N4972JPiper PA-28R-180 · 1968

On October 17, 2015, at 1552 Pacific daylight time, a Piper PA28R-180, N4972J, impacted mountainous terrain near Morongo Valley, California. The private pilot and passenger sustained fatal injuries; the airplane was destroyed. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The cross-country personal flight departed Palm Springs International Airport (PSP), Palm Springs, California, at 1513, with a planned destination of Santa Barbara Municipal Airport, Santa Barbara, California. Visual meteorological conditions prevailed at the departure airport, and no flight plan had been filed.

Earlier on the day of the accident, the pilot and passenger flew the airplane from their home base of Santa Barbara to Palm Springs in order to visit a museum. According to friends, the original planned departure time for the flight to Palm Springs was 0900; however, due to weather conditions, they departed just before noon and arrived about 1330. Radar data revealed that the route of the outbound flight was via Santa Paula, Valencia, and Acton, then across the east-west mountain range of the Angeles National Forest, across the Los Angeles Basin, and through the Banning Pass to Palm Springs.

For the return trip, the pilot requested visual flight rules (VFR) flight following from the clearance delivery controller at Palm Springs and reported that his route of flight back to Santa Barbara would be along a northern route via Palmdale. He initially requested an altitude of 7,500 ft mean sea level (msl) and then immediately corrected himself, requesting 5,500 ft msl. The controller responded, telling the pilot to squawk VFR and to expect a northbound departure with an unrestricted climb.

Radar and audio data provided by the Federal Aviation Administration (FAA) captured the entire flight sequence, beginning with the departure from runway 31R at PSP.

Following takeoff, the airplane began a climb to the north, and, about 6 minutes later, the pilot initiated radio contact with Southern California Terminal Radar Approach Control, stating that he was 6 miles northeast of Palm Springs. He requested VFR flight following to Santa Barbara and, during the exchange, stated, "It looks like we might have to get up to 9,000 ft with the clouds." The air traffic controller responded, providing the pilot with a squawk code, altimeter setting, and instructions to maintain VFR at an altitude at the pilot's discretion. The pilot confirmed the instructions, and, a short time later, the controller responded that he had obtained radar contact with the airplane. The airplane continued to climb, and, about 4 minutes later, after it reached an altitude of about 5,200 ft msl, the controller communicated, "just to be clear you do have the terrain in sight to your left, right?" The pilot responded in the affirmative and added that he was going to perform a 360° turn to gain altitude. The controller responded, "Ok, just wanted to make sure we are on the same page." The controller then transmitted, "Are you guessing you are going to wind up north of Big Bear or do you think you're going to be able to get up through the Banning Pass, is that what your intents are?" The pilot responded, "I'm going to try to go through San Bernardino and out to the desert then out by General Fox." The airplane then began a left 270° turn, rolling out on a northeast heading by which time it had reached an altitude of 7,000 ft msl.

Over the next 14 minutes, the airplane conducted a series of 6 climbing 360° turns, eventually rolling out on a west heading, at an altitude of 10,800 ft msl. By that time, the airplane was about 14 miles east of, and heading directly toward, the 11,500 ft peak of San Gorgonio Mountain. The pilot reported that he was now travelling west, and the controller transmitted, "So you're going to go north side of the peak then, there, correct?" The pilot reported, "Um, say again," and the controller responded, "N72J are you going to go north side of the peak there or south side there?" The pilot responded, "Umm, I show that we're heading right to San Bernardino." The controller retorted, "Ok, I show an eleven seven peak between you and San Bernardino." The pilot responded, "Um, I'm at um, one zero thousand six hundred." The controller responded, "Roger," and, after a brief pause, the pilot continued, "and I'm still climbing."

The airplane maintained the west heading and continued to climb at ground speeds varying between 60 and 70 knots, reaching 11,100 ft msl about 3 minutes later. It then conducted another 360° left turn but had not gained significant altitude once it rolled out about 2 minutes later. The westbound track continued at similar speeds toward the peak for the next 4 minutes, as the airplane climbed 200 ft to 11,300 ft. The next radar target appeared 15 seconds later, indicating the airplane had rapidly reversed course and descended to 9,700 ft msl. The airplane then began a spiraling descent, and the controller transmitted, "Piper 72J you are descending once again in an area of higher terrain just west of you, I have a peak that I show to be at eleven thousand seven hundred feet, just west of your position...72J you cut me out, verify you still have the terrain in sight." The pilot then transmitted, "Negative! Negative!," and in the background the passenger could be heard expressing significant alarm. The controller continued issuing instructions, "N72J remain calm, if you are able proceed eastbound, remain VFR proceed eastbound, hold your altitude if you are able I see you are descending - repeat, eastbound, VFR, hold your altitude if you are able you are in an area of higher terrain." The pilot did not respond, and, over the next 45 seconds, the airplane continued to perform two more spiraling turns, with radiuses of about 1,200 and 700 ft, respectively, to the last recorded radar position, at an altitude of 7,500 ft.

Over the next few minutes, the controller tried reestablishing communication with the pilot but did not receive a response. A Riverside County Sheriff's Department helicopter was flying in the vicinity, so the controller provided the helicopter's crew with vectors to the airplane's last radar location and asked if they could establish radio communication. They attempted to do so, but no response was received. They reported that the search area was mountainous and obscured by clouds, and, after multiple approach attempts, they located burning wreckage along a ridge, about 100 ft below the base of the clouds. The following three figures show the airplane's radar track.

Figure 1 - Route of Flight

Figure 2 - Excerpts of Pilot and Air Traffic Control Communications

Figure 3 - Radar Data Covering Final Two Minutes of Flight

The 71-year-old pilot held a third-class medical certificate limited by a requirement that he must wear corrective lenses for near and distant vision. He was issued a private pilot certificate on September 9, 2014, at which time he reported a total flight experience of 85 hours of which 15 hours were as pilot in command. All the reported flight experience was in a Cessna 172. The pilot did not hold an instrument rating.

The pilot was the general manager for a repair station at Santa Barbara Airport. The airplane was maintained at the repair station, and the passenger worked at the repair station.

No personal flight records were recovered; however, the repair station's chief inspector stated that the pilot had flown regularly in the airplane, taking multiple trips to Oregon and the Mojave area during the period between receiving his private certificate and the accident. He stated that the reason for the flight was to drop off memorabilia at the flight museum in Palm Springs, and he was not aware of any pressing reason for the pilot and passenger to return promptly that night.

The single-engine, retractable-landing-gear airplane was manufactured in 1968 and powered by a fuel-injected Lycoming IO-360-B1E engine. An annual inspection was performed on May 27, 2015. At that time, the airframe had accrued 3,704.90 total flight hours, and the engine had accrued 1,308.0 hours since overhaul.

An avionics upgrade was performed following the May 2015 annual inspection and was completed on August 17, 2015. The upgrade included the installation of a Garmin GTN 650 touchscreen GPS/Nav/Comm and a Garmin GDL 88 ADS-B transceiver. In combination, the pairing provided the pilot with terrain mapping, graphical NEXRAD radar, and weather data on the GTN 650 screen. The chief inspector stated that the pilot was still gaining familiarity with the system and was not fully proficient with its use and features.

The chief inspector also reported that the pilot kept an iPad tablet computer onboard for weather and navigation and that the airplane was equipped with a portable oxygen system. Due to fire damage, neither of these systems could be positively identified in the debris; therefore, their operational status could not be determined. Photographs posted by the passenger on a social media website after the flight to Palm Springs indicated that the pilot had mounted the iPad on the control yoke.

The pilot did not call Lockheed Martin Flight Service for a telephone weather briefing either the day before or the day of the accident, and there was no record of him downloading an official weather briefing from any DUAT vendor.

Satellite Data

Geostationary Operational Environmental Satellite number 15 (GOES-15) imagery taken at 1545 and 1600 indicated an area of low- to mid-level clouds over the accident site, with cloud tops near 11,000 ft (figure 4). During that period, an area of clouds was observed developing near Big Bear, California, 12 miles northwest of the accident site, along with rapidly developing enhanced clouds (tops near 33,000 ft) between the accident site and Palm Springs. Multiple layers of clouds extended from west of Palm Springs through to the accident site and obscured Banning Pass to the south. The Riverside County Sheriff's Department helicopter crew reported cloud bases of about 1,500 ft above ground level (agl) in Banning Pass.

Figure 4 - GOES-15 Visible Image at 1600

Base Reflectivity

An image from Edwards Air Force Base WSR-88D radar (NEXRAD) at 1552 revealed several developing echoes north and south of the accident location. Some very light intensity echoes were identified immediately west of the accident location, consistent with cloud buildups immediately ahead of the airplane's westbound track and over the higher terrain.

Upper Air Data

The NOAA Air Resource Laboratory North American Mesoscale numerical model over the accident site location depicted a conditional unstable atmosphere with an expected cloud base at 2,196 feet agl, cloud tops near 11,000 ft msl, and potential convective cloud tops near 40,000 ft. The freezing level was identified at 14,776 ft. The wind profile indicated southerly winds veering to the west with height; the average wind from 0 ft to 18,000 ft was from 250° at 9 knots. No significant turbulence or mountain wave activity was noted in the model sounding through 18,000 ft.

Area Forecast

An area forecast issued at 1245 and valid to 0100 the following morning indicated cloud tops in the Los Angeles Basin area varying between 3,000 and 4,000 ft, with an outlook for marginal VFR.

Surface Observations

The closest weather reporting facility to the accident location was at Big Bear City Airport, about 11 miles north-northwest of the accident site at an elevation of 6,752 ft. At 1535, an automated report indicated wind from 080° at 3 knots, visibility 10 miles, ceiling broken at 2,100 ft, broken at 2,600 ft, and overcast at 3,500 ft, temperature 13°C, dew point 9°C, altimeter 30.15 inches of mercury. At 1552, similar conditions existed with the addition of light rain.

At 1553, PSP reported wind from 140° at 4 knots, visibility unrestricted at 10 miles, scattered clouds at 7,000 ft, temperature 32°C, dew point temperature 15°C, and altimeter 29.82 inches of mercury.

At 1447, San Bernardino International Airport, about 26 miles west of the accident site, at an elevation of 1,159 ft, reported wind from 240° at 10 knots, visibility 7 miles, scattered clouds at 6,000 ft, temperature 29°C, dew point 14°C, altimeter 29.87 inches of mercury.

At 1556, Yucca Valley Airport, about 17 miles east of the accident site, reported wind from 110° at 8 knots, visibility 10 miles, with scattered clouds at 8,000, 15,000, and 20,000 ft.

Astronomical Data

In Palm Springs at the time of the accident, the sun was 26° above the horizon at an azimuth of 236°. Sunset was at 1810, with the end of civil twilight at 1835.

The single-engine, retractable-landing-gear airplane was manufactured in 1968 and powered by a fuel-injected Lycoming IO-360-B1E engine. An annual inspection was performed on May 27, 2015. At that time, the airframe had accrued 3,704.90 total flight hours, and the engine had accrued 1,308.0 hours since overhaul.

An avionics upgrade was performed following the May 2015 annual inspection and was completed on August 17, 2015. The upgrade included the installation of a Garmin GTN 650 touchscreen GPS/Nav/Comm and a Garmin GDL 88 ADS-B transceiver. In combination, the pairing provided the pilot with terrain mapping, graphical NEXRAD radar, and weather data on the GTN 650 screen. The chief inspector stated that the pilot was still gaining familiarity with the system and was not fully proficient with its use and features.

The chief inspector also reported that the pilot kept an iPad tablet computer onboard for weather and navigation and that the airplane was equipped with a portable oxygen system. Due to fire damage, neither of these systems could be positively identified in the debris; therefore, their operational status could not be determined. Photographs posted by the passenger on a social media website after the flight to Palm Springs indicated that the pilot had mounted the iPad on the control yoke.

The wreckage was located at an elevation of 7,222 ft msl on the eastern flank of the San Bernardino Mountain range, 24 miles north-northwest of PSP, 6 miles east of the San Gorgonio Mountain peak, and about 200 ft northeast of the last recorded radar target.

The airplane came to rest upright on a heading of 330° magnetic, on the 25° uphill slope of a boulder-strewn ridge (Photo 1). The entire cabin forward of the baggage door was consumed by fire. Both wings sustained crush damage through to their main spars, and the empennage had folded up over the tailcone. Fragments of the cabin structure and engine cowling had been propelled forward, creating a debris field about 60 ft long.

Figure 5 - Wreckage Viewed to the North

Regarding supplemental oxygen requirements, 14 CFR 91.211 states:

"No person may operate a civil aircraft of U.S. registry -

(1) At cabin pressure altitudes above 12,500 feet (MSL) up to and including 14,000 feet (MSL) unless the required minimum flight crew is provided with and uses supplemental oxygen for that part of the flight at those altitudes that is of more than 30 minutes duration;

(2) At cabin pressure altitudes above 14,000 feet (MSL) unless the required minimum flight crew is provided with and uses supplemental oxygen during the entire flight time at those altitudes; and

(3) At cabin pressure altitudes above 15,000 feet (MSL) unless each occupant of the aircraft is provided with supplemental oxygen."

The flight from Santa Barbara to Palm Springs lasted about 1 hour 40 minutes and was flown primarily at an average altitude of about 7,500 ft, except for a 20-minute period in the middle of the flight when the altitude was between 10,000 and 11,700 ft.

FAA Medical Records

At the time of the pilot's most recent FAA medical examination, he was 70 inches tall, weighed 157 pounds, and reported hypertension treated with atenolol and amlodipine (prescription blood pressure medications often marketed with the names Tenormin and Norvasc, respectively). The physical examination was unremarkable.

Autopsy and Toxicology

An autopsy was performed by the San Bernardino County Sheriff's Department, Coroner Division; the cause of death was reported as multiple blunt force injuries. Thermal damage limited the scope of the examination, with no significant natural disease identified from the available remains, and no tissues beyond lung and liver available for toxicology testing.

Toxicology testing performed by the Office of the Medical Examiner, County of San Diego, identified an opiate and confirmed the presence of quetiapine and its metabolites in liver tissue. Furthermore, testing performed by the FAA's Bioaeronautical Research Sciences Laboratory identified amlodipine, atenolol, losartan, atorvastatin, hydrocodone (0.116 ug/g) and its metabolites hydromorphone (0.045 ug/g) and dihydrocodeine as well as quetiapine (0.725 ug/g) in liver tissue. In addition, atenolol, hydrocodone (0.056 ug/g), and quetiapine were identified in lung tissue.

Losartan is a prescription blood pressure medication often marketed with the name Cozaar. Atorvastatin is used to treat high cholesterol and is commonly marketed with the name Lipitor. Hydrocodone is a prescription opioid identified as a Schedule II controlled substance by the Drug Enforcement Administration. It is most commonly sold in combination with acetaminophen, often with the names Vicodin and Lortab. It carries several warnings, including, "Hydrocodone, like all narcotics, may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery" and "Alcohol and other CNS (central nervous system) depressants may produce an additive CNS depression, when taken with this combination product, and should be avoided."

Quetiapine is an antipsychotic indicated for the treatment of schizophrenia and bipolar syndrome. It carries several warnings including one for an increased risk of seizures and a specific warning about somnolence, which states, "quetiapine has the potential to impair judgment, thinking, or motor skills, patients should be cautioned about performing activities requiring mental alertness, such as operating a motor vehicle (including automobiles) or operating hazardous machinery until they are reasonably certain that quetiapine therapy does not affect them adversely. Somnolence may lead to falls."

Personal Medical Records

The pilot was receiving treatment from medical facilities of the US Department of Veterans Affairs (VA). According to records obtained from the VA covering the period from 1999 to the date of the accident, the pilot had a history of chronic neck pain requiring the use of opioids, a vitamin D deficiency, hypertension, an abnormal stress thallium test suggesting coronary artery disease, deafness requiring hearing aids, prediabetes, chronic obstructive pulmonary disease, Barrett's esophagus, and low testosterone.

His medications at the time of the accident included a hydrocodone/acetaminophen combination (7.5mg/325mg every 6 hours), losartan, atenolol, amlodipine, aspirin, atorvastatin, finasteride, gabapentin, and topical testosterone.

Gabapentin is a prescription medication initially developed as an antiseizure drug, which is also used to treat nerve pain. It is commonly marketed with the name Neurontin. Gabapentin carries a warning about increased risk of suicidal thoughts or actions with its use and risk of somnolence and dizziness. As a result, it carries a recommendation that patients are to be notified that it "may cause dizziness, somnolence, and other symptoms and signs of CNS depression. Accordingly, they should be advised neither to drive a car nor to operate other complex machinery until they have gained sufficient experience on gabapentin to gauge whether or not it affects their mental and/or motor performance adversely." Gabapentin is excreted unchanged in urine and is not stored in organ tissues. As a result, its absence on the toxicology testing of liver and lung in this case does not indicate whether or not the pilot was using it.

Because of existing risk factors, the pilot underwent cardiac testing in 2001. The results revealed abnormal exercise and thallium stress test results, indicating likely early single vessel coronary artery disease. As the pilot was asymptomatic at the time, the decision was to improve the control of his blood pressure and cholesterol levels. Follow-up stress testing was unchanged, and, as the pilot remained asymptomatic, no further intervention was performed.

The pilot periodically reported neck pain, which was first treated with opioids in 2007. It recurred in 2010, and, following a telephone consultation with the physician, he was prescribed hydrocodone/acetaminophen 5/325mg, one tablet 4 times a day as needed. He continued on this regimen until the dose was increased to the 7.5/325mg tablets in July 2012.

In November 2014, the pilot's prescription for hydrocodone for chronic pain was changed because the Drug Enforcement Administration changed it from a Schedule III to a Schedule II controlled substance, indicating an increased risk for abuse. Over the next few months, he tried using codeine and tramadol instead but was unable to get sufficient pain relief. He returned to hydrocodone/acetaminophen 7.5/325 mg four times a day on February 19, 2015, and maintained that dosing regimen until the accident. Records indicated he routinely refilled the prescription monthly. In a visit with his primary care physician dated August 25, 2015, the physician noted the pilot had a normal neurologic exam including motor and nerve function as well as normal gait and that his mood was stable and calm. The physician documented his impression that the pilot's judgment and insight were intact.

According to the pilot's psychology and psychiatry report, he suffered from post-traumatic stress disorder and major depressive disorder, for which he was treated with quetiapine and psychotherapy from 2003 forward. He attended regular psychotherapy sessions, and, several months before the accident, he had been feeling "pretty bad" and requested biweekly rather than monthly therapy sessions to obtain additional support for the stressors in his life. During a session on September 14, 2015, the therapist noted the pilot reported he was "doing OK" but seemed edgy. On September 22, 2015, about 3 weeks before the accident, the pilot met with his therapist. The records documented that, at that time, he was doing "pretty good." Although the plan was to return to monthly sessions beginning in October, the therapist noted that he "seemed to be isolating" himself and documented her intent to review the issue with him at the next visit.

Engine and Airframe Examinations

The airframe sustained extensive thermal damage that consumed the entire cabin through to the tail cone. Remnants of all the airplane's primary structures were accounted for at the accident site.

The firewall was crushed and detached from the airframe, and the steel remnants of the seat frames, flight control columns, cables, and bellcranks exhibited fragmentation and bending damage with fire consuming all their ancillary components. The landing gear was in the retracted position, and the rudder and stabilator control cables were continuous from the control surfaces through to the cabin controls. The aileron control cables were continuous from the wing-mounted bellcranks through to the chain fittings at the control column. Both wing bellcranks were still connected via the aileron balance cable.

The engine remained partially attached to its mount, which had detached from the firewall. The engine was thermally discolored and covered in soot, and the forward crankcase and forward fins of the No. 1 cylinder were crushed and cracked. The accessory case was consumed by fire along with both magnetos, the vacuum pump, the oil sump, and the induction tubes. The drive train area was exposed, with only the crankshaft and camshaft drive gears remaining.

The top spark plugs were removed and examined. The spark plugs were of the massive electrode type, and the plugs from cylinder Nos. 1, 2 and 4 were dark in color with the plug from cylinder No. 3 exhibiting a lighter grey coloration. The varying coloration of the No. 3 plug was attributed to its being exposed to the thermal effects of the post impact ground fire. According to the Champion Aviation Check-A-Plug AV-27 Chart, the electrodes exhibited minimal wear signatures.

The cylinder combustion chambers were examined using a borescope. The combustion chambers appeared mechanically undamaged, and there was no evidence of foreign object ingestion or detonation. The valves were intact and undamaged, and there was no evidence of valve to piston face contact.

Holes were drilled in the upper crankcase to facilitate examination of the camshaft lobes using a lighted borescope. All lobes appeared undamaged. The crankshaft and attached connecting rods remained undamaged and free of heat distress.

The propeller hub had separated from the crankshaft. The separation features on the crankshaft were conical in appearance with a 45° shear lip around the entire radius of the break. Both propeller blades had separated about 10 inches from their tips. Both inboard blade sections exhibited similar chordwise scratches, tip twist, and leading edge nicks.

Performance

The airplane manufacturer's operating handbook defined a best rate of climb speed at maximum gross weight of 100 mph and a best angle of climb speed of 90 mph. The handbook stated that at lower gross weights, "speeds are reduced somewhat."

For enroute climb, the handbook recommended a speed of 110 mph to produce a better forward speed and increase the visibility over the nose. According to the rate of climb versus density altitude chart, at maximum gross weight with landing gear and flaps retracted, the rate of climb at a density altitude of 13,000 ft would have been about 200 ft per minute. The airplane's service ceiling was 15,000 ft.