NTSB Factual Report

HISTORY OF FLIGHT

On June 1, 1995, approximately 1554 PDT, an Aero Commander 680, N6877S, was destroyed in an inflight collision with water adjacent to the North Bend, OR municipal airport. The commercial pilot/co-owner, whose pilot certificate carried only an airplane single-engine land category and class rating, and his two passengers were fatally injured. The flight was a local 14 CFR 91 flight out of North Bend. Instrument meteorological conditions existed but no flight plan had been filed.

The crew of a U.S. Coast Guard helicopter which had just landed at North Bend, CG6552, saw the airplane take off on runway 31. The pilot-in-command of CG6552 stated that he became concerned about this since the 800-foot ceiling was below minimum weather requirements for normal visual flight rules (VFR) and he had not heard the pilot of this airplane call for or receive an air traffic control (ATC) clearance to operate in North Bend's Class E surface area airspace under either special visual flight rules (SVFR) or instrument flight rules (IFR). He radioed a warning to the crew of another Coast Guard helicopter, CG6529, which was inbound to North Bend from the west on a SVFR clearance, to watch out for the airplane. The pilot-in-command of CG6552 stated that from the Coast Guard wash rack parking spot on the airport, he saw the airplane continue straight ahead after takeoff and enter the clouds in a wings-level climb.

Several members of the crew of CG6529, the airborne Coast Guard helicopter inbound to North Bend from the west, witnessed the water impact. They stated that they initially spotted the airplane as it passed between 400 and 1300 feet off to the right of their helicopter, about 100 feet higher than the helicopter and in a steep climb. Some crew members stated that the airplane went into the clouds in this climb. Ten to twenty seconds later, they spotted the airplane again, this time in a near vertical dive. They described the airplane's flight path in the dive as going from directly over their helicopter, downward and outward along the helicopter's 3-o'clock line and into the Coos River in a near vertical attitude. CG6529 was approximately over the settling ponds immediately across the Coos River from, and to the west of, North Bend airport at the time of the initial sighting. The co-pilot, who was flying the helicopter, stated that CG6529 was eastbound at approximately 100 to 110 knots and 500 feet altitude at the time of the event.

A weather observer at the North Bend airport also witnessed portions of the accident sequence including the water impact. He stated that at approximately 1545 PDT, the pilot of N6877S called him on the North Bend UNICOM frequency for a radio check and then taxied N6877S to runway 31. He said that he then heard the pilot of N6877S call on UNICOM that he was taking runway 31, and saw the airplane take off from runway 31. A certified copy of the North Bend airport flight contact record was annotated "COM 6877S 1545 T/O R/W 31 (MISHAP)". At this time he went off shift from weather observation duties and went out to the edge of Runway 4 to perform bird control and foreign object removal from the runway. From a vantage point approximately 2000 feet east of the impact point, he said his attention was drawn to the aircraft by high-pitched engine noise. He stated that looking up, he saw the airplane in a near vertical dive, impacting the water in this attitude with a slight roll rate to the right.

Another individual witnessed approximately 40 to 50 seconds of the flight immediately before water impact from his front yard, about 1/2 mile southeast of the impact point. This witness stated that he initially saw the airplane climbing to the west, then suddenly make a steep-banked turn of almost 360 degrees. He reported that the turn descended back to the runway at which point the airplane followed a takeoff ground track. The airplane then disappeared behind trees. The witness said the airplane then reappeared in an almost vertical climb, then pivoted around its left wing and entered a near vertical dive. The witness then heard the water impact, but did not see it since the impact point was obstructed from view by terrain. He stated that the engines sounded very smooth and powerful with no sounds of missing or backfiring throughout the sequence, characterizing them as going "full bore" at the time of impact. This witness stated that the airplane never entered the clouds.

Two individuals witnessed portions of the event from the vicinity of a lumber chip dock on the opposite river bank northwest of the airport. One reported that after takeoff, the airplane stopped climbing and made a "flat turn" to the west over his position, then made a banked 90-degree turn to the south. This witness stated that the airplane then disappeared into the clouds in level flight and that he observed no more of the sequence. He reported that the airplane made a "very loud engine noise" with an "odd 'heavy throb' sound". The other witness made the following statement:

...I saw a twin engined [aircraft] take off from the airport heading in a Northwesterly direction. This aircraft attracted my attention because it was extremely loud.... The plane disappeared into the overcast....

In a very short time, 2-3 minutes, my attention was directed to the Coast Guard [helicopter] flying in an easterly direction, or up the Bay, and at this time I saw the plane come out of the overcast and it appeared to me that it was going to collide with the chopper but it passed to its rear. To me it appeared that it came within about 100 feet of the chopper. At this time it seemed to have about 200 ft. elevation. It suddenly pulled up [sharply], almost vertical and disappeared into the overcast.

In just a very short time, possibly seconds, it plunged out of the overcast in an almost vertical flight and crashed into the Bay about 25 to 30 yards from the shore line into shallow water. There was one big splash - then nothing. Something was sticking out of the water, but I [couldn't] tell what portion of the plane it was. Prior to the crash I saw no smoke or fire and I believe the landing gear was still retracted.

I can't say for sure how the engines were operating, if they were on full power or not. There was no apparent rotation by the plane, as if in a spin. It was headed in a south- westerly direction when it crashed.

There were buildings, etc. directly in front of the aircraft when it pulled up into the overcast just prior to the crash....

This witness supplied a sketch with his written statement indicating that the airplane turned left after takeoff, continuing around approximately 270 degrees to an easterly heading over the water. He also indicated the path of the Coast Guard helicopter on his statement, which showed that as seen by him, the airplane passed behind and to the right of the helicopter on an approximately parallel ground track just before the accident.

The Coast Guard took a statement from a witness which read as follows:

At approximately 1550...I witnessed a twin engine plane come from an Easterly direction sloping down to approximately 100 feet from the parking lot at the BLM boat ramp on the North Bend Spit. He then pulled up into the air, made a wide loop and came nearly vertical into the water of Coos Bay. His engines seemed to be nearly full throttle during the entire time....

The Coast Guard provided a tape recording of the North Bend Coast Guard Air Station operations center radio traffic at the time of the accident. On this tape, approximately two minutes elapsed between the radioed warning from the pilot of CG6552 that an aircraft had just taken off from runway 31, and a call from CG6529's crew that they had just witnessed an aircraft crash. A transcript of this recording supplied by the Coast Guard showed that CG6552's radio warning of an aircraft taking off was broadcast between 1552 and 1553 PDT, and that CG6552's crew queried CG6529's crew as to whether the aircraft was on land or in the water at 1555 PDT.

The quality assurance section of the automated flight service station (AFSS) at McMinnville, OR, which controls the North Bend Class E surface area airspace, reported that they had no record of providing any type of service, to include weather briefing, flight plan filing, issuance of ATC clearance, or inflight radio contact, to N6877S.

The airplane impacted in the Coos River, approximately 100 yards offshore from the airport side and abeam a point 1500 feet northeast of the approach end of North Bend runway 4.

The accident occurred during the hours of daylight at 43 degrees 25.14 minutes North and 124 degrees 15.43 minutes West.

PERSONNEL INFORMATION

According to FAA records, the pilot held a commercial pilot certificate with an airplane single-engine land category and class rating, issued in 1969. He did not hold multi-engine or instrument ratings. The pilot's FAA medical records indicated that he had approximately 1,450 hours total pilot time. The most recent FAA medical certificate on file for the pilot was a second class medical certificate issued on October 13, 1992.

Investigators recovered the front cover of the pilot's logbook from the aircraft wreckage. This front cover had old temporary airman certificates, including the temporary commercial pilot certificate, and old medical certificates taped onto the inside portion. The remainder of the pilot's logbook was not found.

Two individuals who knew the pilot personally submitted written statements which indicated that although they believed the pilot and his wife were very friendly and likeable people, they had serious doubts about the pilot's flying proficiency. The assistant manager of the North Bend airport, in a statement dated June 5, 1995, said the following:

...[The pilot and his wife] would fly [their airplane] very seldom....I doubt if they flew the aircraft more than 10 times in the last 30 months that it has been based at North Bend...each flight was a "happening". [The pilot] aborted takeoff 3 times on one occasion and returned to the ramp much to our relief. Often they would taxi out, make a run up and return to the ramp, again to our relief. I was shown by [the pilot's wife] the hand written procedures that she would [read] to [him] during the flight, speeds, RPM, manifold pressures and such. We were [always] fearful for them on each flight. My standing orders to the weather observation crew was to watch them very closely.

All the while [the pilot] and [his wife] were very confident in [his] ability to fly. On a couple of occasions [he] was asked about any recent proficiency training that he had received, to which he answered that he had none because that is where most of the accidents happen....

A certificated flight instructor who stated that he had flown with the pilot submitted an account of his efforts to provide the pilot with a multi-engine checkout in the Aero Commander. This instructor stated that he has about 6,000 hours total flight time including 2,000 hours of multi-engine instructional experience in light twin-engine aircraft. He stated that he gave 9 instructional flights to the pilot in May 1993, after the pilot had become dissatisfied with a previous instructor experienced in the Aero Commander. In his letter, he made, among others, the following remarks concerning the training flights and his opinions of the pilot's flying proficiency which resulted:

"The bulk of the training was remedial in nature, designed to improve [the pilot's] basic flying skills to meet FAA Practical Test Standards (PTS)."

"...his flying, navigation, and communication skills were below acceptable [practical test] standards. Also, his checklist [usage]/discipline, general airmanship, and situational awareness were substandard."

"...we practiced slow flight/minimum controllable airspeed, steep turns, and stalls. In all maneuvers, he exhibited a surprising lack of knowledge of how to properly complete the maneuver....My impression was that I was working with a pre-solo student, not an experienced pilot with 1000+ hours, and many hours of previous instruction in the AC-680...I shifted to a 'remedial, proficiency/airmanship building' syllabus, instead of a more aggressive multi-engine curriculum...."

"...After our last flight together, I had a somewhat frank discussion with [the pilot] recommending a course of instruction to overcome his flying deficiencies. I suggested 1) general flying/cross country proficiency in a single engine aircraft 2) a course of multi-engine instruction to earn the FAA rating in a less complex twin..., and then 3) transition training in the AC- 680....I don't think he took my critique seriously. I believe [he] thought I was being overly critical and he thought his flying ability was OK."

"My bottom line was 'I would not sign [him] off to fly a Cessna 150 solo, let alone an Aero Commander.'...[He] was not competent to fly as pilot-in-command of an AC-680. [He] needed a significant amount of additional instruction...because of deficiencies in airmanship, situational awareness, navigation, communication, etc....he would be unable to competently pass an FAA evaluation in accordance with the PTS...."

No evidence of additional training accomplished after May 1993 was found. The pilot had no history of accidents, incidents, or enforcement actions against his certificate within the past 5 years, according to FAA records.

AIRCRAFT INFORMATION

The aircraft, an Aero Commander 680, was manufactured in December 1956. It was equipped with two Lycoming GSO-480-B1A6 pressure- carbureted, supercharged, 6-cylinder horizontally opposed reciprocating engines rated at 340 b.h.p. each, and 3-bladed Hartzell full-feathering, constant-speed propellers geared down at a ratio of 120:77. According to information on file with Twin Commander Aircraft Corporation, it had been owned by the pilot and his wife since May 1992.

The airplane's last annual inspection was on March 18, 1995, according to the aircraft logbook, which was recovered from the wreckage. An FAA query on the record of the mechanic who signed off this inspection revealed that the mechanic's FAA inspection authorization (IA) had expired 2 years previously. Investigators were unable to contact this mechanic. The previous annual inspection occurred on August 9, 1993. The aircraft logbook dated back to 1967 and indicated that the airframe total time was 4,784.1 hours at the March 18, 1995 annual inspection.

Along with the aircraft logbook, investigators recovered 2 pages of a left engine logbook, consisting of one page dated August 28, 1974 and one page annotated "left prop log" containing entries from December 6, 1988 to January 15, 1995; and a complete right engine logbook dating back to August 28, 1974, from the wreckage. The last entry in the partial left engine logbook was "NOTE: See new left engine log book [dated] 3/18/95." This logbook was not recovered. All three logbooks recovered contained entries of maintenance work signed by the pilot/owner, annotated "A & P 2032332." The FAA coordinator to the investigation performed an FAA record query of this certificate number. This query revealed that the certificate number used by the pilot/owner to sign off the aircraft and engine logbook entries corresponded to a pilot certificate held by another individual. The FAA had no record that the pilot/owner was certified as an A & P mechanic.

According to the response logs of the North Bend Fire Department, the airplane experienced a left engine failure at approximately 1534 PDT on June 1, 1994, one year before the accident. The North Bend deputy fire chief, who saw the airplane after landing during this incident, reported that the engine failure involved a complete separation of one cylinder, exposing a piston, as well as structural damage to the left wing. Several people at the airport, including the assi

NTSB Probable Cause

THE PILOT INITIATING FLIGHT INTO WEATHER CONDITIONS BEYOND WHAT HE WAS CAPABLE OF HANDLING. THE PILOT'S OVERCONFIDENCE IN HIS PERSONAL ABILITY AND THE LOW CEILING WERE FACTORS IN THE ACCIDENT.