WPR13FA013

NTSB accident investigation · Aeropro CZ A240 · Half Moon Bay, CA · October 15, 2012

Accident · FatalField investigationFinal report
Date
October 15, 2012, 05:15 local (12:15 UTC)
Place
Half Moon Bay, CA
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N72AHAeropro CZ A240
Defining event
Initial climb: Collision during takeoff/land
Weather
Instrument (IMC) · Day
Status
Completed · report January 13, 2014
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA-Oakland Flight Standards District Office
FAA report
20121015022499A
Case key
85338

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 non-instrument-rated pilot’s decision to depart into instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of airplane control.

Findings · 4

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: below VFR minimaEnvironmental issues › Conditions/weather/phenomena · Response/compensationAeropro CZ S R O A240: 1 caseAll aircraft: 184 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotAeropro CZ S R O A240: 3 casesAll aircraft: 9,295 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

The sport pilot was departing on a cross-country flight about the time of a reported ¾ mile visibility, mist and a 300 foot overcast ceiling. Recorded radar data identified the airplane during the initial takeoff ascending and turning left to an altitude of 1,100 feet mean sea level (msl). As the left turn continued to an easterly heading, the airplane descended to an altitude of about 600 feet msl. The last recorded radar target was less than a 1/4 mile from the accident site. The wreckage was located about 400 yards west of the airport on a bluff that overlooked and paralleled the runway. Examination of the accident site revealed ground scars and airplane damage consistent with a descent profile continuing to impact. Analyses of weather information and witness statements were consistent with conditions likely to have produced restricted visibility over the area at the time of the accident. These restricted visibility conditions would have been conducive to the development of spatial disorientation, and the pilot’s subsequent loss of airplane control while turning, most likely in an attempt to return to the runway. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Factual narrative

The NTSB investigator-in-charge reviewed recorded radar data from the Northern California TRACON. Ten targets made up the radar track were recorded with altitude varying from 600 up to 1,100 feet mean sea level (msl) at about the time of the accident. The recorded radar data indicated that after the target departed from HAF, it entered a climbing left turn. After turning 90-degrees arc, at the highest altitude of 1,100 feet msl, the target continued its left turn, decreasing in altitude with the last target in direction of HAF in the area of the accident site. According to FAA Advisory Circular (AC) 60-4A "Pilot's Spatial Disorientation," "Surface references and the natural horizon may at times become obscured, although visibility may be above visual flight rule minimums. Lack of natural horizon or surface reference is common on over-water flights, at night, and especially at night in extremely sparsely populated areas or in low visibility conditions. A sloping cloud formation, an obscured horizon, a dark scene spread with ground lights and stars, and certain geometric patterns of ground lights can provide inaccurate visual information for aligning the aircraft correctly with the actual horizon. The disoriented pilot may place the aircraft in a dangerous attitude." The airplane was a light sport Aeropro CZ, serial number 32511. The aircraft logbook reported that the airplane had a total airframe time of 122.7 hours at the most recent annual inspection. The last entry in the aircraft logbook showed 144.9 hours of total time. The engine was a Rotax 912ULS, serial number 6777485. Total time recorded on the engine at the most recent annual inspection was 122.7 hours of total time. According to the last entry in the aircraft logbook, the engine oil and filter was changed at 144.9 hours of total time in service. Fueling records at the Half Moon Bay Airport established that the airplane was last fueled on October 9, 2012 at 1703 with the addition of about 13 gallons of 100LL fuel. Subsequent to the accident, fuel was tested at the HAF fueling facilities for contaminates and tested OK for use. The FAA Digital Airport/Facility Directory indicated that HAF Airport had an Automated Weather Observation System (AWOS)-3, which broadcast on frequency 127.275. The FAA Digital Airport/Facility Directory indicated that HAF runway 30 is ,5000 feet long and 150 feet wide. The runway surface was asphalt and concrete, and had a displaced threshold of 762 feet. On October 15, 2012, about 0515 Pacific daylight time (PDT), a light sport, Aeropro CZ A240 airplane, N72AH, impacted terrain near Half Moon Bay, California. The sport pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The pilot sustained fatal injuries. The airplane sustained substantial damage during the accident sequence and post impact fire. Instrument meteorological conditions prevailed, and no flight plan had been filed. The cross-country personal flightdeparted Half Moon Bay Airport (HAF), Half Moon Bay, California about 0513 with a planned destination of Apple Valley Airport, Apple Valley, California. The airplane did not reach its destination at its expected time, and became the subject of an Alert Notice (ALNOT) issued by the Federal Aviation Administration (FAA). A search was conducted by the Civil Air Patrol and the Coast Guard, and the airplane was subsequently located the morning of October 16. The wreckage was located about 400 yards west of HAF on a west facing slope. The slope was part of Pillar Point Bluffs that overlook and parallel the runway west of HAF. The FAA Bioaeronautical Sciences Research Laboratory Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. Analysis of the specimens detected Warfarin, an anticoagulant medication. Ethanol was tested and none was detected in the specimens. No tests were performed for carbon monoxide or cyanide. An aviation routine weather report was recorded at HAF, near the time of the accident. It indicated at 0555 PDT, wind was from 360 degrees at 6 knots, 3/4 miles visibility, mist, with an overcast ceiling at 300 feet, temperature 13 degrees C, dew point 13 degrees C, and an altimeter setting at 30.08 inches of mercury. A review of FAA airman records revealed that the 75-year-old-pilot held a sport pilot certificate with an endorsement for airplane single-engine land. The most recent FAA medical certificate was issued to the pilot in March 1985, with the limitation that he must wear corrective lenses for near and distant vision. According to the FAA, the pilot was medically eligible to fly as a light sport pilot as long as he had a valid driver’s license and was in compliance with 14 CFR 61.53 “Prohibition on operations during medical deficiency”. The pilot submitted his last medical application on March 7, 1985. He reported he had a total time of 157 hours with 28 hours logged in the last 6 months. According to FAA documentation, on January 17, 1992, the sport pilot voluntarily surrendered his Mechanic-Powerplant; Private Pilot-Single Engine Land and Glider-Aero Tow; and Senior Parachute Rigger Certificates due to failing eye sight. A review of the pilot’s logbook revealed that the last entry was on August 29th, 2012; at that time the pilot had accrued 822.6 hours of total flight time. The engine was examined at Plain Parts, Sacramento, California on October 25, 2012. At the conclusion of the examination no mechanical malfunctions or anomalies were found with the engine components. A full report is contained within the public docket for this accident. Investigators from the National Transportation Safety Board (NTSB) and an inspector from the FAA examined the wreckage at the accident scene. The first identified point of contact (FIPC) was a pattern of broken and displaced brush and limbs about 35 feet in length. Paralleling the pattern was a narrow swath about 15 feet inlength. A red colored lens assembly was found near the (FIPC). The pattern and swath led uphill to the principle impact crater (PIC) which was about 5 feet in diameter. Multiple propeller blade fragments were found near the PIC. The main wreckage was found further uphill surrounded by undamaged trees and bushes about 10 feet in height. Thermal damage was contained only to the main wreckage and was not found in the debris path. Aileron control continuity was established through the impact damaged control rods. The rudder control cables were continuous and remained attached to the rudder horn and the rudder pedals. The elevator control rods were separated at the mid-section connecting supports.

Aircraft

Registration
N72AH
Reported as
Aeropro CZ A240
Category
Airplane
Serial number
32511
Airframe hours
123
Engine
Rotax 912ULS, 100 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
Unknown · May 8, 2012
Departed
HAF · Half Moon Bay, CA
Destination
Apple Valley, CA
Airport
HAF · Half Moon Bay Airport, runway 30, 5,000 × 150 ft, concrete

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
75
Injuries
Fatal
Certificate
Sport Pilot
Airplane ratings
Single-engine land
Seat
Left
Toxicology
Performed
Flight hours
822 total · 999 in this make and model · 822 as pilot in command

Weather

Conditions
Instrument (IMC) · Day
Wind
360° at 6 knots
Visibility
1 statute miles
Lowest ceiling
300 ft overcast
Temperature
55 °F, dew point 55 °F
Altimeter
30.07 inHg
Observed at
HAF

Docket · 10

The files NTSB released with the investigation on November 5, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 16.1 MB in all.

FAA reports on this event · 1

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