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NTSB Report

October 31, 2004 · Cessna 182Q · N95902

Lebec, CA

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
October 31, 2004
Injury Outcomes
4 injuries (4 fatalities)
Location
Lebec, CA
Aircraft
Cessna 182Q
Tail Number
N95902
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
LAX05FA023

While traversing a mountain range between two valleys, the aircraft collided with mountainous terrain after a likely encounter with clouds, moderate turbulence, and up and down drafts in the 500- to 1,000-foot-per-minute range. Examination of the wreckage and the accident site showed that the airplane collided with mountainous terrain while in a wings level cruise flight attitude. The autopilot switch was found in the ON position. The noninstrument rated private pilot departed in VFR conditions with three passengers for a 134-mile trip to celebrate one passenger's birthday at a fly-in restaurant destination. There were no records of the pilot having received weather briefings from any Federal Aviation Administration (FAA) facilities. Recorded radar data showed that instead of flying a direct route the airplane meandered towards a mountain top VOR navigational aid and eventually was about 18 miles off a direct course between the departure and destination airports. About 30 minutes into the flight, the airplane had reversed course and was headed back towards the open desert departure area when radar contact was lost. A moderate north-south surface pressure gradient produced strong, gusty northerly low-level winds over the higher elevations of the mountain range. Observations from satellite imagery indicated that mostly clear skies were present from the departure airport until the accident airplane reached the vicinity of the accident area. A weather satellite visible image showed that cloud cover from the northwest did cover the accident site around the estimated time of the accident though there were clear areas south and west of the VOR. Cloud bases reported around the VOR ranged from on the surface to less than 1,000 feet agl, with tops generally 8,000-10,000 feet mean sea level (msl) in the area. No in-flight advisories (SIGMET or AIRMET) were valid for the accident location when the accident airplane departed. However, AIRMET TANGO was updated at 1335, to include a forecast of occasional moderate turbulence below 12,000 feet over coastal mountain areas. According to pilot reports from very near the accident area around the time of the crash, moderate turbulence and up and down drafts were being experienced from 500 feet to 1,200 feet per minute. There are two small lakes in the vicinity of the VOR. Overflying one lake on the accident flight's last radar observed heading would take the airplane over low terrain on a route back toward the departure airport, whereas overflying the second lake on the last observed heading would take the airplane toward mountainous terrain that rises to 5,430 feet msl within 2 miles, and is the location of the accident site.

NTSB Probable Cause

the pilot's inadequate in-flight planning/decision by his VFR flight into IMC, and his failure to maintain terrain clearance. Contributing factors were mountainous terrain, low ceilings, and turbulence.

Full Narrative

HISTORY OF FLIGHT On October 31, 2004, about 1130 Pacific standard time, a Cessna 182Q, N95902, collided with mountainous terrain near Lebec, California. The pilot-owner was operating the airplane under the provisions of 14 CFR Part 91. The private pilot and three passengers received fatal injuries. The airplane was destroyed. Visual meteorological conditions prevailed at the departure point, and no flight plan had been filed. The personal cross-country flight originated at Lancaster, California, at 1056, and was destined for Harris Ranch, Coalinga, California, where, according to family members, the pilot and passengers had reservations for a birthday lunch. The wreckage was 28.39 miles west of Lancaster at 34 degrees 50 minutes north latitude and 118 degrees 46 minutes west longitude about 5,086 feet mean sea level (msl). The Federal Aviation Administration (FAA) Rancho Murietta Automated Flight Service Station reported an emergency locator beacon (ELT) to the Civil Air Patrol about 1530. According to the Air Force Rescue Coordination Center, because of satellite alignment requirements, an ELT signal may be delayed 2 or 3 hours before being received or confirmed. Investigators recovered a flight record log from the wreckage site. The log noted the accident flight, along with the departure point airport terminal information service information. The pilot routinely recorded each flight with tachometer out time, and the return final tachometer reading. According to this information, and the accident recording tachometer, the accident flight consumed about 30 minutes since the last tachometer in reading. The mechanical tachometer records any time that the engine is running, but only with accuracy at 2,500 revolutions per minute (rpm). PERSONNEL INFORMATION The pilot held a private pilot certificate with a rating for airplane single engine land issued on June 17, 1966. His last recorded biennial flight review occurred on the day before the accident, October 30, 2004. According to his pilot logbook, he had accrued about 415 total flight hours. His most recent third-class flight physical occurred on June 10, 2004. According to the pilot's logbook first page of log No.2, December 30, 1999, the pilot had a total actual instrument time of 3.2 hours with 3 hours simulated time. Near the end of the logbook, September 25, 2004, he recorded actual instrument flight time at 3.2 hours and simulated instrument hours as 6.6. AIRCRAFT INFORMATION Examination of the airplane's logbook revealed the most recent annual inspection occurred on August 22, 2004, at 2,522.5 total airframe hours. The recording tachometer indicated 1,016.0 hours at the annual. The time since engine major overhaul was listed as 983.9 hours. The most recent ATC transponder and encoder per FAR 91-413, and the altimeter static system check per FAR 91-411, was accomplished on May 29, 2003. The most recent fueling records were obtained from American Airports Fox Field. On October 30, 2004, the airplane was fueled at 1512 hours, and took 54.9 gallons of 100 low lead aviation fuel. METEOROLOGICAL INFORMATION There was no record of the pilot obtaining a preflight weather briefing from any FAA facility prior to the accident flight. Visual meteorological conditions prevailed at the departure point with 10 miles visibility; wind 350 degrees at 9 knots; temperature 64 degrees Fahrenheit; dew point 33 degrees Fahrenheit; and the altimeter was 30.09 inHg. Low stratus, fog, and haze developed overnight in the San Joaquin Valley and was gradually lifting and dissipating at the time of the accident. A moderate north-south surface pressure gradient produced strong, gusty northerly low-level winds over higher elevations of southern California. Observations from Lancaster and visible satellite imagery indicated that mostly clear skies were present from the departure airport until the accident airplane reached the vicinity of the Tehachapi Mountains. Cloud bases reported at Bakersfield and Sandberg implied that cloud bases in the mountains probably ranged from 4,000 to 5,500 feet msl. Satellite infrared radioactive temperatures implied cloud tops were generally 8,000-10,000 feet msl in the area. Pilot reports from Lancaster and Bakersfield reported cloud tops about 8,000 feet msl. According to a GOES-10 satellite visible image, at 1100 on October 31, 2004, cloud cover from the northwest did cover the accident site. No in-flight advisories (SIGMET or AIRMET TANGO) were valid for the accident location when the accident airplane departed Lancaster. However, AIRMET TANGO was updated at 1335, to include a forecast of occasional moderate turbulence below 12,000 feet over coastal mountain areas of southern California. According to numerous pilot reports, around the accident area near the time of the accident, moderate turbulence and up and down drafts were being experienced from 500 feet to 1,200 feet per minute. WRECKAGE AND IMPACT INFORMATION The initial examination of the wreckage by the National Transportation Safety Board investigator-in-charge (IIC) occurred on scene November 1, 2004. The wreckage was on private mountainous property about 5,086 feet msl, covered with oak and other trees. The terrain slope was approximately 30 degrees. The IIC measured the wreckage path about 060 degrees scattered upslope. From the accident site, Interstate 5, and Castaic Lake on the Fort Tejon Ranch could be seen. A post accident examination by the IIC occurred November 5, 2004. The IIC accounted for all of the airplane for except the main gear wheels. At the start of the wreckage path was a section of the left wing from the root to station 72, lodged about 20 feet up in an oak tree. From the tree towards the fuselage were scattered fairing parts, Plexiglass, and the outboard section of the left wing. About 22 feet from the oak tree was a crater. Leading to the crater was a cut through the upslope dirt into the crater. The crater was in soft dirt about 5 feet in length and several inches deep. The left landing gear was caked with dirt similar to the crater dirt, and was missing the wheel and brake assembly and exhibited leading edge cuff damage. The fuselage was inverted about 53 feet upslope from the oak tree. The empennage was severed from the aft fuselage just forward of the vertical stabilizer, and rotated/twisted to the right about 90 degrees. The control cables were still attached. The elevator trim tab actuator measured 10 degrees tab up. The IIC noted heavy crushing of the engine compartment and firewall favoring the left side. The nose landing gear was bent aft 90 degrees, and the wheel assembly and fairing were severed from the oleo strut. Both propeller blades revealed chordwise striations and leading edge damage, as well as aft bending of the blades. The right wing was severed from the fuselage and laying over the engine about 90 degrees to the wreckage path. The fuel tank was open at the wing root. Some cables were still attached. The wing strut was attached at the wing and severed from the fuselage. The wing structure was folded about station 72 with heavy leading edge accordioning and folding under. The wing flap actuator was in the retracted position. The IIC established control cable continuity and hardware condition to the primary control system where possible, during the post accident examination. Examination of the instrument panel revealed an updated Garman GNS430 and 530 avionics package, including dual GI-106A VOR (very high frequency omni-directional radio range) indicators. According to the avionics manufacturer, neither of the units contained memory capabilities. The top VOR indicated 275 on the OBS, and the bottom 230. A factory installed Cessna Navomatic 300A electric single-axis autopilot was examined and found with the switch in the on position. The primary function pushbuttons were damaged. The nav switch was selected for nav 2. The directional gyro heading "bug" was indicating 255 degrees. The altimeter barometric pressure was set at 30.08 inHg. The accessible engine spark plugs appeared to be functional as per the Champion reference guide of conditions. The engine cylinders all had compression. The fuel gascolator was clean and the vacuum pump drive was intact. A notation on the oil filter element was dated 5-12-04, 1007.0. MEDICAL AND PATHOLOGICAL INFORMATION On November 2, 2004, the Kern County Medical Examiner performed an autopsy on the pilot. During the procedure, samples were obtained for toxicological analysis by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma. The results of the analysis were negative for carbon monoxide, cyanide, ethanol, and drugs. TESTS AND RESEARCH INFORMATION The Safety Board obtained limited radar information from the Los Angeles TRACON (Terminal Radar Approach Control) facility at Edwards AFB, California. There were no services provided by TRACON, and no one assigned a discreet transponder code to the airplane. The airplane was cleared for takeoff from the William J. Fox Airport, Lancaster, at 1056.30. The recorded radar traffic was viewed for a period of time before the takeoff to look for traffic departing towards or in the direction of Harris Ranch, about 300 degrees magnetic. A departing target at that time was tracked. It departed runway 6, and turned left, westbound. At 1103.30, the target reported a mode C altitude of 6,300 feet msl. At 1107, it was reporting 6,600 feet msl. At 1109, it was heading westbound at 7,200 feet msl, at 120 knots towards Gorman VOR. At 1111, it was reporting 5,000 feet msl. At 1112:45, it was at 5,500 feet msl. From 1113:43 to 1113:57, radar coverage was lost. At 1115:05, the target turned north near the Gorman VOR at 5,400 feet msl. At 1115:20, radar coverage was lost. The engine was moved to Performance Engines, an FAA approved Repair Station at La Verna, California, for testing. On December 9, 2004, technicians installed the engine into a test stand. Due to impact damage, they replaced the carburetor and propeller governor and made repairs to the oil pan and induction system. There was visible damage to the crankshaft flange. They started the engine, and successfully run it at low power, due to the damaged crankshaft flange. The EDM 700 engine monitor was taken to an FAA approved avionics repair station in an attempt to recover non-volatile memory. The attempt was unsuccessful due to damage. Subsequently, the unit was taken to the manufacturer, JP Instruments, for data recovery. They successfully recovered data showing normal engine operating pressures, temperatures, and battery voltage, up to the point of collision with the terrain. ADDITIONAL INFORMATION On November 10, 2004, the IIC released the wreckage to the insurance company representative. There are two small lakes in the vicinity of the Gorman VOR, (a navigational aid). Both lakes are along major highways. An aircraft returning to the Lancaster area could overfly either lake on the accident heading and reach the open flat desert. Quail Lake is about 5.5 miles east of the Gorman VOR, and Castaic Lake is about 2 miles north from the VOR. The Quail Lake route would be a low terrain route free of mountainous terrain, whereas the Castaic Lake route would encompass mountainous terrain to 5,430 feet msl within 2 miles before the open desert. A weather satellite system, GOES-10 visible image, documented at 1100 on October 31, 2004, showed cloud cover from the northwest, and did cover the accident site. There were clear areas south and west of the VOR. A direct route from Lancaster to Harris Ranch would have been about 18 miles north of the Gorman VOR and 134 miles for the direct route.

Flight

Event TypeAccident
Event Time11:30 PST
Nearest Airport28nm W
Flight Plan FiledNone
Flight Plan ActivatedNo
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftCessna 182Q
Tail NumberN95902
Aircraft CategoryAir
DamageDestroyed
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsContinental · O-470-U · Reciprocating · 230
Seats4

People & Injuries

Injury Summary4 injuries (4 fatalities)
Fatal4
Serious0
Minor0
Uninjured0
Total4
Crew 1Age 57 · Third Class · Fatal

Conditions

ConditionsIMC
LightDaylight
Wind350° @ 10 kt, gusting 24 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point46 / 36 C
Altimeter30.12 inHg
Observation Time18:52
Weather SourceWFAC

Appendix: Source Data