CEN10MA367

The degraded performance of the airplane due to the pilot not properly setting the flaps and retracting the landing gear after takeoff. Contributing to the accident was the pilot’s fatigue.

The airplane impacted terrain shortly after takeoff. The wreckage distribution was consistent with a high airspeed, low angle-of-attack impact. Examination of the ground scars and wreckage indicated that the landing gear was down, the flaps were down, and the engines were operating at a high power setting at the time of impact. An examination of the airframe, engines, and related systems revealed no mechanical malfunctions or failures. According to the owner’s manual for the airplane, the flaps should have been retracted and the landing gear should have been brought up as soon as a climb profile was established. Based upon the location of the wreckage, the direction of the impact, and the location of the airport, it is likely that the airplane crashed within one or two minutes after takeoff. The extended landing gear and flaps degraded the climb performance of the airplane. The pilot held an airline transport pilot certificate and had recent night flight experience. Toxicological results were positive for azacyclonol and ibuprofen but were not at levels that would have affected his performance. According to family members, the pilot normally slept from 2230 or 2300 to 0700; the accident occurred at 0015. Although the investigation was unable to determine how long the pilot had been awake before the accident or his sleep schedule in the three days prior to the accident, it is possible that the pilot was fatigued, as the accident occurred at a time when the pilot was normally asleep. The company did not have, and was not required to have guidance or a policy addressing fatigue management.

HISTORY OF FLIGHT On July 4, 2010, approximately 0015 central daylight time, a Cessna 421B, twin-engine airplane, N31AS, operated by O'Hara Flying Service, and doing business as Air Ambulance Stat, was substantially damaged when it impacted terrain 1.3 miles nautical miles (nm) northeast of Alpine-Casparis Municipal Airport (KE38), Alpine, Texas. A post crash fire ensued. Dark night visual meteorological conditions prevailed at the time of the accident. The emergency medical services flight was being operated on an instrument flight rules flight plan under the provisions of 14 Code of Federal Regulations (CFR) Part 135. The airline transport pilot, two flight nurses, a patient, and a passenger were fatally injured. The cross-country flight was originating at the time of the accident and was en route to Odessa-Schlemeyer Field Airport (KODO), Odessa, Texas. The Alpine Police Department took witness statements from four individuals. The National Transportation Safety Board (NTSB) Investigator in Charge (IIC) interviewed three witnesses. Two witnesses were located to the north and two witnesses were located to the south of the impact location. According to these witnesses, the airplane was flying low to the ground from west to east, as if it had just departed KE38. The witnesses added that the airplane lights were on and noted that nothing appeared to be abnormal other than the low altitude. One witness remarked that the airplane appeared to descend and then observed a fireball shortly thereafter. All witnesses interviewed remarked that it was very dark, with overcast skies at the time of the accident. According to O'Hara Flying Service, their initiate, release, and control (IRC) officer had received a call about 2300 from the Big Bend Regional Medical Center, requesting the transfer of one patient to Odessa, Texas. The IRC officer notified the pilot and medical flight crew shortly thereafter and the flight was accepted and dispatched. The pilot contacted the Federal Aviation Administration (FAA) Flight Service Station (FSS) at 2332 to file a flight plan and obtain a weather briefing for the route of flight. Radar and flight track information was not available for the accident flight. PERSONNEL INFORMATION The pilot, age 59, held an airline transport pilot certificate with an airplane multiengine land rating and a commercial pilot certificate with an airplane single engine land rating. In addition, the pilot held a flight instructor certificate with airplane single engine and instrument privileges. He was issued a second-class airman medical certificate on October 12, 2009. The certificate contained the limitation "must have available glasses for near vision." The pilot reported that he was not taking any medications. At the time of medical certificate application, dated October 6, 2009, the pilot reported 1,750 hours total time and zero hours within the previous six months. At the time of airman certificate application, dated November 9, 2009, the pilot reported 1,612 hours total time, 1,281 hours as pilot-in-command (PIC), 250 hours night PIC, 40 hours night second-in-command (SIC), and 306 hours of instrument experience. On the pilot's application for employment, he reported 1,630 hours total time; 860 hours multiengine time, and 180 hours at night. On the pilot experience form filed with O'Hara Flying Service, the pilot reported 1,350 hours of PIC time, 145 hours in a Cessna 421, and 180 hours of night experience. The pilot's family provided the NTSB IIC the last 19 page sets of the pilot's flight log. These pages represented the dates of December 1, 2000, through June 15, 2010. A review of the logbook indicated that the pilot had logged a total flight time of 1,676 hours; 1,365.6 hours PIC, 173.1 hours in a Cessna 421 (10 hours of which were in a simulator), and 185.9 hours at night. O'Hara Flying Service hired the pilot in June of 2010. According to the company records, the pilot also received his initial training in June of 2010. His airman competency/proficiency check for 14 CFR 135.293 (Initial and recurrent pilot testing), 135.297 (Pilot in command: Instrument proficiency check), and 135.299 (Pilot in command: Line checks: routes and airports) were completed with a satisfactory rating in all tested areas on June 6, 2010. The pilot received area familiarization training at several airports including KE38. O'Hara Flying Service based the accident pilot at KE38, but he was to be transferred to Pecos, Texas, once that base opened. According to the company's flight tracking form, the pilot had logged no less than 15 hours in the company airplanes (1 hour was conducted under 14 CFR 135, with 9.2 hours at night, and 5.7 hours in the accident airplane). Prior to the accident, the last logged flight time was June 30, 2010, for 2.7 hours, all of which was at night. The pilot had not logged any flight or duty time from 0300 on July 1, 2010, until he accepted the accident flight. During the interview with the director of operations and check airman, the pilot's training, experience, and flight ability were discussed. The director of operations stated that the training went well. He elaborated that there were no problems noted with the pilot's flying skills and night flying did not seem to be an issue. AIRCRAFT INFORMATION The accident airplane, a Cessna 421B (serial number 421B0473), was manufactured in 1973. It was registered with the FAA on a standard airworthiness certificate for normal operations. Two Teledyne Continental Motors GTSIO-520-H engines, each rated at 375 horsepower at 3,400 rpm, powered the airplane. Each engine was equipped with a three-blade, McCauley propeller. According to Cessna Aircraft Company, the airplane was originally sold with eight seats; according to O'Hara Flying Service, the airplane had been equipped for medical flight operations and had four occupant seats and a medical litter for the patient. The airplane was registered to O'Hara Flying Service II LP, operated under the business name of Air Ambulance Stat, and was maintained under an annual/100 hour inspection program. A review of the maintenance records indicated that an annual/100 hour inspection had been completed on March 23, 2010, at an airframe total time of 2,302.8 hours. The maintenance entries were being kept in a three-ring notebook with loose pre-print pages labeled "Mechanical Irregularities Log." The last annual inspection was completed on March 23, 2010, at a Hobbs time of 2,302.8 hours. The airplane was not equipped, nor was it required to be equipped with a terrain awareness warning system. METEOROLOGICAL INFORMATION The closest official weather observation station was located at KE38, 1.3 nm southwest of the accident site. The elevation of the weather observation station was 4,515 feet mean sea level (msl). The routine aviation weather report (METAR) for KE38, issued at 0005, reported, winds 210 degrees at 5 knots, visibility 10 miles, sky condition scattered clouds at 7,000 feet, temperature 21 degrees Celsius (C), dew point 20 degrees C, and altimeter 30.05 inches of Mercury. According to the United States Naval Observatory, Astronomical Applications Department Sun and Moon Data, the sunset was recorded at 2101 and the end of civil twilight was recorded at 2128 on July 3, 2010. The moon rose at 0040, and set at 1321 on July 3, 2010. The moon rose again at 0109 on the day of the accident. The moon was waning gibbous with 59 percent of the moon's visible disk illuminated. AIRPORT INFORMATION Alpine-Casparis Municipal Airport, was a public, non-towered airport (located 2 miles northwest of Alpine, Texas, at 30 degrees, 23 minutes, 3.2 seconds north latitude and 103 degrees, 41 minutes, 00.9 seconds west longitude, at a surveyed elevation of 4,515 feet msl. The airport had two open runways at the time of the accident, runway 1/19 (6,003 feet by 75 feet, asphalt) and runway 5/23 (5,018 fe