LAX05FA092

During an instrument cross-country flight at night, the pilot encountered a mountain wave with severe turbulence at 9,000 feet mean sea level (msl) and entered an uncontrolled descent to impact with mountainous terrain at an elevation of 2,300 feet msl. The flight was level at 9,000 feet crossing a mountainous area when the pilot reported to air traffic control (ATC) controllers that he was encountering light rime icing conditions. Shortly thereafter, the controller observed the aircraft descending and the pilot asked for a lower altitude. The controller said the flight was already at the minimum altitude that could be assigned. The pilot responded that he was in extreme turbulence. The aircraft then dropped off radar and no further radio transmissions were received. The Area Forecast valid for the flight was predicting multiple layers of broken to overcast ceilings from 6,000 to 12,000 feet, with a freezing level at 10,000 feet. AIRMETS were in effect for mountain obscuration, moderate turbulence, and moderate rime or mixed icing conditions, though the conditions were forecast at elevations above the pilot's planned en route altitude. No SIGMETS were in effect for turbulence. No record was found that the pilot obtained a preflight or in-flight weather briefing from any official aviation weather source. An analysis of the weather conditions found increasing wind velocities from the surface to 7,000 feet over the mountains crossing the airplane's flight path, with several layers of strong vertical wind shear that increased the likelihood of very strong turbulence. In addition, the conditions were favorable for localized mountain wave activity, and supported the potential for moderate to severe turbulence, rotors, and downdrafts to 1,500 feet per minute. An automated weather observation station in the mountains very near the accident site was reporting wind gusts to 45 knots, 10 minutes prior to the accident. The pilot of a Gulfstream G-IV that was descending near the accident location reported encountering strong turbulence with both vertical and lateral components.

1.1 History of flight

On February 10, 2005, at 2033 Pacific standard time, a Cessna P210N, N432AR, reported severe turbulence while in cruise flight and collided with the ground during a rapid descent 8 nautical miles northeast of Lebec, California. Action Air Express, Inc., was operating the airplane as an on-demand air taxi passenger flight under the provisions of 14 CFR Part 135. The commercial pilot and one passenger sustained fatal injuries. The airplane was destroyed. The airplane departed under visual flight rules (VFR) from Fresno Yosemite International Airport, Fresno, California, at 1935, and received an instrument clearance to Santa Monica Municipal Airport, Santa Monica, California, in flight over the Clovis vhf omni-directional range (VOR). A combination of visual and instrument meteorological conditions prevailed along the route of flight.

The Air Force Rescue and Coordination Center (AFRCC) issued an Alert Notice (ALNOT) at 2230 on February 10, 2005. The wreckage was located at 1000 on February 12, 2005.

According to the operator, the purpose of the flight was to transport the passenger from Fresno to Santa Monica. The passenger was scheduled to depart from Fresno at 1700 but was late to arrive. The pilot waited at a fixed-base-operator (FBO) for the passenger who arrived for the flight about 1915. At 1920, the operator called the pilot to verify that the passenger had arrived. The pilot replied affirmatively, and stated that the passenger was just boarding the airplane for departure to Santa Monica.

While en route, the pilot communicated with several Federal Aviation Administration (FAA) facilities. The National Transportation Safety Board investigator reviewed transcripts for the time period from 2021 through 2030.

At 2026:13, the accident pilot stated, "So Cal, four nine three alpha romeo's checkin with you nine thousand." The controller replied "November four nine three alpha romeo Los Angeles center, roger the uh Burbank altimeter two niner eight eight."

At 2026:21, the pilot radioed "two niner eight eight four three two alpha romeo add uh uh you guys had any reports over uh Lake Hughes for any icing or (did it) pretty much cleared up uh we're getting some uh we got some a little bit south of Shafter."

At 2026:31, the controller stated, "Uh there's been a bunch of icing between Shafter and Lake Hughes I believe it's getting a little better closer to Lake Hughes November one five mike what is your flight conditions sir?"

At 2026:40, N9351M reported, "Uh five one mike is experiencing light rime ice."

At 2026:44, the controller reported, "Okay rog roger that uh November two alpha romeo traffic over Lake Hughes at eleven has some light rime ice traffic overhead at eleven had un had a little bit earlier."

At 2026:54, the pilot stated, "Uh roger four three two alpha romeo and what kind of plane is that we're um a two ten."

At 2027:00, the controller stated, "Uh the traffic over Lake Hughes is a Mooney and uh right overhead is a twin Cessna at eleven."

At 2027:07, the pilot responds, "(thanks) four three two alpha romeo."

At 2029:40, the controller stated, "November two alpha romeo can you maintain your altitude, maintain niner thousand."

At 2029:50, the controller stated, "November four three two alpha romeo LA Center."

At 2030:09, the controller stated, "November four three two alpha romeo LA Center."

At 2030:12, the pilot stated, "Four three two alpha romeo uh we have lower request (unintelligible)."

At 2030:18, the controller stated, "Two alpha romeo you're below my minimum uh altitude do your best to climb can you maintain altitude?"

At 2030:23, the pilot reported, "Four three two alpha romeo extreme turbulence."

No further transmissions were received from the accident pilot.

1.2 Personnel information

1.2.1 Pilot

The pilot held a commercial pilot certificate for single and multiengine instrument airplane, and also held a certified flight instructor certificate with ratings for single and multiengine instrument airplane. He held a valid first-class medical certificate issued on October 1, 2004, that did not have any waivers.

The pilot began his flight training on December 5, 2000. He obtained his pilot certificates over a period of 2 years from August 22, 2001, until his last rating, which was a certified flight instructor-instrument on June 24, 2002. During this time period the pilot took seven check rides. He failed the following three check rides on his first attempt: private multiengine; private instrument; and certified flight instructor instrument. Moreover, he took the private instrument check ride two times before passing.

The Safety Board investigator reviewed the pilot's records from Air Action Express, Inc. On May 26, 2004, the pilot satisfactorily completed a 14 CFR Part 135 flight check with an FAA inspector. The flight check satisfied the requirements of 14 CFR 135.293, 135.297, and 135.299.

On December 15, 2004, the pilot failed a 14 CFR 135.297 check. It was noted that item number 1, equipment examination (oral or written), was the reason for disapproval. On December 21, 2004, the pilot received another disapproval. It was noted on FAA Form 8410-3, "Airman Competency and Proficiency Check" that item number 23, holding, was unsatisfactory. Based on the FAA records, all other test areas were completed satisfactorily. On January 26, 2005, the pilot satisfactorily completed the 14 CFR 135.297 check.

Prior to the pilot's initial 14 CFR Part 135 check on May 26, 2004, he had attempted four Part 135 flight checks for the predecessor of Action Air Express, Inc., Peach, Inc. The FAA issued identifier code assigned to both companies was the same (QXNA). On January 30, 2004, the inspector noted, "135.293(a) unsatisfactory." On February 6, 2004, a disapproval was given for item number 1, equipment examination (oral or written). On March 4, 2004, a disapproval noted that item number 10, steep turns were unsatisfactory. On March 9, 2004, a disapproval again indicating item number 10 was unsatisfactory.

Two pilot's logbooks were recovered from the accident site and reviewed by the Safety Board investigator. The first logbook contained entries from December 5, 2000, to December 24, 2002. The second logbook began on May 8, and the last entry was dated October 3, 2004. The entries in the second logbook were intermittent so the times were estimated using the logged flight times. Based on a combination of the recorded flight logbook times and records from Action Air Express, Inc., the pilot's total flight time was estimated to be about 1,850 hours. On the pilot's most recent FAA medical application, the pilot reported a total pilot time of "2,000 est."

1.2.2 Passenger Information

Based on interviews with the passenger's spouse and a review of FAA airman records, the passenger did not hold a pilot certificate nor had he engaged in any flight training. The passenger had flown with the company on previous occasions due to business, and had not reported any complaints regarding Action Air Express, Inc., operations or flights.

1.3 Aircraft information

The single engine pressurized airplane was built in 1978. According to the maintenance records, the last annual was performed on July 14, 2004. The last maintenance performed was a 100-hour inspection on November 1, 2004. At the time of the accident, the airplane had accumulated approximately 97 hours since its last inspection.

In the limitations section of the airplane Pilot's Operating Handbook (POH), the following limitation was noted: Flight into known icing conditions is prohibited.

The airplane was equipped with a System Fifty-Five X Autopilot. Pursuant to the operating requirements of the operator, the autopilot was required to be operational for IFR flights. The autopilot could be disconnected during flight through the following methods: turn