# NTSB LAX02FA166: Socata TB-21, N328CG, New River, AZ, May 17, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 16, 2002, 21:54 local (May 17, 2002, 04:54 UTC) - Place: New River, AZ - Coordinates: 33.961112, -112.012779 - Nearby events: https://openairdocs.org/map.md?lat=33.9611&lon=-112.0128&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report October 27, 2005 - Report: Approved by Office Director - Parties: EADS Socata, Federal Aviation Administration, Textron Lycoming Engines - NTSB case key (mKey): 54734 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX02FA166 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54734/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54734 - Page: https://openairdocs.org/ntsb/LAX02FA166 ## Probable cause the pilot's failure to maintain an adequate terrain clearance altitude during a cruise descent that resulted in controlled flight into terrain (CFIT). Factors in the accident were the rising mountainous terrain, the dark nighttime lighting condition, and the pilot's loss of situational awareness regarding terrain proximity. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, descent - normal - terrain condition - rising (contributing factor) - terrain condition - mountainous/hilly (contributing factor) - light condition - dark night (contributing factor) - other psychological condition, pilot in command (contributing factor) - altitude/clearance - not maintained, pilot in command (cause) ## Analysis During a sales demonstration flight, the pilot descended into the upsloping face of mountainous terrain about 17 nm north of the destination airport. The accident occurred under dark, nighttime, visual meteorological conditions, and after about a 22-minute flight. Illumination of the moon's visible disk was 19 percent. No roads or ground structures were in the vicinity to provide ground reference or to illuminate the accident area terrain. The direct course between the departure and destination airports (71 nm apart) was 180 degrees magnetic. Recorded radar data indicated that during the last 3 minutes of flight, the airplane's average ground track was 176 degrees, and its average ground speed was 168 knots. The radar ground track ended near the centerline of the direct course between the departure and destination airports, and about 1/4-mile north of the initial point of impact (IPI). The wreckage distribution path was 640 feet long on a magnetic bearing of 177 degrees. An examination of the impact ground scars disclosed that the airplane was in controlled flight in a shallow descent when it collided with the terrain. Review of the radar derived accident airplane's flight track in conjunction with the associated underlying terrain and the ambient lighting conditions revealed that the terrain would have been, at best, marginally visible to the pilot. Initially during the descent, the lights of the greater Phoenix area would have been visible to the pilot in the distance, but the area would have disappeared from the pilot's view seconds before impact. The airplane was equipped with an autopilot, a KLN 94 global positioning satellite receiver, and a KMD 550 multifunction color display that, if operated in the topographic mode, had the capability to display terrain elevation information. During the wreckage examination of the airframe's structure and the engine, no evidence of any preimpact failures or malfunctions was found. The avionics components were found too impact-damaged to provide data. Accordingly, the investigation was unable to ascertain if the pilot was using the multifunction display to receive topographic data while descending toward the destination airport. The KLN 94 and the KMD 550 Pilot's Guides state: "CAUTION NEVER USE THE TOPOGRAPHIC ELEVATION DISPLAYED ON THIS EQUIPMENT AS YOUR SOLE REFERENCE FOR TERRAIN AVOIDANCE." ## Factual narrative HISTORY OF FLIGHT On May 16, 2002, about 2154 mountain standard time, a Socata TB-21, N328CG, descended into mountainous terrain in the Tonto National Forest, about 7 nautical miles (nm) northeast of New River, Arizona. The airplane's registered owner was Avex, Inc., and the airplane was operated by The New Avex, Inc., Camarillo, California. The pilot was employed as an airplane salesman for The New Avex, Inc. The airplane was destroyed, and the pilot and a prospective buyer were fatally injured during the sales demonstration flight. The pilot-salesman held a commercial pilot certificate and the prospective purchaser held a student pilot certificate. The dark nighttime flight was performed under the provisions of 14 CFR Part 91. Visual meteorological conditions prevailed, and no flight plan was filed. An associate of the accident pilot, who was also employed by Avex as an airplane salesman, reported to the National Transportation Safety Board investigator that he had spoken with the accident pilot via cell phone at 2114. At that time, the accident pilot indicated to him that he had finished dinner at the Sedona Airport and that he planned to immediately depart and fly to Deer Valley with the prospective airplane purchaser. The associate further reported that he believes the earliest that the accident pilot would have become airborne is 2122. Based upon Federal Aviation Administration (FAA) recorded radar data, the Safety Board investigator estimated that the accident airplane departed Sedona at or before 2132. The wife of the prospective airplane purchaser reported that about 2015 she had spoken with her husband by telephone regarding his plans. The wife indicated that her husband was at Sedona and planned to fly home following dinner. He anticipated returning to Deer Valley by 2200. No witnesses reported observing the accident. The airplane wreckage was discovered the following morning by a helicopter crew that observed smoke emanating from the accident site area. PERSONNEL INFORMATION Pilot-in-Command/Salesman The Safety Board investigator reviewed FAA-maintained airman and medical records, the pilot's personal flight record logbook, and pilot history data received from his employer. In pertinent part, the review indicates that the pilot commenced flight training in 1971, and he was issued a Canadian private pilot license (airplane single engine land) the following year. Subsequently, he was issued airplane single engine sea, airplane multiengine land, and an instrument airplane rating (all foreign based). The pilot also held the following United States FAA-issued certificates/ratings: commercial pilot, airplane single engine land (received in 1990), and instrument airplane (received in 1991). A review of the pilot's flight record logbook indicates that no flights were listed between October 1995 and March 2002. However, an entry dated May 16, 1996, indicates that the pilot satisfactorily completed a biennial flight review and instrument competency check on that date. On an application for the pilot's second-class aviation medical certificate dated March 14, 2002, the pilot reported that he had last applied for a medical certificate in 1994. The pilot was hired by The New Avex, Inc., in April 2002, as an airplane salesman. The pilot's resume indicates that he had flown a variety of different airplane models, including the Cessna 150, 172, 185, 340, and 402. He also listed having flown the Beech F33A, V35, A36, B36TC, Travel Air, Baron 55/58, and the C90. Additionally, the pilot indicated having received 8 hours of dual instruction in the TBM-700. In summary, the pilot's resume indicated that his total flight time was 2,326.0 hours, which included 875 multiengine hours, 33 hours flying turboprop airplanes, and 1,675 hours in retractable gear airplanes. The pilot had no listed flight time in the Socata TB-20/21 airplane. The pilot resumed listing flights in his logbook on April 11, 2002. On that date he commenced receiving flight instruction by Avex personnel in the Socata TB-21, the accident airplane. The pilot satisfactorily passed a biennial flight review in a Beech B36 on April 16, 2002, and he passed an instrument competency check flight in the accident airplane on April 29, 2002. By the accident date and time, the pilot's total flying experience in TB-21 was approximately 14 hours. All of this experience was obtained flying the accident airplane within 90 days of the accident. Additionally, Avex personnel had provided the pilot with all of the dual flight instruction in the airplane. Based upon the cumulative data contained in reviewed documents, the Safety Board investigator estimates that the pilot's total flight time by the accident date was about 2,350 hours. The hours shown in the "Flight Time Matrix" boxes in this factual report are flight time estimates. Prospective Purchaser/Passenger. The prospective purchaser held a combined student pilot and aviation medical certificate. On his May 31, 2000, application for the certificate, the pilot indicated having a total of 300 hours of flight time. No flights were listed as having been flown during the preceding 6 months. An attorney representing the passenger's family provided the Safety Board investigator with a copy of the pilot's flight record logbook and the backside of his aviation medical certificate. The backside of the certificate showed certified flight instructors' flying endorsements. The student pilot had received endorsements for solo flight in a Cessna 152 and 172, and in a Piper PA-28-181, in addition to a solo cross-country endorsement. The logbook indicated that the student pilot had commenced receiving flight instruction in 1989. By October 2000, which was the date of the last logbook entry, the pilot's total flight time was indicated as being 113.7 hours. He had logged 71.6 hours of dual instruction and 42.1 hours of solo pilot time. According to the FAA coordinator, in the year 2000 the pilot had taken flying lessons at Westwind Aviation, a Phoenix-based flight school. Personnel at Westwind reported that about 1 week prior to the accident the pilot had informed them that he intended to resume taking flying lessons. However, by the accident date no lessons had been provided to the student. The FAA coordinator reported to the Safety Board investigator that he was unable to find evidence that the pilot had resumed taking flying lessons. AIRCRAFT INFORMATION A review of the airplane's maintenance records revealed that the airplane's last recorded maintenance was performed on the accident date, May 16, 2002. The Camarillo based operator changed the engine's oil and oil filter, and returned the airplane to service. The engine and airplane's total time was recorded as being 191.6 hours. The Safety Board investigator estimates that, thereafter, the accident pilot flew the airplane for at least 3 hours prior to the accident. The turbocharged and autopilot equipped airplane was also equipped with a Honeywell (Bendix/King) KLN 94 global positioning satellite (GPS) navigation receiver, and a Honeywell (Bendix/King) KMD 550 multifunction (color) display. This equipment provided the pilot with the capability to fly direct (point-to-point) routes. The equipment incorporated a moving map display that included topographical (terrain elevation) information. The KLN 94 and the KMD 550 Pilot's Guides (operating instruction booklets) were found in the wreckage. In pertinent part, according to information printed in the KMD 550 Pilot's Guide, the pilot has the ability to select a map display by pressing the MAP Function Select Key to toggle between depicting topographic features, in the TOPO ON mode, or no topographic features in the TOPO OFF mode. With TOPO ON, classes of data are displayed as a specific color. A color key can also be displayed on the map display when in the TOPO ## Aircraft - Registration: [N328CG](https://openairdocs.org/deregistered/N328CG-2002-10-21), registration cancelled 2002-10-21, S/N 2025, built 2000 (OpenAirDocs) - Reported make and model: SOCATA TB-21 - Registry model: [Socata TB21](https://openairdocs.org/model/socata-tb21) (registry code 8680697) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 2025 - Airframe hours: 145 - Engines: Lycoming TIO-540-AB1AD 250 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Other work use, Part 91 - Operator: The New Avex, Inc. - Registered owner: Avex, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 5, 2002, 50 hours before - Departed: SEZ, Sedona, AZ - Destination: DVT, Phoenix, AZ ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; foreign, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review April 16, 2002; toxicology performed; flight hours: 2,350 total, 14 in this make and model, 2,080 as pilot in command, 17 in the last 90 days, 14 in the last 30 days, 3 in the last 24 hours - Student pilot; age 36; injuries: fatal; student; medical: class 3, without waivers/limitations; toxicology performed; flight hours: 114 total, 0 in this make and model, 42 as pilot in command, 0 in the last 90 days, 0 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 240° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F, dew point 41 °F - Altimeter: 29.93 inHg - Observed at: DVT, 17 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 20020516011379A](https://openairdocs.org/incident/20020516011379A), May 16, 2002: Socata TB21, Newriver, AZ, No damage, 2 fatal. (.19) On may 16, 2002, about 2154 mountain standard time, a Socata TB-21, N328CG, descended into mountainous terrain in the tonto national forest, about 7 NM… ## Docket (30 files) The files NTSB released with the investigation on February 24, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54734. 14.2 MB in all. - Maps of Accident Area (item 1, .PDF, 5.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225222&FileExtension=.PDF&FileName=Maps%20of%20Accident%20Area-Master.PDF - Wreckage Diagram (item 2, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225223&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Weather Report and Moon Illumination Data (item 3, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225750&FileExtension=.PDF&FileName=Weather%20Report%20and%20Moon%20Illumination%20Data-Master.PDF - Socata TB21 Drawing (item 4, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225224&FileExtension=.PDF&FileName=Socata%20TB21%20Drawing-Master.PDF - Photo 1: Southward Aerial View, Wreckage Distribution Path (item 5, .PDF, 787 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225225&FileExtension=.PDF&FileName=Photo%201%3A%20Southward%20Aerial%20View,%20Wreckage%20Distribution%20Path-Master.PDF - Photo 2: Initial Point of Impact (item 6, .PDF, 874 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225226&FileExtension=.PDF&FileName=Photo%202%3A%20Initial%20Point%20of%20Impact-Master.PDF - Photo 3: Northward Direction, Direction From Which Aircraft Came (item 7, .PDF, 883 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225227&FileExtension=.PDF&FileName=Photo%203%3A%20Northward%20Direction,%20Direction%20From%20Which%20Aircraft%20Came-Master.PDF - Photo 4: Main Wreckage (item 8, .PDF, 815 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225228&FileExtension=.PDF&FileName=Photo%204%3A%20Main%20Wreckage-Master.PDF - Photo 5: Cabin Door and Empennage (item 9, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225229&FileExtension=.PDF&FileName=Photo%205%3A%20Cabin%20Door%20and%20Empennage-Master.PDF - Photo 6: Fuselage Fragments (item 10, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225230&FileExtension=.PDF&FileName=Photo%206%3A%20Fuselage%20Fragments-Master.PDF - Photo 7: Aileron and Wing Fragment (item 11, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225231&FileExtension=.PDF&FileName=Photo%207%3A%20Aileron%20and%20Wing%20Fragment-Master.PDF - Photo 8: Cockpit Instrument Panel (item 12, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225427&FileExtension=.PDF&FileName=Photo%208%3A%20Cockpit%20Instrument%20Panel-Master.PDF - Photo 9: Navigation Instruments and Panel (item 13, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225428&FileExtension=.PDF&FileName=Photo%209%3A%20Navigation%20Instruments%20and%20Panel-Master.PDF - Photo 10: Engine (item 14, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225429&FileExtension=.PDF&FileName=Photo%2010%3A%20Engine-Master.PDF - Photo 11: Propeller (item 15, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225430&FileExtension=.PDF&FileName=Photo%2011%3A%20Propeller-Master.PDF - NTSB Letter & FAA Reply RE Honeywell Parts Exam (item 16, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225431&FileExtension=.PDF&FileName=NTSB%20Letter%20%26%20FAA%20Reply%20RE%20Honeywell%20Parts%20Exam-Master.PDF - FAA Email RE NTAP Files & Instructions (item 17, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442101&FileExtension=.PDF&FileName=FAA%20Email%20RE%20NTAP%20Files%20%26%20Instructions-Redacted.PDF - NTAP Radar Data (item 18, .PDF, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225433&FileExtension=.PDF&FileName=NTAP%20Radar%20Data-Master.PDF - Flight Path Diagram & NTAP Track Plots (item 19, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225436&FileExtension=.PDF&FileName=Flight%20Path%20Diagram%20%26%20NTAP%20Track%20Plots-Master.PDF - Lycoming Engine Report (item 20, .PDF, 2 photos, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225434&FileExtension=.PDF&FileName=Lycoming%20Engine%20Report-Master.PDF - Toxicological Report: Braunstein (item 21, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225438&FileExtension=.PDF&FileName=Toxicological%20Report%3A%20Braunstein-Master.PDF - Toxicological Report: Reaveley (item 22, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225440&FileExtension=.PDF&FileName=Toxicological%20Report%3A%20Reaveley-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 23, .PDF, 332 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225738&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 24, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225740&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Correspondence: Reaveley's Pilot Certificate and Logbook (item 25, .PDF, 399 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225742&FileExtension=.PDF&FileName=Correspondence%3A%20Reaveley%27s%20Pilot%20Certificate%20and%20Logbook-Master.PDF - Correspondence Braunstein's Activities (item 26, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442102&FileExtension=.PDF&FileName=Correspondence%20Braunstein%27s%20Activities-Redacted.PDF - Correspondence: Braunstein's Employment (item 27, .PDF, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442103&FileExtension=.PDF&FileName=Correspondence%3A%20Braunstein%27s%20Employment-Redacted.PDF - Braunstein's Logbook (Extract) (item 28, .PDF, 490 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225747&FileExtension=.PDF&FileName=Braunstein%27s%20Logbook%20(Extract)-Master.PDF - Honeywell Bendix/King Pilot's Guide KMD 550/850 (Extract) (item 29, .PDF, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225745&FileExtension=.PDF&FileName=Honeywell%20Bendix%2FKing%20Pilot%27s%20Guide%20KMD%20550%2F850%20(Extract)-Master.PDF - Aircraft Record (item 30, .PDF, 336 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226418&FileExtension=.PDF&FileName=Aircraft%20Record-Redacted.PDF From the NTSB's public API. 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