NTSB Factual Report

HISTORY OF FLIGHT

On November 9, 2008, about 1125 Pacific standard time, a Piper PA-32S-300, N312AG, impacted the side of a mountain in the San Bernardino Mountain range, near Forest Falls, California. The pilot/owner operated the airplane under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal cross-country flight. The pilot and three passengers were killed; the airplane was destroyed. Visual meteorological conditions were prevalent for most of the flight that departed San Felipe International Airport (SFH), Baja, Mexico, about 0700, with an intended destination of Hesperia Airport (L26), Hesperia, California. No flight plan had been filed.

The pilot was in contact with Los Angeles Center, and was issued two discreet Mode 3 transponder codes of 0205 and 4767. At 1051, the pilot input a transponder code of 0205, in the area of Coachella, California. At 1118, over the San Bernardino Mountains, the pilot changed the transponder code to 4767, and approximately 7 minutes later, the last Mode C radar was recorded at 12,500 feet near the accident location. There were no distress calls made by the pilot.

Concerned family members of the pilot and passengers reported the overdue flight to the Federal Aviation Administration (FAA). The FAA issued an ALNOT (Alert Notification).

Following the issuance of the ALNOT on the day of the accident, the San Bernardino County Sheriff’s Aviation Division had to suspend its search along the proposed flight path due to a storm front passing through the San Bernardino Mountains. The following morning the search resumed and the airplane was located about 1230. Deputies reported that the wreckage was about 1/4-mile west of San Gorgornio Peak, and had struck a rock outcropping on the northwest face about 150 feet below the peak of an 11,000-foot mountain. The area was covered in snow, ice, and rock. The deputy pilots involved in the search noted that during the flights on both days there were high wind conditions.

PERSONNEL INFORMATION

A review of FAA airman records revealed that the 74-year-old pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. The pilot held a third-class medical certificate issued on June 30, 2008. It had the limitations that the pilot must wear corrective lenses for near and distant vision.

No personal flight records were located for the pilot. The Safety Board investigator-in-charge (IIC) obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center, Oklahoma City, Oklahoma. The pilot reported on his most recent medical application that he had a total time of 7,303 flight hours with 98 hours logged in the last 6 months. Also on his application for a medical certificate, the pilot answered YES in response to "Do You Currently Use Any Medication," and noted the use of lisinopril, gemfibrozil, levothyroxine, and warfarin. The application also noted a YES response to "Heart or vascular trouble," "High or low blood pressure," "Kidney stone or blood in urine," "Admission to hospital," and "Other illness, disability, or surgery." In the explanation section, it noted "arterial fibrillation… high blood pressure… bladder tumor removed…."

A review of the pilot’s FAA medical records indicated that the pilot had a history of color vision deficiency, and was taking several medications: thyroid hormone for hypothyroidism, gemfibrozil for high cholesterol, lisinopril for high blood pressure, and warfarin for chronic atrial fibrillation. A nuclear myocardial perfusion scan done in 2004 was noted as being consistent with a possible previous heart attack, but a subsequent echocardiogram did not identify any abnormalities of heart motion or function, and the pilot was noted as being “completely asymptomatic.” The pilot received an Authorization for Special Issuance of a Medical Certification on September 19, 2008, for his “history of atrial fibrillation, hypothyroidism, hypertension, and use of medication.”

AIRCRAFT INFORMATION

The airplane was a Piper PA-32S-300, serial number 32S7240096. No aircraft logbooks were located for the accident airplane. Information pertaining to the accident airplane was obtained from AA Aircraft Maintenance, Hesperia. According to their records, the last annual inspection was performed on August 1, 2008; no aircraft or engine times were noted on the paperwork provided to the Safety Board. On September 25, 2008, a receipt from First Flight Corporation, San Diego, California, showed an airplane total time of 3,610.4 hours. The airplane was powered by a Textron Lycoming IO-540-K1A5 engine, serial number RL-11259-48.

METEOROLOGICAL CONDITIONS

A staff meteorologist for the Safety Board prepared a factual report for the area surrounding the accident.

The closest official weather observation station was March Air Reserve Base, Riverside, California (RIV), which was 24 nautical miles (nm) southwest of the accident site. The elevation of the weather observation station was 1,535 feet mean sea level (msl). An aviation routine weather report (METAR) was issued at 1055. It stated: winds from 260 degrees at 13 knots gusting to 20 knots; visibility 10 statute miles; skies 13,000 feet scattered; temperature 17 degrees Celsius; dew point 03 degrees Celsius; altimeter 29.75 inches of mercury.

At 1133, a special report was issued for RIV. Reported winds were from 310 degrees at 11 knots; visibility 10 statute miles; ceiling 8,500 feet broken; temperature 16 degrees Celsius; 01 degree Celsius; altimeter 29.74 inches of mercury.

The Upper Air Data report reviewed by the Safety Board meteorologist specialist noted that the freezing level was at 6,500 feet. The Level II Doppler weather radar data for the Santa Ana Mountains, about 50 miles from the accident site, surrounding the accident time, showed weak weather radar echo intensities in the area, with maximum radar tops greater than 15,000 feet. Geostationary Operational Environmental Satellite (GOES)-11 visual image data surrounding the accident time showed clouds in the accident area. The GOES-11 infrared image identified cloud tops near 13,700 feet to 15,600 feet.

Airmen’s Meteorological Information (AIRMET) Tango Update 4 for turbulence and strong surface winds issued on November 9, 2008, at 0834, and valid until November 9, 2008, at 1300, identified moderate turbulence below 18,000 feet, with sustained surface winds great than 30 knots. AIRMET Zulu Update 2 for Icing issued on November 9, 2008, at 0645, and valid until 1300, identified moderate ice between the freezing level and 24,000 feet. The freezing level was between 6,000 and 10,000 feet.

WRECKAGE AND IMPACT INFORMATION

Responding personnel from the San Bernardino County Sheriff's Department located the airplane the following morning, near the summit of Mount San Gorgonio on a 50- to 55-degree slope in a rock out cropping. The wreckage was about 150 feet from the ridgeline at an elevation of 10,850 feet. The accident location was about 35 miles southeast of the Hesperia airport.

The coroner reported that the airplane wreckage was spread over an area of about 100 yards in diameter. The largest identified components were the tail section and a landing gear strut with wheel. The engine was about 20 yards southwest of the main wreckage in a drainage area; one propeller blade remained attached at the propeller hub assembly.

MEDICAL AND PATHOLOGICAL INFORMATION

The San Bernardino County Sheriff's Department - Coroner Division completed an autopsy of the pilot on November 19, 2008. The autopsy report noted the “Cause of Death” as “Massive blunt force trauma with body fragmentation, instantaneous.” No organ tissue was identified that could be associated with the pilot.

Toxicological testing of the pilot was not performed by the FAA as no specimens were available for testing.

TESTS AND RESEARCH

Radar data

According to radar data, at 1121:12, the airplane was at a mode C reported altitude of 13,600 feet mean sea level (msl), over the San Bernardino Mountains. About a minute later, radar data showed the airplane's altitude as 13,900 feet msl. At 1123:16, the airplane reached a peak radar altitude of 14,000 feet msl. For the remainder of the radar returns, approximately 2 minutes, the airplane descended to 13,700, then climbed to 13,800 feet, with the last radar return at 1124:58, at 12,500 feet msl.

Airplane Inspection

The airframe had fragmented into several small pieces. The airframe manufacturer was able to identify flight control surfaces and associated hardware, which consisted of cables, pulleys, and push-pull tubes. The flight control cables were broomstrawed and the other components of the flight control system were bent with angular breaks. The tail section was the largest piece of wreckage; the leading edge of the horizontal stabilizer was crushed aft, with a separation of both outboard sections of the horizontal stabilizer. The vertical stabilizer/rudder assembly was also crushed aft.

The engine had also fragmented. Visual examination of the engine yielded mechanical continuity of the rotating group and internal mechanisms. The engine manufacturer's representative noted no evidence of lubrication deprivation (heat distress) or contamination. The connecting rods and crankshaft showed a normal appearance; the camshaft was intact and each cam lobe appeared normal in shape. The accessory gears, which included the crankshaft gear, bolt and dowel, were not damaged. The combustion chamber of each cylinder showed no evidence of foreign object ingestion. Both magnetos had mostly separated from their respective mounting pads; pieces of magneto flange had remained securely clamped to the mounting pads. Due to the varying degree of damage to both magnetos a functional test was not performed and magneto-to-engine timing could not be ascertained. The two-bladed propeller remained attached to the crankshaft flange. One of the propeller blades had separated from the hub. The other propeller blade remained attached at the hub, and exhibited leading edge nicks and gouges, and chordwise striations.

NTSB Probable Cause

The pilot's continued flight into instrument meteorological conditions and subsequent impact with mountainous terrain.