NTSB Factual Report

On January 6, 2001, about 2015 hours Pacific standard time, a Cessna 172F, N383CA, collided with terrain during initial climb from San Luis Obispo (SBP), California. The airline transport rated pilot and the nonrated passenger were both fatally injured, and the airplane was destroyed. The flight was being operated by the pilot under the provisions of 14 CFR Part 91. Instrument meteorological conditions prevailed at the time of departure and an instrument flight plan was filed. The airplane was released for departure by Los Angeles Air Route Traffic Control Center (ZLA ) at 2011.

Prior to departure at 1939, the pilot contacted the SBP control tower to request an instrument departure to on-top and was advised to standby. During the course of communication the pilot was advised the "tops" were 300 feet above ground level, and at 1947, he was issued a clearance to taxi to runway 11. At 2001, the tower advised the pilot that they were closing and to contact ZLA for release. The flight departure release required a right turn after takeoff to 130 degrees.

The pilot was employed as a charter pilot and flight instructor by a fixed-base operator at Bakersfield. His employer stated that he had asked for the day off to go to Hearst San Simeon State Park, about 45 miles north of San Luis Obispo. According to a rental car contract, the pilot rented a car at San Luis Obispo at 1020 and returned it at 1930.

PILOT INFORMATION

The pilot held an airline transport rating and was certified as a flight instructor. On October 9, 2000, he was issued a second-class medical certificate. On September 19, 2000, he sucessfully completed an Airman Competency/Proficiency multiengine check ride as a 14 CFR Part 135 pilot. According to an annual company resume update (August 2000), he reported a total flight time of 2,290 hours with 150 hours of instrument time. Actual instrument time was reported as 70 hours with 80 hours hood time. His personal logbook was not recovered.

AIRPLANE INFORMATION

According to logbook records, the last documented annual inspection occurred on March 9, 2000, at a recording tachometer time of 1,503.8, for a total flight time of 6,924.8 hours. At the accident site the damaged recording tachometer indicated 1,565.1. A flight trip log was recovered at the accident site. The last trip noted was November 19, 2000, ending at tachometer reading 1,563.8 hours. No discrepancies were noted in the remarks column.

METEOROLOGICAL INFORMATION

According to the METAR Surface Weather Observation at 1956, the wind was 100 degrees at 3 knots; surface visibility 1.25 statute miles; mist; overcast at 100 feet above ground level; temperature 48 degrees Fahrenheit; dew point 46 degrees Fahrenheit; and the altimeter was 30.05 inHg.

The San Luis Obispo special observation at 2041: wind calm; visibility .5 statute mile; fog; overcast 100 feet above ground level; temperature 48 degrees Fahrenheit; dew point 48 degrees Fahrenheit; and the altimeter was 30.06 inHg.

There was no record of a formal weather briefing of the pilot or the airplane registration number by a Federal Aviation Administration (FAA) facility for the day of the accident.

WRECKAGE AND IMPACT INFORMATION

The Safety Board examined the wreckage on site, located about 1 mile southeast of the departure threshold of runway 11. The accident site was located in a semi residential area of undulating terrain. The nearest home was about 200 feet to the south. Examination of the site revealed green navigation light lens material at the beginning of shallow ground disturbance/initial point of impact (IPI). From the the IPI, wing tip and wing material marked a 23-foot-path heading about 180 degrees. The path changed direction to 160 degrees for about 132 feet, with engine oil spillage at the beginning, and an increase of scattered small parts.

About 104 feet and 135 feet from the IPI, the separated carburetor and propeller were located.

About 25 feet further the main wreckage was located. The left wing displayed accordion like damage to the leading edge, with the aileron and flap still attached. There was hydraulic deformation of the left wing fuel tank. The right wing displayed chordwise accordion like damage to the leading edge with separation of wing structure about midspan outboard. Both wings were still partially connected by way of the cabin roof and spar carry through structure, and separated from all four cabin door post structures. The empennage was separated at the baggage aft bulkhead. Trim tab cable pull was evident, with a measurement of 10 degrees tab up. Tail group counterweights were accounted for with most tail damage to the rudder upper half and vertical stabilizer.

Instruments were found broken from the instrument panel and scattered in the debris trail. The airspeed was recovered indicating 100 mph; the turn coordinator was right wing down; the altimeter kollsman, window found separated from the mechanism, indicated 29.90 inHg; the instrument suction gauge indicated 4.7 inHg; the recording tachometer indicated 2,200 rpm with 1,565.1 hours; the directional gyro indicated about 080 degrees; an ADF was tuned to 385/376; a communication radio was set to a frequency of 118.6 or .5. A man's watch was stopped at 8:08 indicating a date of 6. The attitude gyro rotor displayed rotational damage, the directional gyro did not. The vacuum pump drive coupling was found intact, the carbon block of the pump was fractured. The fuel selector handle was in the "both" position.

The damaged overhead cabin light console was recovered and examined. The console consists of a radio light rheostat, an instrument panel flood light rheostat, and an overhead cabin light with an on/off switch. At the time of examination, the radio light rheostat was found at a low light brilliance position and measured about .8 volts at the rheostat. The rheostat operation was intermittent and occasionally open. The instrument panel flood light rheostat was found positioned near maximum brilliance and operated smoothly without loss of contact. According to records, this rheostat was replaced March 3, 1994, in compliance with Airworthiness Directive 93-24-15. The GE93 lamp from the instrument panel light was destroyed. After minor straightening of the lamp socket, a GE93 lamp was installed and operated smoothly through the range of brilliance. The cabin light switch was found in the off position; the GE1816 lamp from the cabin light appeared to be burnt out.

MEDICAL AND PATHOLOGICAL INFORMATION

On January 6, 2001, the San Luis Obispo Medical Examiner performed a post mortem examination of the pilot. During the course of the procedure samples were obtained for toxicological analysis by the Civil Aeromedical Institute in Oklahoma City, Oklahoma. Due to the lack of suitable samples, tests were not performed for carbon monoxide nor cyanide.

Volatiles detected in muscle tissue were positive for ethanol, which was attributed to postmortem ethanol formation. Drug tests were positive for Dextromethorphan in liver and kidney, Dextrophan in liver and kidney, Diphenhydramine in liver and kidney, Pseudoephedrine in liver and kidney, Ephedrine present in kidney, and Phenylpropaanolamine in liver and kidney.

Diphenhydramine is a sedating antihistamine, available over-the-counter in many multisympton cold and allergy preparations, and often known by the trade name Benadryl.

ADDITIONAL INFORMATION

The wreckage was released to the insurance company representative on January 31, 2002.

NTSB Probable Cause

The pilot's failure to maintain a proper climb rate to VFR conditions on-top.