Tulsa - Council Bluffs
Flight / Schedule
Tulsa - Council Bluffs
Aircraft
Cessna 401Registration
N9DM
MSN
401-0123
Year of Manufacture
1991
Operator
DRDJ SalesDate
May 11, 2012 at 04:30 PM
Type
CRASHFlight Type
Private
Flight Phase
Flight
Crash Site
Plain, Valley
Crash Location
Chanute Kansas
Region
North America • United States of America
Coordinates
37.6817°, -95.4518°
Crash Cause
Technical failure
Narrative Report
On May 11, 2012 at 04:30 PM, Tulsa - Council Bluffs experienced a crash involving Cessna 401, operated by DRDJ Sales, with the event recorded near Chanute Kansas.
The flight was categorized as private and the reported phase was flight at a plain, valley crash site.
5 people were known to be on board, 4 fatalities were recorded, 1 survivors were identified or estimated. This corresponds to an estimated fatality rate of 80.0%.
Crew on board: 1, crew fatalities: 1, passengers on board: 4, passenger fatalities: 3, other fatalities: 0.
The listed crash cause is technical failure. While en route to the destination airport, the pilot turned on the cabin heater and, afterward, an unusual smell was detected by the occupants and the ambient air temperature increased. When the pilot turned the heater off, dark smoke entered the cabin and obscured the occupants' vision. The smoke likely interfered with the pilot’s ability to identify a safe landing site. During the subsequent emergency landing attempt to a field, the airplane’s wing contacted the ground and the airplane cartwheeled. Examination of the airplane found several leaks around weld points on the combustion chamber of the heater unit. A review of logbook entries revealed that the heater was documented as inoperative during the most recent annual inspection. Although a work order indicated that maintenance work was completed at a later date, there was no logbook entry that returned the heater to service. There were no entries in the maintenance logbooks that documented any testing of the heater or tracking of the heater's hours of operation. A flight instructor who flew with the pilot previously stated that the pilot used the heater on the accident airplane at least once before the accident flight. The heater’s overheat warning light activated during that flight, and the heater shut down without incident. The flight instructor showed the pilot how to reset the overheat circuit breaker but did not follow up on its status during their instruction. There is no evidence that a mechanic examined the airplane before the accident flight. Regarding the overheat warning light, the airplane flight manual states that the heater “should be thoroughly checked to determine the reason for the malfunction” before the overheat switch is reset. The pilot’s use of the heater on the accident flight suggests that he did not understand its status and risk of its continued use without verifying that it had been thoroughly checked as outlined in the airplane flight manual. A review of applicable airworthiness directives found that, in comparison with similar combustion heater units, there is no calendar time limit that would require periodic inspection of the accident unit. In addition, there is no guidance or instruction to disable the heater such that it could no longer be activated in the airplane if the heater was not airworthy.
Aircraft reference details include registration N9DM, MSN 401-0123, year of manufacture 1991.
Geospatial coordinates for this crash are approximately 37.6817°, -95.4518°.
Fatalities
Total
4
Crew
1
Passengers
3
Other
0
Crash Summary
While en route to the destination airport, the pilot turned on the cabin heater and, afterward, an unusual smell was detected by the occupants and the ambient air temperature increased. When the pilot turned the heater off, dark smoke entered the cabin and obscured the occupants' vision. The smoke likely interfered with the pilot’s ability to identify a safe landing site. During the subsequent emergency landing attempt to a field, the airplane’s wing contacted the ground and the airplane cartwheeled. Examination of the airplane found several leaks around weld points on the combustion chamber of the heater unit. A review of logbook entries revealed that the heater was documented as inoperative during the most recent annual inspection. Although a work order indicated that maintenance work was completed at a later date, there was no logbook entry that returned the heater to service. There were no entries in the maintenance logbooks that documented any testing of the heater or tracking of the heater's hours of operation. A flight instructor who flew with the pilot previously stated that the pilot used the heater on the accident airplane at least once before the accident flight. The heater’s overheat warning light activated during that flight, and the heater shut down without incident. The flight instructor showed the pilot how to reset the overheat circuit breaker but did not follow up on its status during their instruction. There is no evidence that a mechanic examined the airplane before the accident flight. Regarding the overheat warning light, the airplane flight manual states that the heater “should be thoroughly checked to determine the reason for the malfunction” before the overheat switch is reset. The pilot’s use of the heater on the accident flight suggests that he did not understand its status and risk of its continued use without verifying that it had been thoroughly checked as outlined in the airplane flight manual. A review of applicable airworthiness directives found that, in comparison with similar combustion heater units, there is no calendar time limit that would require periodic inspection of the accident unit. In addition, there is no guidance or instruction to disable the heater such that it could no longer be activated in the airplane if the heater was not airworthy.
Cause: Technical failure
Occupants & Outcome
Crew On Board
1
Passengers On Board
4
Estimated Survivors
1
Fatality Rate
80.0%
Known people on board: 5
Operational Details
Schedule / Flight
Tulsa - Council Bluffs
Operator
DRDJ SalesFlight Type
Private
Flight Phase
Flight
Crash Site
Plain, Valley
Region / Country
North America • United States of America
