LAX94FA056

NTSB accident investigation · Cessna 172M · Julian, CA · November 22, 1993

Accident · FatalField investigationFinal report
Date
November 21, 1993, 18:55 local (Nov 22, 1993, 02:55 UTC)
Place
Julian, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N5312RCessna 172M
Weather
Visual (VMC) · Night/dark
Status
Completed · report September 13, 1994
Report
Approved by Office Director
FAA report
19931121044189A
Case key
28507

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 failure to maintain aircraft control. Factors in this accident were: 1) the dark night and lack of ambient light which resulted in the pilot inadvertently flying from visual meteorological conditions into instrument meteorological conditions; 2) the pilot's lack of instrument flight experience, and 3) spatial disorientation.

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.

Loss of control - in flightCruise
Weather condition - downdraft
Weather condition - turbulenceFactor
Weather condition - clouds
Light condition - dark nightFactor
Vfr flight into imc - inadvertentPilot in command
Lack of total instrument timePilot in commandFactor
Aircraft control - not maintainedPilot in commandCause
Spatial disorientationPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - mountainous/hilly

Analysis

The pilot and his pilot-rated passenger departed for a night cross-country flight. They were receiving visual flight rules advisories and had been assigned a discrete transponder code. They were climbing to an altitude of 9,500 feet msl, and were at 9,100 feet msl when radio and radar contact were lost. The last recorded radio transmission from the pilot was, 'We're in a flat (blocked out), we're going to lose it dad.' A search was initiated, and the airplane and its occupants were found the next day. The cloud bases in the area were reported by other pilots to be about 7,100 feet msl, with tops about 13,000 feet. The light conditions were reported to be 'dark night' with little surface ambient light in the sparsely populated area. The pilot's logbook was examined, and no indication was found of the pilot having flown during the 90-day period preceding the accident. Neither the pilot nor the pilot-rated passenger had an instrument rating. Postaccident examination of the airplane did not reveal any preexisting deficiencies.

Factual narrative

History of flight

On November 21, 1993, at 1855 hours Pacific standard time, a Cessna 172M, N5312R, collided with terrain following an in-flight loss of control near Julian, California. The pilot was conducting a visual flight rules personal flight to Steller Airpark, Chandler, Arizona. The airplane, operated by the pilot/owner, was destroyed. The certificated private pilot and his certificated private pilot/passenger sustained fatal injuries. Instrument meteorological conditions prevailed. The flight originated at Montgomery Field, San Diego, California at 1828 hours as a night cross-country flight to Chandler, Arizona. The pilot did not file a flight plan, nor was he required to.

The pilot was receiving visual flight rules (VFR) advisories and flight following from the Federal Aviation Administration (FAA) San Diego Terminal Approach Control (TRACON). According to recorded radar data obtained from San Diego TRACON, the aircraft had been assigned a discrete transponder code of 7264, and was climbing to an altitude of 9,500 feet mean sea level. The last aircraft position recorded by the radar system was at 1854:49 hours at a mode C reported altitude of 9,100 feet mean sea level. This position was noted to be about one mile from the accident site location.

The recorded radar data mode C reported altitude track history of the aircraft was reviewed. The last four recorded radar beacon returns showed altitudes of 9,400, 9,400, 9,500 and 9,100 feet respectively. The time intervals of the four recorded radar returns were spaced about one minute apart from 1851:44 to 1854:49.

At the time the aircraft disappeared from the San Diego TRACON radar, it also disappeared from the FAA Los Angeles Center radar. The radar disappearance was accompanied by a simultaneous loss of radio contact with the pilot. The last recorded transmission from the pilot was, "We're in a flat (blocked out), we're going to lose it dad."

The family became concerned when the aircraft was overdue, and contacted Riverside Flight Service Station personnel about 2230 hours. An ALNOT (alert notice for missing aircraft) was issued for the aircraft. San Diego County Sheriff's Department personnel and the San Diego Branch of the U. S. Customs searched the area for several hours on the night the ALNOT was issued without success. The air search was resumed the next morning by San Diego County Sheriff's Department personnel. The Sheriff's Department located the wreckage of the airplane at approximately 0735 hours.

The accident site is located about north 32.49 degrees latitude and west 116.24 degrees longitude. The accident occurred during the hours of darkness.

Crew information

The pilot held a private pilot certificate which was issued on September 10, 1990, with airplane ratings for single-engine land aircraft. The most recent third class medical certificate was issued to the pilot on June 13, 1993, without limitations. According to the FAA Civil Aeromedical Institute Certification Division, the pilot reported a total of 270 hours of aeronautical experience as of his last reported FAA medical application form. According to pilot logbook entries, the pilot's total aeronautical experience consisted of about 308.5 hours of flight time. The pilot's records indicated a total of 49 hours of night flying time. The pilot's logbook did not record any flight time in the 90-day period preceding the accident.

The pilot had complied with the biennial flight review requirements of the current Federal Air Regulations by receiving his single-engine refresher on October 3, 1992.

Neither the pilot nor his pilot-rated passenger possessed an instrument rating.

Aircraft information

The airplane was registered to the pilot's father, the occupant reportedly flying in the right seat of the aircraft the night of the accident.

According to aircraft records which were reviewed during the conduction of the investigation, the last annual inspection was performed on August 29, 1993. The aircraft had accrued a total time of 3748.4 hours as of the above mentioned date. National Transportation Safety Board investigators were unable to determine the number of hours flown since the annual inspection, due to impact damage to the cockpit.

The aircraft originally had engine serial number L-382117-27A installed. The engine was removed and replaced with engine serial number L-24324-27A at an unknown date. The engine was overhauled in June of 1992 by Button Aviation Inc., Chandler, Arizona. The engine total time is unknown, but it had accumulated 198.5 hours since major overhaul at the time of its last annual inspection.

Meteorological information

The mother of the first pilot reported to Safety Board investigators that she personally witnessed her son obtain a weather briefing prior to the flight. She said her son called the 1-800-WX-BRIEF telephone number to obtain the weather briefing. She said several other members of the family were present during the briefing, and that her son remarked to the other family members that "they would be home early due to the 17-knot tailwind en route." Safety Board investigators contacted FAA Western Pacific Region Headquarters, Air Traffic (AWP-542), and asked that they search the flight service station records for a transcript of this briefing. San Diego, Hawthorne, and Riverside Flight Service Stations all reported negative contact for a weather briefing, although the 15 days that transcripts normally are saved had passed. (For additional information, see Record of Conversation, which is attached.)

The closest official weather observation facility is located about 33 nautical miles to the west of the accident site at Mirimar Naval Air Station, San Diego, California. A weather observation was taken by a weather observer at 1955 hours local time on November 21, 1993. The report from that observation was: "estimated 12,000 broken, visibility 7 miles, temperature 62 degrees (fahrenheit), dew point 54 degrees (fahrenheit)."

A weather observation was taken by a weather observer located at San Diego International Airport at 1950 hours local time on November 21, 1993. The observation noted in part: "measured 8,500 overcast, 10 miles visibility, temperature 63 degrees fahrenheit, dew point 59 degrees (fahrenheit), wind from 160 (degrees) at 04 knots, altimeter 30.01 inHg, few stratocumulus, moon dimly visible."

Safety Board investigators interviewed the participants in the search and rescue efforts to locate the downed aircraft. The San Diego Sheriff's Department Aerial Support Detail said in part, "...upon our arrival, the sky was partially obscured with cloud cover, with a partial moon that periodically broke through." Prior to their departure to search for the aircraft, the officer reported that "...we learned from LA Center (Los Angeles Air Route Traffic Control Center), that they had recently received a pilot report from the Julian area advising downdrafts and turbulence in the area...the pilot report advised of losing 200-300 feet of altitude and 20-30 knots of airspeed."

Additionally, statements were received from the U. S. Customs Service crews who responded in a Cessna Citation and BK-117 helicopter to assist in the search for the downed aircraft. The crew from the BK-117 helicopter stated they encountered "moderate" turbulence in the area.

An aviation safety inspector from the FAA San Diego Flight Standards District Office (FSDO) interviewed a refueler who fueled the accident airplane prior to departure. The refueler stated that he was told by a pilot who flew in from the "Julian area" about 1900 hours that "the cloud bases were about 7,000 feet." (See Record of Conversation, attached to this report.)

Wreckage and impact information

The accident site is located about 4 miles east of Pine Valley, California. The site is located on a hill with about a 45-degree slope. The hill is vegeta

Aircraft

Registration
N5312R
Reported as
Cessna 172M
Category
Airplane
Serial number
17263514
Engine
Lycoming O-320-E2D, 150 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Charles L. Cook
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · August 29, 1993
Departed
MYF · San Diego, CA
Destination
P19 · Chandler, AZ

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
24
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
309 total · 265 as pilot in command

Weather

Conditions
Visual (VMC) · Night/dark
Wind
190° at 3 knots
Visibility
10 statute miles
Lowest ceiling
9,000 ft overcast
Temperature
63 °F, dew point 59 °F
Altimeter
29.00 inHg
Observed at
SAN, 40 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.