- Date
- March 30, 2007, 01:44 local (08:44 UTC)
- Place
- Los Banos, CA
- Injuries
- 2 fatal
- Damage
- Destroyed
- Phase of flight
- Maneuvering
- Aircraft
- N4369KRyan Navion A
- Weather
- Visual (VMC) · Night
- Status
- Completed · report June 30, 2008
- Report
- Approved by Office Director
- Parties
- Federal Aviation Administration
- FAA report
- 20070330004209A
- Case key
- 65531
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
the pilot's intentional performance of aerobatic maneuvers that exceeded the design stress limits of the airplane structure. Also causal was the pilot's impairment due to the effects of alcohol consumption. Contributory was the pilot's impairment due to the effects of prescription medication.
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.
Analysis
Prior to the flight, the pilot and passenger had each consumed at least 8 to 10 beers. The pilot and passenger had departed from a local bar where patrons had overheard discussions between them about doing some "crazy" aerobatics. Recorded radar data was reviewed. During the last 10 minutes of the flight, the pilot performed high angle turns and pitch up maneuvers. During the last 30 seconds of flight, the pitch angle and vertical speed showed an increase to about 20 degrees and 2,500 feet per minute, respectively. The speed profile revealed the flight's speed was mostly in the region between structural cruise limit and never exceed speeds. Examination of the wreckage revealed the airplane experienced an in-flight break-up. All fracture surfaces were consistent with overload separations. Post accident toxicological tests on specimens from the pilot found a blood ethanol level of 222 mg/dL (0.222 percent) and hydrocodone in the blood at a level of 0.02 mg/L.
Factual narrative
History of flight
On March 30, 2007, at 0144 Pacific daylight time, a Ryan Navion A single engine airplane, N4369K, was destroyed during an in-flight breakup while maneuvering near Los Banos, California. The owner/pilot was operating the airplane under the provisions of 14 CFR Part 91. The private pilot and one passenger sustained fatal injuries. The local personal flight departed Los Banos about 0124 with an unknown destination. Night visual meteorological conditions prevailed, and no flight plan had been filed.
Family and friends of the pilot and passenger were interviewed by the local authorities. During the interviews, local authorities determined that both the pilot and passenger had each consumed between 8 to 10 beers between 1800 and 2400 on March 29, 2007. Prior to the flight, the pilot and passenger had departed from a local bar in Los Banos where patrons had overheard discussions between them about doing some "crazy" aerobatics.
The National Transportation Safety Board investigator-in-charge (IIC) reviewed recorded radar data for the area of Los Banos Airport. At 0124, on March 30, 2007, radar data showed a secondary 1200 (visual flight rules - VFR) beacon code at a mode C reported altitude of 1,500 feet msl (mean sea level). The data showed the recorded radar target departed to the south, and climbed to a mode C reported altitude of 7,000 feet; it then began maneuvering in the general area of Los Banos. The radar target indicated a maximum altitude of 8,000 feet msl, with the indicated altitudes varying erratically between 7,000 and 5,000 feet. The calculated ground speeds during the 20 minutes of radar data returns varied up and down, and at numerous times were greater than 200 mph.
The ensuing 1200 beacon code radar target return matched the projected flight path of the accident airplane, and the last radar return was at 01:43:36, at an indicated altitude of 5,000 feet msl. The main wreckage was located about 2,000 feet northwest of the last radar return.
On March 30, 2007, the Federal Aviation Administration (FAA) issued an alert notification (ALNOT) after receiving 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, and they located the airplane wreckage at 1930, on March 30, 2007.
Personnel information
The pilot, age 31, held a private pilot certificate with single engine land and instrument airplane ratings. The pilot was issued a third-class medical certificate on August 15, 2005, with no limitations or restrictions. According to the pilot's most recent airman rating application dated September 9, 2006, the pilot had accumulated 1,230 total flight hours and 1,160 flight hours as pilot-in-command. The pilot's logbooks were not located, and the pilot's total flight hours in the accident airplane make and model could not be determined.
The airplane's previous owner stated he built the airplane for the pilot and sold it to him. He had also recently trained the pilot to fly AV-L39 airplanes, and the pilot had an interest in aerobatics. The previous owner stated, "[The pilot] flew the Navion almost every day and he would not be surprised if [the pilot] tried some aerobatics in it."
According to acquaintances of the pilot, he "was a drinker...and [recently] he had been drinking heavily."
Aircraft information
The 1948-model Ryan Navion A, serial number NAV41369, was a single engine, low-wing, retractable tri-cycle landing gear airplane. The airplane was powered by a normally aspirated direct drive, air-cooled, horizontally opposed, fuel-injected six-cylinder Continental IO-550-G1 engine, serial 679281, rated at 310 horsepower, and equipped with a three-bladed constant speed propeller. The airplane was configured to carry a maximum of 4 occupants.
The airplane was issued a standard airworthiness certificate for normal category operations on August 25, 1955. The airplane was registered to the owner on February 26, 2007. The maintenance logbooks were not located.
According to the airplane's operating limitations, the Maneuvering speed (Va), Maximum Structural Cruising Speed (Vno) and the Never Exceed Speed (Vne) were 124, 160, and 190 miles per hour true indicated airspeed, respectively. The airplane was not approved for aerobatic flight maneuvers or operations.
Wreckage and impact information
The accident site was located on a private wildlife refuge at global positioning system (GPS) coordinates 37 degrees 13.183 minutes north latitude by 120 degrees 53.100 minutes west longitude, at an elevation of 150 feet msl. FAA inspectors examined the wreckage at the accident scene. The debris field was approximately 2,500 feet long and 1,000 feet wide along a measured magnetic heading of 310 degrees. The fuselage was located on a dry road and came to rest on a magnetic heading of 260 degrees. The engine and propeller assembly were separated from the fuselage and came to rest buried in the terrain.
All flight control surfaces were accounted for within the accident site area. The right wing was separated from the fuselage at the wing root and the fracture surfaces exhibited signatures consistent with an overload separation. The left wing was separated from the fuselage and was located approximately 600 feet from the right wing. The fracture surfaces exhibited signatures consistent with an overload separation. The horizontal and vertical stabilizers were separated and fragmented. The cockpit canopy was separated and the locking mechanism was engaged. The pilot and passenger were located approximately 300 and 200 feet, respectively, from the fuselage.
The instrument panel and cockpit were destroyed and fragmented. The following instrument and switch positions were noted: landing gear handle in the UP position, flap handle in the UP position, airspeed indicator 200 miles per hour, mixture/propeller/throttle controls in the full forward position. Two empty 16-ounce cans of beer were found in the wreckage.
Medical and pathological information
An autopsy was performed on the pilot by the Merced County, Office of the Coroner, on April 2, 2007. The medical doctor's cause of death was noted as "Multiple blunt force traumatic injuries" and contributory, "Alcohol intoxication."
The FAA Civil Aeromedical Institute's (CAMI) performed toxicological screenings on the pilot. According to CAMI's report (#200700068002) the toxicological findings were positive for ethanol (alcohol). Specifically, the following was detected in the pilot's specimens: 222 (mg/dL, mg/hg) ethanol in blood, 192 (mg/dL, mg/hg) ethanol in brain, and 155 (mg/dL, mg/hg) ethanol in muscle.
In addition to CAMI's toxicological screenings, the Merced County toxicological screening was positive for 0.02 mg/L of hydrocodone in blood.
In a vehicle at the airport, local authorities found a backpack that contained a bottle with the label "HYDROC/APAP" and the pilot's name. The bottle contained 2 tablets. The pilot's doctor, who prescribed the medication, stated that based on the number of tablets remaining, the pilot was likely taking a full dose. The medication was the equivalent of vicodin. Due to privilege issues, the doctor could not describe why the pilot was taking the medication.
A review of the pilot's two medical applications for an airman medical certificate, dated August 15, 2005, and August 21, 2003, showed the pilot had checked the box "no" in response to questions 17.a. "Do You Currently Use Any Medication (Prescription or Nonprescription)," 18.n. "Substance dependence or failed a drug test ever, or substance abuse or use of illegal substance in the last 2 years," and 18.v. "History of (1) any conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug; or (2) history of any conviction(s) or admi
Aircraft
- Registration
- N4369K
- Reported as
- Ryan Navion A
- Category
- Airplane
- Serial number
- NAV41369
- Airframe hours
- 3,693
- Engine
- Continental IO-550-G1, 310 horsepower, reciprocating
- Damage
- Destroyed
- Flight
- Personal · Part 91
- Operator
- Grant H. Lindeman
- Registered owner
- Airnav LLC
- Airworthiness certificate
- Standard, Normal
- Departed
- LSN · Los Banos, CA
- Destination
- LSN
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
- 31
- Injuries
- Fatal
- Certificate
- Private
- Airplane ratings
- Single-engine land
- Instrument ratings
- Airplane
- Medical
- Class 3, Without waivers/limitations
- Toxicology
- Performed
- Flight hours
- 1,230 total · 1,160 as pilot in command
Weather
- Conditions
- Visual (VMC) · Night
- Wind
- 70° at 3 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 52 °F, dew point 43 °F
- Altimeter
- 30.12 inHg
- Observed at
- MCE, 15 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.