# NTSB LAX94FA271: Cessna 195A, N9300A, Santa Paula, CA, July 3, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 3, 1994, 08:10 local (15:10 UTC) - Place: Santa Paula, CA - Coordinates: 34.399158, -119.069404 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.3992&lon=-119.0694&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report July 31, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28538 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94FA271 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28538/pdf - Page: https://openairdocs.org/ntsb/LAX94FA271 ## Probable cause the noninstrument-rated pilot's intentional VFR flight into IMC conditions and the resultant in-flight loss of control. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, climb - to cruise - weather condition - low ceiling - light condition - daylight - vfr flight into imc - intentional, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - design stress limits of aircraft - exceeded, pilot in command (contributing factor) - Airframe/component/system failure/malfunction, descent - uncontrolled - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE PRIVATE PILOT AND HIS PASSENGER WERE DEPARTING FOR A SHORT FLIGHT TO ANOTHER AIRPORT. A PILOT EXAMINER WITNESS STATED THAT THE WEATHER WAS ABOUT 600 FOOT OVERCAST WITH ABOUT .50 MILE VISIBILITY. ANOTHER WITNESS STATED THAT HE WAS USING HIS WINDSHIELD WIPERS DUE TO THE HEAVY MIST. GROUND WITNESSES REPORTED HEARING UNUSUAL SOUNDS FROM AN AIRPLANE IN THE OVERCAST. THEY THEN OBSERVED THE AIRPLANE SPIRALING OUT OF THE OVERCAST WITH A WING MISSING. THE PILOT WAS NOT INSTRUMENT RATED. SOME AREAS IN THIS NARROW VALLEY LOCATION WERE REPORTED TO BE IN THE CLEAR. THE LEFT WING OUTBOARD PANEL SEPARATED AT MIDSPAN WITH EVIDENCE OF A POSITIVE OR UPWARDS LOAD. THE LEFT AILERON WAS NOT FOUND AT THE TIME OF THE ON-SCENE INVESTIGATION. SUBSEQUENTLY, THE AILERON WAS RECOVERED. THE WING HINGE FITTINGS FROM THE SEPARATED AILERON WERE METALLURGICALLY EXAMINED. THE EXAMINATION REVEALED THAT THERE WERE EXISTING CRACKS AT THE INBOARD LOWER AILERON ATTACH POINT AT THE WING REAR SPAR. EXAMINATION REVEALED THAT THE FITTINGS HAD PULLED OUT FROM THE AILERON SPAR DURING THE WING OVERLOAD. ## Factual narrative On July 3, 1994, about 0810 hours Pacific daylight time, a Cessna 195A, N9300A, was destroyed after an in-flight breakup at Santa Paula, California. Instrument meteorological conditions prevailed at Santa Paula Airport at the time of departure, and no flight plan was filed for the personal cross-country flight. The private pilot and his passenger were fatally injured. The flight originated about 0805 hours and was destined for Crystal Airport at Llano, California, about 72 miles northeast of Santa Paula. The pilot had an 0930 appointment for dual instruction at the Crystal Air Soaring School. Review of Federal Aviation Administration (FAA) facility records revealed no record of a preflight weather briefing for the pilot. Witnesses reported hearing the airplane make unusual sounds, and, then they saw the airplane spiraling out of the overcast with a wing missing and several other parts falling to the ground. The accident site was located about 2 miles southwest of the Santa Paula airport in the Santa Clara River bed. PERSONNEL INFORMATION The pilot's logbook was not recovered. On the pilot's last two third-class flight physicals, dated April 10, 1992 and May 2, 1994, he reported a total flight time of 800 hours. At the last physical, he reported 10 hours in the past 6 months. AIRCRAFT INFORMATION The coowner of the airplane reported that the last annual inspection was performed in May of 1994. The records, according to the coowner, were kept in the airplane. The airplane was destroyed in a postcrash fire. The person who signed the annual inspection was contacted for details of the inspection; however, he stated that he kept no records. WRECKAGE AND IMPACT INFORMATION The accident site is located about 2 miles southwest of the Santa Paula Airport, near the Santa Clara River. The area is covered with trees and brush, and is adjacent to local oil fields. The main wreckage is located about 30 feet south of some oil field pipelines. A postcrash fire had consumed the cabin, firewall, center section, and most of the wing panels. The right wing structure from about midspan outboard was found in the vicinity of the main wreckage along with the aileron. Both revealed evidence of a tree strike with severing of the wing section. The right aileron was found near the wing structure and had evidence of tree impact damage. Neither the wing outboard structure nor the aileron were fire damaged. The left outboard wing panel, without the aileron, was found about 1,110 feet north-northeast of the main wreckage in a lemon grove along with various wing and rib parts. The panel measured about 5 foot 7 inches long. The panel had separated at about the middle of the aileron span and still had the outboard hinge fittings attached to the rear wing spar. The wing panel exhibited positive or upwards bending of the wing structure. The inboard aileron hinge and actuator assembly were found with the burnt left wing structure. The left aileron was subsequently found by grove workers and returned to the wreckage retriever. Examination of the aileron revealed preexisting cracks in the structure of the aileron, and some of these cracks were stop drilled. A repair was noted on the top outboard end of the aileron. Both aileron hinge fittings were found to be pulled from the aileron spar. METEOROLOGICAL INFORMATION The closest weather reporting facility is located at Camarillo, California. At 0750 hours, they were reporting measured 600 foot overcast, 2 miles fog and haze, temperature 62 degrees Fahrenheit, dewpoint 57 degrees Fahrenheit, wind calm and the altimeter was 29.92 inches of mercury. A pilot examiner witness at Santa Paula reported the weather conditions to be sky obscured, 600 feet overcast with 1/2 mile visibility in fog. The witness said this observation was based on a known geographical point on a hill used for weather observations. Another witness stated that it was misting enough that he had to use his windshield wipers while driving in the area at the time of the accident. The Ventura County deputy coroner was on the accident scene about 0925 hours. He stated in his report that the weather was cool with no wind, low cloud cover, and limited visibility. MEDICAL AND PATHOLOGICAL INFORMATION On July 4, 1994, the Ventura County medical examiner performed an autopsy on the pilot. According to the report, the cause of death was attributed to blunt injuries. During the autopsy, samples were obtained for toxicological analysis by the FAA Aeromedical Institute in Oklahoma City, Oklahoma. The toxicological analysis was negative for carbon monoxide, cyanide, and drugs. The report was positive for volatiles. 15.000 (mg/dl) of ethanol and 2.000 (mg/dl) of acetaldehyde were detected in the blood; also, 1.000 (mg/dl) of acetaldehyde was detected in the bile. TESTS AND RESEARCH Components of the left inboard aileron hinge assembly, push-pull rod assembly, and a portion of the aft bracket of the aileron outboard hinge of the left wing were recovered and sent to the National Transportation Safety Board (NTSB) Metallurgical Laboratory in Washington D.C. According to the metallurgist factual report, fatigue cracks originated on the aft side of the lower rear spar cap in an area where the lower legs of the forward bracket for the inboard hinge assembly attaches to the wing aft spar. ADDITIONAL INFORMATION The uninsured airplane wreckage was released back to the coowner on July 12, 1994. ## Aircraft - Registration: [N9300A](https://openairdocs.org/deregistered/N9300A-1998-04-04), registration cancelled 1998-04-04, S/N 7514 (OpenAirDocs) - Reported make and model: CESSNA 195A - Registry model: [Cessna 195A](https://openairdocs.org/model/cessna-195a) (registry code 2073110) (OpenAirDocs) - Category: Airplane - Serial number: 7514 - Airframe hours: 3000 - Engines: JACOBS 755-B2 275 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: John F. Lires - Registered owner: Lires,John F. Dolan,John W. - Airworthiness certificate: Standard, Normal - Departed: SZP, CA - Destination: L01, LLANO, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 800 total ## Weather - Conditions: Instrument (IMC), Day - Wind: calm - Visibility: 0.5 statute miles - Lowest ceiling: 600 ft overcast - Observed at: 1 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 (OpenAirDocs). - [Accident 19940703017649A](https://openairdocs.org/incident/19940703017649A), Jul 3, 1994: Cessna 195A, Santa Paula, CA, Destroyed, 2 fatal. Took off VFR in IMC. Observed falling out of clouds minus a wing. Fatigue cracks in spar. Failed in extra stress. ## Other investigations on N9300A (2) 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. - [NTSB CHI66D0365](https://openairdocs.org/ntsb/CHI66D0365), Oct 2, 1965: Cessna 195 (N9300A), Fraser, MI, substantial damage - [NTSB UNK64X0157](https://openairdocs.org/ntsb/UNK64X0157), Jan 4, 1964: Cessna 195 (N9300A), Winchester, VA, substantial damage 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.