DIAMOND AIRCRAFT IND INC DA-40

Full Narrative

HISTORY OF FLIGHT

On March 1, 2009, about 2300 Pacific Standard Time, a Diamond DA-40, N521DS, impacted the waters of the Pacific Ocean while its pilot was executing an RNAV/GPS approach to Runway 14 at Arcata Airport, Arcata/Eureka, California. The commercial pilot and his passenger were killed in the accident sequence, and the airplane, which was owned by Mitchell Enterprises Inc., was destroyed by the impact. The Title 14 Code of Federal Regulations Part 91 personal pleasure cross-country flight, which was operating in night visual meteorological conditions (VMC), departed Bakersfield, California, at 1936. The pilot was on an instrument flight rules (IFR) flight plan, and had been issued a clearance for the approach into Arcata, Airport. There was no report of an emergency locator transmitter (ELT) signal. Debris from the wreckage was first discovered on a nearby beach four days after the accident.

According to family members, the pilot spent a number of hours on Friday, February 28, 2009, looking on the internet and calling around his local area in an effort to locate an airplane to use on a cross-country flight from Florida to Les Vegas. Although his first choice was a twin engine airplane, he was not able to find one available. He first contacted the owner of N521DS about 1100, on that Friday. He inquired about renting the airplane for a multi-day cross-country flight, and arranged for a checkout by the owner's check pilot the next morning, and for rental of the airplane beginning on that same day (Saturday). On Saturday morning the pilot and his passenger arrived at Plant City Airport about 0800. The passenger stayed in the office area of the airplane's owner while the pilot went through the pre-rental process. That process included having his log books reviewed by the check pilot, undergoing 30 minutes of ground checkout, and an in-flight checkout lasting one hour. The pilot then completed the rental agreement, put $1,000.00 cash on deposit, and gave the owner his credit card number for billing the flight time beyond the $1,000.00 deposit.

According to the owner, during the rental/checkout process, the pilot said that he was building time, and that he and his passenger were going to fly to Las Vegas, and would return on Tuesday, Wednesday, or Thursday, depending on the weather. According to the check pilot, the checkout went well, with the pilot displaying good knowledge of the airplane, as well as good piloting skills.

The pilot and his passenger departed Plant City Airport about 1100 Eastern Standard Time, and arrived at Mobile Regional Airport, Mobile, Alabama, about 1340 Central Standard Time (CST), for a leg flight time of about three hours and forty minutes. They stayed on the ground at Mobile for about one hour and fifty minutes, and then departed there about 1530 CST. They arrived at Huntsville Municipal Airport, Huntsville, Texas, about 1920 CST, for a leg flight time of about three hours and fifty minutes.

After landing at Huntsville, the pilot had 39 gallons of 100 low-lead aviation fuel added to the fuel tanks. According to the Huntsville Aviation employee who pumped the fuel, the pilot initially stated that after refueling they were going to continue on. But, according to that employee, during the refueling process the pilot and his passenger started discussing how tired each one of them was, and they eventually made the decision to stay in Huntsville overnight.

The owner of Huntsville Aviation then drove them to a local hotel, arriving there about 2000 CST. As he was leaving them at the hotel, they mentioned that after they checked in, they were going to walk to one of the adjacent restaurants for dinner before returning to the hotel.

On the second morning of the trip, about 0700 CST, when the first Huntsville Aviation employee arrived at the airport, the pilot and his passenger where already at the airplane. The pilot was observed performing his preflight inspection, after which he and his passenger came into the Huntsville aviation office, reportedly to get warm. They then went back out to the airplane, and the pilot began to taxi out for takeoff about 0715.

The next known location of the airplane was in Sedona, Arizona, where later that day it took on 31.6 gallons of fuel, before departing that location about 1730 Mountain Standard Time (MST). Although the airplane's arrival time at Sedona (an airport without a control tower) could not be determined, the investigation did reveal that while at Sedona the pilot made a phone call to his mother, ate a meal, and filed two flight plans through the CSC DUATS system. The first flight plan, which was for a leg from Sedona, Arizona to Palmdale, California, was filed at 1607 MST. The second flight plan, which was filed at 1700 MST, was for a leg from Palmdale, California, to Arcata, California.

Although the pilot had filed from Sedona to Palmdale, upon reaching Palmdale he continued on to Meadows Field, Bakersfield, California, which is located about 65 nautical miles northwest of Palmdale. He arrived there at 1841 Pacific Standard Time (PST), for a leg flight time of about two hours and fifteen minutes. Then, at 1900, the pilot took on 29.0 gallons of 100LL aviation fuel from an Atlantic Aviation fueling truck, and departed for Arcata at 1936 PST. An annotation at the top of the refueling slip indicated that the Bakersfield refueling was a "top off."

After departing Bakersfield, the pilot picked up his instrument flight rules (IFR) clearance, whereupon he was cleared to his filed altitude of 8,000 feet, with a route clearance of direct to Arcata. At 2002 PST, while in the vicinity of Visalia, California, he contacted Oakland Flight Watch to inquire about some reports of turbulence that he overhead while airborne. Although the pilot only asked for the turbulence information, the Flight Watch briefer responded with a more expanded weather update. He informed the pilot that there were AIRMET's (Airmen's Meteorological Information) in effect for low level wind shears and moderate turbulence below 18,000 feet, with icing from the freezing level to 20,000 feet. The briefer further advised him that he was moving into an area of moderate precipitation, but that he would move into an area of isolated widely scattered precipitation once he passed Stockton, California. He also indicated that pilot reports were indicating icing in the central California area at an altitude range of about 15,000 to 18,000 feet. He also told the pilot that there was a pilot report of moderate turbulence at 4,000 feet about five miles southeast of Tracy, California. The briefer informed him that there was light rain north of Stockton, with clouds scattered to broken about 4,100 to 5,000 feet. He also informed the pilot that the current conditions in Arcata were light rain, winds from 150 degrees at 10 knots, gusting to 20 knots, visibility 9 miles, scattered clouds at 5,000 feet, a broken ceiling at 6,000 feet, and an overcast ceiling at 9,500 feet. At the end of the update the controller asked, "Is that what you needed, or can I help you with anything else?" The pilot then indicated that that was all he needed, and thanked the briefer for his help. The pilot then continued on direct to his destination.

As the pilot proceeded into the northwest corner of California, he was advised to switch from Oakland Center to Seattle Center. When he first made contact with the Seattle Center, the pilot advised the controller that his transmissions were "broken up." In response the controller said that the Center transmissions should get better as the pilot continued on toward Arcata. About four minutes after the pilot's first contact with Seattle Center, the controller gave him the altimeter setting (29.67) and asked him what his altitude was. The pilot responded that he was indicating 9,300 feet, and the controller then reminded him that his last assigned altitude was 10,000 feet, and then asked if he was "…having difficulty." The pilot then explained that he was climbing back to his assigned altitude, that it was very turbulent, with a lot of ups and downs and moderate to severe turbulence.

About two minutes later, the controller advised the pilot that crews of other aircraft had reported light to moderate turbulence while on the ILS (Instrument Landing system) approach to Arcata. He then cleared him to descend to 9,000 feet, and then about 30 seconds after that, he asked the pilot if he knew what approach he wanted into Arcata. The pilot replied with "negative," and then asked what approach others were doing at the time. The controller advised him that most pilots coming from the south (as he was) were doing the ILS and circling to runway 14. The pilot started to respond with, "I guess I can," but then appeared to terminate his statement mid-sentence, and then said the he would get back to the controller with the approach he wanted. The controller then advised him that there had been a couple of pilots that had chosen to shoot the RNAV/GPS approach from the north to Runway 14. The pilot responded with, "Yeh, we can do an RNAV/GPS for 14."

The controller then cleared the pilot direct to CULDU (the initial approach fix for the RNAV/GPS 14 approach), spelling out CULDU phonetically for the benefit of the pilot. The pilot responded by asking the controller to say the letters again (for CULDU), and the controller responded by spelling out CULDU phonetically again, and explaining to the pilot that CULDU was the initial approach fix for the RNAV/GPS approach to runway 14. The pilot then stated that it was "… really turbulent right now," and then asked if he could get back to the controller for "…that information." The controller approved that request, and then about fifteen seconds later the pilot transmitted, "Alright, can you repeat that fix again?" The controller again stated that the fix was CULDU, that it was the initial approach fix, and then again spelled it out phonetically.

There was no response from the pilot for the next one minute and twenty seconds, and then he asked the controller to verify that the fix was CUDLU (note misspelling). The controller advised the pilot that that was "very close" and that the fix was named CULDU (the controller again spelling it phonetically). The pilot responded with, "Okay, I got it this time. Thank you."

The controller then advised the pilot that the radar depiction of area weather showed moderate to heavy precipitation over the Arcata area, and advised him that those conditions would be along his route of flight the whole time he was inbound. The controller then repeated the fact the rain intensity was showing as moderate to heavy.

About three minutes later, the controller cleared the pilot to descend and maintain 8,000 feet, and the pilot read back the clearance. The controller then told the pilot that the 8,000 feet was the IFR minimum altitude, and that he needed to try to hold that altitude the best he could. He further stated that the pilot could go above it, but that to go below it, "…would be bad." The pilot then acknowledged that transmission.

About six minutes later the pilot was cleared to 7,000 feet, and about two minutes after that he was cleared to 6,000 feet. About 90 seconds after being cleared to 6,000 feet, the controller reminded the pilot that weather radar was showing moderate to heavy precipitation between his present location and CULDU. The pilot acknowledged that transmission, and then stated that he saw the area of precipitation with his onboard equipment. The controller then advised him that turns to both the left and the right was approved if the pilot needed to go around some of the weather. The pilot then advised the controller that he was going to turn toward the west, to a heading of 250 degrees, and then he would come back to CULDU. The controller acknowledged that transmission, and advised the pilot that on that heading he (the controller) would be able to get the pilot to a lower altitude sooner. The controller then told the pilot to continue on his heading of 250 degrees, and then cleared him to descend to 5,000 feet. About two minutes after clearing the pilot to 5,000 feet, the controller advised the pilot that the Arcata altimeter was 29.67, and requested that the pilot, "…maintain at or above 5,000 feet, please." The pilot responded to that call by saying that he was indicating 4,900 feet, and that he was climbing back up. The controller then advised the pilot that he would be able to clear him direct to CULDU in about a minute and a-half.

About one minute and thirty seconds after being cleared down to 5,000 feet, the pilot was cleared to descend to 4,000 feet, and to proceed direct to CULDU. About 90 seconds later, the controller told the pilot to cross CULDU at or above 4,000 feet, and that he was cleared for the RNAV/GPS 14 approach to Arcata airport. The pilot read back the clearance, but read back the altitude limit as, "at or below 4,000 feet," instead of, "at or above 4,000 feet." The controller repeated the altitude clearance limit, and the pilot then correctly acknowledged it.

Recorded radar data shows that the pilot then proceeded to CULDU, executed a course reversal outbound (northwest) of CULDU in order to intercept the inbound course. Then about seven minutes after being cleared for the approach, while back inbound to CULDU at 3,600 feet, the controller advised the pilot that radar service was terminated, that he should report his IFR cancellation or down time to the controller on the controller frequency, and that he was then cleared to switch to the Arcata CTAF (Common Traffic Advisory Frequency). The pilot acknowledged that clearance, and then apparently switched his radio to the CTAF frequency.

Although the controller cleared the pilot to switch frequencies, he (the controller) continued to monitor the progress of the approach. About three minutes after he had cleared the pilot off of his frequency, the controller noticed that the airplane had descended to an altitude of 1,400 feet, but that it had not yet reached UYFOR (the final approach fix, with a published minimum crossing altitude of 2,100 feet). About a minute and a-half later, after seeing the airplane continue to descend while still not yet at UYFOR, the controller attempted to contact the pilot over the Seattle Center frequency. Over the next twelve minutes, the controller attempted contact with the pilot ten separate times. The first five times he transmitted the call sign "November 521 Delta Sierra," and the next five time he used the call sign, "Diamond 521 Delta Sierra." After being unsuccessful at making contact with the pilot during that twelve minute period, the controller contacted Oakland Radio over the land line telephone, and requested that the Oakland Radio operator attempt to contact the pilot at Arcata via Oakland Radio's radio frequency there. That attempt was unsuccessful, and no further contact was made with the pilot. The last radar mode C radar target from the airplane was recorded at 4 degrees, 04.66 minutes North, 124 degrees, 10.63 minutes West (about one-tenth mile from UYFOR), at 300 feet above the ocean surface.

PERSONNEL INFORMATION

The 30 year old pilot held a commercial pilot certificate, with ratings of Airplane Single Engine Land (ASEL), Airplane Multiengine Land (AMEL), and Instrument Airplane (INSTA). He held a C/CL-65 Type Rating, with limitations of Second-In-Command (SIC) privileges only, and circling approaches in visual meteorological conditions (VMC) only. He also held a certified flight instructor (CFI) certificate, with a rating for flight instruction in single engine land airplanes. His last aviation medical certificate, a First Class, was issued on March 20, 2008, with no restrictions or limitations. A resume he completed in October of 2008, indicated that he had accumulated 104 hours of night time, 513 hours of cross-country time, and a total instrument time (both actual and simulated) of 88 hours. The resume also indicated that he had 336 hours of experience with the Garmin G1000 integrated flight instrument system (the system present in the accident airplane).

AIRCRAFT INFORMATION

The airplane was a Diamond DA-40, serial number 40.621, manufactured in May of 2006. It was registered to Mitchell Enterprises of Plant City, Florida, and was equipped with the optional 50 gallons of usable fuel system. Its last annual inspection was completed on September 26, 2008, and its last 100-hour inspection was completed on February 17, 2009. The last update of the airplane's onboard navigational and airfield database (Diamond G1000 software version 0321.9, in accordance with Garmin Service Bulletin 0805A) was performed on December 19, 2008. At the time of the last 100-hour inspection, the airplane's tachometer read 651.9 total hours.

METEOROLOGICAL INFORMATION

The 2253 aviation surface weather observation (METAR) for Arcata Airport recorded winds from 190 degrees at eight knots, six statute miles visibility, light rain, fog, scattered clouds at 1,900 feet, a broken ceiling at 2,800 feet, an overcast ceiling at 3,400 feet, a temperature of 13 degrees Celsius, a dew point of 12 degrees Celsius, and an altimeter setting of 29.69 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

Based upon its descent profile, recorded radar data, local ocean currents, and the ultimate distribution of component parts along the beach, the airplane is assumed to have impacted the ocean's surface about one-half mile offshore (west) of Megwi Point (about one statute mile west of the town of Trinidad, and about seven statute miles northwest of Arcata Airport). Pieces of the airplane washed ashore in an area from Trinidad in the south, to Agate Beach (just north of Patrick Point State Park) in the north. Components were located on the beaches within this area up to about two weeks after the accident.

Altogether about a dozen pieces of the airframe were found. Three of the pieces contained build-up identification tags, two of which identified the part as coming from a DA-40, and the other containing data indentifying it as coming specifically from DA-40 serial number 40.621. The single longest piece was made up of the leading edge and forward upper wing skin of the left wing. This piece measured about seven feet long, starting at the wing root, and was about nine inches wide. It had torn lose from the aft area of the upper wing skin along a very irregular and jagged line. There were two other pieces of left wing skin, one measuring about one foot by one foot, and the other measuring about one foot by two feet. The fracture lines on these two pieces indicated that they fit into the lower inboard structure of the left wing. There was one other section of wing skin that measured about two feet by two feet, and contained a portion of the wing leading edge along one of its borders, but its location on the wing, or which wing it was associated with, could not be determined.

Six of the pieces came from the area around the baggage compartment, which is located in the aft part of the cabin. Four of the pieces made up the majority of the baggage compartment access panel. One of these pieces contained the data tag that identified it as having come specifically from the accident airplane. There was one piece of baggage compartment lower perimeter trim, and a portion of the left (port) side baggage compartment perimeter bulked (with its three readily identifiable louvered vent holes).

The only clearly identifiable piece of exterior fuselage structure, which measured about two feet by four feet, was from the left side, starting just behind the lower half of the firewall, and running rearward to a point just aft of the bottom end of the rear bow of the entry canopy.

In addition to the aforementioned structural debris, there was a seat cushion from one of the two front seats, and several small broken/torn pieces of white or black composite structure that could not be identified as to location on the airplane.

ADDITIONAL INFORMATION

DUTY DAY AND FLIGHT TIMES

On the first day of the trip, the pilot accumulated about eight hours and thirty minutes of flying time. This included the one hour checkout, the leg from Plant City, Florida, to Mobile, Alabama, and the leg from Mobile, Alabama, to Huntsville, Texas. His "duty day," calculated from when he arrived at the Plant City Airport (0800 EST) until he departed the Huntsville, Texas, airport for the hotel that night (1945 CST/2045 EST) was about twelve hours and forty-five minutes.

On the second day, the flight duration and flight track for the flight legs between Huntsville, Texas, and Sedona, Arizona, could not be determined. But, based upon a comparison with the ground speed maintained over the other known legs of the trip, the estimated flight time between Huntsville, Texas, and Sedona, Arizona, would be about eight hours and forty-five minutes, with at least one refueling stop over the total straight line distance of about 855 nautical miles. The pilot's "duty day" for the second day of the trip began with the preflight of the airplane at Huntsville, Texas, at 0700 CST (0500 PST), and ended with the airplane impacting the ocean off Arcata, California, about 2300 PST.

The elapsed time from the pilot's arrival at the Plant City Airport in Florida (0800 on Saturday morning) until the impact with the ocean off Arcata, California, (2300 on Sunday night) was forty-two hours. During that forty-two hour period, the pilot accumulated about twenty-two hours and 45 minutes of flying time, and was "on duty" for thirty hours and forty-five minutes.

ACQUISITION OF WEATHER DATA

As part of the investigation the NTSB IIC contacted both contract DUATS (Direct User Access Terminal System) providers and Lockheed Martin (Automated Flight Service Station provider) to determine whether the pilot used the services of any of these entities to acquire weather data on the day of the accident. Although the pilot had filed flight plans for the last two legs of his flight with CSC DUATS, the records of all three providers indicated that on the day of the accident the pilot had not sought a weather briefing from any of their facilities (except for aforementioned in-fight contact with Oakland Radio to check on reports of turbulence).

DELAY OF SEARCH AND RESCUE EFFORTS

During the time that the pilot of N521DS was executing the RNAV/GPS approach for Runway 14 at Arcata, but no longer in radio contact with Seattle Center (he had been cleared to switch over to Arcata Common Traffic Advisory Frequency), the Seattle Center controller noticed that N521DS was below the specified altitude for the portion of the approach it was on. The controller notified his supervisor of that situation, and the supervisor then observed three radar sweeps showing the airplane between 100 and 200 feet above the ocean. Soon thereafter radar contact with the airplane was lost. At that time, the supervisor had the high altitude sector controller ask aircraft he was working to monitor their radios for an Emergency Locator Transmitter (ELT) signal, of which none was heard.

The supervisor then made phone contact with the Arcata Airport Manger, who was at home because of the time of night. The Center Supervisor advised the Airport Manger that N521DS had been lost from radar, and that it needed to be determined if N521DS, "a Diamond Jet," had arrived safely at Arcata. The supervisor gave the Airport Manager his number to call back with an arrival confirmation and also asked that if the pilot was located on the ground, that he be asked to call the Center Supervisor about his failure to close his flight plan.

About five minutes after the initial call, the Center Supervisor realized that N521DS was not a jet, but instead was an airplane with a single reciprocating engine. He therefore called the Airport Manger back in order to correct the aircraft type information. During that phone call the Airport Manger told the Center Supervisor that N521DS was on the ground at Arcata Airport. The supervisor repeated the statement back to the Manger ("N521DS is on the ground?"), and the Manager responded with "yes," and that someone at the airport was going to give the pilot the Center Supervisor's phone number, and that the pilot would be giving him a call. When the Center Supervisor completed his shift, he left the information about 521DS and the contact with the Arcata Airport Manager with the Operations Manager In Charge (OMIC).

After the Center Supervisor's first call to the Airport Manger, the Airport Manger made phone contact with an Airport Service Worker Supervisor (ASWS) at Arcata Airport. During the investigation, the NTSB Investigator-In-Charge (IIC) conducted a series of interviews with both the Airport Manger and with the ASWS, but due to significant conflicts in their written and oral statements, the content of their phone conversation could not be positively determined. The NTSB IIC determined that the areas of conflict between the statements of the two individuals included, but was not limited to, what information the Airport Manger supplied the ASWS, what exactly the Airport Manger asked the ASWS to do, whether the ASWS was advised the airplane had been lost from radar, whether the ASWS was supposed to call the Airport Manager back, whether the ASWS was advised the airplane was not a jet, whether the ASWS was given the airplane's full registration number, and whether there was more than one call from the Airport Manger to the ASWS.

Regardless of the content of the phone conversation between the Airport Manger and the ASWS, according to the ASWS, he checked the Arcata Airport ramp areas for an airplane with a registration number ending in DS (Delta Sierra), with the intention of telling the pilot to contact Seattle Center at the number the Airport Manager had provided. The ASWS further stated that after not locating the subject airplane or pilot, he made an entry in the Airport Daily Log. A review of that log revealed an entry that stated, "J. H. (Airport Manager's initials) called @ 11:15 P.M.- Asked me to locate pilot who just landed to call Seattle Center to cancel flight plan. The plane and pilot were nowhere to be found."

The next morning (March 2) when the Airport Manger went to the Airport Fire Station (where the Airport Log was kept), the Manger was told by another individual that the ASWS had not located the airplane or talked with the pilot the night before. After the Airport Manger confirmed that information, by talking with the ASWS, the Airport Manger made a phone call to Seattle Center. That phone call was made about 0900, and at that time the Center was advised that the report that N521DS had landed at Arcata Airport the night before was erroneous, and that no contact had yet been made with the pilot. Ultimately, the Humboldt County Sheriff's Department was contacted by the California State Office of Emergency Services (OES) about 1100. A local search was then initiated by the Sheriff's Department.

DISPOSITION OF WRECKAGE

The NTSB did not take custody of the recovered debris. Instead it was shipped directly to the facility of Plain Parts, in Pleasant Grove, California, where it was held for determination of ultimate disposition by the Regional Adjuster of GAB Robins, a representative of the insurer of the airplane.