NTSB Factual Report

HISTORY OF FLIGHT

On May 15, 2003, approximately 1700 mountain daylight time, a Cessna 320-D twin-engine airplane, N4111T, was destroyed when it impacted the airport ramp following a loss of control during takeoff initial climb from runway 26L at the El Paso International Airport (ELP), El Paso, Texas. The airplane was registered to and operated by the Strata Production Company of Roswell, New Mexico. The private pilot, who was the sole occupant, was seriously injured. Visual meteorological conditions prevailed, and a visual flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight. The cross-country flight was originating at the time of the accident and was destined for Roswell, New Mexico.

During a telephone interview, conducted by the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the pilot stated that he departed Roswell in the morning, and did not recall obtaining a weather briefing prior to the flight. The flight arrived at ELP between 0800 and 0900. The pilot left the airplane with an ELP maintenance facility, and requested they check a manifold pressure (MP) problem on the right engine. The pilot stated the right engine throttle had to be in the full forward position in order to maintain adequate manifold pressure while operating "at altitude."

According to the maintenance work order, the maintenance personnel test-ran the engine in an attempt to duplicate the reported problem and check for other indications. The personnel noted no faulty indications during the engine test run and during a visual inspection. Maintenance personnel pressure tested the turbocharger waste gate for operation and checked the waste gate oil lines for blockage. No anomalies were noted during the checks. Maintenance personnel found an aluminum sense line, which connected the controller and the upper deck air pressure reference, was leaking. The line was removed and replaced due to a "bad flare". Maintenance personnel test ran the engine again, and checked for leaks and operation indications of manifold absolute pressure. No anomalies were noted and all indications were "OK."

Prior to departing ELP, the pilot checked the weather radar, satellite, and text reports "because of high winds at El Paso and Roswell." The pilot stated because he grew up in New Mexico and Texas, he was careful about the potential of weather buildups and abnormally high winds. Personnel notified the pilot that the maintenance on the airplane was completed, and the pilot then "went over the work."

At 1643, the pilot contacted ELP ground control and reported that he was ready to taxi to the runway for departure to Roswell. According to the pilot, air traffic control asked the pilot if he wanted a midfield departure on runway 26L, which is a 9,025 feet long and 150 feet wide asphalt runway, and the pilot accepted the midfield departure clearance. Prior to takeoff, the pilot performed an engine run-up and the run-up was normal. Radar data and communication information provided by the Federal Aviation Administration (FAA) indicated the flight departed from the departure end of runway 26L.

At 1646, the air traffic controller reported the wind at 17 knots and gusting to 30 knots. At 1647, the air traffic controller reported a wind shear alert. At 1653, air traffic control cleared the pilot for takeoff from runway 26L with a left downwind departure. The pilot stated that after takeoff approximately 700-800 feet agl, and during the left turn, "he lost the left engine." The pilot felt the airplane was starting to roll, and the left engine gauges, #1 RPM and MP, "were falling to zero." The pilot retarded the right engine throttle, and "knew he had to land the airplane." He realized he would not be able to land back on runway 26L and attempted to land in a large open area, which contained a long taxiway. The pilot lowered the landing gear, flared the airplane, but did not recall the impact with the hard airport surface. In addition, the pilot estimated approximately 75 gallons of 100 low-lead fuel were on-board at the time of the departure.

A witness, a pilot and a mechanic for the maintenance facility, reported he observed the airplane shortly after it became airborne. The takeoff was normal and the landing gear were retracted. The airplane then made a 90-degree left turn to crosswind approximately 300 to 400 feet agl. The witness observed the left wing lower, and the airplane turned 90 degrees to an approximate heading of 100 degrees. "At that very moment, his left wing [came] down then the right then the left again. The aircraft was sinking at a very high rate." The witness reported the landing gear extended and the airplane disappeared behind some T-hangars.

Another witness, a pilot located on the airport at the time of the accident, stated he noticed an airplane that "seemed like it was in trouble." The witness stated the airplane appeared to have lost airspeed, rolled slightly to the left, and began to porpoise. The airplane then banked to the left, nosed downed, and impacted the taxiway left wing and 45 degrees nose down. The airplane bounced once, slid on the taxiway surface approximately 150 feet and came to rest.

Yet another witness, who was a pilot located on the airport at the time of the accident, stated he "noticed something terribly wrong with an aircraft that had just taken off runway 26." The airplane was departing into the wind, then turned left, pitched down, then leveled, and pitched nose up with tailwind. The witness stated, "the aircraft may have stalled then pitched nose down and then we knew he was coming down."

PILOT INFORMATION

The pilot held a private pilot certificate with airplane multiengine land, airplane single-engine land, and airplane instrument ratings. The pilot was issued a third class medical certificate on January 7, 2002, with a limitation for vision correction. The pilot's most recent biennial flight review was completed on July 10, 2001, in the accident airplane. According to the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2), the pilot had accumulated 1,104 total flight hours, 950 multi-engine flight hours, and 909 flight hours in the accident airplane make and model.

AIRCRAFT INFORMATION

A review of the maintenance records revealed the airframe underwent its an annual inspection on October 2, 2002, with a total time in service of 3,703.1 hours. The left engine, a Teledyne Continental Motors TSIO-520-BB, serial number 287587-R, underwent a 100-hour inspection on October 2, 2002, with a total time of 669.3 hours since the engine was rebuilt and zero timed. On October 2, 2002, the right engine, a Teledyne Continental Motors TSIO-520-BB, serial number 287663-R, was installed on the airplane. The engine was rebuilt and zero timed on August 12, 2002. At the time of the accident, the airplane had accumulated approximately 70 hours since the last 100-hour inspection.

According to the most recent weight and balance computations for the airplane, dated December 11, 2000, the maximum gross weight was 5,520 pounds, the empty weight was 3,629.60 pounds, and the useful load was 1,890.40 pounds.

On September 11, 1996, an Aeronautical Testing Service, Inc. 320D vortex generator kit was installed on the airplane as authorized by the Supplemental Type Certificate (STC) SA5757NM. The STC modification consisted of ninety vortex generators mounted on the wings and vertical fin and four metal strakes, one mounted on the inboard and outboard sides of the engine nacelle. As part of the STC, a flight manual supplement was placed in the existing Cessna 320D Owner's Manual.

A review of the flight manual supplement disclosed that the single engine climb performance at a gross weight of 5,474 pounds, at 5,000 feet msl, and a temperature of 41 degrees Fahrenheit, was 305 feet per minute. At a gross weight of 4,400 pounds, the single engine climb performance was 630 feet per minute. The single-engine climb performance at a gross weight of 5,474 pounds, at 10,000 feet msl, and a temperature of 23 degrees Fahrenheit, was 230 feet per minute. At a gross weight of 4,400 pounds, the single-engine climb performance was 540 feet per minute. The calculations were based on the following conditions: flaps and gear up, inoperative propeller - feathered, wing bank 5 degrees toward operating engine, full throttle, 2,600 RPM and mixture at recommended fuel flow. The rate of climb is to be decreased at 25 feet per minute for each 10 degrees Fahrenheit above standard temperature for a particular altitude.

METEOROLOGICAL INFORMATION

At 1551, the ELP weather observation facility reported the wind from 230 degrees at 21 knots, with gusts to 28 knots, sky clear, temperature 93 degrees Fahrenheit, dew point 34 degrees Fahrenheit, and an altimeter setting of 29.78 inches of mercury. The calculated density altitude was 7,272 feet msl. A peak wind from 240 degrees at 39 knots was recorded at 1505.

At 1651, the ELP weather observation facility reported the wind from 260 degrees at 22 knots, with gusts to 35 knots, sky clear, temperature 91 degrees Fahrenheit, dew point 34 degrees Fahrenheit, and an altimeter setting of 29.77 inches of mercury. The calculated density altitude was 7,163 feet msl. A peak wind from 240 degrees at 40 knots was recorded at 1624.

At 1658, the ELP weather observation facility reported the wind from 280 degrees at 22 knots, with gusts to 44 knots, sky clear, temperature 91 degrees Fahrenheit, dew point 34 degrees Fahrenheit, and an altimeter setting of 29.78 inches of mercury. The calculated density altitude was 7,153 feet msl. A peak wind from 240 degrees at 44 knots was recorded at 1655.

WRECKAGE AND IMPACT INFORMATION

On May 16, 2003, two FAA inspectors, and a representative from the airframe manufacturer examined the airplane at the accident site. On May 22-23, a FAA inspector, a representative from the airframe manufacturer, and a representative from the engine manufacturer examined the airplane in a hangar located at ELP. According to the airframe representative, flight control continuity was established from all flight control surfaces to their respective cockpit controls. The left and right cockpit throttle controls were found in the retarded position, the mixture and propeller controls were found in the full forward position.

The right propeller assembly was separated from the propeller flange, and the right engine's propeller flange was partially separated from the crankshaft. The propeller hub was fractured into several pieces, and one blade remained partially attached to the hub. The blades displayed chordwise scratching, bending, and leading edge gouging. The left propeller assembly remained attached to the engine crankshaft, and two blades were separated from the propeller hub. The blade that remained attached to the hub displayed chordwise scratching and the blade tip was curled. One blade displayed leading edge gouging, chordwise scratching, and was twisted aft. The other blade was bent aft and displayed heavy gouging and scratching on the chamber side of the blade. The FAA inspectors reported there was a minimal amount of baggage/cargo on board at the time of the accident.

According to the engine representative, the left engine displayed damage to the left front. The #6 cylinder head and propeller governor were partially separated. All four of the engine mounts were separated. The right engine was intact and the accessories remained attached to their respective mounting structure. All four of the engine mounts were separated. The engines were removed and shipped to Teledyne Continental Motors for further examination by the NTSB.

TEST AND RESEARCH

On August 19th and 20th, the left and right engines were examined at the facilities of Teledyne Continental Motors, near Mobile, Alabama, under the supervision of the NTSB IIC. The inspection and disassembly of the left and right engines and accessories did not reveal any discrepancies that would have precluded operation of the engines prior to the accident. The fuel system components, with the exception of the right engine fuel metering unit, were bench flow tested with no anomalies noted. The right engine fuel metering unit was not bench flow tested due to a separated link rod.

NTSB Probable Cause

the loss of engine power for undetermined reasons and the pilot's failure to maintain aircraft control. Contributing factors were the gusty and high wind conditions, and the pilot's failure to compensate for the wind conditions.