normally on the first attempt without hesitation or stumbling in observed RPM. The engine RPM was advanced in steps for warm-up in preparation for full power operation. The engine was advanced to 1,200 RPM, 1,600 RPM, and 2,450 RPM and held for 5 minutes at each RPM setting to stabilize. The engine throttle was then advanced to the full open position and held for an additional 5 minutes to stabilize. Throughout the test phase, the engine accelerated normally without any hesitation, stumbling, or interruption in power and demonstrated the ability to produce rated horsepower.

ADDITIONAL INFORMATION

The airplane was equipped with two aural warning systems, a landing gear warning horn and a stall warning horn.

According to the Cessna 340A Information Manual, the landing gear warning horn was controlled by the throttles and the wing flap position. The horn would sound intermittently if either throttle was retarded below about 15 inches of manifold pressure with the landing gear retracted or if the wing flaps were lowered past the 15 degree position with the landing gear in any position except extended and locked.

The stall warning horn would sound 5 to 10 knots above the stall in all flight configurations.

NTSB Probable Cause

The pilot's failure to maintain adequate airspeed and altitude on final approach, resulting in an impact with terrain short of the airport.