NTSB Factual Report

HISTORY OF THE FLIGHT

On November 20, 2009, at 1246 Pacific standard time, a Cessna 182K, N2650R, crashed about 1.5 miles east of the Susanville Municipal Airport, Susanville, California, shortly after departure. The private pilot operated the airplane under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot was killed and the airplane was substantially damaged and consumed by a post impact fire. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The flight originated at the Susanville airport about 1245.

A Federal Aviation Administration (FAA) inspector reported that the pilot had filed an IFR flight plan for a flight from Susanville to Lodi, California. The void time of the flight plan was 1250. The airport manager reported that winds had been gusting up to 15 knots, and at 1245, there was 1 inch of snow on the ground. The FAA inspector stated that the pilot never contacted air traffic control over the radio, or activated his flight plan.

A witness who was working in his shop 1/4-mile from the crash site said that it was snowing heavily with limited visibility. He heard an airplane circling his shop, making about five passes. He heard the plane making power changes before finally coming on with full power that was followed by a ‘whump’, which shook the windows of his shop. He looked outside to the west, saw a fire, and knew the airplane had crashed.

Another witness said he was outside, about 1/2-mile north of the crash site, heard an airplane circling the area but was unable to see it due to heavy snow and limited visibility. He could hear the pilot changing power settings, and that the airplane had circled his residence at least three times. Everything got quiet; he looked to the southwest and saw a fireball then heard the explosion.

The pilot was based out of Susanville and was very familiar with the local airspace. The pilot’s girlfriend stated that she flew with him regularly, and he would always make a left turn after takeoff no matter what runway he used and circle over the airport to gain altitude. Another pilot stated that he knew the accident pilot, and that the accident pilot regularly used his own departure procedure of circling over the airport until he reached his desired altitude instead of the published departure procedures. The accident pilot used this self developed departure procedure in both good weather and poor weather.

PERSONNEL INFORMATION

The pilot, age 61, held a private pilot certificate for airplane single-engine land and instrument airplane ratings issued January 12, 2007. He held a third class medical certificate issued February 8, 2008, with the restriction of having eye glasses available for near vision. The pilot’s logbook was not recovered in the wreckage or located by the family. On the pilot’s February 8, 2008, third-class medical application he reported having 1,200 flight hours, accumulating 125 hours within the previous 6 months.

The pilot would normally spend the weekdays in Susanville, and fly to Lodi for the weekend. His girlfriend, who lives in Lodi and was expecting him to arrive there Friday afternoon, said that she had three phone conversations with him the morning before the accident. She stated that he was his normal self and upbeat during the conversations. He told her that he was considering leaving Susanville earlier than planned because of an anticipated storm arriving sooner than he expected. In the third conversation, he called her at 1140 as he was parking his car at the airport, and told her that he was definitely coming early as the “weather was going to turn to crap soon,” and he’d be in the air within 10 to 15 minutes. During this conversation he sounded a bit distracted and a little edgy.

AIRCRAFT INFORMATION

The four-seat, high wing, fixed-gear airplane, serial number (S/N) 18258350, was manufactured in 1967. The airplane was powered by a Teledyne Continental Motor TSIO-520-MCC, which had been de-rated to a P. Ponk O-470-50, 235-hp engine equipped with a 3-bladed McCauley D3A34C401-C constant speed propeller. Review of the maintenance records showed that an annual inspection was completed June 25, 2009, at a recorded tachometer of 3,378.0 hours; airframe total time of 3,727.5 hours; and engine time since major overhaul as 850.1 hours. An altimeter and static system test was performed May 20, 2009. The airplane was equipped with a Garmin 400W series GPS/WAAS Nav Com (global positioning system/wide area augmentation system) integrated panel mounted system, an S-Tec Autopilot System, and an electrically driven vacuum pump as a standby auxiliary pump to the existing instrument air system. The airplane was not equipped with an airframe ice protection system.

METEOROLOGICAL INFORMATION

The Susanville Airport AWOS (automated weather observation system) recorded the following automatic weather observations. Frequency of the observation is every 5 minutes.

Time (local) wind (direction) kts (G=gust) vis (miles) Temp(C) sky condition

1240 140 11G15 1/4 1 overcast 200 feet

1245 140 6G15 1/2 1 overcast 200 feet

1250 130 6G15 1/2 1 overcast 200 feet

1255 120 8 1/2 1 overcast 200 feet

1300 130 7 1/4 1 overcast 200 feet

1305 150 8 1/2 1 overcast 200 feet

1310 130 6 1/2 1 overcast 200 feet

COMMUNICATIONS

At 1225, the pilot filed an IFR (instrument flight rules) flight plan from Susanville to Lodi with Lockheed Martin flight service - Oakland. A written transcript of the recorded conversation was produced. The pilot stated that he was requesting an Amedee departure and wanted to leave as soon as possible. The pilot was briefed that there was an airmet for turbulence, icing, and mountain obscuration, all associated with a cold front coming through central California that afternoon. Moderate turbulence was forecast below 18,000 feet, freezing level up to 20,000 feet, mountain obscuration by clouds, precipitation, and mist all along the route of flight, forecasted to continue through the afternoon. The briefer stated that there was light snow at Blue Canyon (74 miles south of Susanville). Towards the end of the weather briefing the pilot says “alright, not pretty” to which the briefer says, “nah, it’s not gonna be nice and probably won’t improve much until this evening…” The pilot then followed up with, “Alright, well let’s get the flight plan on file and give me the number to call to get it and get out of here.”

At 1239, the pilot received his IFR clearance from Oakland Center via Prescott flight service, “Cleared from Susanville airport to the Amedee VOR-DME via the Amedee One Departure, climb and maintain 14,000 feet, squawk 4553, contact Oakland Center 128.8 upon departure, and clearance void if not off by 2050 (1250).”

Oakland ARTCC (air route traffic control center) records show that the pilot never checked in with Oakland Center.

AIDS TO NAVIGATION

The Amedee One Departure route description from runway 11 is to climb via 112 degrees heading and intersect the Amedee VOR 267 radial inbound. The published takeoff minimums for runway 11 are standard with a minimum climb of 410-feet-per-nautical mile (NM) to 6,000 feet or 1,900 foot ceiling and 2 1/2 mile visibility in visual conditions. The Amedee One Departure route is from Susanville Airport to the southeast over the Amedee VOR-DME station, 23.5 miles away.

For a pilot operating under Federal Aviation Regulation (FAR) Part 91 there are no takeoff minimum visibility requirements.

WRECKAGE AND IMPACT INFORMATION

The airplane wreckage was located 1.5 miles northeast of Susanville Municipal Airport in a flat grass pasture. When emergency responders arrived on scene the airplane had been mostly consumed by fire, and what remained of the airplane was located in the immediate vicinity of the wreckage. A sheriff’s deputy reported that he “was unable to locate any evidence to indicate that the plane had impacted the ground elsewhere and slid to the location where it was resting. It appeared that the plane had impacted the ground vertically or nearly so.”

The wreckage was removed from the pasture and stored at Faeth Aircraft Parts, Sacramento, California. On February 4, 2010, the aircraft wreckage was examined by a Safety Board Investigator assisted by technical representatives from Cessna Aircraft Company, and Teledyne Continental Motors. The airplane had sustained severe thermal and crush damage. Examination of the airplanes' wings showed leading edge crushing along the entire length of both wings, and wing skin was crushed accordion style longitudinally. Pieces from all sections of the airplanes' flight control system and structural components were identified. The propeller hub sustained crush damage and all three propeller blades had separated from the hub. All three blades exhibited leading edge polishing, chordwise scratches, and the blade tips bent slightly forward. The top spark plugs were removed and found to be clean with no mechanical deformation; all electrodes were gray in color, which corresponds to normal operation according to the Champion Aviation Check-A-Plug AV-27 chart. A borescope inspection revealed no damage to the valves, cylinder walls, or internal cylinder heads. Investigators were unable to rotate the crankshaft. The magnetos had been destroyed by fire. The carburetor had partially separated from the induction system, the throttle valve was in the open position, and fire had consumed the carburetor floats.

MEDICAL INFORMAITON

An autopsy was performed on the pilot on November 23, 2009, by the Washoe County Medical Examiner, Reno, Nevada. The autopsy findings included multiple fractures and lacerations on his head, neck, thorax, abdomen, and upper and lower extremities. The cause of death was identified as ‘multiple blunt force injuries.’

Forensic toxicology was performed on specimens from the pilot by the FAA Forensic Toxicology Research Team CAMI, Oklahoma City, Oklahoma. The toxicology report stated the tests for carbon monoxide and cyanide were not performed. No ethanol was detected in muscle or the liver. Diltiazem was detected in the liver and blood, and pseudoephedrine was detected in the liver. Greater than 6.4% hemoglobin A1C was detected in blood.

The pilot’s girlfriend stated that he took numerous medications for gastrointestinal issues, high blood pressure, diabetes, and a thyroid disorder.

ADDITIONAL INFORMATION

The Airplane Flying Handbook (FAA-H-8083-3) states the following concerning flight in icing conditions.

“One of the greatest hazards to flight is aircraft icing. The instrument pilot must be aware of the conditions conducive to aircraft icing. These conditions include the types of icing, the effects of icing on aircraft control and performance, effects of icing on aircraft systems, and the use and limitations of aircraft deice and anti-ice equipment. Coping with the hazards of icing begins with preflight planning to determine where icing may occur during a flight and ensuring the aircraft is free of ice and frost prior to takeoff.”

“Because of their small size and shape, antennas that do not lay flush with the aircraft’s skin tend to accumulate ice rapidly. Furthermore, they often are devoid of internal anti-icing or deicing capability for protection. During flight in icing conditions, ice accumulations on an antenna may cause it to begin to vibrate or cause radio signals to become distorted and it may cause damage to the antenna.”

“Because contamination of the wing reduces lift, even an operational, ice-free stall warning system may be ineffective because the wing will stall at a lower angle of attack due to ice on the airfoil. The stall onset will therefore occur prior to activation of the stall warning devices, leading to a potential pitch or roll upset.”

NTSB Probable Cause

The pilot's decision to takeoff into weather conditions conducive to ice accumulation, which resulted in an inadvertent stall/spin while maneuvering in the initial climb. Contributing to the accident was the likely accumulation of snow and ice on the airborne airplane.