LAX05FA099

NTSB accident investigation · Beech 95 · Calistoga, CA · February 15, 2005

Accident · FatalField investigationFinal report
Date
February 15, 2005, 09:25 local (17:25 UTC)
Place
Calistoga, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N8269DBeech 95
Weather
Visual (VMC) · Day
Status
Completed · report June 28, 2006
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20050215005659A
Case key
61036

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's inadequate preflight and in-flight planning/decision, which resulted in continued VFR flight into instrument meteorological conditions at an altitude insufficient to ensure adequate terrain clearance and impact with rising terrain.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherCruise
Weather condition - clouds
Weather condition - obscuration
Preflight planning/preparation - inadequatePilot in commandCause
Preflight briefing service - not obtainedPilot in command
In-flight planning/decision - inadequatePilot in commandCause
Vfr flight into imc - continuedPilot in commandCause
In flight collision with terrain/waterCruise
Terrain condition - mountainous/hilly
Terrain condition - rising
Altitude/clearance - not maintainedPilot in commandCause

Analysis

The airplane impacted the southeast side of a mountain while the pilot was in a cruise descent and entering the vicinity of the destination airport. The instrument rated pilot departed on the 81 nautical mile (nm) flight and shortly thereafter began receiving visual flight rules (VFR) flight following services. There was no indication that he had ever flown that route prior to the accident flight. The cross-country flight path consisted of flying over level terrain for the first half, with the remainder of the flight crossing over several mountains (the last of which was the mountain the airplane impacted). The pilot regularly flew over level terrain for his commute to work. A regular passenger on those commuter flights (a coworker) reported that there were numerous times when the pilot would fly through a layer of clouds in an effort to descend down to the destination airport. The radar returns and voice tapes of the pilot's communications revealed that the airplane began a gradual descent about 18 nm prior to impact. The majority of the radar returns were all spaced uniformly and followed an anticipated route for the cross-country flight. The area in which the radar returns were lost is a typical region for air traffic controllers to lose radar contact with aircraft due to the surrounding terrain. The airplane's radar-derived ground speed was close to that expected for cruise flight according to the airplane manufacturer's owner's manual. The last radar target observed was about 1.45 nm from the accident site at the same altitude where the wreckage was located. Instrument meteorological conditions were forecasted over the mountainous areas near the destination airport. A pilot who was flying in the vicinity of the accident site stated that he was on an instrument flight rules (IFR) flight plan around the time of the accident. He recalled that the cloud tops were about 5,000 feet mean sea level (msl) and the bases were about 3,000 feet msl. He noted that the mountains in the area were obscured, but did not observe any unusual or hazardous meteorological conditions. The weather observation stations 14 nm southwest, 50 nm east, and 38 nm northwest, were reporting overcast conditions around the time of the accident at 9,000, 4,800, and 4,000 feet, respectively. An AIRMET for the accident area was issued by the National Weather Service indicating cloud layers at the same altitude as the accident site. It additionally stated that mountains in the area were occasionally obscured in clouds, precipitation, fog and mist. There was no evidence that the pilot ever obtained a weather briefing for the accident flight from any official FAA or NWS aviation source. The wreckage came to rest about 1,100 feet below the eastern summit of a mountain, at the 3,300-foot level. The debris was distributed over 90 feet of rugged terrain, on a slope of about 70 to 80 degrees that was comprised of rock outcroppings and wet dirt. Trees were located about 150 to 200 feet from the main wreckage that appeared to have been severed at the tops. After performing victim recovery, search and rescue personnel declined to return to the accident site stating that the terrain was too dangerous for even the most experienced mountaineers. The airplane was not recovered.

Factual narrative

History of flight

On February 15, 2005, about 0925 Pacific standard time, a Beech 95, N8269D, impacted the southeast side of Mount St. Helena while in cruise flight near Calistoga, California. The pilot was operating the airplane under the provisions of 14 CFR Part 91. The private pilot and one passenger sustained fatal injuries; the airplane was destroyed. The personal cross-country flight originated from Oroville Municipal Airport, Oroville, California, at an unknown time, with a planned destination of the Charles M. Schulz- Sonoma County Airport, Santa Rosa, California. Instrument meteorological conditions prevailed in the area surrounding the accident site, and a flight plan had not been filed.

On February 17, 2005, the Federal Aviation Administration (FAA) issued an alert notification (ALNOT) after receiving a notice from a concerned family member that the airplane was missing and overdue. Both the Civil Air Patrol and local authorities were notified of an overdue aircraft; several hours later the airplane wreckage was located.

Family members reported that the purpose of the flight was for the pilot to take his wife (the passenger) to a doctor appointment near Santa Rosa. They did not believe that he had flown her to that airport before, although she did accompany him on trip occasionally. The direct route of flight from Oroville to Santa Rosa is about 81 nautical miles (nm) on a course of 223 degrees true. The terrain during the first half of the flight is level, averaging about 50 feet mean sea level (msl). In the latter portion of the flight there are several mountain ridges that are oriented almost perpendicular to the flight path. The last mountain before reaching Santa Rosa is Mount St. Helena, which summits at 4,339 feet msl.

During the investigation, the recorded voice channels from Oakland Air Route Traffic Control Center and recorded radar data were obtained and reviewed by a National Transportation Safety Board investigator.

While the airplane was en route to Santa Rosa, the pilot was in communication with Oakland Center air traffic controllers receiving radar flight following services. At 0905:22, the pilot made his initial call to Oakland Center, announcing the airplane's altitude to be 6,500 feet. The controller responded, providing the Santa Rosa altimeter setting of 29.97 inches of mercury. At 0908:21, the pilot was instructed to change frequencies.

At 0908:51, the pilot made contact with Oakland Center sector R41 transmitting on a frequency of 125.85, restating that he was at an altitude of 6,500 feet. The controller responded, again providing the current altimeter setting. At 0916:38, about 11 minutes after the initial contact, the pilot made his last transmission stating that he was starting his descent for Santa Rosa. Around 0924, the controller lost radar contact with the airplane. In written statements, controllers at Oakland Center stated that the area where the wreckage was located is a common location to lose radar contact with aircraft.

Recorded radar data covering the area of the accident was examined for the time frame, and a discreet secondary beacon code target was observed that matched the anticipated flight track of the airplane en route from Oroville to Santa Rosa. The data was supplied by the Federal Aviation Administration (FAA) in the form of a National Track Analysis Program (NTAP) printout from Oakland Center.

A review of the data disclosed that the plot stretched over an 18 nm distance throughout a duration of 6 minutes 53 seconds, which equates to a radar derived ground speed of about 157 miles per hour (mph). The target was first identified at 0915:07 as it tracked southwest bound on a Mode C reported altitude of 6,300 feet. After several minutes, radar returns showed a gradual descent toward Santa Rosa. The last 4 nm of the radar plot occurs from 0920:24 to 0922:00, or over the course of 1 minute 36 seconds. During that last section of the plot, the radar returns indicated a varying altitude between 3,100 and 3,300 feet, with a radar derived ground speed of about 150 mph. The last radar return was recorded at 0922:00, at an altitude of 3,300 feet, about 1.45 nm from the accident location on a true course of 196 degrees.

The majority of the radar returns were all spaced uniformly and followed a track of about 228 degrees true. The data plots are contained in the public docket for this report.

The Beech Owner's Manual contains a "Cruising Operation" chart that displays the airplane's performance at a maximum gross weight of 4,000 pounds. The chart indicates that between 3,000 and 4,000 feet msl with the airplane configured at a power setting of 2,300 revolutions per minute (rpm), or 65 percent power, it will cruise at a true airspeed of about 180 mph. At a power setting of 2,200 rpm, or 55 percent power, the airplane will cruise at a true airspeed of about 167 mph.

Based on atmospheric conditions and assuming maximum gross weight conditions, the airplane's single engine service ceiling was estimated to be about 6,000 feet, with an absolute ceiling of about 7,500 feet.

Personnel information

A Safety Board investigator conducted a review of the pilot's personal flight records and the FAA airman and medical records files. He held a private pilot certificate with ratings for airplane single engine land and instruments. The pilot's most recent third-class medical certificate was issued without limitations on May 01, 2004.

The pilot's flight records were obtained from the family, and consisted of a bound logbook (dated from May 2002 to December 2003) and a printout of an electronic database (dated April 2004 to August 2004 and November 2004). The summation of flight hours from both log sources revealed that the pilot had accumulated 581.6 hours total time, with 94.1 in multiengine airplanes, and 88.6 hours amassed in the accident airplane. The logs additionally disclosed that he had accrued 18.9 hours of flight time in actual instrument flight conditions, which were completed in a Cessna 172 airplane. The pilot received his instrument rating on February 07, 2003, and recorded 16.9 hours of instrument time (both simulated and actual) after receiving the rating. There was no instrument time recorded on the electronic logs. A majority of the flights recorded throughout the logs were conducted within at least a week duration from the previous entry.

Based on the airport identifiers listed in the logs for flight origin and destination points, the pilot had never completed the same route as the accident flight. However, he had flown into Santa Rosa on two previous occasions, both of which originated from, and terminated in, Sacramento, California. The most recent of the two flights to Santa Rosa was conducted on December 30, 2002. Most of the flight activity recorded in the logs were daily trips between Oroville and Sacramento.

According to family members, the pilot's wife (passenger) did not have any prior aeronautical experience. No record of the individual was found during a review of the FAA airman and medical records database.

A Safety Board investigator conducted a telephone interview with a coworker of the pilot. He stated that about 3 to 4 days a week he and the pilot would commute to work via the accident airplane. They would regularly leave Oroville about 0530 in the morning and arrive in Sacramento about 0600. He recalled many times where the pilot would fly through a layer of clouds in an effort to descend down to the airport.

Aircraft information

No airplane or engine maintenance records were located. A review was conducted of the material maintained by the FAA in the Aircraft and Registry files for this airplane. The Beech 95 multiengine airplane, serial number TD-59, was manufactured in 1958, and purchased by the pilot on March 29, 2004. According to the Owner's Manual, the airplane was origina

Aircraft

Registration
N8269D
Reported as
Beech 95
Category
Airplane
Serial number
TD-59
Engine
Lycoming O-360-A1A, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Rodney Kirby
Registered owner
Bald Rock, Inc.
Airworthiness certificate
Standard, Normal
Departed
OVE · Oroville, CA
Destination
STS · Santa Rosa, CA
Airport
STS · Charles M. Schulz- Sonoma Coun

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
49
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Toxicology
Performed
Flight hours
581 total · 88 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 7 knots
Visibility
10 statute miles
Lowest ceiling
7,000 ft broken
Temperature
54 °F, dew point 48 °F
Altimeter
29.96 inHg
Observed at
STS, 14 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.