LAX93FA223

NTSB accident investigation · Cessna 172N · Lompoc, CA · May 25, 1993

Accident · FatalField investigationFinal report
Date
May 25, 1993, 02:30 local (09:30 UTC)
Place
Lompoc, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N4783JCessna 172N
Weather
Instrument (IMC) · Night/dark
Status
Completed · report May 19, 1994
Report
Approved by Office Director
FAA report
19930525015129A
Case key
28327

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

VFR flight by the pilot into instrument meteorological conditions (IMC), and his failure to maintain proper altitude (or clearance) from mountainous terrain. Factors relating to the accident were: the low ceiling, fog, drizzle, obscuration, and 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 - low ceilingFactor
Weather condition - fogFactor
Weather condition - drizzle/mistFactor
Weather condition - obscurationFactor
Vfr flight into imc - continuedPilot in commandCause
FatiguePilot in command
In flight collision with terrain/waterManeuvering
Terrain condition - mountainous/hillyFactor
Proper altitude - not maintainedPilot in commandCause

Analysis

The aircraft departed palm springs airport at about 2335 hours on a flight to Lompoc, California. An ELT signal was received at about 0930 hours the following morning by nearby air force base personnel. A search was initiated, and the airplane was located at about 1310 hours. Impact occurred on a hillside about 5 miles southeast of the airport. Witnesses in the area reported that the mountain tops near the accident site were obscured with near zero visibility. The airplane hit a hill at the 1487 foot level, approximately 50 feet from the top of the hill. The pilot began the flight after working from 1500 hours to 2330 hours. He filed a VFR flight plan, but did not activate it. The airplane was observed taking off on a closed runway at palm springs airport. The pilot had 2 hours of actual instrument time. The ndb-b approach plate for Lompoc, California was found clipped open in the aircraft.

Factual narrative

History of flight

On May 25, 1993, at 0230 hours Pacific daylight time, a Cessna 172N, N4783J, entered instrument meteorological conditions and collided with hilly terrain while in cruise flight near Lompoc, California. The pilot was conducting a visual flight rules (VFR) personal flight. The airplane, registered to J and L Aviation, Inc., Palm Springs, California, and operated by Bermuda Air Services, Bermuda Dunes, California, was destroyed. The certificated commercial pilot and his passenger sustained fatal injuries. Instrument meteorological conditions prevailed at the accident site and a VFR flight plan was filed, but not activated. The flight originated at Palm Springs Regional Airport at about 2335 hours.

A witness located at Bermuda Air Services reported that the pilot left Bermuda Dunes Airport in the accident airplane at about 1200. His intermediate destination was to the Palm Springs Regional Airport, where the pilot worked.

The pilot filled out a flight itinerary form with Bermuda Air Services on May 24, 1993. He listed his route of flight as Bermuda Dunes (UDD) Airport, direct to Palm Springs Regional Airport (PSP), direct to Palmdale (PMD), direct to Lompoc Airport (LPC). He said he intended to stop at Palm Springs Regional Airport to complete his work shift. (See item 8,b for further information.)

The pilot called Hawthorne Flight Service Station at about 2258 hours and received an abbreviated weather briefing. The pilot filed a VFR flight plan with a proposed takeoff time of 2330 hours. The pilot did not activate the flight plan.

According to time clock records provided by the pilot's employer, the pilot worked from 1500 hours to 2230 hours on May 24, 1993.

A witness who works for the Palm Springs Airport Police told Safety Board investigators that he observed the pilot taxiing the airplane away from the Million Air hanger, where the pilot worked, at about 2335 hours.

He said the pilot announced his intentions to depart on runway 31R as he taxied out for departure. The airport policeman called the pilot from a two way radio in his police truck and told him, "31 left is the active runway." He said he received no response. He said he observed the pilot of N4783J depart on 31 right, which is a closed runway from 2200 hours to 0600 hours. The runway has no runway lights on during the closed period of time. The airport policeman said that "it's unusual for him to takeoff on the closed runway...he worked at the airport and knew it was closed." (See items 8.6 and 8.7 for additional information).

There were no eyewitnesses to the actual accident sequence. However, one ear-witness reported that between 0200 to 0215 hours, he heard a noise he could not identify. He said his house is located about 900 feet mean sea level. The ear-witness said, "weather was about one mile in drizzle and light rain, and all mountain tops were obscured with zero visibility."

Another ear-witness said he heard an airplane fly over about 0100 hours. He said it started raining about 1900 hours the day prior to the accident. He estimated that visibility was less than 50 feet with a misting, light rain. He said it was foggy the next morning when he woke up.

On May 25, at about 0930 hours, the Lompoc Sheriff's office received a telephone call from Vandenberg Air Force Base (AFB) informing them that they may have a possible search and rescue mission. The caller told the sheriff's office that they were receiving an emergency locator transmitter (ELT) signal, but had not determined the location of the signals.

At about 1310 hours, the Santa Barbara County Sheriff's Department dispatched officers to Migulito Canyon Park to confirm reports of a downed airplane. According to the Sheriff's report, the peaklocated s of the hills in the area were shrouded in fog. There was an occasional light drizzle. When the fog lifted, a United States Air Force rescue helicopter was dispatched from Vandenberg AFB, and visually sighted the airplane wreckage on a hillside located on the J.P. Larsan Ranch. Fire and Sheriff's units responded and found the airplane wreckage and the remains of the two occupants.

Crew information

The pilot held a commercial pilot certificate with airplane single land, multi-engine land, and an airplane - instrument ratings; the multi-engine rating was endorsed for VFR only. The most recent second class medical certificate was issued on January 21, 1993, with no limitations.

Safety Board investigators recovered the pilot's logbooks. The pilot's total aeronautical experience consisted of about 325 hours, with about 70 flight hours in the Cessna 172.

The pilot had accrued about 29 hours of night flight experience, 24 of which were listed as pilot in command. The pilot had logged 2 hours of "actual" instrument flight time, and 50 flight hours of "simulated" instrument flight time. The pilot received an instrument competency check on December 20, 1992.

The pilot had complied with the biennial flight review requirements of the current federal air regulations by receiving his commercial pilot certificate on April 30, 1992.

Aircraft information

The operator, Bermuda Air Services, provided the Safety Board with the airplane's maintenance records. The airframe and engine flight hours reflected on page 4 of this report were derived from the maintenance records examination. The records examination disclosed that maintenance personnel completed the last 100 hour inspection on May 21, 1993. The airplane had accrued 7.6 hours since the last inspection.

The pilot rented the accident airplane with a hobbsmeter reading of 460.9 hours. The hobbsmeter indicated 464.6 hours at the accident site.

An examination of the "maintenance squawk sheet" for the accident airplane revealed a write up concerning the "ADF inoperative", written up on April 7, 1993. The co-owner of Bermuda Air Services told Safety Board investigators on June 30, 1993, that he "recalled somebody saying something about the directional gyro processing, but said he had no recollection about the ADF being written up as inoperative."

Aids to navigation

All of the navigational aids along the airplane's flight path were operating. Lompoc Airport is served with a very high frequency omni range (VOR) and a nondirectional beacon (NDB) approach procedure.

Safety Board investigators found the NDB approach plate clipped open in the cockpit area. There is no record that the pilot requested an instrument approach to Lompoc from any FAA air traffic control facility.

Meteorological information

Instrument meteorological conditions were reported by ear-witnesses near the accident site throughout the evening prior to the accident. Search and Rescue personnel reported that the peaks of the hills in the area were shrouded in fog, and that there was an occasional drizzle. Their observation was taken at 1310 hours, or about 10 1/2 hours after the accident.

The pilot received an abbreviated weather briefing from Riverside Flight Service Station about 2258 hours before departing from the Palm Springs Airport. According to the flight service station, weather at the Lompoc Airport was reported to be: "1500 scattered, 2000 scattered, 2700 scattered, with a flight precaution for turbulence and icing."

Weather was obtained from the National Weather Service in Salt Lake City, Utah, for the Lompoc Airport. At 0215 hours, Lompoc reported "1900 overcast, with 10 miles visibility." At 0235 hours, Lompoc reported "measured 1700 overcast, with 10 miles visibility."

Santa Maria Airport, located about 15 nautical miles north of Lompoc reported the following surface weather observation at 0300 hours: "700 feet scattered clouds, measured ceiling 1200 feet broken clouds, 2500 feet overcast clouds, ten miles visibility with light rain." At 0342 hours, the surface weather observation was: "1400 feet scattered clouds, measured ceiling 1200

Aircraft

Registration
N4783J
Reported as
Cessna 172N
Category
Airplane
Serial number
17273676
Airframe hours
4,911
Engine
Lycoming O-360-A4M, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Bermuda Air Services
Registered owner
J And L Aviation, Inc
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
100 hour · May 21, 1993 · 10 hours before
Departed
PSP · Palm Springs, CA
Destination
LPC

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
29
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
325 total · 70 in this make and model · 275 as pilot in command · 13 in the last 90 days · 5 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark

FAA reports on this event · 1

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