WPR20LA169

NTSB accident investigation · Cessna 175 · Redlands, CA · June 5, 2020

Accident · FatalClass 3 · LimitedFinal report
Date
June 5, 2020, 08:01 local (15:01 UTC)
Place
Redlands, CA
Injuries
3 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N9217BCessna 175
Defining event
Maneuvering: Loss of control in flight
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Textron Aviation, Federal Aviation Administration
FAA report
20200605008819A
Case key
101394

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 noncertificated pilot’s visual flight rules flight into instrument meteorological conditions and subsequent impact with terrain.

Findings · 6

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.

Experience/qualifications: qualification/certificationPersonnel issues › Experience/knowledge · PilotCessna 175: 1 caseAll aircraft: 280 casesProbable cause
Ceiling/visibility/precip: cloudsEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCessna 175: 1 caseAll aircraft: 108 cases
Ceiling/visibility/precip: low visibilityEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCessna 175: 1 caseAll aircraft: 175 cases
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 175: 3 casesAll aircraft: 1,310 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Effect on operationCessna 175: 3 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 noncertificated pilot was conducting a cross-country flight during daytime visual flight rules flight conditions. Recorded automatic dependent surveillance-broadcast (ADS-B) data showed that as the airplane was on a southerly heading, nearing the destination airport, it made a left 270° turn at an altitude of 5,125 ft msl. About 46 second later, the airplane completed the turn, and was established on a west-northwesterly heading, at an altitude of 5,275 ft msl. About 1 minute later, the airplane made a left turn to a southwesterly heading, at an altitude of 3,975 ft msl and continued to descend until ADS-B contact was lost 34 seconds later at an altitude of 2,775 ft, and about 436 ft northeast of the accident site. The accident site was in hilly terrain, about 3.47 miles southeast of the intended destination. There were no known witnesses to the accident sequence. A postaccident examination of the recovered wreckage revealed no evidence of any preexisting mechanical malfunction that would have precluded normal operation. Weather data for the area around the accident site depicted favorable conditions for overcast clouds and restricted visibility with haze and clouds from the surface with tops near 4,300 ft. In addition, marginal visual meteorological conditions to instrument meteorological conditions (IMC) prevailed during the period, with instrument flight rules (IFR) to low IFR conditions being reported at the two closest airports southwest of the accident site. Due to IMC, the pilot likely did not have visible reference to the horizon during the descent to the destination airport, which resulted in a collision with terrain. Whether effects from the pilot’s use of lamotrigine or some underlying medical condition contributed to the accident cannot be determined based on the limited available evidence. Some or all of the detected ethanol may have been from sources other than ingestion. It is unlikely that ethanol contributed to the accident.

Factual narrative

On June 5, 2020, about 0801 Pacific daylight time, a Cessna 175, N9217B, was substantially damaged when it was involved in an accident near Redlands, California. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Recorded automatic dependent surveillance-broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA) showed that the airplane departed Big Bear City Airport (L35), Big Bear City, California, about 0745 and proceeded southwesterly as it climbed to 9,300 ft mean sea level (msl). At 0751:36, the airplane began a descent followed by a left turn to a southeasterly heading. About 6 minutes, 12 seconds later, a right turn to a southerly heading was observed when the airplane was at an altitude of about 5,150 ft msl. The airplane then entered a left 270° turn, which it completed at an altitude of about 5,275 ft msl. About 1 minute later, a left turn to a southwesterly heading at 3,975 ft msl was observed. The airplane remained on a southwesterly heading and continued to descend until ADS-B contact was lost at 0800:58, at an altitude of 2,775 ft, about 436 ft northeast of the accident site. Figure 1: ADS-B data overlay on Google Earth image. There are no known witnesses to the accident sequence. San Bernardino County Sheriff Air Units located the wreckage about 1630. Examination of the accident site by a FAA inspector revealed that the airplane impacted hilly terrain on a southwesterly heading and came to rest at an elevation of 2,874 ft. The wreckage debris path was about 80 ft in length and contained all major structural components of the airplane. A postaccident examination of the recovered airframe and engine revealed no evidence of any preexisting mechanical malfunction that would have precluded normal operation. At the time of the accident, the pilot did not hold a valid pilot certificate. The pilot’s most recent FAA medical certificate was issued in 1994. The pilot’s logbooks were not located. A high-resolution rapid refresh numerical model data from the accident site area was plotted using the Universal RAwinsonde OBservation (RAOB) program software. The plotted data indicated nimbostratus type clouds from the lifted condensation level and level of free convection at 41 ft above ground level (agl), or 2,797 ft mean sea level (msl), to to 4,350 ft msl, with light rain and mist. The closest weather reporting station was at San Bernardino International Airport (SBD), San Bernardino, California. The next closest weather reporting location was March Air Reserve Base (RIV), Riverside, California, located about 14 miles southwest of the accident site at an elevation of 1,536 ft. At 0758, recorded weather data at RIV captured wind calm, visibility 3 miles, light drizzle and mist, ceiling overcast at 400 ft agl, temperature 16° C, dew point temperature 15° C, and an altimeter setting of 29.84 inches of mercury. The Terminal AerodromeForecast for the area, which was issued at 0427, indicated marginal visual flight rules conditions to prevail from 0500 through 1000, with winds variable at 3 knots, visibility better than 6 miles, and ceiling overcast at 1,400 ft agl. A search of the FAA automated flight service station contract provider Leidos indicated that they had no contact with the pilot of the accident airplane for any weather briefing on the day of the accident and no third-party vendors utilized their system for any requests for weather data or to file any flight plans. It is therefore unknown what information the pilot may have used to familiarize himself with forecast weather conditions before departure or en route. The Coroner’s Division of the Office of the Sheriff, San Bernadino, California, performed the pilot’s autopsy. According to the autopsy report, the cause of death was multiple blunt force injuries. Toxicology testing performed at the FAA Forensic Sciences Laboratory detected 11 mg/dl of ethanol in the muscle and unspecified amounts of Lamotrigine in the liver and muscle. Lamotrigine, sometimes marketed as Lamictal, is a prescription medication that can be used to treat seizure disorders, bipolar disorder, and migraine headache prevention. Lamotrigine typically carries a warning that it may cause dizziness, sleepiness, and other symptoms and signs of central nervous system depression, and users should not drive or operate other complex machinery until they have gained sufficient experience to gauge whether the drug adversely affects their mental and/or motor performance. In users with underlying heart disease, the drug may sometimes cause dangerous heartbeat disturbances. Lamotrigine use is generally disqualifying for FAA medical certification. Ethanol is the intoxicating alcohol in beer, wine, and liquor. It can impair judgment, psychomotor performance, cognition, and vigilance. Ethanol can also be produced by microbes in a person’s body after death.

Aircraft

Registration
N9217B
Reported as
Cessna 175
Category
Airplane
Serial number
55017
Built
1958
Engine
Continental GO-300-A, 175 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 10, 2020
Departed
L35 · Big Bear City, CA
Destination
REI · Redlands, CA
Airport
REI · Redlands Muni
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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
Fatal
Seat
Left

Weather

Conditions
Instrument (IMC) · Day
Wind
230° at 6 knots
Visibility
4 statute miles
Lowest ceiling
1,100 ft overcast
Temperature
63 °F, dew point 57 °F
Altimeter
29.84 inHg
Observed at
KSBD, 8 nm away

Docket · 12

The files NTSB released with the investigation on June 1, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.3 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.