# NTSB LAX01FA222: Beech 35-B33, N22CR, Lakeside, CA, June 25, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 25, 2001, 09:54 local (16:54 UTC) - Place: Lakeside, CA - Coordinates: 32.838333, -116.908889 - Nearby events: https://openairdocs.org/map.md?lat=32.8383&lon=-116.9089&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 2, 2004 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Raytheon Aircraft Company (Beech) - NTSB case key (mKey): 53342 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01FA222 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53342/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=53342 - Page: https://openairdocs.org/ntsb/LAX01FA222 ## Probable cause Loss of control in flight due to cardiovascular incapacitation. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - incapacitation(cardiovascular), pilot in command (cause) - aircraft control - not possible, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - residential area ## Analysis The pilot took off at about 0935 pacific daylight time. At 0945, the pilot had advised the radar controller that he was returning to the departure airport, and he stated that he was not feeling well. A minute later, during a subsequent transmission, the controller asked the pilot if he was feeling any better. The pilot's answer was unintelligible. Thereafter, at 0950, the pilot stated "Tower, get an ambulance to the field." Several eyewitnesses observed the airplane approaching the airport at a low altitude. As the airplane descended it entered a steep left bank and collided into the side of a parked truck. The airplane came to rest about 3.3 nm from the airport. In 1999, the manager of the FAA Aeromedical Certification Division had reviewed the pilot's medical information, which revealed a history of congestive heart failure and other ailments. The FAA determined the pilot was ineligible for issuance of a third-class aviation medical certificate. However upon the pilot's submission of additional medical information, the FAA granted authorization for special issuance of the requested third-class medical certificate. The certificate was subsequently renewed, and at the time of the accident it bore an expiration date of August 31, 2001. In the autopsy report the deputy medical examiner indicated that the "history of severe cardiac dysfunction and the findings of severe arteriosclerosis and myocardial scarring and granulation tissue suggest that the [the pilot's] incapacitation was likely due to an acute cardiac event." ## Factual narrative HISTORY OF FLIGHT On June 25, 2001, about 0954 Pacific daylight time, a Beech 35-B33, N22CR, impacted terrain during an uncontrolled descent in Lakeside, California. The accident site was about 3.3 nautical miles east-northeast of the Gillespie Field, El Cajon, California, where the pilot had been cleared to land. The airplane was co-owned and operated by the pilot, and it was destroyed. The private pilot was fatally injured. No one on the ground was injured. Visual meteorological conditions prevailed, and no flight plan was filed. The personal flight was performed under 14 CFR Part 91. The flight originated from Gillespie Field about 0935. The pilot's destination was Deer Valley, Arizona. The National Transportation Safety Board investigator's review of recorded radar data and the Federal Aviation Administration (FAA) radio communications to and from the pilot indicates that at 0938:58 the pilot contacted Southern California Terminal Radar Approach Control (SOCAL) and reported "with you off Gillespie eastbound three thousand climbing seven thousand five." About 0945, the eastbound airplane's altitude had reached 7,000 feet, as reported by the airplane's Mode C equipped transponder. At 0945:19, the airplane began a right turn southbound, and at 0945:22, the pilot advised SOCAL that he was "returning for Gillespie." When asked to identify, at 0945:36, the pilot said "I'm indenting twelve hundred [cough] I'm not feeling well." SOCAL acknowledged the pilot's transmission and inquired regarding his position. At 0945:50, the pilot responded and according to SOCAL his transmission was partially unintelligible and coughing was heard. Thereafter, at 0945:57, SOCAL asked the pilot "Do you require any assistance? I have you radar contact." The pilot's reply was unintelligible. At 0946:07, the SOCAL controller again asked the pilot, "Do you require any assistance sir?" At 0946:11, the pilot responded "I don't know." SOCAL advised the pilot that it would inform the Gillespie tower and let them know he was not feeling well, to which at 0946:19, the pilot replied "thank you." At this time the airplane was traveling westbound toward Gillespie at 7,200 feet. At 0946:21, SOCAL contacted Gillespie tower and notified the tower that the pilot "doesn't sound good." At 0947:17, SOCAL advised the pilot to contact Gillespie tower and asked the pilot if he was "feeling any better." The pilot's answer was unintelligible. According to a local Gillespie air traffic controller, at 0948:46, the pilot's voice was heard on the tower frequency. The controller described his voice as "wavering and weak." At 0948:50, Gillespie tower advised the pilot there was no need to respond, to proceed inbound, and to expect a clearance at 3 miles. In response at 0948:59, a mike click was heard. At 0950:04, the pilot broadcast "tower, get an ambulance to the field." The local controller declared an emergency for the pilot and cleared him to land. Thereafter the controller observed the airplane make a right turn and descend below radar coverage. The last radar return occurred at 0951:56, when the airplane was at 32 degrees 48.138 minutes north latitude by 116 degrees 52.275 minutes west longitude. The airplane's altitude was 4,100 feet. The Safety Board investigator received written statements from five eyewitnesses. They reported observing the airplane during its final minutes of flight. In summary, a fireman/paramedic reported hearing a report over the radio of a pilot coming into Gillespie Field with "shortness of breath." The fireman started looking skyward and observed a small airplane flying southwest in a "hard left" bank. The fireman then reported observing the airplane in a 45-degree bank angle turning south to southeast. Thereafter, the fireman lost sight of the airplane when a mountain obstructed his view. A witness walking from his house to his car on a street near the accident site heard a small airplane flying overhead and observed it at a very low altitude. The witness indicated that he watched the airplane fly in a southerly direction, circle counterclockwise to the east, and then descend. The witness lost sight of the airplane when trees obstructed his view. The witness also reported that during the time of his observations, the airplane's engine sounded "smooth." Two firefighter/paramedics traveling in a vehicle saw a small airplane flying about 500 to 600 feet above ground level. The airplane banked left and flew southward. It continued to turn sharply, losing speed and altitude. The nose began to fall, the wings became nearly perpendicular or vertical to the ground, and the airplane fell in a steep angle toward the ground and disappeared behind a hill. No smoke or fire was visible during the event. Witnesses near the scene of the crash, who were interviewed by a sheriff's deputy, also reported the airplane flying very low, banking steeply to the left and becoming nearly vertical to the ground. The witness located closest to the accident site, who was performing yard work at his residence, saw an airplane coming at him. The witness reported that the airplane's engine was very loud. The airplane's wings were initially horizontal, and then they turned vertical. The witness indicated that the airplane went through his yard, clipped his tree, and passed over his location. The airplane's left wing hit the side of his truck, which was parked in his driveway. The distance and bearing between the last radar hit and the initial point of ground impact (IPI) was 2.8 nm and 303 degrees, magnetic. PERSONNEL INFORMATION The pilot held a private pilot certificate, with an airplane single engine land and instrument ratings. The pilot's personal flight record logbook was not provided to the Safety Board investigator for examination. In an application for an aviation medical certificate in April 1995, the pilot reported that his total pilot (flight) time was 2,300 hours. In April 1997, the pilot estimated his total pilot time was 2,500 hours. In May 1998, the pilot estimated his total pilot time was 2,700 hours. In August 2000, when the pilot applied for his most recent aviation medical certificate, he indicated that his total flight time was 1,800 hours. The co-owner of the airplane verbally reported to the Safety Board investigator that he believed the pilot's total flight time was about 800 hours. During the 90 days preceding the accident, the pilot likely flew the accident airplane for 15 hours, and his total experience flying the accident airplane was 300 hours. No record of the pilot having completed a biennial flight review was found, however, the co-owner opined that the pilot had completed the review 1 year prior to the interview. METEOROLOGICAL INFORMATION At 1005, Gillespie Field reported its weather conditions as follows: scattered clouds at 5,000 feet; visibility 15 miles; wind 250 degrees at 8 knots; and temperature 25 degrees Celsius. WRECKAGE AND IMPACT INFORMATION From an examination of the accident site and airplane wreckage, the airplane was found to have collided with an unoccupied truck in the driveway of a private residence. The elevation of the accident site was about 600 feet mean sea level (msl). The global positioning satellite (GPS) coordinates for the initial point of impact (IPI) were about 32 degrees 50.256 minutes north latitude by 116 degrees 54.532 minutes west longitude. The main wreckage was located about 32 degrees 50.298 minutes north latitude by 116 degrees 54.553 minutes west longitude. Wreckage was principally observed fragmented over a 240-foot-long path between the IPI and a tree, against which the airplane's fuselage had come to rest. Additional wreckage was found 77 feet farther north. The magnetic bearing between the IPI and the main wreckage was about 349 degrees. The IPI was demarked by the pres ## Aircraft - Registration: [N22CR](https://openairdocs.org/deregistered/N22CR-2004-05-18), registration cancelled 2004-05-18, S/N CD-435, built 1961 (OpenAirDocs) - Reported make and model: Beech 35-B33 - Registry model: [Beech 35-B33](https://openairdocs.org/model/beech-35-b33) (registry code 1151406) (OpenAirDocs) - Registry engine: [Continental IO-470 series](https://openairdocs.org/engine/continental-io-470-series) (registry code 17044, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: CD-435 - Airframe hours: 4538 - Engines: Continental IO-470K 225 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Gerald Paller - Registered owner: Gerald Paller & Dennis Dahlberg - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Unknown, June 1, 2001 - Departed: SEE, El Cajon, CA - Destination: DVT, Deer Valley, AZ - Airport: SEE, Gillespie Field, runway 27R, 5,341 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 800 total, 300 in this make and model, 15 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 8 knots - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 77 °F - Altimeter: 29.96 inHg - Observed at: SEE, 3 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20010625016389A](https://openairdocs.org/incident/20010625016389A), Jun 25, 2001: Beech 35B33, Lakeside, CA, No damage. (.19) On June 25, 2001, about 0954 hours pacific standard time, a Beech 35-B33, N22CR, co-owned and operated by the pilot, descended into residential terrain… ## Docket (30 files) The files NTSB released with the investigation on April 8, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=53342. 13.6 MB in all. - Medical Records Information (item 1, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200705&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF - Supplement A (item 2, .PDF, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205824&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 3, .PDF, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205825&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Witness Statements (item 4, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419633&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 5, .PDF, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205827&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Transcript of Radio Communications (item 6, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419634&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - Report from San Diego Sheriff Department (item 7, .PDF, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419635&FileExtension=.PDF&FileName=Report%20from%20San%20Diego%20Sheriff%20Department-Redacted.PDF - FAA Personnel Statements (item 8, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419636&FileExtension=.PDF&FileName=FAA%20Personnel%20Statements-Redacted.PDF - Report from Garmin International, Inc. (item 9, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419637&FileExtension=.PDF&FileName=Report%20from%20Garmin%20International,%20Inc.-Redacted.PDF - Toxicological Report (item 10, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419638&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 302 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419639&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419640&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Radar Track Plot (item 13, .PDF, 584 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205841&FileExtension=.PDF&FileName=Radar%20Track%20Plot-Master.PDF - Golden State Flying Club Fuel Receipt (item 14, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205843&FileExtension=.PDF&FileName=Golden%20State%20Flying%20Club%20Fuel%20Receipt-Master.PDF - Mechanic Activity Report to FAA - Annual Inspection Data (item 15, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419641&FileExtension=.PDF&FileName=Mechanic%20Activity%20Report%20to%20FAA%20-%20Annual%20Inspection%20Data-Redacted.PDF - Aircraft and Engine Logbook Excerpts (item 16, .PDF, 437 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419642&FileExtension=.PDF&FileName=Aircraft%20and%20Engine%20Logbook%20Excerpts-Redacted.PDF - List of Drugs Found in Wreckage (item 17, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205847&FileExtension=.PDF&FileName=List%20of%20Drugs%20Found%20in%20Wreckage-Master.PDF - Medical Records Information (Extract) (item 18, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205848&FileExtension=.PDF&FileName=Medical%20Records%20Information%20(Extract)-Master.PDF - Radar Data RT (item 19, .PDF, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205849&FileExtension=.PDF&FileName=Radar%20Data%20RT-Master.PDF - Radar Data TG (item 20, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205850&FileExtension=.PDF&FileName=Radar%20Data%20TG-Master.PDF - Photo 1. Severed left wing and impacted truck bed. Main wreckage appears in background in center of photo. (item 21, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205924&FileExtension=.PDF&FileName=Photo%201.%20%20Severed%20left%20wing%20and%20impacted%20truck%20bed.%20%20Main%20wreckage%20appears%20in%20background%20in%20center%20of%20photo.-Master.PDF - Photo 2. Propeller (foreground) and main wreckage (background). (item 22, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205925&FileExtension=.PDF&FileName=Photo%202.%20%20Propeller%20(foreground)%20and%20main%20wreckage%20(background).-Master.PDF - Photo 3. Propeller. (item 23, .PDF, 971 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205927&FileExtension=.PDF&FileName=Photo%203.%20%20Propeller.-Master.PDF - Photo 4. Main wreckage, right wing against fence and left wing at gound level. (item 24, .PDF, 880 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205928&FileExtension=.PDF&FileName=Photo%204.%20%20Main%20wreckage,%20right%20wing%20against%20fence%20and%20left%20wing%20at%20gound%20level.-Master.PDF - Photo 5. Fuselage, right side. (item 25, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205929&FileExtension=.PDF&FileName=Photo%205.%20%20Fuselage,%20right%20side.-Master.PDF - Photo 6. Fuselage, left side. (item 26, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205931&FileExtension=.PDF&FileName=Photo%206.%20%20Fuselage,%20left%20side.-Master.PDF - Photo 7. Empennage. (item 27, .PDF, 800 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205932&FileExtension=.PDF&FileName=Photo%207.%20%20Empennage.-Master.PDF - Photo 8. Front view of destroyed cockpit. (item 28, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205933&FileExtension=.PDF&FileName=Photo%208.%20%20Front%20view%20of%20destroyed%20cockpit.-Master.PDF - Photo 9. Instrument panel. (item 29, .PDF, 848 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205934&FileExtension=.PDF&FileName=Photo%209.%20%20Instrument%20panel.-Master.PDF - Photo 10. Engine. (item 30, .PDF, 985 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205935&FileExtension=.PDF&FileName=Photo%2010.%20%20Engine.-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.