LAX06FA256

NTSB accident investigation · Cessna 182P · Whitethorn, CA · August 4, 2006

Accident · FatalField investigationFinal report
Date
August 4, 2006, 11:00 local (18:00 UTC)
Place
Whitethorn, CA
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9904ECessna 182P
Weather
Instrument (IMC) · Day
Status
Completed · report May 29, 2007
Report
Approved by Office Director
Parties
Teledyne Continental Motors, Federal Aviation Administration, Cessna Aircraft Company
FAA report
20060804020339A
Case key
64284

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 loss of situational awareness with regard to the airplane's proximity to mountainous terrain, and her failure to maintain an adequate terrain clearance altitude or flight path, which resulted in an in-flight collision with the 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 collision with terrain/waterClimb - to cruise
Weather condition - fog
Weather condition - clouds
Terrain condition - mountainous/hilly
Altitude/clearance - not maintainedPilot in commandCause
Terrain condition - rising

Analysis

The airplane impacted a mountain about 1 nautical mile from the departure airport during the en route climb phase of an instrument departure. The airport is on the coast next to the ocean with mountains immediately adjacent to the east that rise to 3,000 feet msl. A witness saw the airplane depart to the south in dense fog with the ground visibility less than 1/4-mile and follow the coastline until entering the fog layer. The witness noted that the direction of flight was unusual; typically, airplanes depart to the north, then turn left over the ocean to avoid the mountains. After the airplane entered the fog layer it climbed to about 500 to 700 feet above ground level (agl) and then made a 90-degree turn to the left toward the mountains. The airspace overlying the airport is Class G and there is no radar coverage in the area below 6,000 feet. The left-seated pilot held an instrument rating; the right-seated pilot did not. Both pilots had made flights together to this airport twice before (about 11 days prior to the accident and 2 days prior to the accident). Numerous residents around the airport reported that a dense fog surrounded the airport and cloaked the mountains. One witness stated that as he drove his automobile up the mountains away from the coastline, he came out of the clouds around 1,300 feet mean sea level (msl). Records maintained at the Automated Flight Service Station (AFSS) disclosed that the pilot contacted the facility twice for weather information. During the first call, about 3 hours prior to departure, she requested a weather briefing. The briefer advised that an AIRMET for instrument flight rule (IFR) conditions was current for the area. He then queried her, "how does it look outside?" The pilot responded by saying, "It's foggy probably visibility is less than 2." During her second telephone call, about 1 hour 45 minutes later, she was again told about the AIRMET for IFR conditions in the coastal areas and she filed an IFR flight plan requesting a direct routing and a 6,000 foot cruise altitude. She called the AFSS again and received her IFR clearance "as filed"; no heading or other departure instructions was requested by the pilot nor given in the clearance. The airport does not have a specified instrument departure. Examination of the accident site revealed that the left wing hit a tree first in a wings level, slightly nose high attitude. Post accident examinations revealed no mechanical anomalies with the airframe or engine that would have precluded normal operation. The AFSS specialist who read the IFR clearance to the pilot was given the IFR clearance by the Air Route Traffic Control Center (ARTCC) controller along with a clearance void time, but not a time check as required. When the pilot did not communicate with the radar controller on or before the void time, the controller transmitted "in the blind" and did not receive a reply. At that time, the controller should have considered the aircraft overdue and made the appropriate notifications, including issuing an Alert Notice (ALNOT), which would have initiated search and rescue efforts. However, the controller, with approval from his supervisor, removed the flight plan from the system. This action deleted any record of the flight and adversely impacted search and rescue efforts. Although the actions of the ARTCC controllers did not cause or contribute to this accident, their performance hindered the timeliness of search and rescue efforts.

Factual narrative

History of flight

On August 04, 2006, about 1100 Pacific daylight time, a Cessna 182P, N9904E, impacted a mountain shortly after departing from Shelter Cove Airport, Whitethorn, California. The two pilots, who were partial owners, were operating the airplane under the provisions of 14 CFR Part 91. The two occupants, both private pilots, were fatally injured; the airplane sustained substantial damage. The personal cross-country flight was originating from Shelter Cove Airport, with a planned destination of Ukiah, California. Instrument meteorological conditions prevailed in the area surrounding the accident site. An instrument flight rules (IFR) flight plan had been filed and a clearance had been issued; however, the flight plan was never activated.

On August 05, 2006, paragliders spotted the wreckage while operating in the area. Local authorities were notified of the accident, and located the wreckage about 1900.

Investigators conducted an interview with a witness who resided in a trailer located on a campground adjacent to airport property at the end of runway 12. He recalled observing the accident airplane depart on August 04, 2006. He stated that sometime after 0900, he took his dog for a walk [he was unclear of the exact time]. He noted that there was a dense fog surrounding the airport and the entire Shelter Cove area, which provided less than 1/4-mile visibility. He witnessed the airplane takeoff heading in a southerly direction along the coastline. The witness noted that the direction of flight was unusual, as a majority of the time, airplanes depart to the north. The airplane headed toward a dark cloud to the south and entered the fog layer.

Although he could only discern the airplane's silhouette after it entered the fog, the witness stated that he observed it climb to about 500 to 700 feet above ground level (agl). The airplane subsequently made a 90-degree turn to the left. He heard the engine momentarily increase in revolutions per minute (rpm) as if it were revving. The engine noise ceased and he believed that he heard a faint sound akin to the collapsing of an aluminum can.

During a telephone conversation with the National Transportation Safety Board investigator-in-charge (IIC), an airplane mechanic based in Ukiah stated that the right-seated pilot contacted him about 1500 the day prior to the accident via telephone. He noted that the pilot was utilizing a cell phone during their conversations and the reception was poor, making it difficult to communicate. The pilot stated that he was attempting to troubleshoot an oil leak, as he had previously experienced oil residue covering the cowling and windshield area. The pilot speculated that the oil was originating from the filler cap area. After attempting to find the leak and subsequently performing engine runs, the pilot still could not precisely identify the source of the leak. The mechanic told the pilot to bring the airplane to his facilities in Ukiah where he could attempt to troubleshoot the problem. The pilot agreed, but stated that he would have to wait for the fog to lift before he could depart from Shelter Cove.

The mechanic further stated that the pilot reported that he had "lost 4 quarts" of oil during his pervious flight from Van Nuys, California, to Shelter Cove. The pilot added 3 quarts of oil when he arrived in Shelter Cove, at which point the engine indicated it contained a total of 8 quarts. The pilot also expressed concern that there was no place in the area where he would be able to purchase additional oil.

Personnel information

Left-seated Pilot

A review of the airmen records maintained by the Federal Aviation Administration (FAA) disclosed that the left-seated pilot held a private pilot certificate with airplane ratings for single engine and instrument flight. Her most recent third-class medical certificate was issued on March 20, 2005, with a limitation that she "must have available glasses for near vision."

The Safety Board IIC reviewed copies of the left-seated pilot's personal flight logbooks. According to the logbook entries, she first received her private pilot license in March 1990, followed by her instrument rating in May 1992. The records indicated that her total flight experience equated to 709.6 hours, with 588.5 hours logged as pilot-in-command. She had amassed 149.2 hours under simulated instrument meteorological conditions (IMC), and had acquired 38.7 hours of actual time operating in IMC.

The logbooks additionally revealed that the left-seated pilot had accumulated a majority of her flight time prior to 1998 (650 hours). The entries indicated that she accrued 33.2 hours from April 2005 to July 24, 2006 (the last entry), all of which were performed in the accident airplane. Within that time frame only two flights were noted as being conducted under simulated instrument meteorological conditions, one of which was on June 22, 2005 (1.3 hours) and the other on July 01, 2006 (1.7 hours). The last flight recorded was the only logbook entry that indicated the pilot had flown to an airport near the accident site. The entry showed that she had logged 3.3 hours from Van Nuys to Ukiah; no instrument meteorological conditions were noted for that flight.

The last two entries in the endorsement section of her logbook were dated July 20, 2006, and were signed by the same certificated flight instructor (CFI). One of the entries noted that the pilot had satisfactorily completed a biennial flight review, and the other stated that the pilot had satisfactorily completed an instrument competency check.

Right-seated Pilot

According to the FAA airmen records, the right-seated pilot held a private pilot certificate with an airplane rating for single engine land. His most recent third-class medical certificate was issued without limitations on June 20, 2005.

The pilot's personal flight records were not recovered. On his last application for a medical certificate, he reported a total flight time 670 hours.

Accident Aircraft Pilot Logbook Entries

Within the wreckage, investigators found an airplane log with numerous entries containing both pilots' names. According to the other owners of the airplane, the log was utilized as a means to track the airplane usage by each owner/pilot. The first flight entry listing the accident pilots was dated on March 07, 2006. In pertinent part, the left-seated pilot's name was recorded on an entry dated July 24, indicating that on that date she had flown the airplane 3.3 hours from Van Nuys to Ukiah. The following entry indicated that the right-seated pilot had flown a 3.5-hour flight from Ukiah back to Van Nuys.

The left-seated pilot's next, and final entry, was dated August 02, where she logged 3.6 hours from Van Nuys to Shelter Cove. The following entry contained the right-seated pilot's name and the airplane's starting tachometer reading; no other information was written in that entry.

Aircraft information

The Cessna 182P, serial number 18263964, was manufactured in 1975. A review of the logbooks revealed that the most recent annual inspection were performed on August 12, 2005, at a total time of 4,206.5 hours, corresponding to 110.3 flight hours prior to the accident.

The powerplant, a Teledyne Continental Motors O-470-S, serial number 226420-R, was last overhauled on February 05, 1996, equating to about 1170 hours prior to the accident. The maintenance records listed the last maintenance as occurring on April 20, 2006, where the airplane underwent a 50-hour inspection, which included an oil change.

A review of the voice recordings from the McMinnville, Oregon, Automated Flight Service Station (AFSS) disclosed that the left-seated pilot filed an instrument flight rules (IFR) flight plan indicating that at the time of departure the airplane had 3 hours of fuel on board. The recordings further revealed that the left-seated pil

Aircraft

Registration
N9904E
Reported as
Cessna 182P
Category
Airplane
Serial number
18263964
Airframe hours
4,206.5
Engine
Continental O-470S, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Zero Four Echo, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 1, 2005 · 110.3 hours before
Departed
0Q5 · Whitethorn, CA
Destination
UKI · Ukiah, CA
Flight plan
IFR
Airport
0Q5 · Shelter Cove Airport, runway 12, 3,400 × 75 ft, asphalt

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
57
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
710 total · 589 as pilot in command
Role
Pilot
Age
61
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Seat
Rear
Toxicology
Performed
Flight hours
670 total

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
0.25 statute miles
Lowest ceiling
100 ft
Temperature
64 °F, dew point 50 °F
Altimeter
29.90 inHg

FAA reports on this event · 1

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