NTSB Factual Report

HISTORY OF FLIGHT

On October 17, 2005, at 1038 Pacific daylight time (PDT), a Lancair LC-41-550FG, N285JB, collided with mountainous terrain 6 miles north of Warner Springs, California. The airplane was operated by JB Lauchner Aviation LLC under the provisions of 14 CFR Part 91. The airline transport pilot, private pilot, and single passenger were fatally injured. The airplane was destroyed. Visual meteorological conditions prevailed and a flight plan had not been filed. The personal cross-country flight originated at Gillespie Field, San Diego, California, at 1021, with a destination of Scottsdale, Arizona.

Flight track data recorded from the onboard global positioning system (GPS) was extracted from the onboard multifunctional display (MFD) compact flash memory card that was recovered from the wreckage. The flight data file starts at time 1712:48 UTC (coordinated universal time, 1012:48 PDT); the data is captured at 6-second intervals and is written to the memory card once per minute. Examination of the data revealed that engine rpm increases to 2,500 at 1021:30 PDT and remained in that range for the remainder of the data file. The track departs Gillespie Field and turns east, then northeast over Lake Jennings, and climbs to a pressure altitude of 5,000 feet. The track continues northeast over San Diego Country Estates. When over Warner Springs the track increases altitude to 6,475 feet then it decreases to 5,996 feet. The last recorded time is 1038:00, at an altitude of 5,996 feet, 1.8 miles southwest of the accident site. Radar data was available to fill in the 1.8-mile gap, and continues to depict the track in a turn from the northeast towards the east where the track ends at the south side of Combs Peak (elevation 6,150 feet) and 0.25 miles north of Bucksnort Mountain (elevation 5,995 feet).

The aircraft was a subject of an alert notice (ALNOT) missing aircraft notification and was located by the Civil Air Patrol on the afternoon of October 19, 2005.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records obtained from Oklahoma City, Oklahoma, revealed that two of the occupants held pilot certificates.

The airline transport pilot (ATP) held certificates for certified flight instructor (CFI) and ground instructor, with ratings for single engine and multiengine land. His ATP certificate was dated January 14, 2005. He held a first-class medical certificate that was issued on August 31, 2005. It had the restriction that the pilot must wear corrective lenses. The ATP's logbook was not obtained by the National Transporation Safety Board. The flight time reported by the pilot on his latest FAA medical certificate application, dated August 31, 2005, was 3,000 hours total time, and 150 hours in the previous 6 months.

The other pilot held a private pilot certificate dated April 11, 1985, with a single engine land rating. He held a third-class medical certificate dated September 12, 2003, with the restriction that he must wear corrective lenses for near and distant vision. The private pilot's flight logbook was not located or obtained by the Safety Board. The flight time reported by the pilot on his last FAA medical certificate application, dated September 12, 2003, was 870 hours total time, and zero hours in the previous 6 months.

AIRCRAFT INFORMATION

The airplane is a pre-molded, composite built, semi-monocoque, four seat, single engine, low wing, tricycle design airplane, and is certified in the utility category. A review of the airplane's logbook revealed that the last annual inspection was dated August 18, 2005, at a total airframe time of 309.9 hours. An accompanying service order dated October 3, 2005, listed the total aircraft time as 332.0 hours recorded from the Hobbs meter.

The airplane had a Teledyne-Continental Motors TSIO-550-C(5) engine. Examination of the engine logbook revealed a 100-hour inspection dated August 18, 2005, at an engine total time of 309.9 hours.

Standard avionics equipment included an Avidyne FlightMax EX5000 multi-function display (MFD). The airplane pilot operation handbook describes the MFD system and operation as follows; "The MFD provides a pictorial view of your flight situation based on input from your GPS navigator. It utilizes on-board database information for mapping off-route navigation data such as nearby airports, VOR's, NDB's, special use airspace and restricted airspace, etc., as well as an extensive terrain, interstate highways, water, and obstacle databases. The controls on the bezel of the FlightMax EX5000 are placed to allow you quick and intuitive access to the information you need, when you need it." "The EX5000 uses RS-232 to interface to external sensors such as the GPS."

The EX 5000 also contains a built-in Narrowcast datalink transceiver which uses two-way messaging from Avidyne Network Operations Center, or interfaces with the XM satellite radio system receiving a constant stream of weather data. This system provides NEXRAD (weather radar) images, METAR text, AIRMETS, SIGMETS, TFR's (temporary flight restriction), and route of flight. The broadcast datalink receiver continuously receives all weather data.

The airplane was equipped with crew supplemental oxygen. Supplemental oxygen would allow aircraft operation above 12,500 feet for greater than 30 minutes (FAR 91.211).

The airplane is not certified for flight into known icing conditions. The pilot operation handbook states the following under the subtitle; Icing Conditions, 'Flight into know icing is prohibited.'

METEOROLGICAL INFORMATION

A Surface Analysis chart prepared by the National Weather Service (NWS) National Centers for Environmental Prediction (NCEP) for 1100 October 17 showed an inverted trough of low pressure along the southern California coastline.

Surface weather observations for airports in the accident area surrounding the accident time, in part, follow:

Ramona Airport (KRMN), Ramona, California, field elevation is 1,393 feet mean sea level (msl), is located approximately 215 degrees at 26 nautical miles from the accident location, and is equipped with an augmented Automated Surface Observation System (ASOS). At time 1036 a special observation was recorded; wind was calm; visibility was 10 miles; sky condition was broken at 1,200 feet, and overcast at 6,500 feet; temperature was 15 degrees Celsius; dew point was 12 degrees Celsius; altimeter setting was 29.91 inches Hg; there were no remarks. At time 1053; the wind direction was 300 degrees at 4 knots; the visibility was 10 miles; sky condition was broken at 1,000 feet, overcast at 6,000 feet; temperature was 15 degrees Celsius; dew point was 12 degrees Celsius; altimeter setting was 29.92 inches Hg; there were no remarks.

Jacqueline Cochran Regional Airport (KTRM), Palm Springs, California, field elevation 114 feet msl, is located approximately 058 degrees at 26 nautical miles from the accident location, and is equipped with an unaugmented ASOS. At time 1052; the wind was calm; visibility was 10 miles; sky condition was overcast at 5,500 feet; temperature was 21 degrees Celsius; dew point was 17 degrees Celsius; and the altimeter setting was 29.88 inches Hg; there were no remarks.

Palm Springs International Airport (KPSP), Palm Springs, field elevation 477 feet msl, is located approximately 012 degrees at 26 nautical miles from the accident location, and equipped with an augmented ASOS. At time 1053; the wind was calm; visibility was 10 miles; present weather was light rain; sky condition was scattered at 4,900 feet, overcast at 6,000 feet; temperature was 19 degrees Celsius; dew point was 17 degrees Celsius; altimeter setting was 29.89 inches Hg; the remarks stated rain began at 1001, ended at 1011, and began at 1051.

The San Diego upper air station indicated that the freezing level was at approximately 8,500 feet msl. The EDAS model sounding indicated that the freezing level in vicinity of the accident location was at approximately 10,000 feet msl.

GOES-10 visible and infrared digital data centered on the accident location revealed temperatures below +6 degrees Celsius very near the accident area. This temperature range can be associated with cloud tops between 7,000 and 10,000 feet msl.

The manager of the Warner Springs Glider Port reported that there was mountain wave activity in the vicinity on Monday, October 17.

The entire meteorological factual report is contained in the docket of this investigation report.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located on the summit of Combs Mountain and consisted of a 501-foot-long debris field that ran roughly south to north. The south end of the debris field was located on a 48-degree slope of rock and mud that was populated with dead manzanita bushes. The north end of the debris field was on the level summit of Combs Peak also populated with dead manzanita bushes. The general direction of the debris field was on a 340-degree bearing.

The farthest southern point of the debris field was identified as the initial point of impact (33 degrees 23.639 minutes north by 116 degrees 36.318 minutes west, elevation 6,111 feet), and contained red lens fragments and a narrow patch of disturbed earth that ran 47.2 feet long on a magnetic bearing of 331 degrees, and traveled upslope. A distinct odor similar to 100-octane aviation fuel was identified in the earth of the ground scar. Located at the end of the ground scar was the nose wheel fairing; approximately 20 feet upslope from that point was the right wing wheel fairing and a 6-inch portion of propeller tip. Distributed farther upslope were portions of the left wing, aileron torque tubes, wing wiring harness, and portions of the left side of the fuselage. The three bladed Hartzell propeller was located at the summit of Combs Peak along with sections of the engine exhaust manifold, a turbocharger section, and the right elevator.

The propeller was a Hartzell F7693DF, serial number A70717B, three bladed prop. All blades had portions of or the whole blade tip missing. All three blades exhibited leading edge gouging, chordwise scratching, and blade face polishing. The blades were labeled A, B, and C in clockwise order for identification purposes. Blade A was turned about 90 degrees in the hub, was missing approximately 7 inches of the blade tip, and was curled aft in a pig tail fashion. Blade B was bent at the hub about 15 degrees in the direction opposite to rotation, exhibited sinusoidal s-curving of the trailing edge, and was missing 6 inches of the blade tip. Blade C exhibited forward bending of the last 4 inches of the blade tip, trailing edge s-bending, and a trailing edge fracture 11 inches from the tip. The propeller crankshaft attachment flange was present on the hub and the crankshaft was torsionally sheared exhibiting a 45-degree circumfral fracture face.

Distributed down the north slope from the summit on a bearing of 315 degrees were the right wing, seat components, fuselage, and engine. The right wing was separated at the root; the upper surface separated from the lower revealing the interior of the wing. The right wing spar was located next to the wing debris along with the wing spoiler.

Approximately 350 feet north of the summit on the plateau area below was the main fuselage, tail, engine, and rear cabin seat backs (33 degrees 23.704 minutes north by 116 degrees 36.390 minutes west, elevation 6,120 feet). The main fuselage laid orientated on a northeasterly direction; the engine was separated from the firewall and mounts and laid 7 feet farther north. The mixture, throttle, and propeller control cables were still attached and extended between the cockpit and engine. The fuselage contained no windscreen or window elements and was separated laterally behind the firewall and laterally at the horizontal and vertical stabilizer. The cockpit was totally destroyed with very few recognizable components, and the left side of the fuselage was not present on the wreckage. The rudder cables were traced from the rudder bar to the rudder bell crank. The right rudder cable was separated from the rudder bar at the fitting and was continuous to the rudder bell crank. The left rudder cable was separated in broom straw fashion a few feet from the rudder bar fasteners and the opposite end was attached to the rudder bell crank. The elevator control push tubes were identified on the right side of the cockpit bent and fractured into sections consistent with buckling and overload. The left side elevator and aileron cockpit pushrods were not present with the cockpit wreckage. Aileron control continuity could not be established; however, aileron push tubes were identified upslope from the initial point of impact that exhibited signatures consistent with buckling and overload.

The emergency locator transmitter (ELT) was located in the debris field. The antenna was not present on the ELT; however, a weak signal was reported to be received by radios that were in close proximity to the wreckage. The ELT signal did not assist in the location of the wreckage.

The engine was identified as a Teledyne-Continental TSIO-550-C(5), serial number 802653, and was examined on scene. The engine was not attached to the airframe; the oil pan was completely crushed; the propeller flange was not present; both magnetos had departed the case halves; the induction manifold was detached from all cylinders at the risers; and the exhaust manifold and turbochargers were not present on the engine. Only one magneto was located; a Slick model 6320. The impulse coupling rotated and was found to engage; water was drained from bottom vent hole. The magneto did not produce a spark when rotated by hand. The number 6 cylinder head was cracked open and exhibited extensive cooling fin deformation. The fuel pump was removed, rotated by hand, and the drive coupling was undamaged. The oil pump was disassembled and found to be clear of debris with no identifiable scoring, and rotated freely by hand. The fuel manifold had all fuel injector lines attached with spot putty present. The fuel manifold was disassembled revealing a fuel screen that was clear of debris, and liquid was evident at the base. The number 2 cylinder top spark plug was gray in color, exhibited a symmetric anode with no evidence of mechanical damage.

On December 8, 2005, the wreckage was examined at Aircraft Recovery Services, Pearblossom, California. The Safety Board investigator-in-charge (IIC) conducted the examination with technical assistance from a Columbia Aircraft Manufacturing representative. During the wreckage exam, the MFD was located and the compact flash memory card was removed for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

The San Diego County Medical Examiner completed an autopsy on all three victims. The FAA Forensic Toxicology Research Team performed toxicological testing of specimens from the airline transport pilot and the private pilot that were collected during the autopsy.

The autopsy report stated that the airline transport pilot's palms and soles showed patterned control surface lacerations, and restraint injuries were consistent with occupying the right front seat of the vehicle. The results of the toxicological analysis of his specimens were negative for carbon monoxide, cyanide, volatiles, and tested drugs.

The toxicological report for the private pilot's specimens contained the following positive results: 0.0487 ug/ml tetrahydrocannabinol detected in the liver; 1.604 ug/ml tetrahydrocannabinol detected in the lung; 0.1285 ug/ml tetrahydrocannabinol detected in the kidney; 0.6356 ug/ml tetrahydrocannabinol carboxylic acid detected in the liver; 0.1032 ug/ml tetrahydrocannabinol carboxylic acid detected in the lung; 0.4427 ug/ml tetrahydrocannabinol carboxylic acid detected in the kidney; and vardenafil was present in the blood, bile, liver, lung, kidney, muscle, and heart. Tests for carbon monoxide and cyanide were not performed. The results were negative for volatiles.

TESTS & RESEARCH

Data Recorded on the MFD Compact Flash Card Memory

Technical support from Avidyne enabled the data on the compact flash memory card to

NTSB Probable Cause

The flight crew's failure to maintain adequate terrain clearance and their decision to continue flight into known adverse weather conditions. Contributing to the accident was overcast conditions, and terrain obscuration. A finding of the investigation is that the flight crew may have improperly used the navigation equipment, which had a graphical moving map display capability, to guide the airplane between clouds and mountainous terrain while in obscured visibility conditions.