# NTSB LAX06FA186: Cessna T182T, N451JE, Burney, CA, May 27, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 27, 2006, 13:10 local (20:10 UTC) - Place: Burney, CA - Coordinates: 40.686943, -121.619445 - Nearby events: https://openairdocs.org/map.md?lat=40.6869&lon=-121.6194&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report November 29, 2007 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Cessna Aircraft Company, Textron Lycoming - NTSB case key (mKey): 63790 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX06FA186 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63790/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=63790 - Page: https://openairdocs.org/ntsb/LAX06FA186 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - weather condition - obscuration - weather condition - clouds - weather condition - snow - vfr flight into imc - continued, pilot in command (cause) - In flight collision with terrain/water, cruise - terrain condition - mountainous/hilly - altitude/clearance - not maintained, pilot in command (cause) ## 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](https://openairdocs.org/deregistered/N451JE-2007-11-21), registration cancelled 2007-11-21, S/N T18208272, built 2004 (OpenAirDocs) - Reported make and model: Cessna T182T - Registry model: [Cessna T182T](https://openairdocs.org/model/cessna-t182t) (registry code 2072738) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 18208272 - Airframe hours: 700 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: fatal; 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 ## 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 20060527008659A](https://openairdocs.org/incident/20060527008659A), May 27, 2006: Cessna T182T, Burney, CA, Destroyed, 3 fatal. (-23) The pilot filed an IFR flight plan from long beach, CA (lgb) to fall river mills, CA (O89). The pilot cancelled the IFR at 12:39PDT. Radar plot shows the… ## Docket (14 files) The files NTSB released with the investigation on October 3, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=63790. 12.7 MB in all. - Wreckage Diagram- Recovery Personnel (item 1, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278222&FileExtension=.PDF&FileName=Wreckage%20Diagram-%20Recovery%20Personnel-Master.PDF - Excerpt FAA ATC Transcripts OAK Center (item 2, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278223&FileExtension=.PDF&FileName=Excerpt%20FAA%20ATC%20Transcripts%20OAK%20Center-Redacted.PDF - Excerpt Lockheed Martin FSS Weather Brief (item 3, .PDF, 611 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278225&FileExtension=.PDF&FileName=Excerpt%20Lockheed%20Martin%20FSS%20Weather%20Brief-Redacted.PDF - Avionics Logbook (item 4, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278227&FileExtension=.PDF&FileName=Avionics%20Logbook-Redacted.PDF - Airframe Logbook (item 5, .PDF, 733 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278230&FileExtension=.PDF&FileName=Airframe%20Logbook-Redacted.PDF - Engine Logbook (item 6, .PDF, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278232&FileExtension=.PDF&FileName=Engine%20Logbook-Redacted.PDF - Toxicological Report - Linda Marchisotto (item 7, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278236&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Linda%20Marchisotto-Master.PDF - Toxicological Report - Paul Marchisotto (item 8, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278237&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Paul%20Marchisotto-Master.PDF - Toxicological Report - Amy Marchisotto (item 9, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278238&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Amy%20Marchisotto-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 258 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278241&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278242&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Radar Data (Cessna) (item 12, .PDF, 8.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278842&FileExtension=.PDF&FileName=Radar%20Data%20(Cessna)-Master.PDF - Photo 1 - Aerial View of Accident Site (Shasta County Sheriffs Dept) (item 13, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278843&FileExtension=.PDF&FileName=Photo%201%20-%20Aerial%20View%20of%20Accident%20Site%20(Shasta%20County%20Sheriffs%20Dept)-Master.PDF - Photo 2 - Aerial View of Accident Site (Shasta County Sheriffs Dept) (item 14, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278844&FileExtension=.PDF&FileName=Photo%202%20-%20Aerial%20View%20of%20Accident%20Site%0D%0A%20(Shasta%20County%20Sheriffs%20Dept)-Master.PDF 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.