# NTSB LAX04FA095: Cessna 180K, N61691, Tehachapi, CA, January 16, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 16, 2004, 14:15 local (22:15 UTC) - Place: Tehachapi, CA - Coordinates: 35.128334, -118.561111 - Nearby events: https://openairdocs.org/map.md?lat=35.1283&lon=-118.5611&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 minor - Status: Completed, report May 30, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Raytheon, Cessna Aircraft Company - NTSB case key (mKey): 58628 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04FA095 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58628/pdf - Page: https://openairdocs.org/ntsb/LAX04FA095 ## Probable cause (aircraft 2) The pilot's inadequate visual lookout during climb, and the pilot of the other airplane's inadequate visual lookout during cruise. ## Probable cause (aircraft 1) The pilot's inadequate visual lookout during cruise, and the pilot of the other airplane's inadequate visual lookout during climb. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Midair collision, cruise - visual lookout - inadequate, pilot in command (cause) - visual lookout - inadequate, pilot of other aircraft (cause) - visual/aural detection, pilot in command (contributing factor) - Midair collision, climb - to cruise - visual lookout - inadequate, pilot in command (cause) - visual/aural detection, pilot in command (contributing factor) - visual lookout - inadequate, pilot of other aircraft (cause) ## Analysis (aircraft 2) A Cessna 180K and a Beech 95-B55 collided head-on during cruise flight over a valley, between 1,500 and 2,000 feet above ground level. The Cessna's right wing separated, and the airplane descended to ground impact. The Beech, which had been in a cruise climb, experienced a punctured windscreen and fuselage. The pilot made a precautionary landing without further mishap. The collision occurred on a clear day about 6 miles west of the Tehachapi Airport, from where the Beech pilot had departed. Neither pilot was receiving services from the Federal Aviation Administration. Radar track data indicated that the Cessna had flown in a southeasterly direction after departing the Bakersfield area. Minutes prior to the collision, the pilot changed to a northerly course. Seconds prior to the collision the pilot initiated a northeasterly turn. The Beech pilot had just configured his airplane for a cruise climb, and was flying in a westerly direction toward Bakersfield. The Cessna was flying about 135 knots, and the Beech was flying about 140 knots. The closing speed was about 275 knots, or just over 4 miles per minute. The Cessna was equipped with a Mode S transponder, and its signal was detected by Traffic Collision Alerting Device (TCAD) installed in the Beech. Seconds prior to the collision, the Beech pilot heard the audible "traffic" alert warning in his headset, and he observed an illuminated target in close proximity on the annunicator. The target was within 200 feet of his airplane's altitude, and in his 1 to 2 o'clock position. The Beech pilot reported that although he looked for the target, none was seen. The collision angle between the airplanes was documented. The impact was ascertained by fitting the Cessna's right main landing gear wheel in the punctured right side front windscreen of the Beech. As the Cessna's landing gear passed through the upper portion of the Beech's fuselage, the right wing's lift strut was lacerated upon impacting the leading edge of the Beech's vertical stabilizer. Thereafter, the Cessna's right wing separated. An evaluation of the pilots' visual angles revealed the airplanes were within each pilot's field of vision. ## Analysis (aircraft 1) A Cessna 180K and a Beech 95-B55 collided head-on during cruise flight over a valley, between 1,500 and 2,000 feet above ground level. The Cessna's right wing separated, and the airplane descended to ground impact. The Beech, which had been in a cruise climb, experienced a punctured windscreen and fuselage. The pilot made a precautionary landing without further mishap. The collision occurred on a clear day about 6 miles west of the Tehachapi Airport, from where the Beech pilot had departed. Neither pilot was receiving services from the Federal Aviation Administration. Radar track data indicated that the Cessna had flown in a southeasterly direction after departing the Bakersfield area. Minutes prior to the collision, the pilot changed to a northerly course. Seconds prior to the collision the pilot initiated a northeasterly turn. The Beech pilot had just configured his airplane for a cruise climb, and was flying in a westerly direction toward Bakersfield. The Cessna was flying about 135 knots, and the Beech was flying about 140 knots. The closing speed was about 275 knots, or just over 4 miles per minute. The Cessna was equipped with a Mode S transponder, and its signal was detected by Traffic Collision Alerting Device (TCAD) installed in the Beech. Seconds prior to the collision, the Beech pilot heard the audible "traffic" alert warning in his headset, and he observed an illuminated target in close proximity on the annunicator. The target was within 200 feet of his airplane's altitude, and in his 1 to 2 o'clock position. The Beech pilot reported that although he looked for the target, none was seen. The collision angle between the airplanes was documented. The impact was ascertained by fitting the Cessna's right main landing gear wheel in the punctured right side front windscreen of the Beech. As the Cessna's landing gear passed through the upper portion of the Beech's fuselage, the right wing's lift strut was lacerated upon impacting the leading edge of the Beech's vertical stabilizer. Thereafter, the Cessna's right wing separated. An evaluation of the pilots' visual angles revealed the airplanes were within each pilot's field of vision. ## Factual narrative (aircraft 2) HISTORY OF FLIGHT On January 16, 2004, about 1415 Pacific standard time, a Cessna 180K, N61691, and a Beech 95-B55, N555RD, collided about 6 nautical miles west-southwest of Tehachapi, California. The Cessna was destroyed, and its pilot was fatally injured. The pilot held an airline transport pilot certificate, and he was a partial owner of the airplane, which was operated under the name of ABA Communications, LLC. The Beech was substantially damaged, and its owner-pilot received minor injuries. Visual meteorological conditions prevailed during the personal flights. At the time of the head-on midair collision, neither airplane was on a flight plan. Both flights were performed under the provisions of 14 CFR Part 91. The Cessna's flight originated at an undetermined time from Lancaster, California. The Beech's flight originated from Tehachapi, the pilot's home base airport, approximately 1412. The Federal Aviation Administration (FAA) was not providing any services to the pilots at the time of the accident. The Cessna airplane's co-owner reported to the National Transportation Safety Board investigator that the accident pilot had initiated his flight from the General Wm. J. Fox Airfield (WJF). The pilot intended to fly the airplane for a few hours. The pilot's route of flight from WJF to Bakersfield, California, was not determined. The FAA reported that at 1316, the Cessna pilot contacted the Bakersfield Terminal Radar Approach Control facility (TRACON) and requested practice instrument approaches to the Bakersfield Meadows Airport. The pilot received the requested clearance, and he performed practice instrument and missed approaches. Subsequently, at 1355, the pilot requested a climb to visual meteorological conditions en route to WJF. At 1358, the pilot reported having reached visual conditions and canceled his instrument clearance. At 1409, the pilot requested cancellation of the flight following services. The FAA controller acknowledged the request and approved the pilot to change frequencies to the WJF advisory frequency. There were no further radio communications to or from the Cessna pilot. The Beech pilot provided the Safety Board investigator with oral and written statements regarding the accident flight. In pertinent part, the pilot stated that his airplane was equipped with a traffic alert system consisting, in part, of a Ryan International Traffic Collision Alerting Device (TCAD), model 9900BX, and a Garmin global positioning satellite receiver, model GNS 530. Integrated in the GNS 530 was the display for the Ryan TCAD. The pilot indicated that this type of equipment had been in his airplane for about 1.5 years, and he was familiar with its operating protocols and functionality. The pilot stated that during the flight there were no indications of any mechanical malfunctions with the airplane engines, systems, or avionics. According to the pilot, upon climbing through 5,000 feet mean sea level (msl) he established the airplane in a cruise climb configuration. The rate of climb was between 800 and 1,000 feet per minute, and the airspeed was about 140 knots. The range on the GNS 530 was set for 35 miles. Initially, no traffic was observed in his vicinity. Then, he heard the words "traffic, traffic" in his headphone. The pilot reported that he recognized this voice sound as being a "traffic alert" signal instigated by activation of the Ryan TCAD. The position of the conflicting traffic was displayed on the GNS 530. In response to the alert signal, the pilot glanced at the display and observed a yellow dot in the 1 o'clock position, relative to his airplane. The pilot stated that the display of a yellow colored dot indicated that the traffic was in close proximity to his airplane. In a written statement subsequently provided by the pilot, he reported that the first traffic alert he heard was for traffic at his 2 or 3 o'clock position. He searched to his right and did not observe traffic. Thereafter, upon again looking again at the GNS 530's display screen, he observed traffic in his 1 or 2 o'clock position and close to the airplane symbol. He began a turn to the left. The pilot looked again at his 1 to 2 o'clock area and did not see traffic. The pilot stated that he could not recall what altitude value was displayed for the approaching airplane. But, he recalled the altitude was not "zero zero." He believes that it may have been plus or minus 100 or 200 feet, but he did not have a specific recollection. The pilot did not recall seeing the numeric altitude value change when he subsequently glanced at the GNS's display. The pilot reported that the collision avoidance system had no provision for resolution of the alert warning. He indicated that, on previous flights, he had observed the display of a "ghost target." He indicated that initially when a ghost target is detected, it might move from the left side to the right side or be in various positions until it finally is permanently displayed. Because of his experience with the unit, he was initially uncertain whether the depicted yellow target was to the airplane's right or left side. The pilot stated that after he saw the yellow target, he then "looked around," but did not see any approaching aircraft. He indicated that the accident occurred several seconds thereafter. Upon further questioning by the Safety Board investigator, the pilot reported that less than 1 minute elapsed between the time the collision alert system first activated and the time of the collision. The pilot indicated that just before the impact he observed what he believed was the right landing gear of an approaching aircraft in his 12:30 position. The pilot ducked to the left instinctively and while ducking he heard the "boom" of impact. He thought that he may have initiated left bank input on the control yoke, but he was uncertain. He believes that the accident occurred only a moment after seeing the approaching aircraft's landing gear. Following the collision the pilot looked up, observed his bodily injuries, and decided to immediately land while he had both physiological capability and control of his airplane. He was concerned about losing consciousness. In the pilot's written statement he stated that he thought about calling Mayday, but made the decision not to use the radio but rather to "fly the plane, fly the plane, fly the plane." Below and to the left of the airplane he observed an unfamiliar dirt surfaced airstrip (subsequently determined to be the PSK (private) airstrip). The pilot initiated a left-hand pattern approach to its runway and made the precautionary landing. The pilot indicated that throughout the entire approach and landing, power was available on both engines. Regarding his flight controls, the pilot reported that he had no difficulty moving the ailerons, but upon application of rudder pressure he felt that the rudder's movement was "stiff." The pilot reported that he did not recall his actual landing. However, after the airplane rolled to a stop on the runway, rather than exiting the cockpit through the cabin door, he exited by stepping over the area where the door and window had been located. The pilot then walked away from the airplane and called 911 to report what had transpired and to seek assistance. Two ground-based witnesses reported to the Safety Board investigator that they had observed both airplanes seconds prior to the collision. In summary, the witnesses reported that the larger (Beech) airplane was flying in a westerly direction and appeared to be cruising in level flight. The smaller (Cessna) airplane appeared to be cruising in an easterly direction and also appeared to be in level flight. Neither airplane appeared to change course or alter its wing level appearance prior to the collision. Following the collision, the Beech continued flying in a westerly ## Factual narrative (aircraft 1) HISTORY OF FLIGHT On January 16, 2004, about 1415 Pacific standard time, a Cessna 180K, N61691, and a Beech 95-B55, N555RD, collided about 6 nautical miles west-southwest of Tehachapi, California. The Cessna was destroyed, and its pilot was fatally injured. The pilot held an airline transport pilot certificate, and he was a partial owner of the airplane, which was operated under the name of ABA Communications, LLC. The Beech was substantially damaged, and its owner-pilot received minor injuries. Visual meteorological conditions prevailed during the personal flights. At the time of the head-on midair collision, neither airplane was on a flight plan. Both flights were performed under the provisions of 14 CFR Part 91. The Cessna's flight originated at an undetermined time from Lancaster, California. The Beech's flight originated from Tehachapi, the pilot's home base airport, approximately 1412. The Federal Aviation Administration (FAA) was not providing any services to the pilots at the time of the accident. The Cessna airplane's co-owner reported to the National Transportation Safety Board investigator that the accident pilot had initiated his flight from the General Wm. J. Fox Airfield (WJF). The pilot intended to fly the airplane for a few hours. The pilot's route of flight from WJF to Bakersfield, California, was not determined. The FAA reported that at 1316, the Cessna pilot contacted the Bakersfield Terminal Radar Approach Control facility (TRACON) and requested practice instrument approaches to the Bakersfield Meadows Airport. The pilot received the requested clearance, and he performed practice instrument and missed approaches. Subsequently, at 1355, the pilot requested a climb to visual meteorological conditions en route to WJF. At 1358, the pilot reported having reached visual conditions and canceled his instrument clearance. At 1409, the pilot requested cancellation of the flight following services. The FAA controller acknowledged the request and approved the pilot to change frequencies to the WJF advisory frequency. There were no further radio communications to or from the Cessna pilot. The Beech pilot provided the Safety Board investigator with oral and written statements regarding the accident flight. In pertinent part, the pilot stated that his airplane was equipped with a traffic alert system consisting, in part, of a Ryan International Traffic Collision Alerting Device (TCAD), model 9900BX, and a Garmin global positioning satellite receiver, model GNS 530. Integrated in the GNS 530 was the display for the Ryan TCAD. The pilot indicated that this type of equipment had been in his airplane for about 1.5 years, and he was familiar with its operating protocols and functionality. The pilot stated that during the flight there were no indications of any mechanical malfunctions with the airplane engines, systems, or avionics. According to the pilot, upon climbing through 5,000 feet mean sea level (msl) he established the airplane in a cruise climb configuration. The rate of climb was between 800 and 1,000 feet per minute, and the airspeed was about 140 knots. The range on the GNS 530 was set for 35 miles. Initially, no traffic was observed in his vicinity. Then, he heard the words "traffic, traffic" in his headphone. The pilot reported that he recognized this voice sound as being a "traffic alert" signal instigated by activation of the Ryan TCAD. The position of the conflicting traffic was displayed on the GNS 530. In response to the alert signal, the pilot glanced at the display and observed a yellow dot in the 1 o'clock position, relative to his airplane. The pilot stated that the display of a yellow colored dot indicated that the traffic was in close proximity to his airplane. In a written statement subsequently provided by the pilot, he reported that the first traffic alert he heard was for traffic at his 2 or 3 o'clock position. He searched to his right and did not observe traffic. Thereafter, upon again looking again at the GNS 530's display screen, he observed traffic in his 1 or 2 o'clock position and close to the airplane symbol. He began a turn to the left. The pilot looked again at his 1 to 2 o'clock area and did not see traffic. The pilot stated that he could not recall what altitude value was displayed for the approaching airplane. But, he recalled the altitude was not "zero zero." He believes that it may have been plus or minus 100 or 200 feet, but he did not have a specific recollection. The pilot did not recall seeing the numeric altitude value change when he subsequently glanced at the GNS's display. The pilot reported that the collision avoidance system had no provision for resolution of the alert warning. He indicated that, on previous flights, he had observed the display of a "ghost target." He indicated that initially when a ghost target is detected, it might move from the left side to the right side or be in various positions until it finally is permanently displayed. Because of his experience with the unit, he was initially uncertain whether the depicted yellow target was to the airplane's right or left side. The pilot stated that after he saw the yellow target, he then "looked around," but did not see any approaching aircraft. He indicated that the accident occurred several seconds thereafter. Upon further questioning by the Safety Board investigator, the pilot reported that less than 1 minute elapsed between the time the collision alert system first activated and the time of the collision. The pilot indicated that just before the impact he observed what he believed was the right landing gear of an approaching aircraft in his 12:30 position. The pilot ducked to the left instinctively and while ducking he heard the "boom" of impact. He thought that he may have initiated left bank input on the control yoke, but he was uncertain. He believes that the accident occurred only a moment after seeing the approaching aircraft's landing gear. Following the collision the pilot looked up, observed his bodily injuries, and decided to immediately land while he had both physiological capability and control of his airplane. He was concerned about losing consciousness. In the pilot's written statement he stated that he thought about calling Mayday, but made the decision not to use the radio but rather to "fly the plane, fly the plane, fly the plane." Below and to the left of the airplane he observed an unfamiliar dirt surfaced airstrip (subsequently determined to be the PSK (private) airstrip). The pilot initiated a left-hand pattern approach to its runway and made the precautionary landing. The pilot indicated that throughout the entire approach and landing, power was available on both engines. Regarding his flight controls, the pilot reported that he had no difficulty moving the ailerons, but upon application of rudder pressure he felt that the rudder's movement was "stiff." The pilot reported that he did not recall his actual landing. However, after the airplane rolled to a stop on the runway, rather than exiting the cockpit through the cabin door, he exited by stepping over the area where the door and window had been located. The pilot then walked away from the airplane and called 911 to report what had transpired and to seek assistance. Two ground-based witnesses reported to the Safety Board investigator that they had observed both airplanes seconds prior to the collision. In summary, the witnesses reported that the larger (Beech) airplane was flying in a westerly direction and appeared to be cruising in level flight. The smaller (Cessna) airplane appeared to be cruising in an easterly direction and also appeared to be in level flight. Neither airplane appeared to change course or alter its wing level appearance prior to the collision. Following the collision, the Beech continued flying in a westerly ## Aircraft 1 - Registration: [N61691](https://openairdocs.org/deregistered/N61691-2004-06-18), registration cancelled 2004-06-18, S/N 18052790 (OpenAirDocs) - Reported make and model: Cessna 180K - Registry model: [Cessna 180K](https://openairdocs.org/model/cessna-180k) (registry code 2072624) (OpenAirDocs) - Category: Airplane - Serial number: 18052790 - Airframe hours: 3555 - Engines: Continental O-470U-R14 230 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: David A. Lazerson - Registered owner: ABA Communications, LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 1, 2003, 104 hours before - Departed: WJF, Lancaster, CA - Destination: WJF, Lancaster, CA - Airport: TSP, Tehachapi ## Aircraft 2 - Registration: [N555RD](https://openairdocs.org/aircraft/N555RD), registered now, S/N TC-2025, built 1977 (OpenAirDocs) - Reported make and model: Beech 95-B55 - Registry model: [Beech 95-B55 (T42A)](https://openairdocs.org/model/beech-95-b55-t42a) (registry code 1152706) (OpenAirDocs) - Category: Airplane - Serial number: TC-2025 - Airframe hours: 4570 - Engines: Continental IO-470-L 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Robert H. Gates - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2003, 98 hours before - Departed: TSP, Tehachapi, CA - Destination: BFL, Bakersfield, CA - Airport: TSP, Tehachapi ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N61691; age 40; injuries: fatal; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review August 1, 2002; toxicology performed; flight hours: 5,276 total, 365 in this make and model, 4,764 as pilot in command - Pilot, aircraft N555RD; age 58; injuries: minor; private; airplane ratings: single-engine sea, multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review January 1, 2003; seat: left; toxicology performed; flight hours: 2,500 total, 1,100 in this make and model, 2,500 as pilot in command, 34 in the last 90 days, 8 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 30 °F - Altimeter: 29.89 inHg - Observed at: WJF, 28 nm away ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20040116012941A](https://openairdocs.org/incident/20040116012941A), Jan 16, 2004: Cessna 180K, Tehachapi, CA, Destroyed, 1 fatal. (-23) On January 16, 2004, at about 14:15 PST, a Cessna 180K and a Beech 95-B55, collided about 6.5 nautical miles west of Tehachapi, California. The Cessna… - [Accident 20040116012942A](https://openairdocs.org/incident/20040116012942A), Jan 16, 2004: Beech 95B55, Rosamond, CA, Substantial damage. (-23) On January 16, 2004, at about 14:15 PST, a Cessna 180K, N61691, and a Beech 95-B55, N555RD, collided about 6.5 nautical miles west of tehachapi,… 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.