NTSB Factual Report

HISTORY OF FLIGHT

On February 7, 1994, at 1936 Pacific standard time, a Cessna 310R, N1976Y, operated by Pacific Air Charter, Inc., as flight 1920, experienced an in-flight loss of control and descended into the Pacific Ocean approximately 2 miles north of La Jolla, California. Instrument meteorological conditions prevailed, and an instrument flight plan was filed for the air taxi flight to Burbank, California. The airplane was destroyed, and the commercial pilot was fatally injured. The nonstop all cargo flight originated from Montgomery Field, San Diego, California, on February 7, 1994, at 1931.

Recorded radar data from San Diego Terminal Radar Approach Control (TRACON) and the Los Angeles Air Route Traffic Control Center (ARTCC) indicated that after the airplane took off, it climbed on a westerly course until passing the shoreline at approximately 2,900 feet mean sea level (transponder altitude). The airplane continued climbing while proceeding on a northwesterly course which initially nearly paralleled federal airway V23.

Air traffic control authorized the pilot to climb to 6,000 feet. By 1936:11, the Mode C altitude report had reached 4,400 feet, and the aircraft had turned onto a westerly course away from V23. The ground speed was recorded at 148 knots. The radar beacon target commenced a descent while turning southward.

The last radar hit for which the Mode C altitude was recorded was at 1936:25 as the target descended through 600 feet at a ground speed of 39 knots. According to the Federal Aviation Administration (FAA) quality assurance staff at its Western-Pacific Regional Headquarters, at this time the airplane's position was approximately 32 degrees, 53 minutes, 16.5 seconds north latitude, by 117 degrees, 16 minutes, 57.7 seconds west longitude. No distress calls were recorded.

PERSONNEL INFORMATION

On August 19, 1993, the pilot completed an air taxi competency/proficiency check ride in the accident airplane. The pilot had been approved to fly in instrument flight conditions as pilot-in-command during cargo flights.

The operator estimated that the pilot's total flight time was in excess of 2,500 hours. The pilot had flown more than 90 hours in actual instrument weather conditions. Since the pilot's initial air taxi check ride in August of 1993, she had flown for the operator a total of 290 hours of which 90 hours were flown while serving as pilot-in-command since November 22, 1993. All of the pilot-in-command time was obtained flying the Cessna 310R. According to the FAA coordinator, the operator's air taxi files were reviewed and no training, experience, or piloting skill deficiencies were noted. No deficiencies were noted regarding the pilot's rest period and currency.

The pilot's family reported that the pilot had received her typical amount of sleep during the day which preceded the accident flight. The family further reported that the pilot desired to increase her flight experience by flying charter flights, and she aspired to work for the airlines.

AIRPLANE, LOADING, AND WEIGHT & BALANCE INFORMATION

The operator reported that the accident airplane was neither equipped nor required to be equipped with weather radar. A review of the maintenance records and pilot "squawks" did not reveal any outstanding safety-related maintenance or equipment discrepancies. The pilot who had flown the airplane just prior to the accident flight reported that during his instrument flight all of the airplane's instruments and navigation aids had worked properly, and the airplane had performed normally.

According to the FAA coordinator, a review of the airplane's maintenance records did not reveal evidence of deficiencies. The airplane was being maintained in accordance with annual and 100-hour inspection requirements.

A bank courier who delivered cargo to the accident airplane was interviewed by the National Transportation Safety Board. The courier reported that he had arrived at the airport at 1911. He stated that he had placed the cargo on the airplane's floor and then the pilot positioned the cargo where she wanted it. According to the courier, the pilot had completed loading the airplane at 1923 and then signed the courier's transfer log (load receipt) sheet.

The airplane was parked next to the operator's office building. The pilot did not leave a copy of the computed weight and balance paperwork at the office.

Based upon information which the operator gathered postcrash and at the request of the Safety Board, the operator calculated the airplane's weight and balance for the accident flight using information supplied from the couriers. The operator reported that the airplane had been loaded within applicable limits. The Safety Board subsequently received corrected cargo weight information from the primary banking institution which had contracted for the flight. Using the revised data (of 19 pounds less weight), the Safety Board recomputed the airplane's weight and balance by repositioning the load to reflect a center of gravity (CG) shift in a forward direction toward the nearest balance limit line in the airplane's operating envelope. The revised loading computation did not yield a CG change which would produce any out of balance condition.

METEOROLOGICAL INFORMATION

The two aviation weather observation stations closest to the airplane's last known position were located at NAS Miramar (NKX) and at the pilot's departure airport, Montgomery Field (MYF). These airports were located approximately 7 1/2 and 8 1/2 miles east (082 and 108 degrees, respectively) of the last known position.

At 1955 NKX, elevation 477 feet mean sea level, reported, in pertinent part, the following weather: clouds--600 feet scattered, measured ceiling 1,100 feet broken, 2,500 feet overcast; visibility--7 miles; and altimeter 29.68 inches of Hg. At 1947 MYF, elevation 423 feet mean sea level, reported, in pertinent part, the following weather: clouds--estimated ceiling 500 feet overcast; visibility--7 miles; moderate rain showers, and altimeter 29.71 inches of Hg.

The pilot had received two telephone briefings from the San Diego Automated Flight Service Station around 1550 and 1845. The transcripts of the briefings showed that the briefer summarized the weather and provided the pilot with advisories, observations, and forecasts. In part, the pilot was informed that a frontal system was moving over the San Diego area and an in-flight weather advisory (called an AIRMET) was in effect. The air mass was described as "very moist and unstable." Precipitation and occasional moderate turbulence below 18,000 feet with isolated severe turbulence was forecast.

During the accident flight, the pilot was informed of weather conditions experienced by another light airplane in the general area. While climbing en route, the accident pilot was behind an airplane which was identified as AMF 101. Both airplanes were using the same radio frequency. At 1934:08, the pilot of AMF 101 asked the radar controller, "are you painting anything up about fourteen south of ah oceanside." The controller replied, " . . . I got something right ahead of you . . . from uh looks like ah all the way to your seven o'clock position all the way around to your one o'clock position . . . ," and, thereafter, the pilot reported experiencing moderate chop.

At 1935:12, the controller informed the accident airplane pilot that "ahead of you moderate turbulence" was reported by a Cherokee Lance, and there was heavy rain. At 1935:19, the accident pilot replied with her flight identification number. There were no further transmissions from the pilot.

WRECKAGE AND IMPACT INFORMATION

Fragments from the airplane's fuselage, the cockpit seats, portions of engine cowling, and two vertical stabilizer-mounted VHF navigation antennas were found over a 2 1/2-mile-long shoreline debris field between Del Mar and Torrey Pines. Under the direction of the Safety Board, a search and recovery team headed by Champion Air Salvage responded to the airplane's last known position and nearby observed evidence of an oil slick and fuel on the surface of the water. During the following underwater search and by early March, an estimated 200 pieces of wreckage were located about 2 miles west of Torrey Pines between 900 and 1200 feet below sea level.

The main wreckage was found approximately 1,000 feet below sea level at 32 degrees, 53 minutes, 08.1 seconds north latitude, by 117 degrees, 17 minutes, 06.8 seconds west longitude. This location was about 0.2 miles from the airplane's last known position.

No evidence of fire was observed on any of the skin fragments, insulation, cargo, or debris recovered from the beach, or observed during review of the underwater video tape.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot's family reported that the pilot was in good health, was not taking any medication, and was rested. The operator reported that when he observed the pilot within minutes of her takeoff, she appeared alert and in good spirits.

The couriers who delivered cargo to the airplane reported that the pilot appeared and acted as she typically did. The couriers further reported that they observed the pilot enter the airplane and take off. Nothing unusual was noted.

Insufficient portions of the body were recovered from the Pacific Ocean to perform an autopsy or toxicology tests.

ADDITIONAL INFORMATION

The small portions of the airplane which were found in the surf and on the beach during the month of February 1994, were transported to the Montgomery Field. Some of the components were photographed (see attachments), and in late February they were all verbally released to the owner's insurance representative. No parts, records, or cargo were retained.

NTSB Probable Cause

the pilot's failure to maintain control of the airplane. Factors in the accident were the dark night lighting conditions, moderate to severe turbulence, and heavy rain.