Sunday, July 23, 2017

Incident occurred July 23, 2017 at Minneapolis-St. Paul International Airport (KMSP), Minnesota



Fire crews were called to the Minneapolis-St. Paul International Airport on Sunday after smoke was seen coming from an airplane on the taxiway.

The Delta Air Lines plane had just landed and smoke could be seen as it was on the taxiway, an MSP spokesperson said. 

There was no fire, but some sort of fluid had leaked onto a hot portion of the Delta airplane, causing smoke to rise, the spokesperson said. 

The incident was resolved late Sunday afternoon.

The plane was towed to Gate F7 after crews had dealt with the issue. 

http://kstp.com

Mooney M20J, N205TG: Incident occurred July 22, 2017 at Washington County Airport (KAFJ), South Franklin Township, Pennsylvania

Federal Aviation Administration / Flight Standards District Office; Allegheny, Pennsylvania

http://registry.faa.gov/N205TG

Aircraft landed gear up.

Date: 22-JUL-17
Time: 18:51:00Z
Regis#: N205TG
Aircraft Make: MOONEY
Aircraft Model: M20J
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: UNKNOWN
Flight Phase: UNKNOWN (UNK)
City: WASHINGTON
State: PENNSYLVANIA

A pilot who apparently forgot to put down his landing gear averted injury Saturday afternoon when he landed his plane at Washington County Airport.

The Mooney M20J piloted by Jean-Dominique Le Garrec, of Squirrel Hill, sustained damage, but no fuel was spilled, according to Bob Griffin of Redevelopment Authority of Washington County, which manages and operates the airport in South Franklin Township.

Griffin said the runway was closed for about 90 minutes to clear debris.

He said Le Garrec, who was alone, mistakenly thought he had put down the landing gear of his plane, which is stationed at Allegheny County Airport.

Bill McGowen, the redevelopment authority’s executive director, said a crane was used to raise the plane to allow the gear to be put down.

County maintenance and Skyward Aviation FBO personnel responded, along with fire departments from South Franklin and Morris townships, and North Franklin Township police. 

http://www.observer-reporter.com

Piper PA-31-350 Navajo Chieftain, N55GK, Spohrer & Dodd Aviation LLC: Fatal accident occurred October 26, 2015 in Weston, Broward County, Florida

Pilot James Alexander Townsend
Yulee, Florida



The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Miramar, Florida
Piper Aircraft; Vero Beach, Florida
Lycoming Engines; Williamsport, Pennsylvania
Hartzell Propeller; Piqua, Ohio

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Spohrer & Dodd Aviation, LLC: http://registry.faa.gov/N55GK

NTSB Identification: ERA16LA026
14 CFR Part 91: General Aviation
Accident occurred Monday, October 26, 2015 in Weston, FL
Aircraft: PIPER PA31, registration: N55GK
Injuries: 1 Fatal, 1 Minor, 1 Uninjured.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

HISTORY OF FLIGHT

On October 26, 2015, at 1233 eastern daylight time, a Piper PA-31-350, N55GK, was substantially damaged during a forced landing to a marsh in Weston, Florida, while on approach to Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The airline transport pilot was fatally injured, one passenger incurred minor injuries, and one passenger was not injured. The business flight was operated by Spohrer & Dodd Aviation LLC., and conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed in the area, and an instrument flight rules flight plan was filed for the flight, which departed Jacksonville Executive Airport (CRG), Jacksonville, Florida, about 1033.

According to a fueling receipt and statements from the passengers, the flight originated from Herlong Recreational Airport (HEG), Jacksonville, Florida, about 1010. Before departure, the airplane was fueled with 17.3 gallons of 100 low-lead aviation gasoline, which brought the fuel quantity in the main fuel tanks to full. No fuel was added to the auxiliary fuel tanks at this time. The flight departed for FXE but diverted to CRG due to a cockpit window that was not properly closed. The pilot secured the window at CRG and departed on the accident flight.

According to information from the Federal Aviation Administration (FAA), the flight was in radio and radar contact with air traffic control (Miami Approach) while being vectored for a visual approach to runway 9 at FXE. At 1230, the air traffic controller instructed the flight to descend from 3,000 ft to 2,000 ft mean sea level (msl), which the pilot acknowledged. The controller subsequently instructed the pilot to turn right from a heading of 160° to 180°, which the pilot acknowledged. About 1 minute later, the controller instructed the pilot to turn left to a heading of 090° and report the airport in sight. The pilot acknowledged the vector but did not initiate a left turn. About 20 seconds later, the controller asked whether the pilot was turning left, and the pilot replied that he might have to land on the interstate highway. He then asked where the airport was, and the controller told him it was 15 miles east. At 1233:28, the pilot reported that he saw the interstate highway. No further communications were received from the airplane.

Review of radar data revealed that the airplane entered a right turn about 1230 and then continued on a straight course of about 180° magnetic from approximately 1232:18, when the airplane was at 2,000 ft msl, until the last radar target was recorded at 1233:41, when the airplane was at 200 ft msl. Further review of the radar data revealed that the majority of the cruise portion of the flight was flown about 40 knots slower than the final portion of the flight. The data indicated about 120 knots groundspeed from 1045 to 1154, then 160 knots groundspeed from 1155 until 1213, when the descent from cruise altitude began.

PERSONNEL INFORMATION

The pilot held an airline transport pilot certificate with ratings for airplane single-engine land and airplane multiengine land. He also held a flight instructor certificate with ratings for airplane single-engine, airplane multiengine, and instrument airplane. The pilot's most recent FAA second-class medical certificate was issued on April 27, 2015. At that time, he reported a total flight experience of 11,000 hours. Review of the pilot's most recent logbook revealed that he had accumulated about 6,379 hours of multiengine flight experience; of which, 105 hours were flown in the accident airplane, dating back to 2006.

AIRCRAFT INFORMATION

The eight-seat, low-wing, retractable-gear airplane, serial number 31-7852013, was manufactured in 1978. It was powered by two Lycoming TIO-540, 350-hp engines equipped with Hartzell propellers. According to maintenance records, the airplane's most recent annual inspection was completed on June 8, 2015. At that time, the airframe had accumulated 6,003.3 total hours of operation and each of the engines had accumulated 1,260.2 hours since major overhaul. At the time of the accident, the airplane had flown 2.9 hours since the annual inspection.

The airplane's fuel system consisted of four fuel bladder tanks. Each wing was equipped with an inboard main fuel tank and an outboard auxiliary fuel tank. Each main fuel tank held 56 gallons and each auxiliary fuel tank held 40 gallons, totaling 192 gallons, of which, 182 gallons were useable. Each main fuel tank was equipped with a flapper valve located on the baffle nearest the wing root, where the fuel pickup was located. The purpose of the flapper was to trap fuel near the fuel pickup and prevent it from flowing outboard, away from the pickup. When the main fuel tank bladders were replaced, the flapper valve would have to be removed and reinstalled. The manufacture year printed on the right main fuel tank bladder was 1994.

Review of FAA records revealed that the operator purchased the airplane in 2008. A previous owner sold the airplane to a company in Guatemala on May 13, 1992. The airplane was then sold to a company in Florida on November 29, 1999. Further review of the airframe logbooks did not reveal any entries regarding removal and replacement of the right main fuel tank bladder; therefore, the location and date of the bladder replacement could not be determined. Further review of maintenance records revealed that the left main fuel tank bladder was removed and replaced in 2004.

METEOROLOGICAL INFORMATION

The 1253 recorded weather at FXE included wind from 110° at 16 knots gusting to 20 knots; visibility 10 miles; few clouds at 3,300 ft, scattered clouds at 4,100 ft, scattered clouds at 5,500 ft; temperature 29°C; dew point 20°C, altimeter 30.03 inches Hg.


WRECKAGE INFORMATION

Examination of the wreckage by an FAA inspector revealed that it came to rest upright in a marsh. The landing gear was retracted, and both engines had separated from their respective wings. The right wing outboard section and the left wingtip had also separated. The left engine fuel selector was positioned to the left auxiliary fuel tank, and the right engine fuel selector was positioned to the right main fuel tank. The inspector observed fuel in both the left main and left auxiliary fuel tanks. About 13 gallons of fuel were then drained from the left wing via a large fuel line behind the left engine, which simultaneously drained fuel from both left wing fuel tanks. The inspector did not observe fuel in the right main or right auxiliary fuel tanks; however, the right auxiliary fuel tank was compromised during impact, and the inspector could not confirm the integrity of the right main fuel tank due to the position of the wreckage.

The wreckage was re-examined at a recovery facility. Review of the cockpit revealed that the pilot's seatbelt and shoulder harness remained intact. The throttle, mixture, and propeller levers for both engines were in the forward positions; however, the control pedestal was canted right, consistent with movement by first responders to extricate the pilot. The battery master, both engine magnetos, and the emergency fuel boost pumps were on. The alternator switches were in the off positions. Although the right engine firewall fuel shut-off lever was partially engaged, the fuel valve was open at the wing root, consistent with lever movement during impact or by rescue personnel.

The wing flaps were in the retracted position. Measurement of the rudder trim jackscrew corresponded to a full nose-right rudder position. Measurement of the elevator trim jackscrew corresponded to an approximate neutral setting. Measurement of the aileron trim jackscrew corresponded to an approximate 1/4-scale right aileron trim setting. Control continuity was confirmed from the ailerons, rudder, and elevator to the mid-cabin area. In addition to the breached right wing auxiliary fuel tank, the right wing main fuel tank bladder was ruptured, consistent with impact. The breach in the right main wing fuel tank bladder was an approximate 1-inch tear near the fuel vent. The right wing main fuel tank flapper valve was absent; the left wing main fuel tank flapper valve was installed.

The valve covers, top spark plugs, oil filter, and vacuum pump were removed from the left engine. The spark plug electrodes were intact and light gray in color. The vacuum pump vanes and drive coupling were intact. When the propeller was rotated by hand, crankshaft, camshaft, and valve train continuity were confirmed to the rear accessory section, and thumb compression was obtained on all cylinders. The fuel injector servo and dual magneto were also removed. The fuel injector servo screen was absent of debris. No fuel was recovered from the fuel injector servo, fuel lines, or engine-driven fuel pump. The dual magneto shaft was rotated via an electric drill, and spark was observed at all 12 leads.

The valve covers, top spark plugs, oil filter, starter, and vacuum pump were removed from the right engine. The spark plug electrodes were intact and light gray in color. The vacuum pump vanes and drive coupling were intact. When the propeller was rotated by hand, crankshaft, camshaft, and valve train continuity were confirmed to the rear accessory section, and thumb compression was obtained on all cylinders. The fuel injector servo and dual magneto were also removed. The fuel injector servo screen was absent of debris. Fuel was recovered from the fuel injector servo and engine-driven fuel pump. The dual magneto shaft was rotated via an electric drill, and spark was observed at all 12 leads.

Teardown examination of both propellers revealed that the four left propeller blades remained attached to the hub. Three blades were bent aft, and one was bent forward. All four blades exhibited leading edge gouging and chordwise scratching consistent with powered rotation at impact. All four left propeller blades were found in the feather position.

The four right propeller blades remained attached to the hub. All four blades were bent aft and exhibited rotational scoring and leading edge damage; however, the damage was less than the damage observed on the left propeller blades. The right propeller blades were found in a normal operating position near the low pitch stop.

MEDICAL AND PATHOLOGICAL INFORMATION

The 63-year-old male pilot had reported to the FAA chronic obstructive pulmonary disease (COPD) and the use of an inhaled combination medication containing budesonide and formoterol to limit his symptoms. This combination of a steroid and long acting beta-agonist is not considered impairing. He was issued a time-limited special issuance second class medical certificate with a limitation for corrective lenses for near and distant vision and marked, "Not valid for any class after 04/30/2016."

The Office of the Medical Examiner & Trauma Services, Broward County, Florida, determined the pilot's cause of death was multiple blunt force injuries and the manner of death was accident. A specimen of blood was drawn on the day of the accident by the treating hospital for toxicological testing at the FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. Testing identified acetone, methanol at 0.003 gm/dl, and ethanol at 0.037 gm/dl in blood. In small amounts, acetone and methanol are not considered impairing. Assuming that the blood sample tested was drawn on admission to the hospital at 1400 (and not later), the pilot's level of ethanol at the time of departure at 1010 was likely between 0.077 gm/dl and 0.177 gm/dl.

ADDITIONAL INFORMATION

A JPI engine monitor and Shadin fuel flow indicator were removed from the airplane and forwarded to the NTSB Vehicle Recorder Laboratory, Washington, DC. Data were successfully downloaded from both units. The Shadin fuel flow indicator displayed 561.4 gallons of fuel used with 0.0 gallons of fuel remaining; however, the unit had to be manually reset after every fueling for accurate information.

Review of plotted data from the JPI engine monitor revealed that the right engine exhaust gas temperature (EGT) decreased from about 1,300°F to 800°F at 1225:15 (the JPI clock was about 5 minutes behind the ATC clock), then increased to 1200°F at 1225:25, followed by a decrease to 200°F at 1226:00, which was about the time the airplane was making a right turn from a course of 160° to 180° magnetic. The left engine exhaust gas temperature remained between 1,150°F to 1,400°F throughout the data to 1228:40. The particular model JPI engine monitor did not store fuel flow or fuel quantity information.




Passenger being brought out from scene on golf cart.








NTSB Identification: ERA16LA026 
14 CFR Part 91: General Aviation
Accident occurred Monday, October 26, 2015 in Weston, FL
Aircraft: PIPER PA 31-350, registration: N55GK
Injuries: 1 Fatal, 1 Minor, 1 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On October 26, 2015, about 1232 eastern daylight time, a Piper PA-31-350, N55GK, operated by Spohrer & Dodd Aviation LLC., was substantially damaged during a forced landing to a marsh in Weston, Florida, while on approach to Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The airline transport pilot was fatally injured, one passenger incurred minor injuries, and one passenger was not injured. The business flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the planned flight to FXE, which departed Jacksonville Executive Airport (CRG), Jacksonville, Florida, about 1033.

According to the passengers and a fueling receipt, the flight originated from Herlong Recreational Airport (HEG), Jacksonville, Florida, about 1010. Prior to departure, the airplane was fueled with 17.3 gallons of 100 low-lead aviation gasoline, which brought the fuel quantity in the main fuel tanks to full. The pilot and passengers departed for FXE, but diverted to CRG due to a cockpit window that was not completely sealed. They secured the window at CRG and departed on the accident flight.

According to preliminary information from the Federal Aviation Administration (FAA), the flight was in radio and radar contact with air traffic control (Miami Approach) while being vectored for a visual approach to runway 9 at FXE. About 1229, the air traffic controller instructed the flight to descend from 3,000 feet to 2,000 feet, which the pilot acknowledged. The controller subsequently provided vectors and instructed the pilot to report the airport insight. The pilot acknowledged the vectors, but had not reported the airport in sight when he stated twice that he might have to land on an interstate highway. He then asked where the airport was and when told it was 15 miles east, he said he saw the interstate highway. No further communications were received from the accident airplane.

Examination of the wreckage by an FAA inspector revealed that it came to rest upright in a marsh. The landing gear was retracted and both engines had separated from their respective wing. The right wing outboard section and the left wingtip had also separated. The left engine fuel selector was found positioned to the left auxiliary fuel tank and the right engine fuel selector was found positioned to the right main fuel tank. Additionally, the right engine firewall fuel shut off lever was engaged. The inspector observed fuel in both the left main fuel tank and left auxiliary fuel tank. He did not observe fuel in the right main fuel tank or right auxiliary fuel tank; however, the right auxiliary fuel tank was compromised during impact and the inspector could not confirm the integrity of the right main fuel tank due to the disposition of the wreckage. The right propeller blades appeared to be at or near the feathered position and the left propeller blades exhibited some rotational damage. The wreckage was retained for further examination.

The pilot held an airline transport pilot certificate, with ratings for airplane single-engine land and airplane multiengine land He also held a flight instructor certificate, with ratings for airplane single-engine, airplane multiengine, and instrument airplane. The pilot's most recent FAA second-class medical certificate was issued on April 27, 2015. At that time, he reported a total flight experience of 11,000 hours.

According to maintenance records, the airplane's most recent annual inspection was completed on June 8, 2015. At that time, the airframe had accumulated 6,003.3 total hours of operation and the engine had accumulated 1,260.2 hours since major overhaul. The airplane had flown 2.9 hours from the time of the inspection, until the accident.

The recorded weather at FXE, at 1253, was: wind from 110 degrees at 16 knots, gusting to 20 knots; visibility 10 miles; few clouds at 3,300 feet, scattered clouds at 4,100 feet, scattered clouds at 5,500 feet; temperature 29 degrees C; dew point 20 degrees C, altimeter 30.03 inches Hg.

Piper PA-28R-180, N4594J, Foluain Fabhcun, LLC: Accident occurred July 23, 2017 at Reid–Hillview Airport (KRHV), San Jose, Clara County, California

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket  - National Transportation Safety Board:  https://dms.ntsb.gov/pubdms

NTSB Identification: WPR17LA164 
14 CFR Part 91: General Aviation
Accident occurred Sunday, July 23, 2017 in San Jose, CA
Aircraft: PIPER PA 28R-180, registration: N4594J
Injuries: 1 Uninjured.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On July 23, 2017, about 1247 Pacific daylight time, a Piper PA-28R-180, N4594J, was substantially damaged during takeoff from the Reid-Hillview Airport (RHV), San Jose, California. The commercial pilot, sole occupant of the airplane, was not injured. The airplane was registered to Foluain Fabhcun LLC., Aptos, California, and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the cross-country flight, which was originating at the time of the accident with an intended destination of Marina, California.

The pilot reported that the airplane had just had extensive maintenance performed, which included installation of several avionics upgrades, and right seat brake pedals; the accident flight was the first flight since the maintenance had been completed. During takeoff on runway 31R, as the airplane became airborne at an airspeed of about 80 miles per hour, it immediately entered an uncommanded roll to the left. The pilot said that he attempted to correct for the roll; however, he was unable to, and instead reduced engine power. Subsequently, the airplane impacted the ground and came to rest upright on runway 31L. 

Examination of the airplane by a Federal Aviation Administration inspector revealed that the fuselage and left wing were structurally damaged. 

Examination of the airplane by the National Transportation Safety Board investigator-in-charge revealed that when the control yoke was rotated for input of right aileron, the left aileron moved upward and the right aileron moved downward. Examination of the aileron cables revealed that they remained attached to the "T" bar aileron control chains. The right aileron control cable was attached to the left side aileron control chain and the left aileron control cable was attached to the right-side aileron control chain. The cables were oriented in a nature that they crossed underneath the flap handle and center console area. 

During a telephone conversation with one of the two mechanics that had worked on the airplane prior to the accident flight, he reported that he performed an oil change along with various other work while another mechanic was installing a second set of rudder pedals with brake controls on the right seat side of the airplane. In addition, the mechanic stated that he checked the airplane for flight control cable tension, noting that the operation was smooth, and visually looked at the ailerons while he was moving the control yoke. He added that at no time did he noticed that the aileron cables were installed backwards. The mechanic further reported that all work on the airplane was performed in accordance with the Piper Aircraft Maintenance Manual. 

The second mechanic reported that he disconnected aileron cables to facilitate installation of rudder pedals and brake assemblies, and subsequently reattached the aileron cables. The mechanic stated that he did not observe the ailerons while the other mechanic checked aileron control deflections. 

During a telephone conversation with the pilot, he reported that prior to the flight, he performed a walk around inspection of the airplane and recalled that he moved the ailerons, but did not verify which direction the control yoke moved. In addition, he said that prior to takeoff, he checked the movement of all the flight controls, but did not verify which direction the ailerons moved when he moved the control yoke. The pilot stated that his primary focus was on the rudder and brakes as they were recently worked on.

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; San Jose, California

Aviation Accident Preliminary Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Foluain Fabhcun, LLC: http://registry.faa.gov/N4594J

NTSB Identification: WPR17LA164
14 CFR Part 91: General Aviation
Accident occurred Sunday, July 23, 2017 in San Jose, CA
Aircraft: PIPER PA 28R-180, registration: N4594J
Injuries: 1 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On July 23, 2017, about 1247 Pacific daylight time, a Piper PA-28R-180, N4594J, was substantially damaged during takeoff from the Reid-Hillview Airport (RHV), San Jose, California. The commercial pilot, sole occupant of the airplane, was not injured. The airplane was registered to Foluain Fabhcun LLC., and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the cross-country flight, which was originating at the time of the accident, with an intended destination of Marina, California.

The pilot reported that this was the airplane's first flight after extensive maintenance, which included installation of several avionics upgrades and right seat brake pedals. During takeoff on runway 31R, as the airplane became airborne at an airspeed of about 80 miles an hour, it immediately entered an uncommanded roll to the left. The pilot said that he attempted to correct the roll, without success, and the airplane impacted the ground.

Examination of the airplane by a Federal Aviation Administration inspector revealed that the fuselage and left wing were structurally damaged. The airplane was recovered to a secure location for further examination.




SAN JOSE — A small plane trying to take off from Reid-Hillview Airport Sunday afternoon tilted and skidded off the runway, prompting a brief halt in takeoffs and landings, according to fire officials.


The pilot suffered minor injuries and was treated at the airport. There were no other passengers aboard.

About 12:45 p.m. San Jose Fire dispatchers received an emergency call from the airport, fire Capt. Brad Cloutier said.

“The Piper PA-28R-180 had just departed Runway 31 Right when it crashed onto Runway 31 Left under unknown circumstances,”  Allen Kenitzer of the FAA Office of Communications wrote in an email.

“One wing tip got tilted, hit the pavement and caused the plane to skid off the runway,” Randy Christopher, a fire department senior dispatcher, said.

The pilot was able to get out of the plane, Cloutier said. The plane ended up losing its nose gear on the pavement.

The aircraft sustained substantial damage, according to Kenitzer.

Landings and takeoffs were suspended for about a half-hour until firefighters could clean up spilled oil and airport officials could move the plane away from the landing strip area.

The Federal Aviation Administration and the National Transportation Safety Board, as is usual in aircraft crashes, will investigate, Kenitzer said.

http://www.mercurynews.com

Piper PA-28R-180 Arrow, N4972J: Fatal accident occurred October 17, 2015 in Morongo Valley, California

Bob Trimble

Terri Day died in a Piper PA-28R-180 Arrow crash after flying to Palm Springs from Santa Barbara to deliver a military bracelet to the local air museum for display.





The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Riverside, California
Lycoming Engines; Williamsport, Pennsylvania
Piper Aircraft; Vero Beach, Florida

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

http://registry.faa.gov/N4972J 

NTSB Identification: WPR16FA014 
14 CFR Part 91: General Aviation
Accident occurred Saturday, October 17, 2015 in Morongo Valley, CA
Probable Cause Approval Date: 07/20/2017
Aircraft: PIPER PA 28R-180, registration: N4972J
Injuries: 2 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The non-instrument rated private pilot and his passenger completed a cross-country flight from their home base to another airport in the airplane earlier that day. They delayed their initial planned departure time for that flight due to weather concerns, ultimately arriving 3 hours later than planned. During that flight, they flew over a high mountain range and through a mountain pass.

For the return (accident) flight a few hours later, the weather had deteriorated, resulting in low ceilings along the original route (including in the pass), with high cloud tops and rapidly building cloud formations west and north of the departure airport in the intended direction of the return flight. However, there is no record that the pilot obtained weather information before departing on the return flight.

While on the ground, the pilot reported to air traffic control that he was planning to take a "northern route," which would have taken them around the north side of the east-west mountain range that they had crossed on the inbound leg. Shortly after takeoff, the pilot reported to air traffic control that, due to clouds, he would need to climb to an altitude of 9,000 ft mean sea level (msl), which was almost twice as high as originally requested. The request was most likely because, once airborne, the pilot could see the full extent of the building cloud formations to the north along his route, as well as the formations building just west of the departure airport.

As the flight proceeded, the air traffic controller began the first of what would become a series of warnings to the pilot about mountainous terrain. The pilot responded that he was aware of the terrain. He then began a series of six climbing 360° turns, rolling out on a west heading directly toward, and about 700 ft lower than, the mountain peak. The controller warned the pilot of the peak several times, and the pilot responded, sounding confused, stating that he was still climbing.

Now cruising at an altitude of about 11,000 ft msl, the airplane's climb capabilities had diminished. Furthermore, the pilot did not appear to be flying the airplane at a speed that would have resulted in optimal climb performance. The airplane continued heading west, now no longer climbing and most likely just above the cloud tops. With high and ominous-looking cloud formations now building to the left and right of the flight track, the pilot most likely opted to continue on his homeward westerly track, while attempting to climb over the terrain and clouds ahead.

The airplane then suddenly reversed course and rapidly descended. It then transitioned to a fast spiraling descent, and, when challenged by the controller as to whether he had the terrain in sight, the pilot exclaimed, "Negative! Negative!" The turn rate increased as the airplane descended to about 7,500 ft msl and then impacted mountainous terrain just below the cloud bases. Examination of the accident site indicated that the airplane struck the ground in a wings-level attitude at a high forward speed. Damage patterns indicated that the engine was producing power at impact.

It is likely that, unable to outclimb the terrain and the cloud tops, the airplane entered the clouds and thus instrument meteorological conditions during the final portion of the flight, and the pilot then experienced spatial disorientation and lost control of the airplane, which resulted in the rapid descent. Additionally, prior to the descent into clouds, he was flying almost directly towards the sun, which could have been a further distraction and additional source of stress.

Many of the 71-year-old pilot's medical conditions, including hypertension, low testosterone, Barrett's esophagus, chronic obstructive pulmonary disease, deafness, chronic neck pain, vitamin D deficiency, and prediabetes, were unlikely to cause acute symptoms or be chronically impairing. Similarly, his blood pressure medication, cholesterol medication, testosterone, and prostate medication would not have impaired judgement, decision-making, or flight skills. 

However, several medications that the pilot was using would have impairing effects. Hydrocodone, which was detected in the toxicology testing, is an impairing opiate pain medication and carries warnings regarding hazards while driving or operating machinery; however, with regular use, a chronic user may appear to function normally, so the pilot may not have been impaired by his use of opiods. Quetiapine, also detected during toxicology testing, is an antipsychotic indicated for the treatment of schizophrenia and bipolar syndrome and carries warnings for an increased risk of seizures and somnolence. It can also impair judgment, thinking, or motor skills, and may have impaired the pilot's performance during the accident flight. 

The pilot's medical records revealed that he had required years of ongoing psychotherapeutic support to manage the combined symptoms of PTSD and depression; at the time of the accident he had been experiencing an exacerbation of those symptoms for several months, and it did not appear that the symptoms had been completely resolved. Patients with PTSD experience marked cognitive, affective, and behavioral responses to stimuli. These symptoms are likely to occur in stressful situations and may have contributed to his confusion during the high workload period while attempting to ascend above mountain peaks. Further, depression is associated with cognitive degradation, particularly in executive functioning. 

Therefore, under the stressful conditions of this flight, the combined effects of impairing medications, depression, and PTSD likely resulted in the pilot experiencing significant cognitive degradation.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The non-instrument rated pilot's improper inflight decision-making to attempt to outclimb clouds along his planned route rather than reverse course, which resulted in his inadvertent entry into instrument meteorological conditions, spatial disorientation, and a resultant loss of control. The pilot's preexisting medical conditions and his use of impairing medications contributed to his degraded performance.

On October 17, 2015, at 1552 Pacific daylight time, a Piper PA28R-180, N4972J, impacted mountainous terrain near Morongo Valley, California. The private pilot and passenger sustained fatal injuries; the airplane was destroyed. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The cross-country personal flight departed Palm Springs International Airport (PSP), Palm Springs, California, at 1513, with a planned destination of Santa Barbara Municipal Airport, Santa Barbara, California. Visual meteorological conditions prevailed at the departure airport, and no flight plan had been filed.

Earlier on the day of the accident, the pilot and passenger flew the airplane from their home base of Santa Barbara to Palm Springs in order to visit a museum. According to friends, the original planned departure time for the flight to Palm Springs was 0900; however, due to weather conditions, they departed just before noon and arrived about 1330. Radar data revealed that the route of the outbound flight was via Santa Paula, Valencia, and Acton, then across the east-west mountain range of the Angeles National Forest, across the Los Angeles Basin, and through the Banning Pass to Palm Springs.

For the return trip, the pilot requested visual flight rules (VFR) flight following from the clearance delivery controller at Palm Springs and reported that his route of flight back to Santa Barbara would be along a northern route via Palmdale. He initially requested an altitude of 7,500 ft mean sea level (msl) and then immediately corrected himself, requesting 5,500 ft msl. The controller responded, telling the pilot to squawk VFR and to expect a northbound departure with an unrestricted climb.

Radar and audio data provided by the Federal Aviation Administration (FAA) captured the entire flight sequence, beginning with the departure from runway 31R at PSP.

Following takeoff, the airplane began a climb to the north, and, about 6 minutes later, the pilot initiated radio contact with Southern California Terminal Radar Approach Control, stating that he was 6 miles northeast of Palm Springs. He requested VFR flight following to Santa Barbara and, during the exchange, stated, "It looks like we might have to get up to 9,000 ft with the clouds." The air traffic controller responded, providing the pilot with a squawk code, altimeter setting, and instructions to maintain VFR at an altitude at the pilot's discretion. The pilot confirmed the instructions, and, a short time later, the controller responded that he had obtained radar contact with the airplane. The airplane continued to climb, and, about 4 minutes later, after it reached an altitude of about 5,200 ft msl, the controller communicated, "just to be clear you do have the terrain in sight to your left, right?" The pilot responded in the affirmative and added that he was going to perform a 360° turn to gain altitude. The controller responded, "Ok, just wanted to make sure we are on the same page." The controller then transmitted, "Are you guessing you are going to wind up north of Big Bear or do you think you're going to be able to get up through the Banning Pass, is that what your intents are?" The pilot responded, "I'm going to try to go through San Bernardino and out to the desert then out by General Fox." The airplane then began a left 270° turn, rolling out on a northeast heading by which time it had reached an altitude of 7,000 ft msl.

Over the next 14 minutes, the airplane conducted a series of 6 climbing 360° turns, eventually rolling out on a west heading, at an altitude of 10,800 ft msl. By that time, the airplane was about 14 miles east of, and heading directly toward, the 11,500 ft peak of San Gorgonio Mountain. The pilot reported that he was now travelling west, and the controller transmitted, "So you're going to go north side of the peak then, there, correct?" The pilot reported, "Um, say again," and the controller responded, "N72J are you going to go north side of the peak there or south side there?" The pilot responded, "Umm, I show that we're heading right to San Bernardino." The controller retorted, "Ok, I show an eleven seven peak between you and San Bernardino." The pilot responded, "Um, I'm at um, one zero thousand six hundred." The controller responded, "Roger," and, after a brief pause, the pilot continued, "and I'm still climbing."

The airplane maintained the west heading and continued to climb at ground speeds varying between 60 and 70 knots, reaching 11,100 ft msl about 3 minutes later. It then conducted another 360° left turn but had not gained significant altitude once it rolled out about 2 minutes later. The westbound track continued at similar speeds toward the peak for the next 4 minutes, as the airplane climbed 200 ft to 11,300 ft. The next radar target appeared 15 seconds later, indicating the airplane had rapidly reversed course and descended to 9,700 ft msl. The airplane then began a spiraling descent, and the controller transmitted, "Piper 72J you are descending once again in an area of higher terrain just west of you, I have a peak that I show to be at eleven thousand seven hundred feet, just west of your position...72J you cut me out, verify you still have the terrain in sight." The pilot then transmitted, "Negative! Negative!," and in the background the passenger could be heard expressing significant alarm. The controller continued issuing instructions, "N72J remain calm, if you are able proceed eastbound, remain VFR proceed eastbound, hold your altitude if you are able I see you are descending - repeat, eastbound, VFR, hold your altitude if you are able you are in an area of higher terrain." The pilot did not respond, and, over the next 45 seconds, the airplane continued to perform two more spiraling turns, with radiuses of about 1,200 and 700 ft, respectively, to the last recorded radar position, at an altitude of 7,500 ft.

Over the next few minutes, the controller tried reestablishing communication with the pilot but did not receive a response. A Riverside County Sheriff's Department helicopter was flying in the vicinity, so the controller provided the helicopter's crew with vectors to the airplane's last radar location and asked if they could establish radio communication. They attempted to do so, but no response was received. They reported that the search area was mountainous and obscured by clouds, and, after multiple approach attempts, they located burning wreckage along a ridge, about 100 ft below the base of the clouds. The following three figures show the airplane's radar track.

PERSONNEL INFORMATION

The 71-year-old pilot held a third-class medical certificate limited by a requirement that he must wear corrective lenses for near and distant vision. He was issued a private pilot certificate on September 9, 2014, at which time he reported a total flight experience of 85 hours of which 15 hours were as pilot in command. All the reported flight experience was in a Cessna 172. The pilot did not hold an instrument rating.

The pilot was the general manager for a repair station at Santa Barbara Airport. The airplane was maintained at the repair station, and the passenger worked at the repair station.

No personal flight records were recovered; however, the repair station's chief inspector stated that the pilot had flown regularly in the airplane, taking multiple trips to Oregon and the Mojave area during the period between receiving his private certificate and the accident. He stated that the reason for the flight was to drop off memorabilia at the flight museum in Palm Springs, and he was not aware of any pressing reason for the pilot and passenger to return promptly that night.

AIRPLANE INFORMATION

The single-engine, retractable-landing-gear airplane was manufactured in 1968 and powered by a fuel-injected Lycoming IO-360-B1E engine. An annual inspection was performed on May 27, 2015. At that time, the airframe had accrued 3,704.90 total flight hours, and the engine had accrued 1,308.0 hours since overhaul.

An avionics upgrade was performed following the May 2015 annual inspection and was completed on August 17, 2015. The upgrade included the installation of a Garmin GTN 650 touchscreen GPS/Nav/Comm and a Garmin GDL 88 ADS-B transceiver. In combination, the pairing provided the pilot with terrain mapping, graphical NEXRAD radar, and weather data on the GTN 650 screen. The chief inspector stated that the pilot was still gaining familiarity with the system and was not fully proficient with its use and features.

The chief inspector also reported that the pilot kept an iPad tablet computer onboard for weather and navigation and that the airplane was equipped with a portable oxygen system. Due to fire damage, neither of these systems could be positively identified in the debris; therefore, their operational status could not be determined. Photographs posted by the passenger on a social media website after the flight to Palm Springs indicated that the pilot had mounted the iPad on the control yoke.

METEOROLOGICAL INFORMATION

The pilot did not call Lockheed Martin Flight Service for a telephone weather briefing either the day before or the day of the accident, and there was no record of him downloading an official weather briefing from any DUAT vendor.

Satellite Data

Geostationary Operational Environmental Satellite number 15 (GOES-15) imagery taken at 1545 and 1600 indicated an area of low- to mid-level clouds over the accident site, with cloud tops near 11,000 ft (figure 4). During that period, an area of clouds was observed developing near Big Bear, California, 12 miles northwest of the accident site, along with rapidly developing enhanced clouds (tops near 33,000 ft) between the accident site and Palm Springs. Multiple layers of clouds extended from west of Palm Springs through to the accident site and obscured Banning Pass to the south. The Riverside County Sheriff's Department helicopter crew reported cloud bases of about 1,500 ft above ground level (agl) in Banning Pass.

Base Reflectivity

An image from Edwards Air Force Base WSR-88D radar (NEXRAD) at 1552 revealed several developing echoes north and south of the accident location. Some very light intensity echoes were identified immediately west of the accident location, consistent with cloud buildups immediately ahead of the airplane's westbound track and over the higher terrain.

Upper Air Data

The NOAA Air Resource Laboratory North American Mesoscale numerical model over the accident site location depicted a conditional unstable atmosphere with an expected cloud base at 2,196 feet agl, cloud tops near 11,000 ft msl, and potential convective cloud tops near 40,000 ft. The freezing level was identified at 14,776 ft. The wind profile indicated southerly winds veering to the west with height; the average wind from 0 ft to 18,000 ft was from 250° at 9 knots. No significant turbulence or mountain wave activity was noted in the model sounding through 18,000 ft.

Area Forecast

An area forecast issued at 1245 and valid to 0100 the following morning indicated cloud tops in the Los Angeles Basin area varying between 3,000 and 4,000 ft, with an outlook for marginal VFR.

Surface Observations

The closest weather reporting facility to the accident location was at Big Bear City Airport, about 11 miles north-northwest of the accident site at an elevation of 6,752 ft. At 1535, an automated report indicated wind from 080° at 3 knots, visibility 10 miles, ceiling broken at 2,100 ft, broken at 2,600 ft, and overcast at 3,500 ft, temperature 13°C, dew point 9°C, altimeter 30.15 inches of mercury. At 1552, similar conditions existed with the addition of light rain.

At 1553, PSP reported wind from 140° at 4 knots, visibility unrestricted at 10 miles, scattered clouds at 7,000 ft, temperature 32°C, dew point temperature 15°C, and altimeter 29.82 inches of mercury.

At 1447, San Bernardino International Airport, about 26 miles west of the accident site, at an elevation of 1,159 ft, reported wind from 240° at 10 knots, visibility 7 miles, scattered clouds at 6,000 ft, temperature 29°C, dew point 14°C, altimeter 29.87 inches of mercury.

At 1556, Yucca Valley Airport, about 17 miles east of the accident site, reported wind from 110° at 8 knots, visibility 10 miles, with scattered clouds at 8,000, 15,000, and 20,000 ft.

Astronomical Data

In Palm Springs at the time of the accident, the sun was 26° above the horizon at an azimuth of 236°. Sunset was at 1810, with the end of civil twilight at 1835.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located at an elevation of 7,222 ft msl on the eastern flank of the San Bernardino Mountain range, 24 miles north-northwest of PSP, 6 miles east of the San Gorgonio Mountain peak, and about 200 ft northeast of the last recorded radar target.

The airplane came to rest upright on a heading of 330° magnetic, on the 25° uphill slope of a boulder-strewn ridge (Photo 1). The entire cabin forward of the baggage door was consumed by fire. Both wings sustained crush damage through to their main spars, and the empennage had folded up over the tailcone. Fragments of the cabin structure and engine cowling had been propelled forward, creating a debris field about 60 ft long.

MEDICAL AND PATHOLOGICAL INFORMATION

FAA Medical Records

At the time of the pilot's most recent FAA medical examination, he was 70 inches tall, weighed 157 pounds, and reported hypertension treated with atenolol and amlodipine (prescription blood pressure medications often marketed with the names Tenormin and Norvasc, respectively). The physical examination was unremarkable.

Autopsy and Toxicology

An autopsy was performed by the San Bernardino County Sheriff's Department, Coroner Division; the cause of death was reported as multiple blunt force injuries. Thermal damage limited the scope of the examination, with no significant natural disease identified from the available remains, and no tissues beyond lung and liver available for toxicology testing.

Toxicology testing performed by the Office of the Medical Examiner, County of San Diego, identified an opiate and confirmed the presence of quetiapine and its metabolites in liver tissue. Furthermore, testing performed by the FAA's Bioaeronautical Research Sciences Laboratory identified amlodipine, atenolol, losartan, atorvastatin, hydrocodone (0.116 ug/g) and its metabolites hydromorphone (0.045 ug/g) and dihydrocodeine as well as quetiapine (0.725 ug/g) in liver tissue. In addition, atenolol, hydrocodone (0.056 ug/g), and quetiapine were identified in lung tissue.

Losartan is a prescription blood pressure medication often marketed with the name Cozaar. Atorvastatin is used to treat high cholesterol and is commonly marketed with the name Lipitor. Hydrocodone is a prescription opioid identified as a Schedule II controlled substance by the Drug Enforcement Administration. It is most commonly sold in combination with acetaminophen, often with the names Vicodin and Lortab. It carries several warnings, including, "Hydrocodone, like all narcotics, may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery" and "Alcohol and other CNS (central nervous system) depressants may produce an additive CNS depression, when taken with this combination product, and should be avoided."

Quetiapine is an antipsychotic indicated for the treatment of schizophrenia and bipolar syndrome. It carries several warnings including one for an increased risk of seizures and a specific warning about somnolence, which states, "quetiapine has the potential to impair judgment, thinking, or motor skills, patients should be cautioned about performing activities requiring mental alertness, such as operating a motor vehicle (including automobiles) or operating hazardous machinery until they are reasonably certain that quetiapine therapy does not affect them adversely. Somnolence may lead to falls."

Personal Medical Records

The pilot was receiving treatment from medical facilities of the US Department of Veterans Affairs (VA). According to records obtained from the VA covering the period from 1999 to the date of the accident, the pilot had a history of chronic neck pain requiring the use of opioids, a vitamin D deficiency, hypertension, an abnormal stress thallium test suggesting coronary artery disease, deafness requiring hearing aids, prediabetes, chronic obstructive pulmonary disease, Barrett's esophagus, and low testosterone.

His medications at the time of the accident included a hydrocodone/acetaminophen combination (7.5mg/325mg every 6 hours), losartan, atenolol, amlodipine, aspirin, atorvastatin, finasteride, gabapentin, and topical testosterone.

Gabapentin is a prescription medication initially developed as an antiseizure drug, which is also used to treat nerve pain. It is commonly marketed with the name Neurontin. Gabapentin carries a warning about increased risk of suicidal thoughts or actions with its use and risk of somnolence and dizziness. As a result, it carries a recommendation that patients are to be notified that it "may cause dizziness, somnolence, and other symptoms and signs of CNS depression. Accordingly, they should be advised neither to drive a car nor to operate other complex machinery until they have gained sufficient experience on gabapentin to gauge whether or not it affects their mental and/or motor performance adversely." Gabapentin is excreted unchanged in urine and is not stored in organ tissues. As a result, its absence on the toxicology testing of liver and lung in this case does not indicate whether or not the pilot was using it.

Because of existing risk factors, the pilot underwent cardiac testing in 2001. The results revealed abnormal exercise and thallium stress test results, indicating likely early single vessel coronary artery disease. As the pilot was asymptomatic at the time, the decision was to improve the control of his blood pressure and cholesterol levels. Follow-up stress testing was unchanged, and, as the pilot remained asymptomatic, no further intervention was performed.

The pilot periodically reported neck pain, which was first treated with opioids in 2007. It recurred in 2010, and, following a telephone consultation with the physician, he was prescribed hydrocodone/acetaminophen 5/325mg, one tablet 4 times a day as needed. He continued on this regimen until the dose was increased to the 7.5/325mg tablets in July 2012.

In November 2014, the pilot's prescription for hydrocodone for chronic pain was changed because the Drug Enforcement Administration changed it from a Schedule III to a Schedule II controlled substance, indicating an increased risk for abuse. Over the next few months, he tried using codeine and tramadol instead but was unable to get sufficient pain relief. He returned to hydrocodone/acetaminophen 7.5/325 mg four times a day on February 19, 2015, and maintained that dosing regimen until the accident. Records indicated he routinely refilled the prescription monthly. In a visit with his primary care physician dated August 25, 2015, the physician noted the pilot had a normal neurologic exam including motor and nerve function as well as normal gait and that his mood was stable and calm. The physician documented his impression that the pilot's judgment and insight were intact.

According to the pilot's psychology and psychiatry report, he suffered from post-traumatic stress disorder and major depressive disorder, for which he was treated with quetiapine and psychotherapy from 2003 forward. He attended regular psychotherapy sessions, and, several months before the accident, he had been feeling "pretty bad" and requested biweekly rather than monthly therapy sessions to obtain additional support for the stressors in his life. During a session on September 14, 2015, the therapist noted the pilot reported he was "doing OK" but seemed edgy. On September 22, 2015, about 3 weeks before the accident, the pilot met with his therapist. The records documented that, at that time, he was doing "pretty good." Although the plan was to return to monthly sessions beginning in October, the therapist noted that he "seemed to be isolating" himself and documented her intent to review the issue with him at the next visit.

TESTS AND RESEARCH

Engine and Airframe Examinations

The airframe sustained extensive thermal damage that consumed the entire cabin through to the tail cone. Remnants of all the airplane's primary structures were accounted for at the accident site.

The firewall was crushed and detached from the airframe, and the steel remnants of the seat frames, flight control columns, cables, and bellcranks exhibited fragmentation and bending damage with fire consuming all their ancillary components. The landing gear was in the retracted position, and the rudder and stabilator control cables were continuous from the control surfaces through to the cabin controls. The aileron control cables were continuous from the wing-mounted bellcranks through to the chain fittings at the control column. Both wing bellcranks were still connected via the aileron balance cable.

The engine remained partially attached to its mount, which had detached from the firewall. The engine was thermally discolored and covered in soot, and the forward crankcase and forward fins of the No. 1 cylinder were crushed and cracked. The accessory case was consumed by fire along with both magnetos, the vacuum pump, the oil sump, and the induction tubes. The drive train area was exposed, with only the crankshaft and camshaft drive gears remaining.

The top spark plugs were removed and examined. The spark plugs were of the massive electrode type, and the plugs from cylinder Nos. 1, 2 and 4 were dark in color with the plug from cylinder No. 3 exhibiting a lighter grey coloration. The varying coloration of the No. 3 plug was attributed to its being exposed to the thermal effects of the post impact ground fire. According to the Champion Aviation Check-A-Plug AV-27 Chart, the electrodes exhibited minimal wear signatures.

The cylinder combustion chambers were examined using a borescope. The combustion chambers appeared mechanically undamaged, and there was no evidence of foreign object ingestion or detonation. The valves were intact and undamaged, and there was no evidence of valve to piston face contact.

Holes were drilled in the upper crankcase to facilitate examination of the camshaft lobes using a lighted borescope. All lobes appeared undamaged. The crankshaft and attached connecting rods remained undamaged and free of heat distress.

The propeller hub had separated from the crankshaft. The separation features on the crankshaft were conical in appearance with a 45° shear lip around the entire radius of the break. Both propeller blades had separated about 10 inches from their tips. Both inboard blade sections exhibited similar chordwise scratches, tip twist, and leading edge nicks.

Performance

The airplane manufacturer's operating handbook defined a best rate of climb speed at maximum gross weight of 100 mph and a best angle of climb speed of 90 mph. The handbook stated that at lower gross weights, "speeds are reduced somewhat."

For enroute climb, the handbook recommended a speed of 110 mph to produce a better forward speed and increase the visibility over the nose. According to the rate of climb versus density altitude chart, at maximum gross weight with landing gear and flaps retracted, the rate of climb at a density altitude of 13,000 ft would have been about 200 ft per minute. The airplane's service ceiling was 15,000 ft.

ADDITIONAL INFORMATION

Regarding supplemental oxygen requirements, 14 CFR 91.211 states:

"No person may operate a civil aircraft of U.S. registry -

(1) At cabin pressure altitudes above 12,500 feet (MSL) up to and including 14,000 feet (MSL) unless the required minimum flight crew is provided with and uses supplemental oxygen for that part of the flight at those altitudes that is of more than 30 minutes duration;

(2) At cabin pressure altitudes above 14,000 feet (MSL) unless the required minimum flight crew is provided with and uses supplemental oxygen during the entire flight time at those altitudes; and

(3) At cabin pressure altitudes above 15,000 feet (MSL) unless each occupant of the aircraft is provided with supplemental oxygen."

The flight from Santa Barbara to Palm Springs lasted about 1 hour 40 minutes and was flown primarily at an average altitude of about 7,500 ft, except for a 20-minute period in the middle of the flight when the altitude was between 10,000 and 11,700 ft.






NTSB Identification: WPR16FA014
14 CFR Part 91: General Aviation
Accident occurred Saturday, October 17, 2015 in Morongo Valley, CA
Aircraft: PIPER PA 28R-180, registration: N4972J
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On October 17, 2015, at 1552 Pacific daylight time, a Piper PA28R-180, N4972J, impacted mountainous terrain near Morongo Valley, California. The airplane was registered to, and operated by, the pilot under the provisions of 14 Code of Federal Regulations Part 91. The private pilot and passenger sustained fatal injuries; the airplane was destroyed. The cross-country flight departed Palm Springs International Airport, Palm Springs, California, at 1513, with a planned destination of Santa Barbara Municipal Airport, Santa Barbara, California. Visual meteorological conditions prevailed at the departure location, and no flight plan had been filed.

The pilot and passenger departed in the accident airplane on the outbound leg from Santa Barbara to Palm Springs earlier that morning. According to friends, the original departure time for that flight was due to be 0900; however, due to weather conditions they departed just before noon, landing about 1330. Preliminary radar data revealed that for the outbound flight they travelled via Santa Paula, Valencia, and Acton, where they then traversed the Angeles National Forest, crossed the Los Angeles Basin, and flew through the Banning Pass to Palm Springs.

They visited a museum while in Palm Springs, and then departed for the return to Santa Barbara. Radar and audio data provided by the FAA captured the entire flight sequence, beginning with the departure from runway 31R. Following takeoff the airplane began a climb to the north, and about 6 minutes later, the pilot initiated radio contact with Southern California TRACON (Terminal Radar Approach Control), stating that he was 6 miles to the northeast of Palm Springs. He requested visual flight rules (VFR) flight following to Santa Barbara, and during the exchange stated, "It looks like we might have to get up to 9,000 feet with the clouds." The air traffic controller responded, providing the pilot with a squawk code, altimeter setting, and instructions that he maintain VFR conditions at an altitude at the pilot's discretion. The pilot confirmed, and a short time later the controller responded that he had made radar contact. The airplane continued to climb, and about 4 minutes later, having reached an altitude of about 5,200 ft mean sea level (msl), the controller communicated, "just to be clear you do have the terrain insight to your left, right?" The pilot responded in the affirmative, further stating that he was going to perform a 360-degree to turn to gain altitude. The controller responded, "Ok, just wanted to make sure we are on the same page." The controller then transmitted, "Are you guessing you are going to wind up north of Big Bear or do you think you're going to be able to get up through the Banning Pass, is that what your intents are?" The pilot responded, "I'm going to try to go through San Bernardino and out to the desert then out by General Fox." The airplane then began a left 270-degree turn, rolling out on a northeast heading by which time it had reached an altitude of 7,000 ft.

For the next 14 minutes, the airplane began a series of six climbing 360-degree turns, eventually rolling out on a west heading, at an altitude of 10,800 ft. By that time the airplane was about 12 miles east of, and heading directly towards, the 11,500 ft peak of San Gorgonio Mountain. The airplane initiated another 360-degree turn, this time gaining 100 ft, when the pilot reported that he was now travelling west. The controller transmitted, "So you're going to go north side of the peak then, there, correct?" The pilot reported, "Um, say again" and the controller responded, "N72J are you going to go north side of the peak there or south side there?" The pilot responded, "Umm, I show that we're heading right to San Bernardino." And the controller retorted, "Ok, I show an eleven seven peak between you and San Bernardino." The pilot responded, "Um, I'm at um, ten thousand six hundred." The controller responded "Roger," and after a brief pause the pilot continued, "and I'm still climbing."

The airplane maintained a west heading for another 7 minutes, and then began to descend. The controller transmitted, "Piper 72J you are descending once again in an area of higher terrain just west of you, I have a peak that I show to be at eleven thousand seven hundred feet, just west of your position...72J you cut me out, verify you still have the terrain in sight." The pilot then transmitted, "Negative! Negative!" The controller continued issuing instructions, "N72J remain calm, if you are able proceed eastbound, remain VFR proceed eastbound, hold your altitude if you are able I see you are descending - repeat, eastbound, VFR, hold your altitude if you are able you are in an area of higher terrain." The pilot did not respond and over the next 45 seconds the airplane continued to descend to the last recorded position at an altitude of 7,775 ft.

The wreckage was located at an elevation of 7,222 ft, on the eastern flank of the San Bernardino Mountain range, about 200 ft northeast of the last recorded radar target. The airplane came to rest on a heading of 330 degrees magnetic, on the 25-degree uphill slope of a boulder-strewn ridge. The entire cabin forward of the baggage door was consumed by fire. Both wings sustained crush damage through to their main spars, and the empennage had folded up over the tailcone. Fragments of the cabin structure and engine cowling had been propelled forward, creating a debris field about 60 ft long.