NTSB Factual Report

1.1 HISTORY OF FLIGHT

On February 10, 2005, at 2033 Pacific standard time, a Cessna P210N, N432AR, reported severe turbulence while in cruise flight and collided with the ground during a rapid descent 8 nautical miles northeast of Lebec, California. Action Air Express, Inc., was operating the airplane as an on-demand air taxi passenger flight under the provisions of 14 CFR Part 135. The commercial pilot and one passenger sustained fatal injuries. The airplane was destroyed. The airplane departed under visual flight rules (VFR) from Fresno Yosemite International Airport, Fresno, California, at 1935, and received an instrument clearance to Santa Monica Municipal Airport, Santa Monica, California, in flight over the Clovis vhf omni-directional range (VOR). A combination of visual and instrument meteorological conditions prevailed along the route of flight.

The Air Force Rescue and Coordination Center (AFRCC) issued an Alert Notice (ALNOT) at 2230 on February 10, 2005. The wreckage was located at 1000 on February 12, 2005.

According to the operator, the purpose of the flight was to transport the passenger from Fresno to Santa Monica. The passenger was scheduled to depart from Fresno at 1700 but was late to arrive. The pilot waited at a fixed-base-operator (FBO) for the passenger who arrived for the flight about 1915. At 1920, the operator called the pilot to verify that the passenger had arrived. The pilot replied affirmatively, and stated that the passenger was just boarding the airplane for departure to Santa Monica.

While en route, the pilot communicated with several Federal Aviation Administration (FAA) facilities. The National Transportation Safety Board investigator reviewed transcripts for the time period from 2021 through 2030.

At 2026:13, the accident pilot stated, "So Cal, four nine three alpha romeo's checkin with you nine thousand." The controller replied "November four nine three alpha romeo Los Angeles center, roger the uh Burbank altimeter two niner eight eight."

At 2026:21, the pilot radioed "two niner eight eight four three two alpha romeo add uh uh you guys had any reports over uh Lake Hughes for any icing or (did it) pretty much cleared up uh we're getting some uh we got some a little bit south of Shafter."

At 2026:31, the controller stated, "Uh there's been a bunch of icing between Shafter and Lake Hughes I believe it's getting a little better closer to Lake Hughes November one five mike what is your flight conditions sir?"

At 2026:40, N9351M reported, "Uh five one mike is experiencing light rime ice."

At 2026:44, the controller reported, "Okay rog roger that uh November two alpha romeo traffic over Lake Hughes at eleven has some light rime ice traffic overhead at eleven had un had a little bit earlier."

At 2026:54, the pilot stated, "Uh roger four three two alpha romeo and what kind of plane is that we're um a two ten."

At 2027:00, the controller stated, "Uh the traffic over Lake Hughes is a Mooney and uh right overhead is a twin Cessna at eleven."

At 2027:07, the pilot responds, "(thanks) four three two alpha romeo."

At 2029:40, the controller stated, "November two alpha romeo can you maintain your altitude, maintain niner thousand."

At 2029:50, the controller stated, "November four three two alpha romeo LA Center."

At 2030:09, the controller stated, "November four three two alpha romeo LA Center."

At 2030:12, the pilot stated, "Four three two alpha romeo uh we have lower request (unintelligible)."

At 2030:18, the controller stated, "Two alpha romeo you're below my minimum uh altitude do your best to climb can you maintain altitude?"

At 2030:23, the pilot reported, "Four three two alpha romeo extreme turbulence."

No further transmissions were received from the accident pilot.

1.2 PERSONNEL INFORMATION

1.2.1 Pilot

The pilot held a commercial pilot certificate for single and multiengine instrument airplane, and also held a certified flight instructor certificate with ratings for single and multiengine instrument airplane. He held a valid first-class medical certificate issued on October 1, 2004, that did not have any waivers.

The pilot began his flight training on December 5, 2000. He obtained his pilot certificates over a period of 2 years from August 22, 2001, until his last rating, which was a certified flight instructor-instrument on June 24, 2002. During this time period the pilot took seven check rides. He failed the following three check rides on his first attempt: private multiengine; private instrument; and certified flight instructor instrument. Moreover, he took the private instrument check ride two times before passing.

The Safety Board investigator reviewed the pilot's records from Air Action Express, Inc. On May 26, 2004, the pilot satisfactorily completed a 14 CFR Part 135 flight check with an FAA inspector. The flight check satisfied the requirements of 14 CFR 135.293, 135.297, and 135.299.

On December 15, 2004, the pilot failed a 14 CFR 135.297 check. It was noted that item number 1, equipment examination (oral or written), was the reason for disapproval. On December 21, 2004, the pilot received another disapproval. It was noted on FAA Form 8410-3, "Airman Competency and Proficiency Check" that item number 23, holding, was unsatisfactory. Based on the FAA records, all other test areas were completed satisfactorily. On January 26, 2005, the pilot satisfactorily completed the 14 CFR 135.297 check.

Prior to the pilot's initial 14 CFR Part 135 check on May 26, 2004, he had attempted four Part 135 flight checks for the predecessor of Action Air Express, Inc., Peach, Inc. The FAA issued identifier code assigned to both companies was the same (QXNA). On January 30, 2004, the inspector noted, "135.293(a) unsatisfactory." On February 6, 2004, a disapproval was given for item number 1, equipment examination (oral or written). On March 4, 2004, a disapproval noted that item number 10, steep turns were unsatisfactory. On March 9, 2004, a disapproval again indicating item number 10 was unsatisfactory.

Two pilot's logbooks were recovered from the accident site and reviewed by the Safety Board investigator. The first logbook contained entries from December 5, 2000, to December 24, 2002. The second logbook began on May 8, and the last entry was dated October 3, 2004. The entries in the second logbook were intermittent so the times were estimated using the logged flight times. Based on a combination of the recorded flight logbook times and records from Action Air Express, Inc., the pilot's total flight time was estimated to be about 1,850 hours. On the pilot's most recent FAA medical application, the pilot reported a total pilot time of "2,000 est."

1.2.2 Passenger Information

Based on interviews with the passenger's spouse and a review of FAA airman records, the passenger did not hold a pilot certificate nor had he engaged in any flight training. The passenger had flown with the company on previous occasions due to business, and had not reported any complaints regarding Action Air Express, Inc., operations or flights.

1.3 AIRPLANE INFORMATION

The single engine pressurized airplane was built in 1978. According to the maintenance records, the last annual was performed on July 14, 2004. The last maintenance performed was a 100-hour inspection on November 1, 2004. At the time of the accident, the airplane had accumulated approximately 97 hours since its last inspection.

In the limitations section of the airplane Pilot's Operating Handbook (POH), the following limitation was noted: Flight into known icing conditions is prohibited.

The airplane was equipped with a System Fifty-Five X Autopilot. Pursuant to the operating requirements of the operator, the autopilot was required to be operational for IFR flights. The autopilot could be disconnected during flight through the following methods: turn the autopilot master switch to OFF; press the autopilot disconnect/trim interrupt switch on the aircraft's control wheel; and/or pull the aircraft's AUTOPILOT circuit breaker.

1.4 METEOROLOGICAL INFORMATION

1.4.1 Pilot Weather Briefing

There was neither an FAA Flight Service Station nor Direct User Access Terminal Service record of the pilot receiving a weather briefing the day of the accident; nor was one required. According to the FAA accepted operations specifications for the operator, the pilot "will use National Weather Service (NWS) reports and forecasts or the PIC may use his own observations when operating in Visual Flight Rules."

According to the FBO from which the airplane departed in Fresno, a weather station is setup in a private room in their facility. The pilot was not witnessed utilizing the FBO weather station; however, FBO personnel stated that it would have been possible for the pilot to use the weather station without them witnessing it.

Loose, undated papers were located within the wreckage that contained hand written weather observations for various geographic areas and routes of flight.

1.4.2 Weather Study

A Safety Board meteorologist performed a weather study of the accident area and time.

1.4.2.1 General National Weather Service (NWS) Reports

The southwest section of the NWS Surface Analysis Chart for 1900 on February 10, 2005, depicted three separate high pressure systems with a central pressure of 1034 millibars (mb) extending over western Wyoming and Colorado. A low pressure system with a central pressure of 1002 mb was located to the south of the accident site in the Pacific Ocean off Baja of California, with a trough of low pressure extending northward along the California coast. The location of the pressure systems resulted in a pressure gradient along eastern California and western Nevada with an east to northeast wind flow pattern across southern California and in the vicinity of the accident site.

The NWS observation station at Sandberg, California (KSDB), located approximately 10 miles south of the accident site at an elevation of 4,521 feet, reported the following conditions:

KSDB weather observation at 1952, automated observation, wind from 060 degrees at 18 knots gusting to 32 knots; visibility 10 miles in light rain; ceiling overcast at 5,000 feet; temperature 7 degrees Celsius (C); dew point -4 degrees C; altimeter 29.96 inches of Mercury (Hg). Remarks: automated weather observation system, peak wind from 070 degrees at 37 knots occurred at 1930; rain began at 1923; sea level pressure 1012.9 mb; hourly precipitation less than 0.01 inches (trace); temperature 7.2 degrees C; dew point -3.9 degrees C; thunderstorm sensor not operating.

KSDB weather observation at 2052, automated observation, wind from 060 degrees at 27 knots gusting to 35 knots; visibility 10 miles in light rain; ceiling overcast at 5,000 feet above ground level (agl); temperature 7 degrees C; dew point -1 degrees C; altimeter 29.95 inches of Hg. Remarks: automated weather observation system, peak wind from 070 degrees at 45 knots occurred at 2023; rain ended at 1953 and began again at 2015; sea level pressure 1012.6 mb; hourly precipitation less than 0.01 inches (trace); temperature 6.7 degrees C; dew point -1.1 degrees C; thunderstorm sensor not operating.

Santa Monica Municipal Airport (KSMO), the planned destination, was located approximately 55 miles southeast of the accident site at an elevation of 175 feet mean sea level (msl), and had an automated surface observation system (ASOS), which reported the following conditions:

KSMO at 1951, wind calm; visibility 10 miles in light rain; ceiling overcast at 8,000 feet; temperature 17 degrees C; dew point 7 degrees C; altimeter 29.88 inches of Hg. Remarks: automated observation system, rain began at 1951; sea level pressure 1011.5 mb; hourly precipitation less than 0.01 inches (trace); temperature 16.7 degrees C; dew point 6.7 degrees C.

KSMO at 2051, automated observation, wind from 040 degrees at 5 knots; visibility 10 miles; ceiling overcast at 7,500 feet; temperature 17 degrees C; dew point 7 degrees C; altimeter 29.88 inches of Hg. Remarks: automated observation system, rain ended at 2036; sea level pressure 1011.6 mb; hourly precipitation less than 0.01 inches (trace); temperature 17.2 degrees C; dew point 6.7 degrees C.

Meadows Field Airport (KBFL), Bakersfield, California, located approximately 32 miles northwest of the accident site at an elevation of 507 feet msl, reported the following conditions:

KBFL weather at 1954, wind calm; visibility 4 miles in haze; scattered clouds at 10,000 feet; temperature 12 degrees C; dew point 8 degrees C; altimeter 29.95 inches of Hg.

KBFL weather at 2054, wind from 190 degrees at 4 knots; visibility 3 miles in mist; ceiling overcast at 9,000 feet; temperature 11 degrees C; dew point 9 degrees C; altimeter 29.94 inches of Hg.

1.4.2.2 Upper Air Sounding or Rawinsonde Observation (RAOB)

The closest upper air sounding or rawinsonde observation (RAOB) site was located at Vandenberg Air Force Base (KVGB), located approximately 90 miles west of the accident site. The 1600 sounding from Vandenberg was plotted on a standard Skew-T log P diagram from the surface to 500 mb or approximately 18,000 feet.

The Lifted Condensation Level (LCL) was identified at 822 mb or 5,370 feet. Low-level moisture was limited with relative humidity of 55 percent or less below 1,000 feet where there was a temperature inversion between 840 and 1,100 feet, where temperature increased with altitude. Relative humidity decreased above this inversion until reaching another inversion, which was noted between 10,000 and 11,000 feet. Moisture increased above this level with relativity humidity greater than 75 percent between 14,000 and 19,000 feet. The Lifted Index (LI) was 8.8, which indicated a stable atmosphere. The freezing level was identified at 702 mb or 9,934 feet with a potential for light to moderate icing between 14,000 and 19,000 feet.

The wind profile indicated light and variable winds below 1,000 feet with wind increasing from the southeast at 35 knots at 7,000 feet and then decreasing and backing to the east at 14,000 feet. The wind profile indicated several layers of strong vertical wind shear that increased the likelihood of turbulence.

The RAOB program also indicated favorable conditions for a localized mountain wave activity and support the potential for moderate to severe turbulence. The lowest wave was identified near the accident airplane's reported altitude and indicated a wave between 10,600 and 11,000 feet with potential updrafts and downdrafts to 1,500 feet per minute (fpm).

1.4.2.3 Geostationary Operations Environmental Satellite Number 10 (GOES-10)

The Geostationary Operations Environmental Satellite number 10 (GOES-10) data was obtained from the National Climatic Data Center (NCDC) and displayed on the Safety Board's Man-computer Interactive Data Access System (McIDAS) workstation. The infrared longwave and shortwave imagery (band 4 and 2) at a wavelength of 10.7 microns ( m) and 3.9 m, respectively, provided a 4-kilometer (km) resolution with radiative cloud top temperatures. The satellite imagery surrounding the time of the accident from 2000 through 2130 on February 10, 2005, approximately every 15 minutes were reviewed.

The GOES-10 longwave band 4 image for 2030 on February 10, 2005, at 4X depicted an extensive area of overcast skies over southern California, which extended over the accident site. Several bands of enhanced clouds associated with precipitation extended over the area oriented in northeast-to-southwest bands. The accident site was located on the southern edge of one of these bands. The radiative cloud top temperature over the accident site was 233.70 degrees Kelvin or -39.46 degrees C, which corresponded to cloud tops near 28,000 feet based on the KVGB sounding.

1.4.2.4 Pilot Reports

Pilot reports (PIREPs) were recorded over California surrounding the time of the accident. The following reports are in chronological order and in standard format but in narrative form versus standard code and abbreviations.

Bakersfield (BFL) routine pilot report (UA); Over - over the route from Watsonville (WVI) to Bakersfi

NTSB Probable Cause

the pilot's in-flight loss of control due to the flight's encounter with unforecasted localized mountain wave activity with severe to potentially extreme turbulence, downdrafts, and rotors.