Alpine - Odessa

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 According to the owner’s manual for the airplane, the flaps should have been retracted and the landing gear should have been brought up as soon as a climb profile was established.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.

Flight / Schedule

Alpine - Odessa

Registration

N31AS

MSN

421B-0473

Year of Manufacture

1973

Date

July 4, 2010 at 03:00 PM

Type

CRASH

Flight Type

Ambulance

Flight Phase

Takeoff (climb)

Crash Site

Airport (less than 10 km from airport)

Crash Location

Alpine-Casparis Texas

Region

North America • United States of America

Coordinates

30.3828°, -103.6907°

Crash Cause

Human factor

Narrative Report

On July 4, 2010 at 03:00 PM, Alpine - Odessa experienced a crash involving Cessna 421B Golden Eagle II, operated by Ohara Flying Service, with the event recorded near Alpine-Casparis Texas.

The flight was categorized as ambulance and the reported phase was takeoff (climb) at a airport (less than 10 km from airport) crash site.

5 people were known to be on board, 5 fatalities were recorded, 0 survivors were identified or estimated. This corresponds to an estimated fatality rate of 100.0%.

Crew on board: 2, crew fatalities: 2, passengers on board: 3, passenger fatalities: 3, other fatalities: 0.

The listed crash cause is human factor. 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.

Aircraft reference details include registration N31AS, MSN 421B-0473, year of manufacture 1973.

Geospatial coordinates for this crash are approximately 30.3828°, -103.6907°.

Fatalities

Total

5

Crew

2

Passengers

3

Other

0

Crash Summary

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.

Cause: Human factor

Occupants & Outcome

Crew On Board

2

Passengers On Board

3

Estimated Survivors

0

Fatality Rate

100.0%

Known people on board: 5

Operational Details

Schedule / Flight

Alpine - Odessa

Flight Type

Ambulance

Flight Phase

Takeoff (climb)

Crash Site

Airport (less than 10 km from airport)

Region / Country

North America • United States of America

Aircraft Details

Registration

N31AS

MSN

421B-0473

Year of Manufacture

1973

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