WPR11FA027

NTSB accident investigation · Reed Glasair III SH-3R · Lake Mathews, CA · October 23, 2010

Accident · FatalField investigationFinal report
Date
October 23, 2010, 13:32 local (20:32 UTC)
Place
Lake Mathews, CA
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N2XZReed Glasair III SH-3R
Defining event
Maneuvering: Low altitude operation/event
Weather
Visual (VMC) · Day
Status
Completed · report January 15, 2013
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Lycoming Engines
FAA report
20101023050789A
Case key
77661

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 clearance from terrain while maneuvering at low altitude beneath a cloud layer.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Ceiling/visibility/precip: low ceilingEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeReed Philip L III GLASAIR III SH-3R: 1 caseAll aircraft: 190 cases
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedReed Philip L III GLASAIR III SH-3R: 1 caseAll aircraft: 990 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Review of recorded radar data found a flight track that was consistent with the airplane's high performance capabilities, with its departure point, and ultimately with the accident site. The radar data indicated that a few seconds after the airplane passed over the runway's end, it turned toward the southeast, accelerated to about 190 knots ground speed, and proceeded directly toward the accident site area around a lake. No mode C altitude data was transmitted by the transponder. Upon arrival over the lake, the airplane made two counterclockwise oval-shaped 360-degree turns, with the steepest bank performed as the airplane approached the lake's eastern shoreline. The last radar return was located over the lake's eastern shoreline and within 250 feet of the wreckage location. Based on weather reports from an airport 7 miles northeast of the accident site, an overcast or broken cloud layer at 2,500 feet above ground level likely existed over the accident site. Based on an examination of the crater and airplane wreckage, the airplane impacted the ground at a high airspeed while descending in a slight bank and with the airplane's longitudinal axis pitched downward (nose low) between 55 and 70 degrees. The impact signatures could be consistent with the pilot attempting either a loop or split "S"-type maneuver at an altitude insufficient to recover. There were no witness reports and postaccident examination of the wreckage did not reveal any evidence of a preimpact mechanical malfunction or failure of any airframe or engine component or system.

Factual narrative

HISTORY OF FLIGHT On October 23, 2010, about 1332 Pacific daylight time, a Philip L. Reed III, Glasair III SH-3R, N2XZ, impacted sandy terrain on the east side shoreline of Lake Mathews. Lake Mathews is a Metropolitan Water District reservoir located about 9 miles east of Corona, California. The airplane fragmented upon impacting the ground and sustained substantial damage. The airplane was owned and operated by the airline transport certificated pilot, and he was killed along with the second pilot/passenger, who also held an airline transport pilot certificate. Visual meteorological conditions prevailed at the time of the personal flight in the dual control, experimental, amateur built airplane. The flight was performed under the provisions of 14 Code of Federal Regulations Part 91, and no flight plan was filed. The flight originated from Corona Municipal Airport, Corona, California, about 1324. No witnesses reported observing the accident. A search for the overdue airplane commenced when it did not return to Corona by the afternoon of the 23rd. During the search for the overdue airplane, Federal Aviation Administration (FAA) recorded radar data was reviewed. A flight track was found that was consistent with the airplane's high performance capabilities, with its departure point, and ultimately with the accident site. The FAA radar data revealed the presence of an airplane track that started at 1324:46 near the departure end of Corona Airport's runway 25. The airplane's transponder squawk code (code 1200) was being transmitted without Mode C altitude data. The track indicated that a few seconds after the airplane passed over the runway's end, it turned toward the southeast, accelerated to approximately 190 knots (ground speed) and proceeded directly toward Lake Mathews. Upon arrival over the lake, the airplane made two counterclockwise oval shaped 360-degree turns, with the steepest bank performed as the airplane approached the lake's east side shoreline where the accident site is located. The last radar hit was recorded at 1331:36. The accident site was located over the lake's east side shoreline and within 250 feet from the radar target's last recorded position. PERSONNEL INFORMATION Both occupants were ejected in the impact sequence and their preimpact seating positions in the airplane could not be conclusively established. The airplane had fully functioning dual controls and could be piloted from either of the front seats. The 41-year-old first pilot was the registered owner of the airplane. A close personal friend of the pilot reported to the National Transportation Safety Board investigator that earlier in the morning the pilot had taken another passenger for a ride in his airplane. The accident occurred during the subsequent flight. No flight records logbooks were provided to the Safety Board for examination. The pilot was current in his airplane, according to the friend, who was also a professional pilot. FAA records indicated that thepilot held an airline transport pilot certificate and was type rated to fly Boeing 747 and Embrier EMB-120 airplanes. He also held an expired certified flight instructor (CFI) certificate for single and multiengine airplanes, and instruments, and an advanced and instrument ground school instructor certificate. The pilot was employed as a captain and regularly flew Boeing 747 airplanes on international cargo flights. In October, 2010, the pilot reported to the FAA that his total flight time was 11,305 hours. The pilot's personal flight record logbook was not provided to the Safety Board investigator for review. The builder of the airplane reported to the Safety Board investigator that he had spoken with the pilot on numerous occasions since selling him the airplane about 6 months before the accident. The builder opined that the pilot had flown the airplane at least 20 hours since that time. Prior to the pilot having acquired the Glasair, he had no flying experience in this model of airplane. The pilot's employer reported that in April, 2010, the pilot upgraded to the rank of captain and was flying Boeing 747 airplanes. The pilot's last company flight was performed on October 9, 2010. The 50-year-old second pilot was a passenger in the airplane. The friend reported to the Safety Board investigator that the second pilot had previously flown high performance, light, single engine airplanes. The pilot's flight records logbooks were not provided to the Safety Board for examination. Neither the pilot's flying experience in the accident model of Glasair nor his currency flying single engine airplanes was able to be established. FAA records indicate that the pilot held an airline transport pilot certificate and was type rated to fly Boeing 747 and Embraer 120 airplanes. He also held an expired certified flight instructor certificate for single and multiengine airplanes and instruments, and an advanced and instrument ground school instructor certificate. The pilot was employed as a captain and regularly flew the Boeing 747 airplane on international cargo flights. In October, 2010, the pilot reported to the FAA that his total flight time was 11,305 hours. The pilot's employer reported that in June, 2006, the pilot upgraded to the rank of captain and was flying Boeing 747 airplanes. The pilot's last company flight was performed on October 8, 2010. Both pilots were employed by the same air cargo company. AIRCRAFT INFORMATION The experimental, amateur kit built, composite structure 2 seat airplane, serial number 3155, was issued a FAA airworthiness certificate on September 24, 1990. The airplane was equipped with a Lycoming 330 horsepower engine (model IO-540-K1A5, serial number L-10843-48A), and a 2-blade Hartzell propeller (model HC-C2YK-1BF, hub CH29521). According to builder-supplied data, the airplane's maximum gross weight was 2,500 pounds. It had a 75 percent power cruise speed of 235 knots, and a rate of climb between 2,000 and 3,000 feet per minuteat 150 knots. The airplane's structural "G-Ratings" were listed as follows: "+9Gs, -6Gs Ultimate" and "+6Gs, -3Gs Standard." FAA records revealed that the pilot purchased the airplane in June, 2010. At the time, the airplane's listed total time was 580 hours. The pilot was the listed sold owner. No airplane operation or maintenance logbooks were located. The airplane's total times and inspection information could not be established. METEOROLOGICAL INFORMATION The closest airport to the accident site was Riverside Municipal Airport (RAL), elevation 819 feet msl. RAL is located about 7 miles north-northwest from the site. In pertinent part, at 1253, RAL reported an overcast layer of clouds at 2,900 feet above ground level (agl). At 1353, RAL reported scattered clouds at 3,400 feet agl, and a broken ceiling at 4,900 feet agl. No precipitation was reported, and the wind was reported at 3 knots or less. COMMUNICATION The FAA reported that no communications were recorded between its facilities and N2XZ. WRECKAGE AND IMPACT INFORMATION The accident site is located at the following global positioning system coordinates: 33 degrees 50.760 minutes north latitude by 117 degrees 25.443 west longitude. The accident site elevation is estimated between 1,350 and 1,390 feet mean sea level (msl). During the subsequent examination of the accident site, all airframe flight control surfaces and major structural components were found at or within about 90 feet from the main wreckage. No ground scar was observed leading up to the main wreckage. The propeller and engine were found in a 3-foot-deep impact crater and were partially buried. The engine was positioned on top of the propeller assembly, which was about 2 feet below ground level. A 1/2 to 1-foot-deep imprint of the wings, along with left and right navigation light lens fragments, were located adjacent to the fragmented cockpit, which was at ground level and in an upright attitude. Based upon an examination of the crater and airplane wreckage, evidence was found consistent with the airplane having impacted the ground while descending in a near wings level bank and with the airplane's longitudinal axis pitched downward (nose low) between 55 and 70 degrees. Wing skin was crushed in an aft direction from the wings' leading edges to the main spars, and the entire cockpit and cabin were fragmented and destroyed. The landing gear was in the retracted position. No evidence of fire or oil residue was observed on any examined component. The airplane heading and impact crater were oriented in an east-southeasterly direction. No ground scar evidence was observed in any location other than at the location of the main wreckage, where an imprint of the airplane was present in the hard-packed sandy soil. All of the flight control surfaces were found in the vicinity of the main wreckage. The elevator was found attached to horizontal stabilizer, which was attached to the empennage. The integrity of the elevator and rudderflight control surfaces were confirmed from their respective surfaces to the mid-fuselage, where overload signatures were noted in the heavily impact-damaged area of the cabin. Both wings were broken from the fuselage, and they exhibited leading edge crush signatures in an aft direction to their spars. An imprint of the wings was observed in the terrain few yards aft of where the fragmented cockpit was observed. Red and green navigation light lens fragments were found in the impact crater at locations consistent with where the wing tips are located. No evidence of preimpact control system separation signatures were observed with the ailerons or wing flaps. The propeller assembly was found between 2 and 3 feet below ground level, and one blade remained attached to the hub. The engine was found above the propeller assembly, and was between 1 and 2 feet below ground level. The engine was separated from the firewall. The longitudinal axis of the buried engine was about 70 degrees to the horizontal. The entire instrument panel, cockpit, and fuselage were fragmented and destroyed. The wings were separated from the airframe and their leading edges were crushed/fragmented in an aft direction. The empennage, with attached horizontal and vertical stabilizer was intact. The rudder was found torn from its attachment point. The landing gear was observed in the retracted position. No evidence of Plexiglass was found east of the main wreckage. No evidence of oil residue was noted on the empennage. No evidence of fire was noted in any of the examined wreckage. MEDICAL AND PATHOLOGICAL INFORMATION Both pilots sustained fatal injuries in the accident and autopsies were conducted by the Riverside County Sheriff-Coroner’s office. The causes of death were ascribed to blunt force injuries. The results of the toxicological tests on samples from both occupants were negative for alcohol and all screened drug substances. TESTS AND RESEARCH Engine Under the direction and observation of the Safety Board investigator, the engine was examined by the Lycoming Engine participant following its recovery. In pertinent part, the spark plugs were removed and exhibited normal operation signatures. Fuel was observed in a main line to the flow divider. The engine's case was impact damaged, and the crankshaft could not be rotated. Cylinders were examined using a borescope, and no evidence of abnormal operation signatures were observed. In summary, the Lycoming participant found no evidence of preimpact failure or malfunction. Propeller The propeller blades exhibited leading edge abrasions and scratches in a chordwise direction. They also exhibited torsional deformation. ADDITONAL INFORMATION The accident site location was reported to the Safety Board investigation as being a local practice area where airplanes frequently perform maneuvers. During the on-scene examination of the wreckage, several airplanes were observed maneuvering within a few hundred feet above ground (lake) level andperformed medium bank turns while circling over the lake. Lake Mathews is depicted on the Los Angeles "VFR Terminal Area Chart." Next to the lake the following statement is written: "CAUTION INTENSIVE FLIGHT TRAINING." An acquaintance of the pilot reported to the Safety Board investigator that the pilot enjoyed flying his high performance airplane over this practice area. He was skilled in performing various flight maneuvers. Based upon the acquaintance's description of the maneuvers, the maneuvers could be classified by the FAA as being, by regulation, acrobatic. Another acquaintance of the pilot reported that the pilot stated he enjoyed performing acrobatic maneuvers, including rolls. The pilot was also reportedly performing split-S maneuvers. The builder of the airplane stated to the Safety Board investigator that the airplane accelerated quickly in a nose low attitude. When performing maneuvers, a hard altitude of at least 2,500 feet above the ground feet would be the minimum for maneuvering. The builder reviewed the accident data and opined that, based upon the airframe fragmentation and impact crater, the airplane likely impacted the ground while descending at a high rate of speed, estimated at least 200 knots, and while descending at an 80-degree angle.

Aircraft

Registration
N2XZ
Reported as
Reed Glasair III SH-3R
Category
Airplane, amateur-built
Serial number
3155
Airframe hours
600
Engine
Lycoming IO-540-K1A5, 330 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Annual · May 1, 2010 · 20 hours before
Departed
AJO · Corona Muni., CA
Destination
AJO · Corona Muni., CA

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
41
Injuries
Fatal
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Toxicology
Performed
Flight hours
11,305 total · 20 in this make and model
Role
Pilot
Age
50
Injuries
Fatal
Certificates
Flight engineer, Airline transport, Flight instructor
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Toxicology
Performed
Flight hours
11,500 total

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
2,900 ft overcast
Temperature
66 °F, dew point 54 °F
Altimeter
30.06 inHg
Observed at
RAL, 6 nm away

Docket · 27

The files NTSB released with the investigation on November 16, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 38.6 MB in all.

Map - Accident Site and Last Radar HitItem 1 · .PDF · 387 KBMeteorological InformationItem 2 · .PDF · 337 KBRadar TrackItem 3 · .PDF · 236 KBFAA StatementItem 4 · .PDF · 41 KBRecord of Conversation - David R. StevensonItem 5 · .PDF · 80 KBRecord of Conversation - Phil ReedItem 6 · .PDF · 220 KBCorrespondence - Phil ReedItem 7 · .PDF · 108 KBAirplane Specifications June 1992 - Data Located in AircraftItem 8 · .PDF · 63 KBAirplane Specifications May 2010 - Data Filed with FAAItem 9 · .PDF · 71 KBGlasair III SpecificationsItem 10 · .PDF · 74 KBStatement of Party Representatives to NTSB InvestigationItem 11 · .PDF · 5.2 MBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 12 · .PDF · 227 KBToxicological ReportItem 13 · .PDF · 594 KBPhoto 1. Aerial view of airplane main wreckage. Photo provided by Riverside Sheriff.Item 14 · .PDF · 694 KBPhoto 2. Airplane, front view.Item 15 · .PDF · 2.8 MBPhoto 3. Airplane, front view close-up.Item 16 · .PDF · 2.9 MBPhoto 4. Airplane, right side, wing tip fragments (foreground).Item 17 · .PDF · 2.7 MBPhoto 5. Right wing, nav light lens fragments.Item 18 · .PDF · 1.5 MBPhoto 6. Empennage, aft view.Item 19 · .PDF · 2.6 MBPhoto 7. Empennage, left side.Item 20 · .PDF · 2.6 MBPhoto 8. Aft fuselage, left side.Item 21 · .PDF · 2.3 MBPhoto 9. Fuselage, left side and wing imprint with fragments.Item 22 · .PDF · 1.5 MBPhoto 10. Empennage, bottom view.Item 23 · .PDF · 2.8 MBPhoto 11. Propeller blade found separated from hub.Item 24 · .PDF · 2.8 MBPhoto 12. Propeller blade found attached to hub.Item 25 · .PDF · 1.8 MBPhoto 13. Engine, top view.Item 26 · .PDF · 2.1 MBPhoto 14. Engine, bottom view.Item 27 · .PDF · 1.8 MB

FAA reports on this event · 1

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