WPR22FA160

NTSB accident investigation · Cessna 337 · Sylmar, CA · April 20, 2022

Accident · FatalClass 3 · FieldFinal report
Date
April 20, 2022, 12:26 local (19:26 UTC)
Place
Sylmar, CA · embankment near industrial area
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N143JBCessna 337
Defining event
Enroute-climb to cruise: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Textron Aviation
FAA report
20220420005669A
Case key
104976

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 loss of airplane control while troubleshooting a landing gear issue, which resulted in an aerodynamic stall/spin at an altitude too low to recover. Contributing to the accident was the pilot’s impairment from alcohol consumption.

Findings · 5

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.

Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 337: 1 caseAll aircraft: 1,681 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 337: 1 caseAll aircraft: 990 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 337: 1 caseAll aircraft: 9,295 casesProbable cause
Attention/monitoring: attentionPersonnel issues › Psychological · PilotCessna 337: 1 caseAll aircraft: 226 casesProbable cause
Impairment/incapacitation: alcoholPersonnel issues › Physical · PilotCessna 337: 1 caseAll aircraft: 87 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

Shortly after takeoff, the pilot reported to the tower controller that he was not able to retract the airplane’s landing gear and requested to circle the airport at 2,500 ft. The airplane climbed to and remained at about 2,000 ft for about 2 minutes before entering a descent that continued until ground contact. Witnesses saw the airplane descending in a steep, nose-down attitude, and a surveillance video showed the airplane rotating in a nose-down attitude as it collided with terrain. Examination of the airframe and engines revealed no preaccident mechanical malfunctions or failures that would have precluded normal operation. Toxicology testing of the pilot revealed 65 (mg/dL, mg/hg) ethanol in blood, 133 (mg/dL, mg/hg) ethanol in urine, and 10 (mg/dL, mg/hg) glucose in vitreous fluid. The ethanol production was not attributed to putrefaction. Based on the levels found and their distribution, it is likely that the pilot’s blood ethanol concentrations were around 0.12 gm/dL. It is likely that, while trying to troubleshoot the landing gear issue, the pilot allowed the airplane to slow and exceed its critical angle of attack. The airplane subsequently entered a spin from which the pilot was not able to recover. Given the levels of ethanol found in toxicology testing, the pilot would have likely experienced degradation of judgment, reasoning, and coordination that would have affected his ability to safely manage the airplane, and it is likely that his impairment due to alcohol consumption contributed to his loss of control.

Factual narrative

HISTORY OF FLIGHT On April 20, 2022, at 1226 Pacific daylight time, a Cessna 337, N143JB, was substantially damaged when it was involved in an accident near Sylmar, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Review of the recorded communication between the air traffic controller and accident pilot revealed that, shortly after takeoff, the pilot reported to the tower controller that his landing gear did not retract all the way and he would like to stay over the airport. The controller asked the pilot his intentions, to which the pilot replied that he was going to climb to 2,500 ft and circle the airport. The controller instructed the pilot to climb to 2,500 ft and make a left pattern; the pilot acknowledged. There were no further communications received from the pilot despite repeated attempt by the tower controller. Automatic Dependent Surveillance - Broadcast (ADS-B) data showed that the airplane departed runway 12 at Whiteman Airport (WHP), Los Angeles, California. The ADS-B target showed a left turn to a northwesterly heading and a climb to about 2,000 ft mean sea level (msl). The data showed that the airplane continued at an altitude of about 2,000 ft for about 1 minute, 41 seconds until a left 90° turn was observed. At 1226:12, the airplane entered a descent from 1,900 ft. The last ADS-B target was recorded at 1226:19, about 75 ft north-northeast of the accident site at an altitude of 1,500 ft msl. One witness stated that he saw the airplane descending “nose first at a very steep angle.” Another stated that he saw the airplane flying at slow speed before it performed a 180° turn, leveled momentarily, then “nosedived” to the ground. Security video near the accident site captured the impact. Just before the airplane impacted the ground, it could be seen rotating in a nose-down attitude. WRECKAGE AND IMPACT INFORMATION The airplane came to rest on an embankment wedged between two trees, upright and in a nose-low attitude about 80 ft from the roadway. The airplane’s left wing impacted a fence before the airplane struck the ground. The left wing remained near the top of the embankment. The rear engine/propeller assembly separated at the engine crankshaft propeller flange and came to rest just forward of the right wing. The forward propeller assembly also separated at the engine crankshaft propeller flange and was found underneath the engine. Flight control continuity was established from the cockpit area to the respective flight control surfaces. The smell of fuel was present at the accident site, and the left wing outboard and inboard fuel tanks had been breached. The right wing inboard fuel tank had not been breached and fuel was observed in the tank; the outboard right fuel tank had been breached. A postaccident examination of the airframe and engines revealed no evidence of mechanical malfunctions or failures that would have precluded normaloperation. Examination of the landing gear revealed that the nose and left main landing gear were in the extended position, and the right main landing gear had separated during the accident sequence; the main landing gear door actuators were determined to be in the extended position. The landing gear handle was in the intermediate position. MEDICAL AND PATHOLOGICAL An autopsy of the pilot was performed by the County of Los Angeles, Department of Medical Examiner-Coroner, Los Angeles, California. The autopsy report was reviewed by the NTSB medical officer. According to the autopsy report, the cause of death was multiple blunt force injuries, and the manner of death was accident. Toxicology testing performed by the FAA Forensic Sciences Laboratory found 65 (mg/dL, mg/hg) ethanol in the pilot’s blood, 133 (mg/dL, mg/hg) ethanol in the pilot’s urine, and 10 (mg/dL) glucose in the pilot’s vitreous. Toxicology testing further revealed no drugs of abuse, and the ethanol detected was not a result of postmortem production. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. Ethanol acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance.

Aircraft

Registration
N143JB
Reported as
Cessna 337
Category
Airplane
Serial number
337-0102
Built
1965
Engines
Cont Motor IO-360 SER, 300 horsepower, reciprocatingCont Motor IO-360 SER, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
WHP · Los Angeles, CA
Airport
WHP · Whiteman Airport
Equipment
ADS-B

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
62
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
2,550 total · 50 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
5,500 ft broken
Temperature
64 °F, dew point 45 °F
Altimeter
30.03 inHg
Observed at
KWHP, 3 nm away
METAR
METAR KWHP 201855Z 00000KT 10SM BKN055 18/07 A3003=

Docket · 17

The files NTSB released with the investigation on May 16, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 46.3 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.