Safety
Engineer
Jay W. Preston, CSP, PE, CMIOSH
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Jay W. Preston, CSP, PE, CMIOSH
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THE SAGA OF N6497K NTSB (preliminary) FACT REPORT FOLLOWS: JWP NOTES ARE IN BLUE ITALIC (Scroll down for final report) DEN99FA142 HISTORY OF FLIGHT On August 2, 1999, between 2020 and 0004 on August 3rd, mountain daylight time, a Cessna 172P, N6497K, operated by Robertson Aviation, Jenks, Oklahoma, was destroyed when it collided with terrain near Grants, New Mexico, while on a cross-country flight from Hawthorne, California, to Tulsa, Oklahoma. The private certificated, instrument rated, pilot, who was the sole occupant, received fatal injuries. The flight was operating under Title 14 CFR Part 91 and no flight plan was filed. Instrument meteorological conditions prevailed in the area where the accident occurred. JWP NOTE: But they can’t establish when because the FAA lost Yujin and only looked at 4.5 hours of radar data from the time of his last contact. According to documents provided by the Federal Aviation Administration, the pilot's family reported the aircraft overdue at its destination on August 4th. An alert notice (ALNOT) was issued and subsequently, a search was begun for the aircraft in the area around Winslow (INW), Arizona, which was the last confirmed location of the aircraft. JWP NOTE: August 4, Robinson Aviation notified us that Yujin had not arrived in Tulsa. JWP called FAA to report missing aircraft and was told that the arriving airport had to originate the search effort, and they couldn't respond until pilot was over 24 hours late. JWP went to work and upon returning found Yujin still missing. At this point FBOs were called, starting with Flagstaff which had no record of Yujin. Other contacts were attempted for Blythe, Banning, French Valley, but all were closed. The search was begun August 5, at Yujin Father’s (JWP) insistence, because he had determined from a contact with Yujin’s bank in Tulsa, OK, that a fuel purchase was made in Flagstaff. That purchase was shown made at about 8:30 PM (2130 MST) local time in Flagstaff. This was well after dark, and would have indicated that Yujin might have stayed on the ground in Flagstaff. JWP contacted the FBO (Fixed Base Operator) at Flag, who had no recollection of the sale. Tower had no record of any takeoff. JWP tried to determine if the aircraft was still on ground in Flag, and JWP made a missing persons report to Sheriff for the Flagstaff airport. Sheriff investigated and found that fuel sale had been made two hours earlier than on the bank charge because the sale had been made from a remote pump that wasn’t closed until later. Also, the FBO had mis-noted both Yujin’s tail number and aircraft type on his records. He sent me a copy of the sales slip. It was in Yujin's hand. Reconstruction of pertinent portions of the flight provided information that the pilot contacted the Flagstaff airport control tower at 1854 and reported he was 9 miles southwest of the airport inbound for landing. The aircraft landed at 1901 and taxied to parking. Following fueling of the aircraft, the pilot called Flagstaff ground control at 1934 for taxi. He was told to taxi to runway 21 for departure. At 1938, the aircraft took off, made a left turnout, and departed the area eastbound. JWP NOTE: THESE TIMES ARE MDT. LOCAL, ARIZONA, TIME IS ONE HOUR EARLIER (MST). The pilot contacted Albuquerque Air Route Traffic Control Center (ABQ ARTCC) at 1949 and stated he was 12 miles east of Flagstaff at 9,500 feet. He requested flight following for a flight to Double Eagle (AEG) Airport in Albuquerque, New Mexico. The controller obtained the necessary information from the pilot to set up flight following and assigned a transponder beacon code of 0752. The controller established radar contact, issued the INW altimeter setting and advised the pilot that at 9,500 feet the aircraft would have intermittent radar contact. At 1952, the controller advised the pilot that radar contact was lost and requested the pilot report over or abeam INW. The pilot acknowledged this instruction, and at 2006 the pilot reported the flight was abeam INW. The controller asked the pilot to "IDENT," followed by the information, at 2008, that radar contact was still not established and that the controller would keep the pilot advised. The pilot acknowledged this information. Between 2003 and 2017, several primary (non beacon radar returns) were recorded, but the identity of the targets could not be confirmed without a beacon code. At 2017, a beacon return showing the aircraft to be at 9,300 feet and heading eastbound was recorded. One minute later, at 2018, a beacon return provided information that the aircraft was in a right descending turn and was passing through 9,000 feet. Several more beacon codes were received and showed the aircraft in a continuing descending right turn. The last beacon code from the aircraft was received at 2019 and gave the aircraft altitude as 8,500 feet on a westbound heading. At 2020, a primary target return was recorded along the projected aircraft track, which appeared to be proceeding towards the INW aircraft navigation aid. No further radar targets were recorded. JWP NOTE: The turn was initiated about 10 miles ENE of Winslow. (INW). Which means that Yujin should have reported in to ARTCC. He did, and this was only shortly after receiving the weather notice (at 2003). Direction is listed by NTSB as "westbound," but the CAP (Civil Air Patrol) radar specialist indicated that Yujin was headed southwest, which looks like an approach for INW, which would have been a very inviting landing spot. Winslow has a restaurant on the field (which was closed that Monday night), and a big FBO (that even sells jet fuel) which closes at 3:30 on Mondays. JWP NOTE: Only the ARIZONA CAP was mustered, although one CAP flier reported flying to Gallup to check. New Mexico CAP was never notified or in the air. The CAP reported that there were ARMY helicopters in the area doing terrain avoidance training. No airline traffic ever listened for Yujin’s Emergency Locator Transmitter (ELT), even though one Victor Airway goes almost directly over Mt. Taylor. Yujin would have switched to INW radio frequency if he were making the INW approach and listening for local air traffic. The Rescue Response Center at Langley reported the coordinates of Yujin's last contacts as well as the fact that somebody in Santa Rosa, NM reported sighting Yujin's plane. The reporter allegedly took the pilot a middle-aged guy in a ball cap into town to get a couple gallons of gas that could take him to the next airport (Santa Rosa does not sell fuel anymore). When quizzed by JWP, it was determined that the witness was unreliable. And, yet, the CAP for New Mexico was not scrambled. Everyone seemed absolutely convinced that Yujin went down between Flagstaff and Winslow. BUT WHY?! The controller attempted several radio contacts with the pilot but received no reply. At 2035, the controller removed the flight following strips from his board. JWP NOTE: Why did Yujin deviate from flight following without reporting? Yujin was obsessive about things like closing his flight plans and following instructions. Why was the controller content to let Yujin disappear? The INW beacon has radio repeater equipment and there was no chance of interference or lack of a signal due to terrain. For another 161 miles further east Yujin said no further word on the radio, this after virtually continuous conversation from Flagstaff to Winslow. ATC had no further radar contact (for the 4.5 hours they checked). Why was nothing further done? And why was there no radar contact for the 4.5 hours of radar data? The Albuquerque radar is said to be so sensitive that it sometimes picks up trucks on I-40 south of Mt. Taylor. The obvious conclusion is that Yujin was not in the air for that 4.5 hours. So where was he? Why did Yujin not contact ATC once he popped up from Winslow? CAP reported that there was a flight of Army helicopters in the area. Reports varied. They were en route just passing through. They were doing low level terrain avoidance drills. They were helping with the search. Nobody could say who they were. The NTSB made no attempt to contact them for the investigation. No further radio or radar contacts with the aircraft occurred. JWP NOTE: During the time span of the incident, Winslow was the scene of one of the biggest drug raids in the history of Arizona. Arrests of some 39 individuals were made. Some arrests were made within sight of the INW runways. The raids were multi-agency with the DEA, FBI, County Sheriff and Winslow P.D. involved. Is it possible that Yujin completed his INW approach and was held on the ground by the narcs? I would hold such a pilot. What they had was a 20-year-old kid in a rented plane on a cross-country run, who just happens to land in the middle of a drug raid of historical proportions. All the agencies I talked to could not give me any certain information about the raid or raids. Traditionally an airport is closed during them. Winslow PD said raid was finished by 7:00 AM 8/2. FBI said following Wed (8/4). Others reported preceding Friday. On August 11, 1999, about 1830, the New Mexico State Police found the aircraft near Grants, New Mexico, on Mount Taylor, at the 10,600 foot level. The state police aircraft was in the area on another matter and was alerted by a weak emergency locator transmitter (ELT) signal. Mount Taylor is approximately 161 miles from the point, near Winslow, where radar and communications contact was lost. The route and flight time from the last confirmed radar target of the aircraft to the location of the aircraft was not established JWP NOTE: On August 10, in the late afternoon, a private pilot (and a Jehovah’s Witness Elder) en route from Canyon de Chelly to his congregation in Sedona, Arizona, and about 30 miles west of Mt. Taylor, reported Yujin’s ELT to Albuquerque ATC, but was unable to localize the signal after about 30 minutes of flying. Apparently ATC did not notify anybody. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) airmen records, the pilot was 20 years old. He held a private pilot certificate with a rating in aircraft single engine land issued on October 22, 1998. As of the date of inquiry, August 6, 1999, the FAA had no records concerning the pilot holding an instrument rating. However, documentation was found in the pilot's logbook and on documents in the pilot's personal effects found in the aircraft, which provided evidence that an instrument rating in airplanes was earned on July 13, 1999. JWP NOTE: Yujin’s school, Spartan School of Aeronautics, reported that Yujin was on the way to becoming the youngest Certified Flight Instructor (CFI) in the school’s history. He was said to have passed the written part of his instrument rating with the highest grade yet recorded. He was said to have gotten a perfect score on the practical part of his instrument test. Spartan is in Oklahoma, and Yujin had a great deal of experience flying in and around thunder storms. He was a good student in his weather classes. When we talked after his flight out from Tulsa, we specifically discussed thunderstorms and Mt. Taylor. Yujin had recounted flying around it. Yujin had tried out for the NIFA Flight Team at Spartan, and he had a shot at making the team. They had crammed him into a C-152 for the tryouts, and he had made one rough landing. He always trained in C-172's because at a bit over six feet and 280 pounds, he was a big kid. Hence, the 152 was a bit unfamiliar. He was ready for the next time. The pilot held a first class medical certificate issued on June 6, 1999, with the restriction that he wear corrective lenses. A review of the pilot logbook provided the following information: First logged instructional flight - October 20, 1997, in a Cessna 172. Private pilot certificate practical test - October 22, 1998, in a Cessna 172. Total flight time when exam was given, 21 hours. Instrument airplane practical test - July 13, 1999, in a Cessna 172. Total flight time when exam was given, 111 hours. According to the pilot's logbook, at the time of the accident, the pilot had logged 213 total pilot hours, all of which was in Cessna 172 aircraft. He had 71 hours of cross-country flight time, 206 hours flight experience in daylight and 7 hours at night. His instrument experience was 3 hours actual, and 32 hours simulated. His pilot in command experience was 147 hours and he had 159 hours of dual instructional flight time. AIRCRAFT INFORMATION The aircraft was a 1981 Cessna 172P, serial number 17274203. A Lycoming O-320-D2J engine, serial number RL-18587-39A, rated at 160 brake horsepower at sea level on a standard day powered it. The propeller was a McCauley DTM7557M1 75 inch, 2-bladed, fixed pitch aluminum alloy propeller, serial number 82422. The aircraft had a seating capacity for 4 people and was equipped with dual flight controls. Maximum certificated gross weight for takeoff/landing was 2,400 pounds. The service ceiling was 13,000 feet above mean sea level and the aircraft's endurance (equipped with 40 usable gallon fuel tanks) ranged from 3.8 hours to 5.6 hours depending on the operating method and environment. Maximum range according to the flight manual is 520 miles. Average endurance for the operating conditions used was calculated to be 4.5 hours. METEOROLOGICAL INFORMATION (temperatures are in degrees Fahrenheit, distances in statute miles, and altitudes are in feet) The closest reporting station to the accident was located at Albuquerque. Prior to the accident, the 2056 observation was wind from 330 degrees at 12 knots; visibility 10 miles; thunderstorm; ceiling 4,100 broken cumulonimbus clouds; 6,000 foot overcast skies; temperature 64; dew point 63; altimeter 30.31 inches of mercury (hg). Remarks - wind shift at 25; thunderstorm began at 44; rain began at 36, ended at 46; sea level pressure 1018.9 hectopascals; thunderstorm, frequent lightning in cloud and cloud to ground northwest, little movement; less than one-hundredth of an inch of precipitation fell since last hour; a trace of precipitation has fallen; temperature 64, dew point 62; a steady increase of 2.3 hectopascals. The conditions near the calculated time of the accident taken at Albuquerque, provided by a 2156 observation was wind 360 at 3 knots; visibility 10 miles; thunderstorm, light rain; ceiling 6,500 broken cumulonimbus clouds, 8,500 overcast skies; temperature 66, dew point 62; altimeter 30.33 hg. Remarks - rain began at 26; sea level pressure 1019.0; thunderstorm, occasional lightning in clouds west through northwest, little movement; less than one hundredth of an inch of precipitation fell since last hour; temperature 67, dew point 67. At 2232, the wind was calm; visibility 5 miles; thunderstorm, rain, mist; ceiling 2,100 broken cumulonimbus clouds, 7,000 overcast, temperature 66, dew point 63, altimeter 30.34 hg. Remarks - thunderstorm, occasional lightning in clouds west through northwest, little movement; seven hundredths of an inch of precipitation fell since last hour. The radar summary chart for 2135 indicated the western half of New Mexico was almost completely covered with thunderstorms. At 2003, an aircraft hazardous weather information Convective SIGMET Three West for Arizona, New Mexico, and Texas was issued over the air traffic control frequency that the accident aircraft was using. JWP NOTE: So Yujin would have been well aware of potential weather conditions, had he been in the air at the time. Winslow would have been a logical place for him to set down for the night. He would have been 30 minutes out of Flagstaff for the weather warning. According to the U. S. Forest Service manager in Grants, the weather conditions, the evening of the accident, were cloudy skies with thunderstorms. JWP NOTE: Assuming that the crash actually occurred that evening. The body was reported in remarkably good condition. A ten-day run of an ELT is also considered remarkable. The plane had been given a good going over prior to the flight. This included fresh batteries for the ELT. AIDS TO NAVIGATION Between Flagstaff, Arizona, and Albuquerque, New Mexico, four aerial navigation aids are installed. Winslow is 44 miles 083 degrees from Flagstaff. The minimum en route altitude (mea) is 9,500 feet. Between Winslow and Albuquerque there are four instrument airway routes with navigation aids. The most direct route is 080 degrees from Winslow, 81 miles to Zuni with a mea of 9,000 feet, and 073 degrees from Zuni, 115 miles to Albuquerque, with a mea of 11,000 feet. JWP NOTE: It was Yujin’s practice to follow rather closely the Victor Airways, and his path to INW indicates no deviation in this practice prior to his last contact. He reported in as instructed and then made the turn where he disappeared from the radar. There is a southern route which is 101 degrees from Winslow for 90 miles to Saint Johns with an mea of 8,900 feet and 059 degrees for 121 miles to Albuquerque with an mea of 11,500 feet. A possible route taken by the accident aircraft (based on the location of the accident) was 061 degrees from Winslow for 98 miles to Gallup. On this leg, the mea is 9,000 feet changing to 9,400 feet when within 25 miles from Gallup. When departing Gallup, the route is 090 degrees for 104 miles to Albuquerque. On this leg the mea is 13,300 feet. The remaining route is 075 degrees from Gallup for 60 miles to CROIN intersection 110 degrees from CROIN to Albuquerque for 49 miles. The mea is 11,000 feet. Based on the accident location, this is also a possible route. The most prominent visual guide to flight between Winslow and Albuquerque is the interstate highway, which is four lanes. It passes south of Mount Taylor and to the south of Double Eagle Airport in Albuquerque. COMMUNICATIONS After the accident aircraft departed Flagstaff, the only known communications were with ABQ ARTCC. A transcript of the communications is attached. WRECKAGE AND IMPACT INFORMATION The accident site was a mountainside 10,600 feet above sea level. JWP NOTE: This is well above the radar window for ABQ ARTCC. The slope was approximately 40 degrees and was covered with a dense pine forest with trees ranging to about 80 feet in height. Witness marks found during the on scene examination of the accident site provided evidence the aircraft impacted trees parallel to the slope, in a wings level attitude and created a track 230 feet in length oriented on a heading of 259 degrees. First contact was made with the right wing and right main landing gear, which separated from the aircraft. The right horizontal stabilizer and elevator also separated during initial impact and remained lodged in the trees approximately 60 feet above ground level. The rest of the aircraft rotated to the right and went between two trees, which separated the cabin overhead and center wing section. The left wing also separated and was located approximately 20 feet from the main wreckage. JWP NOTE: Yujin had apparently flown through the saddle between Mt. Taylor and a peak about ½ mile north and 600 feet lower, called La Mosca. He was on the down-hill leg toward Gallup. La Mosca is notable by its antenna farm and old Forestry Lookout with repeaters for utilities, police agencies, and government functions. These towers appear to be lit. Mt. Taylor has no towers, and it is unlit and in its natural state. The engine remained attached and exhibited impact related damage to cylinders and accessories. The engine was removed for transport of the wreckage. The propeller separated during impact and was found on the uphill side of the wreckage near the nose portion of the aircraft. One of the propeller blades was bent aft and exhibited chordwise scratches and paint removal. The other blade was bent aft at mid span and forward approximately 8 inches inboard from the blade tip. This blade also exhibited chordwise scratches and gouges. Several tree branches were found with smooth angular cuts across their diameter. Additional specific documentation at the accident site is as follows: All flight control surfaces were accounted for. The flaps were in the up position and verified by the right flap actuator position. Elevator trim could not be verified due to jackscrew damage. The pilot's seat was separated from the track and emergency personnel had cut the seat belt. The shoulder harness remained attached to the cabin mount. The fuel selector was in "both." The gascolator screen was observed clean and free of contaminates. Both fuel tanks were compromised and no fuel was present. The altimeter was a 2-pointer type and both needles were separated. The Kolsman window had a setting of 30.24. The cabin heat switch was on. The emergency locator transmitter (ELT) was intact but the antenna was separated. The battery due date was July 1999. The magnetos were on "both." The hour meter read 4468.0. The tachometer was at zero and 5236.9 hours. The throttle was in full power position, the mixture was in the "rich" position, the primer was locked in, and the carburetor heat was off. Flight instruments and radio settings were not readable. JWP NOTE: Some transponder knobs were missing and/or broken. By inserting knob stem "A" of a good knob into hole "B," I was able to determine what the transponder was set for. NTSB, and FAA, you can do the same or ask me what the transponder was set for. The instrument panel clock was readable. I have a photograph of the panel taken at Hawthorne immediately prior to Yujin’s take off. This photo has not yet been enhanced, because Robertson said that cockpit clocks are notoriously inaccurate. The clock dial is right at the limits of resolution for the photograph. Examination of wing tip light bulb filament indicates that running lights were on at time of impact (based on the wing tip JWP recovered at the scene). MEDICAL AND PATHOLOGICAL INFORMATION The Office of the Medical Examiner, State of New Mexico, performed an autopsy on the pilot. The case number is 3868-899-13C. JWP NOTE: No attempt was apparently made to determine the actual time of death. This may have been determined from insect damage. Univ. New Mexico is the foremost learning center for this research. Blunt force trauma was listed as the cause of death. Date of death is reported as August 12, 1999. The Federal Aviation Administration's Civil Aeronautical Medical Institute, Oklahoma City, Oklahoma, performed toxicological tests. The results of the tests are attached to this report and provided no evidence pertinent to the investigation. TESTS AND RESEARCH An examination of the engine was done at the facilities of Air Transport, Phoenix, Arizona, on November 16, 1999. The engine was placed on a hoist and external examination provided evidence of damage to the number 1 rocker box, and most of the push rods. The crankcase was fractured near the front governor-mounting pad, which in the engine application was not machined or used. The muffler and exhaust system were smashed and there was no evidence of exhaust shroud leakage. The carburetor inlet fuel screen was clean and the mixture control at the carburetor was near idle. The crankshaft rotated freely and all cylinders had compression. Both magnetos were Slick model 4371. They were intact and produced spark at all leads. The carburetor was a Precision model MA-4SPA. It was attached, clean, and examination provided no evidence of pre impact failure or malfunction. The spark plugs were Champion REM 40E. Examination provided the following: Top 1 - Broken/bent barrel, gray in color Bottom 1 - Damp with oil, gray in color Top 2 - Carbon debris, damp with oil, gray in color Bottom 2 - Damp with oil, gray in color Top 3 - Light gray to white in color Bottom 3 - Worn electrode, gray in color Top 4 - Damp with oil, gray in color Bottom 4 - Wet with oil, gray in color All electrodes were slightly ovaled with #3 bottom spark plug exhibiting more advanced ovaling. The ignition harness wires were attached to their respective spark plugs. The #2 top wire had impact damage. The harness tested to be operational. The starter remained attached to its mounting pad. There were gouges on the gear and the starter gear was in the forward/extended position. The alternator remained attached. Rotational rub markings were noted on the alternator housing from the fan. The vacuum pump remained attached. There was no nut installed on the lower left mounting. The pump was free to rotate and suffered no internal damage. The oil cooler received impact damage. The suction and pressure screens were clean and the oil lines were secure. The oil filter was free of contaminates and was marked with an installation date of July 16, 1999, at a tachometer time of 5191 hours. ADDITIONAL DATA/INFORMATION The wreckage was released to the owner's representative on November 16, 1999. No parts were retained. JWP NOTE: SO, WHAT HAPPENED TO YUJIN? Why, after jabbering to ABQ ARTCC since leaving Flagstaff, would he deviate from his route without a peep? Why would he continue east into the dark thunderstorms? Why would he ignore the 2003 warning? Why would he not remain in Winslow for the night? Why would he rise up into the air lanes for 160 more miles without a peep? Why was he not on the radar or in the radio transcripts? Or is it possible that some narcs with big guns, after interrogating him on the ground in Winslow told him, "Get out of here kid," and sent him to his doom? Or was it more sinister than that? And finally: Why would a back channel inquiry via the military with the mention of Yujin's tail number yield a "you really don't want to know what happened" response?
NTSB Final Report Follows: DEN99FA142 HISTORY OF FLIGHT
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