WPR17FA063

NTSB accident investigation · Cessna 172 · Ramona, CA · February 12, 2017

Accident · FatalField investigationFinal report
Date
February 12, 2017, 14:10 local (22:10 UTC)
Place
Ramona, CA
Injuries
1 fatal, 2 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N2179LCessna 172
Defining event
Maneuvering: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Day
Status
Completed · report March 18, 2019
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Lycoming Engines, Textron Aviation, FAA FSDO
FAA report
20170212002379A
Case key
94707

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 flight instructor's failure to ensure that adequate clearance from terrain was maintained after performance of a simulated engine failure maneuver, which resulted in controlled flight into terrain.

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.

Attention/monitoring: monitoring environmentPersonnel issues › Psychological · Instructor/check pilotCessna 172S: 11 casesAll aircraft: 809 casesProbable cause
Action: delayed actionPersonnel issues › Action/decision · Instructor/check pilotCessna 172S: 30 casesAll aircraft: 894 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Decision related to conditionCessna 172S: 6 casesAll aircraft: 329 cases

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 airplane departed on an instructional flight with a flight instructor in the right front seat, a student pilot in the left front seat, and a passenger in the right rear seat. They completed maneuvers in a practice area, flew to a valley located in mountainous terrain, and performed a simulated engine failure maneuver. The flight instructor and the student pilot provided differing accounts of the events that followed the simulated engine failure maneuver. According to the flight instructor, after performing the simulated engine failure maneuver, the student pilot advanced the throttle to full power and turned east toward rising terrain. The flight instructor reported that the gauges all read normal, but the airplane would not outclimb the approaching terrain. He took over the controls but could not turn left or right due to the rising terrain on both sides of the airplane. According to the instructor, he had no choice but to crash the airplane. According to the student pilot, the flight instructor told him to turn east towards the rising terrain and then took control of the airplane. The student reported that the flight instructor made a comment about demonstrating the airplane's performance, added full power, leaned the mixture, flew straight for 5 seconds, and then said an expletive shortly before the airplane crashed into a mountain. Flight track data recovered from a personal electronic device onboard the airplane showed that, after the simulated engine failure maneuver, the airplane climbed and turned east entering terrain that rose in front and on both sides of the airplane. The track continued to climb for about 1 minute 5 seconds before reaching the accident site. Postaccident examination of the airplane revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. According to the pilot's operating handbook for the airplane, at its maximum gross weight, under standard conditions, with no flaps and full throttle, the airplane was capable of climbing at a maximum rate of 625 ft per minute, at 73 knots indicated airspeed, at 2,000 ft mean sea level (msl). The flight track data for the final 1 minute 5 seconds of the flight indicated that the airplane climbed about 584 ft, corresponding to a rate of climb slightly less than the published maximum rate of climb. During the climb, the left turn towards the east would have decreased the rate-of-climb performance, which likely accounts for the rate of climb being less than the published maximum. During the impact sequence, a tree penetrated up through the center of the cabin floor just behind the front seats and exited through the cabin roof. The airplane came to rest upright. The instructor was able to unbuckle his seatbelt but had to cut the student pilot's seatbelt to free him. After examining the passenger, the instructor realized that her seatbelt was not latched and that her injuries were fatal. The autopsy of the passengerdetermined her cause of death to be blunt force injuries of the head and neck. These injuries were likely due to impact with the tree that penetrated the cabin area.

Factual narrative

On February 12, 2017, about 1410 Pacific standard time, a Cessna 172S airplane, N2179L, impacted terrain while maneuvering near the Pamo Valley about 5 miles north of Ramona, California. The flight instructor and the student pilot sustained minor injuries, and the passenger was fatally injured. The airplane sustained substantial damage. The airplane was registered to American Aviation Academy, Inc, Gillespie, California, and operated by the company under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local instructional flight, which originated from Gillespie Field Airport (SEE), Gillespie, California about 1325. A witness saw the airplane flying northbound from his home located in the Pamo Valley, about 1 mile southwest of the accident site. The witness watched as the airplane turned and flew straight towards his location. The airplane passed over the witness about 100-150 ft above ground level (agl) when he made "eye contact" with the pilot. After the airplane passed by, the witness heard the "full acceleration of the engine" as it flew towards the mountain to the east of the witness's location. He watched as the airplane turned towards the northeast; he then lost sight of it over a ridge. The flight instructor reported that this was his third instructional flight of the day. The passenger was a student pilot who joined the flight when her own instructional flight was cancelled. During the preflight of the airplane, the passenger was added to the company's manifest, and she sat in the rear right seat. The student pilot and the flight instructor were seated in the forward left and right seats respectively. The flight instructor reported they performed the usual protocols before the engine start up until prior to takeoff. They departed a practice area about 8 miles north of Ramona and performed flight training maneuvers. After departing the practice area, they performed a simulated engine failure maneuver over Pamo Valley about 1.5 miles west of the accident site. According to the flight instructor, the maneuver was completed at least 700 ft agl, and the student pilot advanced the throttle to full power and turned left about 90° to an east heading, toward rising terrain. The flight instructor stated that the gauges all read normal, but the airplane could not outclimb the rising terrain ahead. He verified that all settings were normal and took over the controls from the student pilot. The flight instructor stated that he could not turn left or right due to the rising terrain on both sides and decided to stay centered over the narrow and wooded ravine that ascended the mountain. He stated that he had no choice but to crash the airplane. He further stated that before impacting terrain, he brought back the throttle halfway then advanced it to full power to cushion the impact with the trees. The airplane came to rest upright. The flight instructor wasable to unbuckle his seatbelt but had to cut the student pilot's seatbelt to free him. After examining the passenger, he realized that her seatbelt was not latched and that she was fatally injured. First responders arrived on scene about an hour after the accident. According to the student pilot, while flying south over Pamo Valley, the flight instructor told him to turn left toward the east. He looked up and said "mountain, mountain." The flight instructor then took control of the airplane saying, "I have control, I have the plane." The student stated that the airplane was running fine and that there were no power output problems. According to the student, the flight instructor said, "I will show you performance like Big Bear," added full power, leaned the mixture, flew straight for 5 seconds, and then said an expletive shortly before the airplane crashed into the mountain. A personal electronic device was recovered from the airplane and revealed the accident flight track data was obtained from the ForeFlight application on the device. The track data depicted the airplane departing SEE and performing maneuvers between 2,000 and 5,100 ft agl in a practice area about 5 miles west of the accident site. The airplane departed the practice area to the east and made multiple turns over Pamo Valley, descending to about 285 ft agl. The airplane then climbed and turned east entering an area of terrain that rose in front and on both sides of the airplane. The track continued to climb for about 1 minute 5 seconds, about 584 ft, before reaching the accident site. Refer to Figure 1. Figure 1-Aerial View of Accident Flight TrackPERSONNEL INFORMATION The flight instructor held commercial pilot and flight instructor certificates with airplane single- and multi-engine land and instrument ratings. He was issued an FAA second-class airman medical certificate on March 30, 2016, with no limitations. According to the operator, the flight instructor had accumulated 954 total hours of flight experience, of which 649 hours were as a flight instructor. He had accumulated 195 hours as an instructor in the accident make and model airplane and had flown 190 hours in the last 90 days. The student pilot had accumulated 71 total hours of flight experience , all in the accident airplane make and model. He was issued an FAA first-class airmen medical certificate on August 24, 2016. AIRCRAFT INFORMATION The four-seat, high-wing airplane, serial number 17259633, was manufactured in 2004. It was powered by a Continental Motors IO-360-L2A engine. According to the operator, the last 100-hour inspection was completed on February 1, 2017, at which time the engine had accumulated about 1,000 hours since major overhaul and the airframe had accumulated 8,564 hours of total time. The operator reported that the airplane was topped off with fuel before departing on the accident flight and calculated the airplane's weight at 2,363 pounds at the time of the accident. According to theairplane's Pilot's Operating Handbook (POH), when flying at the airplane's maximum certificated gross weight of 2,550 pounds, under standard conditions, with no flaps and full throttle, at 2,000 ft mean seal level (msl) and, 73 knots indicated airspeed, the airplane's maximum rate of climb is 625 ft per minute. METEOROLOGICAL INFORMATION At 1353, Ramona Airport (RNM), Ramona, California, elevation 1,395ft, located 5 miles south of the accident site, reported wind 300° at 10 knots, visibility 10 miles or greater, scattered clouds at 3,000 ft agl, temperature 21°C, dew point 8°C, and an altimeter setting of 29.99 inches of mercury. Based on the RNM wind, the climb to the east from Pamo Valley would have had an approximate 10 knot left-quartering tailwind. Local temperature, humidity, and elevation conditions at the time of the accident resulted in a density altitude of about 2,300 ft. WRECKAGE AND IMPACT INFORMATION The accident site, at an elevation of 1,869 ft, was located on the southeast side of Black Mountain, which has an elevation of 4,051 ft at the summit. The elevations of the surrounding peaks are near 4,000 ft. Examination of the accident site by a Federal Aviation Administration (FAA) inspector revealed that the airplane impacted a large tree in steep terrain. The tree penetrated up through the center of the main cabin floor just behind the front seats and out the roof. The main wreckage remained intact with the exception of the propeller assembly, which separated and was located near the main wreckage. The wreckage was relocated to a secure facility for further examination. The follow-up wreckage examination revealed no evidence of any preimpact mechanical malfunctions or failures. For further information see the Wreckage Examination Summary in the docket for this accident. ADDITIONAL INFORMATION The County of San Diego, Office of the Medical Examiner, San Diego, California, performed an autopsy of the passenger. The cause of death was blunt force injuries of the head and neck.

Aircraft

Registration
N2179L
Reported as
Cessna 172 (S)
Category
Airplane
Serial number
172S9633
Built
2004
Airframe hours
8,564
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · February 1, 2017 · 23 hours before
Departed
SEE · San Diego/El Cajon, CA
Destination
SEE · San Diego/El Cajon, CA
Equipment
Stall warning system

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
Flight instructor
Age
25
Injuries
Minor
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Right
Restraint
3-point
Flight hours
954 total · 363 in this make and model · 843 as pilot in command · 190 in the last 90 days · 60 in the last 30 days · 4 in the last 24 hours
Role
Student pilot
Age
27
Injuries
Minor
Certificate
Student
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
71 total · 71 in this make and model · 4 as pilot in command · 35 in the last 90 days · 24 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 46 °F
Altimeter
29.98 inHg
Observed at
KRNM, 8 nm away

Docket · 8

The files NTSB released with the investigation on December 18, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.5 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.

Other investigations on N2179L · 1

Matched to the same aircraft by N-number and date.