# NTSB LAX02FA061: Cessna T337H, N1348L, Buena Park, CA, January 5, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 5, 2002, 12:59 local (20:59 UTC) - Place: Buena Park, CA - Coordinates: 33.869445, -117.99028 - Nearby events: https://openairdocs.org/map.md?lat=33.8694&lon=-117.9903&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 29, 2004 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Cessna, Teledyne Continental Motors - NTSB case key (mKey): 54013 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX02FA061 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54013/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54013 - Page: https://openairdocs.org/ntsb/LAX02FA061 ## Probable cause the pilot's failure to maintain control of the airplane during the landing approach. Factors included the pilot's distraction when informed that his landing gear was not down, and his impairment from the effects of prescription drugs. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - vfr pattern - base turn - diverted attention, pilot in command (contributing factor) - landing gear - not deployed - impairment(drugs), pilot in command (contributing factor) - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane collided with terrain while turning from base to final for landing. The pilot contacted the air traffic control tower approximately 20 miles from the airport. The controller cleared the pilot into the traffic pattern, and shortly thereafter, cleared the airplane to land. The turn to base was early, and the airplane remained high during the base leg and the turn to final. The controller informed the pilot that the landing gear did not appear to be down, and then the airplane rolled to the right. A pilot witness observed the right wing drop 70-80 degrees and the airplane enter a sharp right turn through 180 degrees of rotation. The nose started dropping and after 360 degrees of turn, the nose was down about 70 degrees. to a vertical nose down attitude. After 360 degrees of turn, the nose was down about 70 degrees. In a post accident examination, investigators discovered no preimpact engine or control malfunctions with the airplane. Review of the pilot's personal medical records indicated that he had routinely used a prescription sleep aid (triazolam) and two prescription medications (codeine and butalbital) for the treatment of severe headaches. The pilot noted none of these medications on his applications for a medical certificate. A postmortem toxicological examination of the pilot detected the presence of these medicationscodeine and butalbital, consistent with recent use. Barbiturates (the class of medications which include butalbital) have been shown in many studies to impair judgment and performance; impairment that does not always correlate with subjective effects. They have an effect on the inner ear, and may increase susceptibility to spatial disorientation. Studies have shown residual adverse effects of triazolam on piloting related skills in the morning following its use. Codeine, a narcotic painkiller, has been shown to have mild impairing effects on performance at typical doses. ## Factual narrative HISTORY OF FLIGHT On January 5, 2002, at 1259 Pacific standard time, a Cessna T337H, N1348L, collided with terrain in Buena Park, California. The airplane rolled to a vertical nose down attitude while in a right turn from base to final for landing on runway 06 at Fullerton Municipal Airport, Fullerton, California. The commercial pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The pilot sustained fatal injuries; the collision sequence and post crash fire destroyed the airplane. The personal local flight departed Fullerton about 1245. Visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 33 degrees 52.161 minutes north latitude and 117 degrees 59.418 minutes west longitude. The National Transportation Safety Board investigator-in-charge (IIC) interviewed the air traffic control tower (ATCT) controller that handled the airplane as it approached Fullerton. The pilot contacted the ATCT and said that he was 20 miles east and inbound for landing. The controller cleared him into the traffic pattern on the south side of the airport for right traffic to runway 06, because there were slower planes in the pattern on the north side for left traffic. The controller cleared the airplane to land, and watched the airplane execute a continuous right turn while it was on the base leg for landing. The controller thought that the airplane appeared to be a little high and that the landing gear down was not down. The controller informed the pilot that the gear did not appear to be down, and then saw the airplane roll to the right to a vertical nose down attitude. Once in the vertical attitude, the controller did not see any more roll as the airplane disappeared behind buildings just prior to impact. After the pilot acknowledged the clearance to land, the controller heard no other transmissions from the airplane. The pilot never informed him of any problems. Throughout all of the transmissions the controller thought that the pilot sounded very competent. Another witness was a pilot, airframe and powerplant mechanic, engineer, and familiar with this pilot and airplane. He watched the airplane continuously from downwind. He said that the downwind was normal, but the turn to base was early. The airplane remained high during the base leg and the turn to final. He observed that the landing gear was still in the retracted position. The witness observed the right wing drop 70-80 degrees, and the airplane entered a sharp right turn through 180 degrees of rotation. The nose started dropping and after 360 degrees of turn, the nose was down about 70 degrees. He heard the engines go to full power, and noted an effort to stop the rotation after 450 degrees of turn. The nose rose to 60 degrees nose low prior to impact. He did not see a change in the landing gear configuration, and did not observe the flap position. One pilot witness reported that the airplane departed Fullerton about 15 minutes prior to the accident. The engines sounded good, and he noticed nothing wrong with the airplane. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a commercial pilot certificate with airplane single engine and multiengine land ratings. The pilot held a third-class medical certificate issued on May 29, 2001. It had the limitations that the pilot shall wear lenses that correct for distant vision, and possess glasses that correct for near vision. An examination of the pilot's logbook indicated an estimated total flight time of 1,650 hours. He logged an estimated 7 hours in the last 90 days; 6 were in this make and model. He had an estimated 340 hours in this make and model. AIRCRAFT INFORMATION The airplane was a Cessna T337H, serial number 33701840. A review of the airplane's logbooks revealed a total airframe time of 1,821.7 hours. The logbooks contained an entry for an annual inspection dated November 17, 2000. The front engine was a Teledyne Continental Motors TSIO-360H1B, serial number 233262-R. Total time recorded on the factory-rebuilt engine at the last 100-hour inspection was 670.6 hours. The rear engine was a Teledyne Continental Motors TSIO-360-HB2B, serial number 239964-R. Total time recorded on the factory-rebuilt engine at the last 100-hour annual inspection was 849.1 hours. COMMUNICATIONS The pilot was in contact with the ATCT at Fullerton on a frequency of 119.1. AIRPORT INFORMATION The Airport/ Facility Directory, Southwest U. S., indicated that Fullerton's runway 06 was 3,121 feet long and 75 feet wide, and it had a displaced threshold of 427 feet. The runway surface was asphalt. The traffic pattern altitude was 1,600 feet msl (1,504 agl) for multiengine aircraft. WRECKAGE AND IMPACT INFORMATION The airplane came to rest in a vacant lot between commercial and residential buildings. The airplane crushed so that the tallest piece of wreckage was about 3-feet high. A post crash fire consumed a majority of the cabin. The orientation of the wings was primarily 040/260 (left and right wing, respectively). The outboard 6 1/2 feet of the right wing sheared off when it contacted a concrete block fence. The principal impact crater (PIC) was about 3-feet deep, and was in the center of the main wreckage. The main wreckage area contained all of the major airframe and engine components. All wreckage that investigators located was within 100 feet of the PIC. The most distant piece of wreckage was the front propeller, which was 100 feet southeast of the main wreckage. MEDICAL AND PATHOLOGICAL INFORMATION The Orange County Coroner completed an autopsy. The autopsy report included a toxicology report. It contained the following results: butalbital, acetaminophen, and pseudoephedrine detected, and 0.053 (mg/L) of codeine in postmortem blood. The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the pilot. They did not test for carbon monoxide or cyanide. The FAA toxicology report contained the following results: no ethanol detected in the kidney; 17 (mg/dL, mg/hg) ethanol detected in muscle; 2 (mg/dL, mg/hg) acetaldehyde detected in muscle. A note indicated that the ethanol was from postmortem ethanol formation, and not from the ingestion of ethanol. The report contained the following results: 3.101 (ug/ml, ug/g) butalbital detected in kidney; 4.061 (ug/ml, ug/g) butalbital detected in liver; amlodipine present in blood; amlodipine present in liver; azacyclonol present in liver; ephedrine present in blood; pseudoephedrine present in liver; and pseudoephedrine present in blood. The Safety Board's Medical Officer examined the autopsy report, personal medical records, and a certified copy of the airman's medical records. He prepared a factual report, and the following paragraphs summarize the findings. The pilot did not indicate the use of butalbital-, codeine-, or triazolam-containing products on any application for Airman Medical Certificate in the FAA maintained records. Although a 1977 application did indicate "yes" in response to "Frequent or severe headaches,"and physician reports in the FAA records noted probable "vascular headaches" treated previously with Fiorinal #3 (butalbital, aspirin, caffeine, and codeine) and Cafergot (ergotamine and caffeine). The pilot noted that a food allergy caused the headaches. He reported that diet corrected the problem, and that he no longer needed medication. The pilot's most recent application for an Airman Medical Certificate on May 29, 2001, indicated "no" to questions that asked if the applicant currently used any medication or experienced frequent or severe headaches. Records subpoenaed from a physician seen by the pilot documented the use of Fiorinal, Fioricet (butalbital, acetaminophen, and caffeine), and Tylenol #3 (acetaminop ## Aircraft - Registration: [N1348L](https://openairdocs.org/deregistered/N1348L-2002-06-25), registration cancelled 2002-06-25, S/N 33701840, built 1978 (OpenAirDocs) - Reported make and model: Cessna T337H - Registry model: [Cessna T337H](https://openairdocs.org/model/cessna-t337h) (registry code 2075733) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 33701840 - Airframe hours: 1821.7 - Engines: Teledyne Continental TSIO-360 225 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Donald Dirian - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 17, 2000 - Departed: FUL, Fullerton, CA - Destination: FUL, FULLERTON, CA - Airport: KFUL, Fullerton, runway 06, 3,121 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; medical: class 3, valid medical--w/ waivers/lim; last flight review May 31, 2001; seat: right; toxicology performed; flight hours: 1,650 total, 340 in this make and model, 7 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 34 °F - Altimeter: 30.29 inHg - Observed at: FUL, 1 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 20020105006259A](https://openairdocs.org/incident/20020105006259A), Jan 5, 2002: Cessna T337H, Fullerton, CA, No damage, 1 fatal. (-23) On January 5, 2002 at 1259 hours pacific standard time, a Cessna T337H, N1348L crashed during the landing phase in buena park, CA. The pilot sustained… ## Docket (10 files) The files NTSB released with the investigation on August 14, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54013. 2.4 MB in all. - Medical Records Information (item 1, .PDF, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40172150&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF - Witness Statement (4) (item 2, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356413&FileExtension=.PDF&FileName=Witness%20Statement%20(4)-Redacted.PDF - Wreckage Diagram (item 3, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216314&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Photo 1. Left Front Main Wreckage (item 4, .PDF, 468 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216315&FileExtension=.PDF&FileName=Photo%201.%20%20Left%20Front%20Main%20Wreckage-Master.PDF - Photo 2. Right Rear Main Wreckage (item 5, .PDF, 558 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216316&FileExtension=.PDF&FileName=Photo%202.%20%20Right%20Rear%20Main%20Wreckage-Master.PDF - Photo 3. Right Wing Tip (item 6, .PDF, 547 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216317&FileExtension=.PDF&FileName=Photo%203.%20%20Right%20Wing%20Tip-Master.PDF - Pilot Logbook Excerpts (item 7, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356414&FileExtension=.PDF&FileName=Pilot%20Logbook%20Excerpts-Redacted.PDF - Maintenance Logbook Excerpts (item 8, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356420&FileExtension=.PDF&FileName=Maintenance%20Logbook%20Excerpts-Redacted.PDF - Toxicological Report (item 9, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356422&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 246 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356419&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.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.