NTSB releases factual report on Missouri governor’s crash

 - October 8, 2007, 6:40 AM

One year after the death of former Missouri Governor Mel Carnahan in the crash of a Cessna 335, the NTSB released factual information in the continuing investigation. His son, Roger “Randy” Carnahan, who was flying the light twin, reported problems with his primary attitude indicator just five minutes after departure from St. Louis Downtown Airport (CPS). An ATC controller worked with him for the next 30 min but sensed no urgency until the pilot’s final transmissions. Ultimately, the airplane crashed, killing all three aboard, 10 mi northwest of Hillsboro, Mo.

Randy Carnahan called for an initial briefing for the flight from CPS to New Madrid (Mo.) airport (EIW) at 1609 CDT. According to the factual report, the St. Louis AFSS briefer told Carnahan of a low pressure system over southern Missouri, with a cold front to the southwest and a stationary front to the east. Airmet Sierra, update seven, was in effect for IFR across the region. METARs in the surrounding region showed broken to overcast layers between 600 ft and 2,500 ft; visibilities from two to five miles; and dew-point spreads between zero and three degrees. Surface winds across the route of flight were out of the northeast around 10 kt with some higher gusts. The crash occurred a half hour past the end of twilight.

Witnesses said the governor and his assistant on October 16 last year boarded the twin Cessna at 1845; it taxied out for departure about 10 min later. The pilot received from ATC his filed clearance to EIW. As part of that clearance, ATC told him to climb and maintain 2,100 ft and to expect 7,000 ft 10 min after departure. Saying that he needed a few minutes, the pilot departed close to 30 min after engine start. Young Carnahan was cleared for takeoff, with a left turn to 200 deg on departure.

The tower turned the flight over to departure, and about three minutes passed before the pilot checked in. At 1918:22 departure asked him to “squawk ident and say altitude.” Carnahan did not respond but 26 sec later the controller confirmed radar contact “three miles southwest of the Spirit Airport,” which is 25 mi west of CPS. He told the pilot to turn left to 180 deg and to climb and maintain 2,600 ft, which Carnahan acknowledged.

Thirteen seconds later the controller asked for the course heading, to which the answer came, “060, 067.” Investigators estimate the actual heading should have been 165 deg. “N8354N turn, uh that’s all right, heading 180 is fine” came six seconds later. At 1920 the controller, an ATP with about 6,000 hr TT, instructed the pilot to turn left to 150 deg and maintain 2,600 ft.

Radar data later showed the aircraft heading southwest and indicating 3,200 ft. Seven seconds later the first call for help came: “We’re having some problems with primary attitude indicator, we’d like little bit higher climb.” The controller requested confirmation on the airplane’s altitude; Carnahan confirmed, “3,600 ft.” The controller reminded the pilot of the 2,600 ft clearance limit but gave the go ahead to climb to 4,000 ft.

Six seconds later the pilot transmitted, “We got our hands full right now,” followed by “…having to try and fly off of copilot.” At 1921:06, radar data showed the aircraft tracking southeast and maintaining 3,600 ft. The controller told the pilot to fly “level at any heading” and he’d try to secure a higher altitude.

At 1922:50 Carnahan requested to divert to Jefferson County Airport (JEF), where he thought the weather was better. The pilot and controller confirmed the aircraft was heading due south at the time and the controller asked Carnahan to confirm his new destination. The controller assigned a heading of 120 deg and a climb to 7,000 ft. Carnahan acknowledged and again asked for the diversion.

About a minute later, ATC told him to fly a heading of 270 deg. During this time the controller was trying to establish the cloud tops, thinking he could get Carnahan reoriented. The controller recounted to investigators calling across the consoles for anyone who knew what the tops were; 12,500 ft was the answer.

Two minutes later the controller said the airplane was headed northwest, a “good direction.” At 1929:31 the pilot asked for vectors to “somewhere where we can [get] down VFR.” The controller was looking for that spot and told the pilot to continue straight ahead. He then reported the weather at Columbia (7,000 ft ceiling and seven miles visibility) and asked the pilot if he’d like to go westbound. The pilot replied, “Fine.” The controller then asked the pilot for a standard-rate turn to the west because the radar data showed him tracking, southeast at 1930:37.

Less than a minute later he told the pilot to stop the turn and provided words of encouragement, saying he was doing fine. Radar data showed the airplane descending from 7,000 ft to 6,500 ft. Carnahan made no more transmissions and radar data showed various headings and a climb to 7,700 ft, which was followed by a rapid descent to the last radar return of 3,900 ft.

Investigators pieced together Carnahan’s flight times based on the pilot’s logbooks, campaign flight logs and logs from the other airplanes he flew. Both Randy and his father, Gov. Carnahan, were pilots–the former holding a commercial certificate with instrument single- and multi-engine ratings, and the latter a private pilot with an instrument rating. Gov. Carnahan owned a Beech Debonair that both father and son flew. The records showed Randy had approximately 1,830 hr TT, with 735 hr multi-engine, 460 hr at night and about 150 hr instrument, 88 of which were logged in actual IMC. In the Cessna twin he logged 513 hr, of which 157 were at night, one hour of simulated instrument and 22.4 hr in actual IMC.

The report noted the last logbook entry for partial panel work was Feb. 27, 1994, and the most recent entry of any kind was April 27 last year. Investigators also noted the position of the copilot’s attitude indicator on the lower right side of the instrument panel, which was partially obscured by the copilot’s yoke.

Investigators interviewed maintenance personnel and found the pitch-trim servo was removed from the airplane on September 28 last year. Mechanics placarded the autopilot as inoperative, though they did not pull or safety the circuit breaker. Further, the maintenance personnel told the NTSB that the autopilot repair station said the autopilot system was still operable.

The mechanic relayed that he was not comfortable without the complete system operating and so told Randy Carnahan, whose law firm owned the Cessna 335. A logbook entry dated September 28 last year stated: “The pitch trim servo was removed, the copilot’s attitude indicator was removed, overhauled and reinstalled, the left engine’s vacuum pump was replaced and a new vacuum filter was installed.”
Investigators found the first page of a “Cessna Service Bulletin ME99-19: Vacuum System Check-Pilot Operating Handbook/ Owner Manual/Flight Manual Supplement” at the accident scene. According to the report, “following the procedures resulted in a vacuum system component check.” Maintenance personnel did this check before releasing the aircraft after the copilot’s attitude indicator was overhauled.

As is customary, no conclusions are drawn with the factual report. Investigators continue to sort through the information in search of the cause of the attitude indicator failure and what contributing factors led to the flight’s final outcome.