# NTSB WPR13FA013: Aeropro CZ A240, N72AH, Half Moon Bay, CA, October 15, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 15, 2012, 05:15 local (12:15 UTC) - Place: Half Moon Bay, CA - Coordinates: 37.510276, -122.505279 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.5103&lon=-122.5053&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report January 13, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA-Oakland Flight Standards District Office - NTSB case key (mKey): 85338 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR13FA013 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85338/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85338 - Page: https://openairdocs.org/ntsb/WPR13FA013 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Response/compensation (probable cause); cases with it: [Aeropro CZ S R O A240, 1 case](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=060006U), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Aeropro CZ S R O A240, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=060006U), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Aeropro CZ S R O A240, 2 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=060006U), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aeropro CZ S R O A240, 3 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=060006U), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [Aeropro CZ S R O A240, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=060006U), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Initial climb: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Aeropro CZ S R O A240, 1 case](https://openairdocs.org/ntsb-events/490/sequence.md?model=060006U), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Aeropro CZ S R O A240, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=060006U), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N72AH-2017-10-26), registration cancelled 2017-10-26, S/N 32511, built 2011 (OpenAirDocs) - Reported make and model: AEROPRO CZ A240 - Registry model: [Aeropro CZ S R O A240](https://openairdocs.org/model/aeropro-cz-s-r-o-a240) (registry code 060006U) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 32511 - Airframe hours: 123 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 75; injuries: fatal; 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 ## 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 20121015022499A](https://openairdocs.org/incident/20121015022499A), Oct 15, 2012: Aeropro Cz A240, Moss Beach, CA, Destroyed, 1 fatal. FAA radar data indicates the aircraft departing Half Moon Bay Airport (haf) from runway 30 on 10/15/2012 at or about 05:13 PDT, 20:13 UTC. The radar plot… ## Docket (10 files) The files NTSB released with the investigation on November 5, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85338. 16.1 MB in all. - Record of Conversation-Pilot's Wife (item 1, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391877&FileExtension=.PDF&FileName=Record%20of%20Conversation-Pilot%27s%20Wife-Master.PDF - Google Earth View 1 (item 2, .PDF, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385101&FileExtension=.PDF&FileName=Google%20Earth%20View%201-Master.PDF - Google Earth View 2 (item 3, .PDF, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385102&FileExtension=.PDF&FileName=Google%20Earth%20View%202-Master.PDF - Rotax-Report of Findings (36 Embedded Images) (item 4, .PDF, 36 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385060&FileExtension=.PDF&FileName=Rotax-Report%20of%20Findings%20(36%20Embedded%20Images)-Redacted.PDF - Radar Track Data (item 5, .PDF, 239 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385112&FileExtension=.PDF&FileName=Radar%20Track%20Data-Redacted.PDF - Radar Track Data-Aerial View (item 6, .PDF, 273 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385113&FileExtension=.PDF&FileName=Radar%20Track%20Data-Aerial%20View-Master.PDF - Toxicology Report (item 7, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389355&FileExtension=.PDF&FileName=Toxicology%20Report-Master.PDF - Photo 1-Accident Site (item 8, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403163&FileExtension=.PDF&FileName=Photo%201-Accident%20Site-Master.PDF - Photo 2-Accident Site (item 9, .PDF, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403186&FileExtension=.PDF&FileName=Photo%202-Accident%20Site-Master.PDF - Photo 3-Accident Site (item 10, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403206&FileExtension=.PDF&FileName=Photo%203-Accident%20Site-Master.PDF 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.