LAX06FA186

NTSB accident investigation · Cessna T182T · Burney, CA · May 27, 2006

Accident · FatalField investigationFinal report
Date
May 27, 2006, 13:10 local (20:10 UTC)
Place
Burney, CA
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N451JECessna T182T
Weather
Instrument (IMC) · Day
Status
Completed · report November 29, 2007
Report
Approved by Office Director
Parties
Federal Aviation Administration, Cessna Aircraft Company, Textron Lycoming
FAA report
20060527008659A
Case key
63790

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 decision to continue VFR flight into instrument meteorological conditions and his failure to maintain clearance from mountainous 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 - obscuration
Weather condition - clouds
Weather condition - snow
Vfr flight into imc - continuedPilot in commandCause
In flight collision with terrain/waterCruise
Terrain condition - mountainous/hilly
Altitude/clearance - not maintainedPilot in commandCause

Analysis

The airplane collided with a mountain while in cruise flight. The airplane became the subject of an alert notification (ALNOT) after Oakland Center (ZOA) lost radar and radio contact with the airplane and pilot. The controller working the flight reported that the pilot had cancelled the IFR portion of his flight at 1239, south of Red Bluff, California. The pilot requested visual flight rules (VFR) flight following for the remainder of the flight to his destination. At 1308, the controller reported a loss of radar and radio contact. There were no reports of a distress call from the pilot. A California Highway Patrol (CHP) air unit located the accident site on May 29, 2006, at 0936. It was at the 8,229-foot mean sea level (msl) elevation of an 8,500-foot mountain. The airplane came to rest on a 45-degree slope on top of 6 feet of an ice/snow pack, with some of the wreckage suspended in the nearby trees. The sheriff's department reported that on Saturday when the accident occurred, it was snowing and cloudy on the mountain. Recorded radar data showed the flight level at a mode C reported 10,000 msl for most of the early flight in the southern half of California. The flight then climbed to 12,000 feet for a short time. At the time the pilot cancelled his IFR clearance with Oakland Center, the radar data showed the flight descending normally to about 8,500 feet and on a straight track to the accident site just before the collision with the mountain. Review of the GEOS Weather Satellite image for the area showed that there was cloud coverage over the accident site at the time of the event. Examination of the wreckage did not discover any anomalies that would have precluded normal operation of the airframe or engine.

Factual narrative

History of flight

On May 27, 2006, about 1310 Pacific daylight time, a Cessna T182T, N451JE, impacted mountainous terrain near Burney, California. California Flight Center operated the airplane as a rental flight under the provisions of 14 CFR Part 91. The airplane was destroyed; the private pilot and two passengers were fatally injured. Visual meteorological conditions prevailed for the personal cross-country flight that departed Long Beach Airport (Daugherty Field), Long Beach, California, at 0903. An instrument flight rules (IFR) flight plan had been filed. The flight was destined for Fall River Mills Airport (O89), Fall River Mills, California.

The airplane became the subject of an alert notification (ALNOT) after Oakland Center (ZOA) lost radar and radio contact with the airplane and pilot. A Federal Aviation Administration (FAA) Quality Assurance employee reviewed radio transmissions between the Oakland Center controller and the pilot. The controller working the flight reported that the pilot had cancelled the IFR portion of his flight at 1239, near Chico, California. The pilot requested visual flight rules (VFR) flight following for the remainder of the flight to Fall River Mills. At 1308, at 11,000 feet, the controller reported a loss of radar and radio contact. There were no reports of a distress call from the pilot. The controller initiated search and rescue efforts.

Personnel information

A review of FAA airman records revealed the pilot held a private pilot certificate with an airplane single engine land and instrument ratings. The pilot received his instrument rating on April 24, 2006.

The pilot held a second-class medical certificate issued on March 17, 2006. It had the limitations that the pilot shall wear lenses that correct for distant vision and possess glasses that correct for near vision while exercising the privileges of his airman certificate.

The airplane rental agreement, signed and dated August 14, 2004, recorded a total flight time of 450 hours. The pilot's last biennial flight review was on August 16, 2004.

Aircraft information

The airplane was a Cessna T182T, serial number 18208272. A review of the airplane's logbooks revealed a total airframe time of 709.1 hours at the last routine maintenance completed on May 8, 2006; the standby battery was recharged. The last annual inspection was completed on April 12, 2006.

The engine was a Textron Lycoming TIO-540-AK1A engine, serial number L-11675-61A. A logbook entry in the engine logbook, dated May 2, 2006, recorded a total time of 700.2 hours. Maintenance personnel had replaced the Nos. 2 and 3 lower spark plugs, and the number 5 upper spark plug; a test run was completed with no discrepancies noted.

The airplane was equipped with a Garmin G1000. A recorded entry in the avionics logbook dated September 12, 2004, indicated that the Service Bulletin (SB) 04-23-01 inspection had been complied with; steps 1-4, 6, 7-15 had been completed. A system software upgrade (SB05-34-01) had been complied with on February 24, 2005.

An entry dated October 12, 2005, recorded the installation of MD182-34-02 GDL69A Flight Information System to comply with SB05-34-06, SB05-34-05 G1000 Software upgrade, SB05-34-07 G1000 Terrain and Obstacle Avoidance System. The systems were operationally tested with no discrepancies and the airplane was returned to service.

The last entry in the avionics logbook dated November 15, 2005, recorded the replacement of all three deice boots; replacement of GDU1040 PFD and MFD, serial number 86501592 and 86500971. Jeppesen software was loaded and the system was functionally tested with no discrepancies noted, and the airplane was returned to service.

Wreckage and impact information

A California Highway Patrol (CHP) air unit located the accident site on May 29, 2006, at 0936. The site was in the Thousand Lakes Wilderness area on the south side of Magee Peak at global positioning system (GPS) coordinates of 40 degrees 41.218 minutes north, 121 degrees 37.170 minutes west. The airplane was located on the south facing side of an 8,500-foot mountain at the 8,229-foot mean sea level (msl).

The Shasta County Sheriff's Department high mountain rescue team reported that the airplane came to rest on a 45-degree slope on top of 6 feet of an ice/snow pack, with some of the wreckage suspended in the trees. The sheriff's department reported that on Saturday when the accident occurred, it was snowing and cloudy.

The airplane debris traveled upslope from the initial impact point, with the main wreckage coming to rest in one area. The airplane came to rest within a 15-foot diameter. The engine remained attached to the firewall and cockpit area, and the main landing gear remained connected in its normal positions. The empennage section, to include the tail, horizontal stabilizer, and rudder separated from the aft fuselage. A 5-foot section of the inboard portion of the right wing was about 5 feet from the main wreckage with a semicircular depression on the bottom portion of the wing. About 15 feet of the right wing was 150 feet downslope of the main wreckage. A felled portion of a tree was found about 75 feet upslope of the right wing. The estimated height was 60 feet with the top 40 feet separated from its base. The left wing separated at the wing root attachment area, and came to rest about 50 feet west of the main wreckage.

Medical and pathological information

The TC, FAA, Forensic Toxicology Research Team CAMI, Oklahoma City, Oklahoma, performed a toxicological analysis from samples obtained during the autopsy. The results of the analysis of the specimens were negative for carbon monoxide, cyanide, volatiles, and tested drugs.

Tests and research

The National Transportation Safety Board investigator-in-charge (IIC), Cessna Aircraft Company, and Textron Lycoming, parties to the investigation, examined the airframe and engine at Plain Parts, Sacramento, California, on November 14-15, 2006.

There was no visually obvious catastrophic failure noted with the engine. The engine remained attached to the engine mounts and firewall. The accessory section was intact. Investigators noted that there was a localized fire in the engine compartment, and the inlet fitting had been displaced at the engine attachment area.

Investigators removed the top spark plugs; they were oil soaked. However, according to the Champion Aviation Check-A-Plug AV-27 Chart, the electrodes were normal with no mechanical deformation noted. A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder heads.

Investigators established mechanical and drive train continuity through manual rotation of the engine. The valves moved approximately the same amount of lift in firing order achieving thumb compression on all cylinders in firing order. The vacuum pump drive gear remained unbroken, and the vacuum pump turned freely. The vacuum pump rotor and vanes were undamaged, in position, and moved freely.

Both magnetos remained attached and secured to their respective mounting pads. The right magneto sustained thermal damage, and the left magneto was not damaged. Both magnetos were removed. Manual rotation of the right magneto was not achieved due to internal thermal damage. The left magneto was manually rotated, and produced spark at all posts.

The oil suction screen was clean and free of foreign debris. The turbocharger remained attached to the bottom of the engine in its normal location with no deformation noted. The turbine blades were undamaged, and it rotated freely with no binding. The interior of the exhaust exhibited gray coloration, which the Lycoming investigator said corresponded to normal operation.

The fuel flow divider remained secured in its normal position, but sustained impact damage. The rubber diaphragm had broken, and investigators did not o

Aircraft

Registration
N451JE
Reported as
Cessna T182T
Category
Airplane
Serial number
18208272
Airframe hours
700
Engine
Lycoming TIO-540-AK1A, 235 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
California Flight Center
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2006
Departed
LGB · Long Beach, CA
Destination
O89 · Fall River Mill, CA
Flight plan
IFR

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
Instrument ratings
Airplane
Medical
Class 2
Seat
Left
Toxicology
Performed
Flight hours
450 total

Weather

Conditions
Instrument (IMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 30 °F
Altimeter
29.88 inHg
Observed at
RDD

Docket · 14

The files NTSB released with the investigation on October 3, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.7 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.