NTSB Factual Report

HISTORY OF FLIGHT

On October 14, 1993, at 0820 Pacific daylight time, a Cessna 172P, N115FR, collided with mountainous terrain approximately five miles north of Kelso, Washington. Instrument meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed for the business flight that was being conducted under 14 CFR 91. The airplane was destroyed and the commercial pilot and his passenger were fatally injured. The flight originated from Seattle, Washington, on October 14, 1993, at 0709 and was en route to Kelso.

The pilot had been cleared for the Kelso NDB approach by Seattle Air Route Traffic Control. After completing the approach, the pilot reported to Seattle Center that he was on the missed approach and that he was going to perform the approach again. The pilot's last communication with air traffic control, three minutes after he reported the missed approach, was that he was at 2,200 feet and climbing.

The wreckage was not located until October 15, 1993. The accident site was located at the 1,000 foot level of a 1,200 foot mountain.

A pilot flying a King Air in the area reported that he had approached the airport from the south. The weather to the south and to the west were under visual conditions, however, the weather to the north, east over the mountains, and at the airport were rapidly deteriorating. The King Air pilot was maneuvering around the airport for landing when he heard the Cessna on the approach. The King Air pilot departed the airport environment to the west to wait for the Cessna to complete the approach and land. While the King Air pilot was maneuvering in the west, he heard the Cessna pilot make the missed approach announcement. The King Air pilot then headed toward the airport. At this time, the King Air pilot stated that the weather had deteriorated to the point that a visual approach was not possible. Before departing the area, the King Air pilot tried to contact the Cessna pilot for a weather update, however, the Cessna pilot did not respond.

PERSONNEL INFORMATION

The pilot held a commercial certificate for single engine and multi engine operations with an instrument rating. The pilot's flight logbook indicated he had accumulated a total flight time of 647 hours. Since July 13, 1990, the start of the reviewed logbook, the pilot had accumulated a total of 40 hours in the Cessna 172. A total of 45 hours had been logged in actual instrument flying, with three hours in the past 90 days.

The operator of the aircraft reported that the pilot had passed an instrument competency flight check on September 20, 1993.

AIRCRAFT INFORMATION

On May 21, 1993, a 2360.9 hour engine was installed in this airplane. At the time of the accident, the engine had accumulated a total time of 3732.4 hours. The engine was scheduled for an overhaul in November 1993.

The operator's mechanic reported that the engine had been inspected on October 1, 1993, after notifications of intermittent rough running engine conditions were noted by other pilots. The mechanic stated that an extensive inspection of the engine was performed and no abnormalities were noted during the inspection and subsequent test flight. The airplane was then returned to service.

METEOROLOGICAL INFORMATION

The 0815 Automated Weather Observing Service (AWOS) at Kelso was reporting 500 feet scattered with five miles visibility. The temperature was 54 degrees with 50 degrees dew point. The winds were calm and the altimeter was 29.99" Hg.

The King Air pilot reported that at the time the Cessna was flying the approach, the clouds were solid north and east of the airport and extended to the surface. The approach end of the runway and the NDB approach path were also solid to the ground with fog and clouds. The area to the south and the west was under visual conditions.

COMMUNICATIONS

At 0736, the pilot made contact with Seattle Center and reported that he was level at 7,000 feet on Victor 23. One minute later, the pilot requested a frequency change to contact flight watch.

At 0749, the pilot confirmed that he would be initiating the approach into Kelso and at this time was cleared for the NDB approach.

At 0756, a King Air pilot repeated the weather conditions at the airport for the benefit of the Cessna pilot. The King Air pilot reported that the center of the airport was clear, however, the approach end of the runway and to the east was solid clouds at 4,000 to 5,000 feet.

At 0759, the pilot reported that he wanted to proceed to Kelso and hold. This request was approved by Seattle Center.

At 0801, the pilot reported that he wanted to amend the last request and perform the full procedure turn for the NDB approach. The controller approved this request and cleared the pilot for the NDB approach.

At 0806, Seattle Center confirmed for the pilot that the airplane was over the Kelso NDB at 3,600 feet.

At 0815, the pilot reported to Seattle Center that he wanted to return for another procedure turn. The Seattle Center controller asked if the pilot was on the missed approach and the pilot responded affirmative. The controller then cleared the pilot for another NDB approach.

At 0817, the pilot asked Seattle Center if he had the airplane's distance from Kelso. The controller responded that the flight was not in radar contact.

At 0818, the controller asked the pilot what his altitude was, and the pilot responded that he was 2,200 and climbing.

At 0822, Seattle Center asked the pilot to report when he was on the procedure turn inbound. The pilot did not respond.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located at the 1,000 foot level of a 1,200 foot mountain. The mountain was covered with dense trees measuring in height to approximately 100 feet. The soft moist ground was covered with dense vegetation. The terrain angle was measured at approximately 42 degrees. Several of the tree tops were broken off from trees that were approximately 150 feet away from the main wreckage. The bark of several trees, along the wreckage distribution path, showed evidence of impact damage. The distribution path through the trees was measured on a magnetic bearing of 210 degrees.

Small pieces of the fuselage were found throughout the distribution path that led to the main wreckage. The empennage was the first large piece of the aircraft that was found approximately 40 feet north of the main wreckage. The empennage had separated from the fuselage at an area just forward of the vertical stabilizer. The rudder remained attached to the vertical stabilizer and the elevators remained attached to the horizontal stabilizers. The right horizontal stabilizer displayed a circular impact signature along the leading edge. The left horizontal stabilizer displayed minor damage.

The main wreckage was positioned inverted with the nose of the airplane pointing uphill on a magnetic bearing of 120 degrees. The right wing was positioned against a tree and was partially torn away from the fuselage. The flap and aileron were in place, however, badly deformed. The wing strut remained attached at the wing attachment. The attachment to the fuselage had pulled away.

The fuel tank was ruptured.

The section of the left wing inboard of the wing strut attachment remained attached at the root. A circular indentation was noted along the leading edge. The flap remained attached at the hinges. The wing strut remained attached at both attachment ends. The outboard section of the wing was found a few feet away. The aileron remained attached by one hinge.

The flap motor, located in the right wing, was examined and noted that the flaps were in the retracted position. Control continuity was not established, as all the control cables had been stretched and broken.

A log measuring six inches in diameter was entangled in the under side of the airplane. The log was protruding through the lower engine cowling just aft of the nose gear. The underside of the engine cowling sustained extensive impact damage and the cowling was torn, partially exposing the under side of the engine. The propeller remained attached to the crankshaft and was partially buried in the soft soil. An impact crater was noted just forward of the nose. One propeller blade was straight, however, chordwise scratches along the blade back were noted. The other blade was bent rearward and displayed an "S" bending. Chordwise scratches along the blade back were also noted.

MEDICAL AND PATHOLOGICAL INFORMATION

The post mortem examination was performed at St. Johns Medical Center, Longview, Washington. The pathologist reported that the cause of death to the pilot was due to multiple injuries with probable terminal hypothermia.

SURVIVAL ASPECTS

Evidence indicates that the pilot survived the accident as the pilot's body was found approximately 500 feet downhill from the wreckage. The pilot had removed most of his clothing as he descended down the hill. Search and rescue personnel found the pilot by following the trail of clothing. The county coroner reported that due to the extent of the pilot's injuries, he would have been very disoriented.

Survival gear and suitcases of clothing were found in the wreckage, however, none of these items appeared to have been disturbed.

TESTS AND RESEARCH

The Emergency Locator Transmitter (ELT) was found attached to its bracket just aft of the baggage compartment on the right side wall of the fuselage. The fuselage structure was torn away exposing the unit, which was easily removed. The outer case showed visible impact damage to the base plate, the top and side of the unit. The switch guard was bent inward toward one another. The switch was found in the off position. The switch was placed in the on position, and with the aid of a receiver, a faint signal was emitted. In the armed position, the unit would not emit a signal when a force was applied. Further testing revealed that the unit's crystal was inoperative. The protective plate separating the battery pack and the circuit board was bent downward toward the board. Components next to the crystal that were larger and higher than the crystal did not appear to be damaged.

The new Artex battery pack had been replaced by a mechanic at Wings Aloft on June 30, 1993. The mechanic logged this entry in the aircraft logbook with a note stating "ops check on 121.5 good." This battery pack meets Federal Aviation Administration (FAA) Technical Standard Order (TSO) C91.

The avionics were removed from the instrument panel and sent to Allied Signal, Olathe, Kansas, for examination. The ADF and ADF indicator displayed that the ADF needle was positioned to 55 degrees and the heading was at 4 degrees. The ADF indicator was set to an in use frequency of 256 KHz, with 207 KHz in standby. The unit was tested for accuracy and found that it tested within specifications.

The number one NAV/COMM unit was powered up and found that the in use COMM was set to 124.20 MHz, which is the frequency for Seattle Center. The standby frequency was 120.40 MHz, which is Seattle Approach/Departure Control for Seattle Boeing Field. The NAV in use was set to 116.80 MHz, which is Seattle VOR. The standby frequency was 113.40 MHz, which is Olympia, Washington, VOR.

The number two NAV/COMM unit was set to 122.00 MHz, which is the frequency for Seattle Flight Watch. The standby frequency was 126.50 MHz, which is Klamath Falls, Oregon, ATIS. The NAV in use was set to 113.40 MHz, which is Olympia, VOR. The standby frequency was 116.80 MHz, which is Seattle VOR. The engine was initially inspected to determine its ability to operate. The crankshaft was rotated by hand and rocker arm, valve train and accessory gear continuity were established. The bottom spark plugs were removed and inspected. It was found that the number three plug was oily. After the plug was cleaned off, it was reinstalled. The engine was prepared for a test run by supplying a fuel supply and electrical power. The engine was found to start, however, it ran rough with a significant rpm drop when the ignition switch was placed on the left magneto. The engine was shut down, and it was found that the number one top spark plug was not firing. The ignition lead to this plug was found damaged at the left magneto. Damage to the right magneto leads were also noted. The lead was repaired and the engine was again started. The engine was run-up to 1,500 to 1,700 rpm where a satisfactory magneto check was performed. The engine ran smooth at these rpm settings for several minutes before it was shut down.

ADDITIONAL DATA/INFORMATION

The wreckage was released for removal on October 17, 1993, and was transported to Specialty Aircraft, Redmond, Oregon. The wreckage was verbally released to the owner's representative on November 19, 1993. The avionics were returned to Specialty Aircraft after the completion of the testing. The ELT was returned to the owner's representative on April 11, 1994.

Radar contact for the Kelso area is established at approximately 3,000 feet and above. Seattle Center reported that radar contact was not re-established after the pilot reported the missed approach. The missed approach procedure states "climbing right turn to 3,300 direct to LSO NDB and hold."

NTSB Probable Cause

THE PILOT'S FAILURE TO FOLLOW THE PUBLISHED MISSED APPROACH PROCEDURE. FACTORS IN THE ACCIDENT WERE: THE WEATHER AND MOUNTAINOUS TERRAIN.