Salinas Muni Airport
Aircraft Accident/Incident Report

Shaver Lake, California 93664
Saturday, November 10, 2012 19:20 PST

NTSB Narrative Summary Released at Completion of Accident

The private pilot departed about 90 minutes after sunset in the high-performance multiengine airplane on the cross-country flight. The climb and level off at cruise altitude were uneventful and, based on the radar data, appeared to have been accomplished with the use of the autopilot. The cruise altitude of 27,000 feet was the highest the airplane had been flown in recent history, and the highest altitude it had been operated at with the pilot flying. The pilot made a routine radio exchange with air traffic control personnel shortly after levelling for cruise. Five minutes later, the airplane, with no further radio transmissions, rolled to the right and rapidly descended 10,000 feet, where it subsequently broke apart. Both wings, along with the horizontal stabilizer and elevators, separated during the breakup sequence. Analysis of their fracture surfaces, along with the debris field distribution and radar data, revealed that the breakup sequence was most likely inadvertently induced by the pilot, as he attempted to recover control of the airplane during the dive. The airplane sustained extensive thermal damage after ground impact, and examination of the engine components, surviving primary airframe components, the cabin heater, and the autopilot system remnants did not reveal any mechanical malfunctions or failures that would have precluded normal operation. There was no evidence of bird strike, inflight fire, or that the engine fire extinguisher system had been activated. The airplane was flying toward an uninhabited mountain range and a largely unpopulated desert area at the time of the upset. The moon had set, and the pilot would have had limited reliable external visual cues should the airplane have experienced a failure of either the flight instruments or autopilot. The pilot was instrument rated, however the majority of his flight experience was garnered in aircraft equipped with modern "glass cockpit" avionics, as opposed to the traditional flight instruments installed in the accident airplane (which he had recently purchased). The airplane was equipped with a dual vacuum pump system, which drove the primary flight instruments and, in turn, the autopilot. One of the vacuum pumps had failed on the previous flight, and the pilot was unable to get it repaired in time for the accident flight. The dual nature of the vacuum system allowed for flight with a single failed pump, however failure of the remaining pump or associated vacuum system components would have left the pilot to hand fly the airplane, using backup flight instruments, at an altitude perilously close to the limit of the airplane's flight envelope (the maximum altitude was 30,200 feet). Examination revealed that the second pump was most likely operational; however, fire damage precluded an accurate assessment of the operability of the remaining vacuum system components. Although operation of the airplane did not require adherence to a minimum equipment list, the airplane's FAA Master Minimum Equipment List stated that one of the vacuum pumps can be inoperative, provided the airplane is operated under VFR and not operated at night. Given the pilot's overwhelming experience with "glass cockpit" instruments, as opposed to the traditional type in the accident airplane, along with the failure of one of the vacuum pumps, he should have reconsidered making the flight, particularly during night conditions. The airplane had experienced multiple anomalies with the autopilot and vacuum system prior to the accident flight. Maintenance records indicated that these discrepancies had been resolved; however, damage to the airplane precluded a substantive confirmation of their operation. Additionally, an oversight by an avionics repair facility 1 week before the accident resulted in the airplane's pitot/static system being inadvertently tested and certified to 20,000 feet, rather than the airplane's service ceiling of 30,200 feet. The relevance of this finding, if any, could not be determined. The airplane was equipped with a supplemental oxygen system; however, maintenance records indicated that the pilot's mask, while operational, had degraded. Additionally, the mask had been relocated to a position behind the pilot's seat, which would have been hard to reach in the event of a rapid decompression. Ultimately, the NTSB was unable to determine the cause of the rapid descent because of the postcrash damage to the airplane systems and components.

NTSB Probable Cause Narrative

The pilot's failure to regain airplane control following a sudden rapid descent during cruise, which resulted in an in-flight breakup. Contributing to the accident was the pilot's decision to make the flight with a failed vacuum pump, particularly at high altitude in night conditions.

Event Information

Type of Event Accident
Event Date 11/10/2012
Event Day of the Week Saturday
Time of Event 1920
Event Time Zone Pacific Standard Time
Event City Shaver Lake
Event State CALIFORNIA
Event Country --
Zipcode of the event site 93664
Event Date Year 2012
Event Date Month 11
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 370545N
Event Location Longitude 1191757W
Event Location Airport SALINAS MUNI
Event Location Nearest Airport ID SNS
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 114
Degrees magnetic from airport 76
Airport Elevation 84
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1853 Pacific Standard Time
Direction of event from weather observation facility (degrees) 235
Weather Observation Facility ID KMAE
Elevation of weather observation facility 255
Distance of event from weather observation facility (units?) 42
Time Zone of the weather observation PST
Lighting Conditions Night
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 6
Dew Point at event time (in degress fahrenheit) 2
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator Calm
Wind Gust Indicator --
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 31.17
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 2
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 32750
NTSB Notification Source FAA LAX ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record May 22 2014 7:28PM
User who most recently changed record sime1
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N700EM
NTSB Number WPR13FA037
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name CESSNA
Aircraft Model 421C
Aircraft Series Identifier --
Aircraft Serial Number 421C1010
Certified Max Gross Weight 7450
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats 6
Total number of seats on the aircraft 8
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Feb 8 2012 12:00AM
Airframe hours since last inspection 135
Airframe Hours 5118
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type C126
Aircraft Owner Name Scott H Clarke
Aircraft Owner Street Address --
Aircraft Owner City SPRINGFIELD
Aircraft Owner State MO
Aircraft Owner Country USA
Aircraft Owner Zipcode 65809
Operator is an individual? Yes
Operator Name Scott H Clarke
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City SPRINGFIELD
Operator State MO
Operator Country USA
Operator Zip code 65809
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code KSNS
Departure City Salinas
Departure State CA
Departure Country USA
Departure Time 1837
Departure Time Zone PST
Destination Same as Local Flt --
Destination Airport Code KOMA
Destination City Omaha
Destination State NE
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record May 30 2014 6:32PM
User who most recently changed record stam
Since inspection or accident Last Inspection
Event Location Runway Number and Location 26
Runway Length 6004
Runway Width 150
Sight Seeing flight No
Air Medical Flight No
Medical Flight --