# NTSB LAX06FA014: Lancair LC-41-550FG, N285JB, Warner Springs, CA, October 17, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 17, 2005, 10:38 local (17:38 UTC) - Place: Warner Springs, CA - Coordinates: 33.395, -116.606391 - Nearby events: https://openairdocs.org/map.md?lat=33.3950&lon=-116.6064&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report March 26, 2007 - Report: Approved by Office Director - Parties: Columbia Aircraft, Teledyne Continental Motors, Federal Aviation Administration - NTSB case key (mKey): 62691 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX06FA014 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62691/pdf - Page: https://openairdocs.org/ntsb/LAX06FA014 ## Probable cause The flight crew's failure to maintain adequate terrain clearance and their decision to continue flight into known adverse weather conditions. Contributing to the accident was overcast conditions, and terrain obscuration. A finding of the investigation is that the flight crew may have improperly used the navigation equipment, which had a graphical moving map display capability, to guide the airplane between clouds and mountainous terrain while in obscured visibility conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - normal - weather condition - clouds (contributing factor) - weather condition - obscuration (contributing factor) - weather condition - turbulence (contributing factor) - in-flight planning/decision - improper, flightcrew (cause) - flight into known adverse weather - continued, flightcrew (cause) - In flight collision with terrain/water, cruise - normal - improper use of equipment/aircraft, flightcrew - altitude/clearance - not maintained, flightcrew (cause) - terrain condition - mountainous/hilly (contributing factor) ## Analysis The single engine airplane collided with mountainous terrain at the 6,111-foot level while maneuvering below an overcast cloud layer. Meteorological conditions over the area consisted of overcast cloud bases between 6,000 and 7,000 feet mean sea level (msl), and a patchy broken cloud layer with bases around 2,000 to 3,000 feet msl. Cloud tops were between 7,000 and 10,000 feet msl, and the freezing level was at 10,000 feet msl. Light to moderate rime or mixed icing was likely in clouds above the freezing level. Terrain ridgelines above 6,000 feet were occasionally obscured in the vicinity of the accident location, and occasional moderate turbulence was present. The airplane was not certified for flight into known icing. The airplane was equipped with a global positioning system (GPS) that was tied into a moving map cockpit display, which included terrain features and obstacles. The onboard avionics had received via a real time data downlink the latest weather radar images, station meteorological reports, and flight route data. The airplane's onboard GPS track data history and the Federal Aviation Administration (FAA) recorded radar data tracked the airplane from its departure, following a northeasterly track and cruising at altitudes between 5,000 and 6,500 feet msl for about 40 miles. The airplane then made a gradual descent from 6,500 feet to about 6,000 feet msl, and entered a shallow turn to the east where the track ends at the accident site on the south slope of a 6,150-foot mountain. The easterly turn was consistent with a turn towards the first en route waypoint that was delivered by the datalink. The initial point of impact on the mountain slope was the left wing tip at the 6,111-foot level causing the airplane to tumble and breakup over a distance of 501 feet along the mountain ridgeline. Analysis of the impact ground scars and the track history data disclosed the airplane was in level controlled flight when the terrain collision occurred. The airplane's owner, a non instrument rated private pilot, was in the left seat. The right seat occupant held airline transport pilot and certified flight instructor certificates. ## Factual narrative HISTORY OF FLIGHT On October 17, 2005, at 1038 Pacific daylight time (PDT), a Lancair LC-41-550FG, N285JB, collided with mountainous terrain 6 miles north of Warner Springs, California. The airplane was operated by JB Lauchner Aviation LLC under the provisions of 14 CFR Part 91. The airline transport pilot, private pilot, and single passenger were fatally injured. The airplane was destroyed. Visual meteorological conditions prevailed and a flight plan had not been filed. The personal cross-country flight originated at Gillespie Field, San Diego, California, at 1021, with a destination of Scottsdale, Arizona. Flight track data recorded from the onboard global positioning system (GPS) was extracted from the onboard multifunctional display (MFD) compact flash memory card that was recovered from the wreckage. The flight data file starts at time 1712:48 UTC (coordinated universal time, 1012:48 PDT); the data is captured at 6-second intervals and is written to the memory card once per minute. Examination of the data revealed that engine rpm increases to 2,500 at 1021:30 PDT and remained in that range for the remainder of the data file. The track departs Gillespie Field and turns east, then northeast over Lake Jennings, and climbs to a pressure altitude of 5,000 feet. The track continues northeast over San Diego Country Estates. When over Warner Springs the track increases altitude to 6,475 feet then it decreases to 5,996 feet. The last recorded time is 1038:00, at an altitude of 5,996 feet, 1.8 miles southwest of the accident site. Radar data was available to fill in the 1.8-mile gap, and continues to depict the track in a turn from the northeast towards the east where the track ends at the south side of Combs Peak (elevation 6,150 feet) and 0.25 miles north of Bucksnort Mountain (elevation 5,995 feet). The aircraft was a subject of an alert notice (ALNOT) missing aircraft notification and was located by the Civil Air Patrol on the afternoon of October 19, 2005. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records obtained from Oklahoma City, Oklahoma, revealed that two of the occupants held pilot certificates. The airline transport pilot (ATP) held certificates for certified flight instructor (CFI) and ground instructor, with ratings for single engine and multiengine land. His ATP certificate was dated January 14, 2005. He held a first-class medical certificate that was issued on August 31, 2005. It had the restriction that the pilot must wear corrective lenses. The ATP's logbook was not obtained by the National Transporation Safety Board. The flight time reported by the pilot on his latest FAA medical certificate application, dated August 31, 2005, was 3,000 hours total time, and 150 hours in the previous 6 months. The other pilot held a private pilot certificate dated April 11, 1985, with a single engine land rating. He held a third-class medical certificate dated September 12, 2003, with the restriction that he must wear corrective lenses for near and distant vision. The private pilot's flight logbook was not located or obtained by the Safety Board. The flight time reported by the pilot on his last FAA medical certificate application, dated September 12, 2003, was 870 hours total time, and zero hours in the previous 6 months. AIRCRAFT INFORMATION The airplane is a pre-molded, composite built, semi-monocoque, four seat, single engine, low wing, tricycle design airplane, and is certified in the utility category. A review of the airplane's logbook revealed that the last annual inspection was dated August 18, 2005, at a total airframe time of 309.9 hours. An accompanying service order dated October 3, 2005, listed the total aircraft time as 332.0 hours recorded from the Hobbs meter. The airplane had a Teledyne-Continental Motors TSIO-550-C(5) engine. Examination of the engine logbook revealed a 100-hour inspection dated August 18, 2005, at an engine total time of 309.9 hours. Standard avionics equipment included an Avidyne FlightMax EX5000 multi-function display (MFD). The airplane pilot operation handbook describes the MFD system and operation as follows; "The MFD provides a pictorial view of your flight situation based on input from your GPS navigator. It utilizes on-board database information for mapping off-route navigation data such as nearby airports, VOR's, NDB's, special use airspace and restricted airspace, etc., as well as an extensive terrain, interstate highways, water, and obstacle databases. The controls on the bezel of the FlightMax EX5000 are placed to allow you quick and intuitive access to the information you need, when you need it." "The EX5000 uses RS-232 to interface to external sensors such as the GPS." The EX 5000 also contains a built-in Narrowcast datalink transceiver which uses two-way messaging from Avidyne Network Operations Center, or interfaces with the XM satellite radio system receiving a constant stream of weather data. This system provides NEXRAD (weather radar) images, METAR text, AIRMETS, SIGMETS, TFR's (temporary flight restriction), and route of flight. The broadcast datalink receiver continuously receives all weather data. The airplane was equipped with crew supplemental oxygen. Supplemental oxygen would allow aircraft operation above 12,500 feet for greater than 30 minutes (FAR 91.211). The airplane is not certified for flight into known icing conditions. The pilot operation handbook states the following under the subtitle; Icing Conditions, 'Flight into know icing is prohibited.' METEOROLGICAL INFORMATION A Surface Analysis chart prepared by the National Weather Service (NWS) National Centers for Environmental Prediction (NCEP) for 1100 October 17 showed an inverted trough of low pressure along the southern California coastline. Surface weather observations for airports in the accident area surrounding the accident time, in part, follow: Ramona Airport (KRMN), Ramona, California, field elevation is 1,393 feet mean sea level (msl), is located approximately 215 degrees at 26 nautical miles from the accident location, and is equipped with an augmented Automated Surface Observation System (ASOS). At time 1036 a special observation was recorded; wind was calm; visibility was 10 miles; sky condition was broken at 1,200 feet, and overcast at 6,500 feet; temperature was 15 degrees Celsius; dew point was 12 degrees Celsius; altimeter setting was 29.91 inches Hg; there were no remarks. At time 1053; the wind direction was 300 degrees at 4 knots; the visibility was 10 miles; sky condition was broken at 1,000 feet, overcast at 6,000 feet; temperature was 15 degrees Celsius; dew point was 12 degrees Celsius; altimeter setting was 29.92 inches Hg; there were no remarks. Jacqueline Cochran Regional Airport (KTRM), Palm Springs, California, field elevation 114 feet msl, is located approximately 058 degrees at 26 nautical miles from the accident location, and is equipped with an unaugmented ASOS. At time 1052; the wind was calm; visibility was 10 miles; sky condition was overcast at 5,500 feet; temperature was 21 degrees Celsius; dew point was 17 degrees Celsius; and the altimeter setting was 29.88 inches Hg; there were no remarks. Palm Springs International Airport (KPSP), Palm Springs, field elevation 477 feet msl, is located approximately 012 degrees at 26 nautical miles from the accident location, and equipped with an augmented ASOS. At time 1053; the wind was calm; visibility was 10 miles; present weather was light rain; sky condition was scattered at 4,900 feet, overcast at 6,000 feet; temperature was 19 degrees Celsius; dew point was 17 degrees Celsius; altimeter setting was 29.89 inches Hg; the remarks stated rain began at 1001, ended at 1011, and began at 1051. The San Diego upper air station indicated that the freezing level was at approximately 8,500 feet msl. The EDAS model sounding indi ## Aircraft - Registration: [N285JB](https://openairdocs.org/deregistered/N285JB-2007-04-06), registration cancelled 2007-04-06, S/N 41014, built 2004 (OpenAirDocs) - Reported make and model: Lancair LC-41-550FG - Registry model: [Lancair LC41-550FG](https://openairdocs.org/model/lancair-lc41-550fg) (registry code 5150001) (OpenAirDocs) - Registry engine: [Continental TSIO-550 series](https://openairdocs.org/engine/continental-tsio-550-series) (registry code 17043, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 41014 - Airframe hours: 309.9 - Engines: Teledyne Continental TSIO-550-C 310 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: JB Lauchner Aviation LLC - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, August 1, 2005 - Departed: KSEE, El Cajon, CA - Destination: KSDL, Scottsdale, AZ - Airport: KSEE, Gillespie Field ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: fatal; airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1; seat: right; toxicology performed; flight hours: 3,000 total - Pilot; age 49; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3; seat: left; toxicology performed; flight hours: 870 total ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 1,200 ft broken - Temperature: 59 °F, dew point 54 °F - Altimeter: 29.90 inHg - Observed at: KRMN, 26 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 20051017028409A](https://openairdocs.org/incident/20051017028409A), Oct 17, 2005: Amtr LC41550FG, Warner Springs, CA, Destroyed, 3 fatal. (-23) On October 17, 2005, at approximately 1032 PDT, a Lancair LC41-550G, N285JB, collided with mountainous terrain six miles north of Warner Springs,… 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.