# NTSB LAX04GA051: Piper PA-28-180, N7292W, Big Bear City, CA, November 22, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Final report - Date: November 21, 2003, 21:00 local (Nov 22, 2003, 04:00 UTC) - Place: Big Bear City, CA - Coordinates: 34.257778, -116.70333 - Nearby events: https://openairdocs.org/map.md?lat=34.2578&lon=-116.7033&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 28, 2004 - Report: Approved by Office Director - Parties: Civil Air Patrol, Textron Lycoming, USAF (HQ-CAP), Piper Aircraft Company, Federal Aviation Administration - NTSB case key (mKey): 58380 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04GA051 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58380/pdf - Page: https://openairdocs.org/ntsb/LAX04GA051 ## Probable cause The pilots inadequate preflight planning and intentional flight into known adverse weather conditions. Contributing to this accident was the fact that it was a dark night with no moon illumination. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - light condition - dark night - weather condition - mountain wave (contributing factor) - weather condition - downdraft (contributing factor) - preflight planning/preparation - inadequate, pilot in command (cause) - flight into known adverse weather - performed, pilot in command (cause) - descent - encountered - In flight collision with terrain/water, maneuvering - turn to reverse direction - aircraft performance,climb capability - exceeded - clearance - not maintained, pilot in command - terrain condition - mountainous/hilly ## Analysis While flying on a moonless night in mountainous terrain to an airport in a mountain valley, the aircraft encountered mountain wave conditions and downdrafts in the 500 to 1,000 foot-per-minute range, which resulted in a collision with mountainous terrain. The two-man aircrew participated in a Civil Air Patrol (CAP) search and rescue training exercise (SAREX) being held over the weekend, and had flown from the mountain valley airport along the accident route of flight that morning. The CAP group was informed that high winds were expected the following day and flying operations might be cancelled. The aircrew decided to return to their home base in a small mountain town (elev: 6,748 feet) instead of staying at the SAREX base for the night. The aircrew had commented to the CAP Incident Commander that they had experienced some moderate turbulence on the flight out of the mountains severe enough to have their heads hit the cockpit canopy and toss a cell phone out of the passenger's shirt pocket. They departed the SAREX base at night and there was no moon illumination at the time they approached the 8,000-9,000 foot mountain ridgeline. The airplane approached the mountains at 10,300 feet, and shortly thereafter entered a mountain wave, and experienced turbulence and downdrafts. Radar data showed that the airplane steadily descended through 8,000 feet during the last 4 minutes of the flight. The airplane impacted the side of the mountain at the 6,970 foot elevation with low energy, in a very steep left turn; left wing down. Analysis of the weather conditions established that mountain wave conditions existed at 9,000 feet with a wavelength of 2.79 miles, amplitude of 717 feet, and a maximum vertical velocity of 1,185 fpm. This wave had a potential for moderate to severe turbulence. There is no record that the pilot requested or received a weather briefing. At the cruise altitude of the airplane, the performance charts show that it had a maximum climb capability of about 400 feet per minute. ## Factual narrative HISTORY OF FLIGHT On November 21, 2003, about 2100 Pacific standard time, a Piper PA-28-180, N7292W, collided with mountainous terrain 9 miles east of Big Bear City Airport, California. The airplane was a privately owned airplane operated by the Civil Air Patrol under the provisions of 14 CFR Part 91. The commercial pilot and single observer/crewmember sustained fatal injuries and the airplane was destroyed. Visual meteorological conditions prevailed and a visual flight plan had not been filed. The flight originated at Palm Springs Airport, California at 2028. The two-man aircrew was participating in a Civil Air Patrol (CAP) search and rescue training exercise (SAREX) being held at the Palm Springs Airport over the weekend. The crew arrived in Palm Springs about 1730. They attended a class room training session. The group was informed that high winds were expected the following day and flying operations might be cancelled. The aircrew decided to return to their home base at Big Bear Airport instead of staying in Palm Springs for the night. The aircrew had commented to the CAP Incident Commander that they had experienced some moderate turbulence on the flight out of Big Bear severe enough to have their heads hit the cockpit canopy and toss a cell phone out of the passenger's shirt pocket. Palm Springs Airport tower recorded that the airplane departed at 2028. The aircrew never returned to the Palm Springs Airport for the CAP Search and Rescue exercise (SAREX) the next day. The CAP notified the FAA of a missing airplane and the wreckage was located by the San Bernardino County Sheriff Air Support Unit at 1700, Saturday, November 22, on the north west slopes of Tip Top Mountain, at 6,900 feet. No record was found of a weather briefing given to the pilot either under his name or the registration number of the aircraft. PERSONNEL INFORMATION: The pilot obtained his commercial pilot certificate with single engine land, multiengine land, and instrument airplane rating s on June 13, 1971. He received his Certified Flight Instructor Certificate on October 6, 1977. His third class medical was dated September, 2002. Examination of the pilots log book revealed that he had logged 2,640 total flight hours with 224 hours at night, 322 hours simulated instrument, and 30 hours multiengine. Interviews with friends and family revealed that the pilot had lived in Big Bear for the last 3 years and was very familiar with the local flying area. Another pilot that had flown with the accident pilot said that he felt the pilot was a careful and conscientious pilot. The passenger was not a rated pilot but was a current Civil Air Patrol member. AIRCRAFT INFORMATION: The four seat, low wing airplane was powered by a Lycoming O-360-A36A, 180 horsepower engine with a fixed pitch Sensenich propeller. The airplane and engine underwent its last 100 hour/annual inspection on July 1, 2003. At that time the airframe had a total of 4,364 hours, total engine time was 2,390 hours with 232 hours since major overhaul (SMOH). The airplane was equipped with an Aztek 40 autopilot. A hand held GPS receiver was found at the accident site. Airplane performance information available in the Piper Cherokee B Owners Handbook shows that at a max gross weight of 2,400 pounds and between 8,000 and 10,000 feet density altitude the airplane had a maximum climb performance of 360 to 410 feet per minute. METEORLOGICAL INFORMATION: The Safety Board performed a full meteorological study surrounding the day, time, and location of this accident. The full factual report is available in the official docket. Meteorological Synopsis The surface analysis chart shows an approximate 12-mb change in pressure across southern California, which resulted in strong westerly surface winds. Meteorological stations west of the accident site indicate calm winds at the surface with fog or mist, broken cloud cover, temperature and dew points in the mid 50's (degrees Fahrenheit), with a temperature-dew point spread of 1 degree F. Other coastal locations across southern California indicated westerly winds with overcast skies. The constant pressure chart depicted a long wave trough of low pressure extending over northern California and into the Pacific Ocean. The accident site was on the front side of the upper level trough with westerly winds. Weather Advisories AIRMET Sierra was active during the time of the accident and warned of IFR conditions and mountain obscuration over California AIRMET Tango was active over portions of California, Nevada, Utah, Colorado, Arizona, and New Mexico, and warned of occasional moderate turbulence below 16,000 feet due to moderate-to-strong winds over rough terrain. Pilot Reports Numerous pilot reports (PIREPS) were recorded over southern California surrounding the time of the accident and reported turbulence and down drafts around 500 fpm. Terminal Aerodrome Forecasts Big Bear City Airport does not have a terminal aerodrome forecast (TAF) issued for the airport. The departure airport of Palm Springs terminal aerodrome forecast issued at 2320Z (1530 PST) and valid from 0000Z to 2400Z (24 hours, 1600-1600 PST) expected between 0200Z (1800 PST) and 0800Z (2400PST) winds from 320 degrees at 10 knots gusting to 20 knots, visibility better than 6 miles, scattered cloud at 15,000 feet. At 0316Z (1916PST) the forecast was amended changing the winds between 0300Z and 0600Z (1900 to 2200 PST) to wind form 320 degrees at 15 knots gusting to 25 knots, wind temporary conditions to winds variable at 5 knots. Mountain Wave Information The RAOB mountain wave module was used to help identify the mountain wave activity over the region during the period. The 1600PST sounding on November 21, 2003, from San Diego (KMYF) indicated favorable conditions for mountain wave activity with the primary wave at approximately 19,000 feet, with several secondary waves. The lowest wave at 6,000 feet had a wavelength of 2.23 miles, amplitude of 551 feet, and a maximum vertical velocity of 568 feet per minute (fpm). The wave also had a potential for producing light to moderate turbulence. The1600PST sounding from the next closest station at Mercury/Desert Rock (KDRA), Nevada, located 100 miles northeast of the accident site also confirmed favorable conditions for mountain wave activity. That sounding indicated the potential for a wave at 9,000 feet with a wavelength of 2.79 miles, amplitude of 717 feet, and a maximum vertical velocity of 1,185 fpm. This wave had a potential for moderate to severe turbulence. Astronomical Information Data collected from the U.S. Naval Observatory indicated sunset at Big Bear City to be 1640 PST and no moon illumination during the period between 1800 and 2300 PST. AIDS TO NAVIGATION: Big Bear Airport is serviced from the east by a GPS RWY 26 instrument approach. The final approach course is 256 degrees, a minimum altitude to start the approach is 9,600 feet at the initial approach fix, and a visual descent point is set at a minimum altitude of 8,600 feet, 5.1 miles from the airport. The glide slope angle is 3.34 degrees. WRECKAGE AND IMPACT INFORMATION: The San Bernardino Mountain Range runs roughly east-west. Big Bear City is located in a valley, at 6,748 feet, in the San Bernardino Mountains, and is surrounded by 8,000 to 9,000 foot mountain to the north and south and 7000 foot mountains to the east. To the northeast, east, and southeast of the San Bernardino Mountains is sparsely populated high desert terrain. The airplane wreckage was located at 34 degrees 15.452 minutes North latitude and 116 degrees 41.723 minutes West longitude at 6,900 feet msl on a northeast facing mountain slope. The terrain was moderately populated with small cedar like pine trees and 12 foot high shrubs on a 30 degree sand and gravel slope. The ridge line directly above the wreck ## Aircraft - Registration: [N7292W](https://openairdocs.org/deregistered/N7292W-2007-05-02), registration cancelled 2007-05-02, S/N 28-1136, built 1963 (OpenAirDocs) - Reported make and model: Piper PA-28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-1136 - Airframe hours: 4364 - Engines: Lycoming O-360-A36A 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Public aircraft, Public use - Operator: Civil Air Patrol - Registered owner: John Lawrence - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 1, 2003 - Departed: PSP, Palm Springs, CA - Destination: L35, Big Bear City, CA - Airport: L35, Big Bear ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; last flight review October 21, 2002; seat: left; toxicology performed; flight hours: 2,640 total, 102 in this make and model, 11 in the last 90 days, 0 in the last 30 days, 1 in the last 24 hours - Other flight crew; injuries: fatal ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 180° at 3 knots, gusting 12 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 37 °F, dew point 14 °F - Altimeter: 30.12 inHg - Observed at: L35, 9 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 20031121030169A](https://openairdocs.org/incident/20031121030169A), Nov 21, 2003: Piper PA28180, Big Bear, CA, Destroyed, 2 fatal. (-23) The aircraft was flown from psp to Big Bear airport under VMC conditions. No flight plan was filed. The aircraft crashed at the 6900 ft level of tip top… 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.