History of Flight
On July 4, 2010, approximately 0015 central daylight time, a Cessna 421B twin-engine airplane, registration N31AS, operated by O'Hara Flying Service and doing business as Air Ambulance Stat, was substantially damaged when it impacted terrain 1.3 nautical miles northeast of Alpine-Casparis Municipal Airport (KE38), Alpine, Texas. A post-crash fire ensued. Dark night visual meteorological conditions prevailed at the time. The emergency medical services flight was being operated on an instrument flight rules flight plan under 14 CFR Part 135. The airline transport pilot, two flight nurses, a patient, and a passenger sustained fatal injuries. The cross-country flight was originating at the time of the accident and was en route to Odessa-Schlemeyer Field Airport (KODO), Odessa, Texas.
Witnesses reported the airplane flying low from west to east as if it had just departed KE38. The airplane lights were on and nothing appeared abnormal other than the low altitude. One witness saw the airplane descend and then observed a fireball. All witnesses noted very dark conditions and overcast skies.
According to O'Hara Flying Service, their initiate, release, and control (IRC) officer received a call at about 2300 from Big Bend Regional Medical Center requesting patient transfer to Odessa. The pilot contacted FAA Flight Service Station at 2332 to file a flight plan and obtain a weather briefing. Radar and flight track information were not available.
Personnel Information
The pilot, age 59, held an airline transport pilot certificate with multiengine land and commercial single-engine land ratings, and a flight instructor certificate with single-engine and instrument privileges. He was issued a second-class medical certificate on October 12, 2009, with the limitation "must have available glasses for near vision." He reported no medications.
At medical certificate application (October 6, 2009), the pilot reported 1,750 total hours, zero in previous six months. At airman certificate application (November 9, 2009), he reported 1,612 total hours, 1,281 PIC, 250 night PIC, 40 night SIC, and 306 instrument hours. On an employment application, he reported 1,630 total hours, 860 multiengine, and 180 night. On a company experience form, he reported 1,350 PIC, 145 hours in Cessna 421, and 180 night.
Pilot logbook pages from December 2000 through June 2010 showed 1,676 total hours, 1,365.6 PIC, 173.1 hours in Cessna 421 (10 in simulator), and 185.9 night hours.
O'Hara Flying Service hired the pilot in June 2010. He completed initial training and received competency checks with satisfactory ratings on June 6, 2010. He received area familiarization at KE38 and was based there. Company tracking showed he logged at least 15 hours in company airplanes (1 hour Part 135, 9.2 night, 5.7 in accident airplane). His last logged flight before the accident was June 30, 2010, for 2.7 hours, all at night. He had no flight or duty time from 0300 July 1 until accepting the accident flight. The director of operations stated training went well with no issues in flying skills or night flying.
Aircraft Information
The accident airplane, a Cessna 421B (serial number 421B0473), was manufactured in 1973. It was registered with a standard airworthiness certificate. Two Teledyne Continental Motors GTSIO-520-H engines, each rated 375 hp at 3,400 rpm, powered it. Each engine had a three-blade McCauley propeller. The airplane was originally sold with eight seats; O'Hara Flying Service had equipped it for medical flight operations with four occupant seats and a medical litter for the patient.
It was registered to O'Hara Flying Service II LP, operated as Air Ambulance Stat, and maintained under an annual/100-hour inspection program. An annual/100-hour inspection was completed on March 23, 2010, at airframe total time of 2,302.8 hours. The airplane was not equipped, nor required, with a terrain awareness warning system.
Meteorological Information
The closest official weather observation station at KE38, 1.3 nm southwest of the accident site, reported at 0005: winds 210° at 5 knots, visibility 10 miles, scattered clouds at 7,000 feet, temperature 21°C, dew point 20°C, altimeter 30.05 inHg. Sunset was at 2101, end of civil twilight at 2128 on July 3. Moon rose at 0040 and set at 1321 on July 3; rose again at 0109 on accident day. Moon was waning gibbous with 59% illumination.
Airport Information
Alpine-Casparis Municipal Airport was a public, non-towered airport 2 miles northwest of Alpine, Texas, at elevation 4,515 ft msl. It had two runways: 1/19 (6,003 ft by 75 ft, asphalt) and 5/23 (5,018 ft by 60 ft, asphalt), both reported in good condition.
Wreckage and Impact Information
The accident site was east of the airport in rolling hills, elevation 4,400 ft msl. The airplane impacted on a magnetic heading of about 075°. Ground scars indicated the landing gear was extended, with parallel scars. The right engine propeller left perpendicular ground gashes. Debris included a wheel rim, landing gear door, lights, and fuel tank pieces. Vegetation blight suggested right fuel tank rupture. Further along, a red beacon glass fragment and left wing fuel tank impact evidence were found, followed by a fuel fire burst pattern. The airplane came to rest inverted; post-crash fire consumed most of the left wing and cabin/cockpit area. Flaps were extended. Right main landing gear was torn off; left main gear was in wreckage partially consumed. Nose gear attached minus tire. Flight control continuity was established. Elevator trim measured 1.7 inches (6° tab up, nose down). Rudder measured 1.8 inches (7.5° left tab, nose right). Aileron trim was off-scale. Each propeller separated at the crankshaft flange, located away from main wreckage, with twisting, curling, and leading edge gouges.
Medical and Pathological Information
An autopsy on the pilot at Permian Basin Forensic Center on July 9, 2010, concluded cause of death as trauma and multiple blunt force injuries. FAA toxicology tests on urine and liver revealed azacyclonol (a metabolite of antihistamines) and ibuprofen. Carbon monoxide and cyanide tests were not performed.
Tests and Research
Both engines were examined at the manufacturer's facility in Mobile, Alabama, under NTSB, FAA, Cessna, Teledyne Continental Motors, and O'Hara representatives. The examination revealed no pre-impact anomalies that would have precluded normal operation.
Organizational and Management Information
FAA issued a Part 135 certificate to O'Hara Flying Service in 1991 for on-demand EMS transports. At the time, the company operated three bases (Alpine, Odessa, Amarillo) and six airplanes, employing seven pilots (four exclusively for air ambulance). Pilots required minimum 1,500 total hours and 200 multiengine hours; no minimum for night or instrument experience. The company did not have a formal risk assessment program or safety reporting system. After the accident, they added a risk assessment form. Dispatch used an initiate, release, and control method; the IRC officer coordinated with hospitals and pilots. Flight monitoring included telephone calls and Flight Aware service. Weight and balance was computed via computer program; the accident flight calculated gross weight was 6,925 lbs (CG 156.58 inches). Maximum takeoff weight was 7,450 lbs. Passengers could accompany if capacity allowed.
Additional Information
The pilot's family reported he worked a 1000-2200 shift but was available 24/7. He usually slept 7 hours, waking about 0700 and going to bed between 2230 and 2330. He spoke with his fiancé at 0850 on the accident day and again at 2230, stating he was preparing for bed. It is unknown if he napped during the day. O'Hara did not provide formal fatigue training. The Cessna Owner's Manual specifies flaps up before takeoff and landing gear retraction after climb established. The FAA AIM advises VFR night pilots to maintain altitude at or above minimum en route altitude, especially in mountainous terrain. The FAA Airplane Flying Handbook notes distance and altitude deception at night and recommends reliance on flight instruments.
FAA oversight was provided by Lubbock Flight Standards District Office. The former principal operations inspector (POI) had managed the certificate for two years and interacted mainly with the director of operations. He had flown only with the director and had not observed checkrides for line pilots. Training attendance by the former POI was limited to one 30-minute session that was truncated by the operator.