# NTSB LAX02FA212: Beech S35, N576Q, Ojai, CA, June 30, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 30, 2002, 11:00 local (18:00 UTC) - Place: Ojai, CA - Coordinates: 34.558334, -119.468612 - Nearby events: https://openairdocs.org/map.md?lat=34.5583&lon=-119.4686&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report May 30, 2006 - Report: Approved by Office Director - Parties: Beech Raytheon, Federal Aviation Administration - NTSB case key (mKey): 55084 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX02FA212 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/55084/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=55084 - Page: https://openairdocs.org/ntsb/LAX02FA212 ## Probable cause the pilot's inadequate in-flight planning and failure to maintain an adequate terrain clearance altitude within the canyon. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, maneuvering - terrain condition - mountainous/hilly - terrain condition - blind/box canyon - in-flight planning/decision - inadequate, pilot in command (cause) - low altitude flight/maneuver - attempted, pilot in command - altitude/clearance - not maintained, pilot in command (cause) ## Analysis The airplane collided with mountainous terrain while maneuvering through a box canyon; it was the second airplane of a group of airplanes. The group consisted of eight airplanes that were traveling together; there were three groups of airplanes with three airplanes in two groups, and two airplanes in one group. The first group, containing three airplanes with this airplane second behind the lead, descended to an estimated 500 to 1,000 feet above ground level (agl), and proceeded up a canyon. The lead proceeded to descend into the canyon and the other airplanes followed about 500 feet behind. The pilot of the number three airplane in the group estimated that he was about 200 feet above the leader's altitude and number two airplane was between them. He noticed that number two was getting closer to the leader, and he was closing in on number two. As the airplanes proceeded toward the end of the canyon, the pilot of the number three airplane became concerned about terrain clearance and decided to exit the formation. A few seconds later, the number three pilot initiated a hard pull up to the left and began to climb. He completed about 15 degrees of turn and saw the lead airplane collide with trees and terrain at his 2 o'clock position. The number two airplane was a little to the right of the lead when it collided with the terrain. Both airplanes came to rest within 75 feet of each other at the head of the canyon at an estimated elevation of 4,925 feet, about 400 feet below the crest of the saddle at the end of the canyon. The lead airplane was N156U, a Beech V35A; see NTSB report LAX02FA211. ## Factual narrative HISTORY OF FLIGHT On June 30, 2002, about 1100 Pacific daylight time, a Beech S35, N576Q, collided with mountainous terrain while maneuvering in a canyon near Ojai, California. The pilot was operating the borrowed airplane under the provisions of 14 CFR Part 91. The private pilot and two passengers sustained fatal injuries; the airplane was destroyed. The personal cross-country flight departed Van Nuys (VNY), California, about 1030, en route to Oceano (L52), California. Visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 34 degrees 33.495 minutes north latitude and 119 degrees 28.120 minutes west longitude. A witness reported that the pilot was one of a group that routinely gathered on weekends for local flights. They all met at Van Nuys about 0930 for a preflight briefing. The accident pilot flew the number two airplane. The flight leader obtained a weather brief. He then briefed the group on weather, communications, route, altitudes, alternates, and safety issues. The flight consisted of a group of eight airplanes. The airplanes departed as three groups in formation. Two groups consisted of three airplanes, and a third group consisted of just two airplanes. The group formed up at 4,500 feet. The witnesses reported that after flying around the area for about 25 minutes, the lead instructed everyone to separate and follow in trail. The lead and the number two airplane stayed in formation with the second airplane on the right wing. The rest of the airplanes followed in loose trail as the leader maneuvered in a serpentine manner. The flight was now over the Ojai area, and proceeded on a northerly heading. Members of the group reported that they had flown in this area before. Witnesses reported that the first two airplanes separated from the rest of the group. They descended into a canyon to an estimated 500 to 1,000 feet above ground level (agl). The other airplanes followed about 500 feet behind the airplane that they were following. The number three pilot estimated that he was about 200 feet above the leader's altitude and number two was between them. Number three was flying at 120 knots and heard "90." He noticed that number two was getting closer to the leader, and he was closing on number two. As the airplanes proceeded toward the end of the canyon, number three noticed that the terrain was rising, and the canyon was getting narrow. Due to his concern about terrain clearance, he decided to exit the formation. He asked the leader if he was going to make it, but he had his microphone keyed and did not hear a response. Other pilots heard someone say, "I don't think so." A few seconds later, number three initiated a hard pull up to the left and began to climb. He completed about 15 degrees of turn and saw the lead airplane collide with trees and terrain at his 2-o'clock position. The number two airplane was a little to the right of the lead when it also collided with the terrain. The lead airplane caught fire and then the second airplane caught fire. The first airplane was N156U, a Beech V35A; see NTSB accident report LAX02FA211. Number three estimated that the ridgeline elevation was 6,000 feet, and he cleared the ridgeline by 50 feet. He noted an outside air temperature of 87 degrees Fahrenheit. He immediately notified authorities in Santa Barbara, California, and entered an orbit at 8,000 feet. Within 7 to 8 minutes a helicopter arrived and dropped water on the fire. About 20 minutes later several aircraft arrived on scene and number three departed the area. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a private pilot certificate with airplane single engine land and instrument ratings. The pilot held a third-class medical certificate issued on May 4, 2002. It had no limitations. No logbooks were recovered for the pilot. Information supplied by the FAA indicated a total time of 840 hours at the pilot's last application for a medical certificate. AIRCRAFT INFORMATION The airplane was a Beech S35, serial number D-7605. The engine was a Teledyne Continental Motors IO-520-B, serial number 121093. The IIC did not recover logbooks for the airplane or engine. METEOROLOGICAL INFORMATION An aviation routine weather report (METAR) for Santa Barbara was issued at 1053. It stated: skies 700 feet broken; visibility 5 miles; mist; winds from 170 degrees at 9 knots; temperature 66 degrees Fahrenheit; dew point 60 degrees Fahrenheit; altimeter 29.96 inches of mercury. A pilot in the formation reported that the skies were clear at the accident site. WRECKAGE AND IMPACT INFORMATION Investigators from the Safety Board and a representative from Raytheon Beech examined the wreckage on scene. The two airplanes came to rest within 75 feet of each other at the head of the canyon at an estimated elevation of 4,925 feet. The slope of the terrain at the accident site was approximately 45 degrees. A saddle on top at the head of the canyon was at an estimated elevation of 5,400 feet, and less than 1/2 mile from the accident site. The airframe structure was not identifiable. The ash outline of the fuselage was on a magnetic bearing of 160 degrees. Investigators observed the control cables going to the ash outline of their respective control surfaces. The head of cylinder no. 2 was not identified, but investigators recovered the valves, which did not exhibit any mechanical damage. The IIC removed the top spark plugs for cylinders no. 1, 3, and 4. The plugs did not exhibit any mechanical damage; the electrodes appeared circular and gray in color. The magnetos and fuel control units sustained extensive thermal damage. The propeller separated from the crankshaft at the propeller flange, and was buried in the dirt approximately 2 feet from the engine. One blade fractured and separated along an angular plane about 18 inches from the hub, and exhibited a leading edge gouge about 1 inch deep. A second blade exhibited S-bends. The third blade fractured and separated about a foot from the hub, and the edges melted. The fuel selector valve was destroyed. The manufacturer's representative determined that the landing gear was in the up position. Investigators did not identify the flap actuator and the elevator trim actuators. The Safety Board did not take possession of the wreckage. ## Aircraft - Registration: [N576Q](https://openairdocs.org/deregistered/N576Q-2007-05-15), registration cancelled 2007-05-15, S/N D-7605, built 1964 (OpenAirDocs) - Reported make and model: Beech S35 - Registry model: [Beech S35](https://openairdocs.org/model/beech-s35) (registry code 1151532) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-7605 - Engines: Continental IO-520 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Dennis J Giangreco - Airworthiness certificate: Standard, Utility - Departed: VNY, VAN NUYS, CA - Destination: L52, Oceano, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 840 total ## Weather - Conditions: Instrument (IMC), Day - Wind: 150° at 8 knots - Visibility: 9 statute miles - Lowest ceiling: 700 ft broken - Temperature: 66 °F, dew point 61 °F - Altimeter: 29.96 inHg - Observed at: SBA, 23 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 20020630013989A](https://openairdocs.org/incident/20020630013989A), Jun 30, 2002: Beech S35, Ojai, CA, No damage, 3 fatal. (.19) On June 30, 2002, about 1100 pacific daylight time, a Beech S-35, N576Q, collided with terrain while maneuvering near Ojai, California. The pilot/owner… ## Docket (10 files) The files NTSB released with the investigation on March 15, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=55084. 13.4 MB in all. - Witness Statements (item 1, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244339&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Topo of Accident Area (item 2, .PDF, 803 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244736&FileExtension=.PDF&FileName=Topo%20of%20Accident%20Area-Master.PDF - Photo 1. View from top of ridge. (item 3, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40196342&FileExtension=.PDF&FileName=Photo%201.%20%20View%20from%20top%20of%20ridge.-Master.PDF - Photo 2-Beech Composite of Accident Canyon (item 4, .PDF, 525 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244340&FileExtension=.PDF&FileName=Photo%202-Beech%20Composite%20of%20Accident%20Canyon%20-Master.PDF - Photo 3-Main Wreckage (item 5, .PDF, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244341&FileExtension=.PDF&FileName=Photo%203-Main%20Wreckage-Master.PDF - Photo 4-Accident Site looking Toward Both Airplanes (item 6, .PDF, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244342&FileExtension=.PDF&FileName=Photo%204-Accident%20Site%20looking%20Toward%20Both%20Airplanes-Master.PDF - Photo 5-Right Side View of Engine (item 7, .PDF, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244343&FileExtension=.PDF&FileName=Photo%205-Right%20Side%20View%20of%20Engine-Master.PDF - Photo 6-Propeller (item 8, .PDF, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244344&FileExtension=.PDF&FileName=Photo%206-Propeller-Master.PDF - Coroner Record of Conversation (item 9, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40196338&FileExtension=.PDF&FileName=Coroner%20Record%20of%20Conversation-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244346&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.