NTSB Factual Report

HISTORY OF FLIGHT

On May 25, 1993, at 0230 hours Pacific daylight time, a Cessna 172N, N4783J, entered instrument meteorological conditions and collided with hilly terrain while in cruise flight near Lompoc, California. The pilot was conducting a visual flight rules (VFR) personal flight. The airplane, registered to J and L Aviation, Inc., Palm Springs, California, and operated by Bermuda Air Services, Bermuda Dunes, California, was destroyed. The certificated commercial pilot and his passenger sustained fatal injuries. Instrument meteorological conditions prevailed at the accident site and a VFR flight plan was filed, but not activated. The flight originated at Palm Springs Regional Airport at about 2335 hours.

A witness located at Bermuda Air Services reported that the pilot left Bermuda Dunes Airport in the accident airplane at about 1200. His intermediate destination was to the Palm Springs Regional Airport, where the pilot worked.

The pilot filled out a flight itinerary form with Bermuda Air Services on May 24, 1993. He listed his route of flight as Bermuda Dunes (UDD) Airport, direct to Palm Springs Regional Airport (PSP), direct to Palmdale (PMD), direct to Lompoc Airport (LPC). He said he intended to stop at Palm Springs Regional Airport to complete his work shift. (See item 8,b for further information.)

The pilot called Hawthorne Flight Service Station at about 2258 hours and received an abbreviated weather briefing. The pilot filed a VFR flight plan with a proposed takeoff time of 2330 hours. The pilot did not activate the flight plan.

According to time clock records provided by the pilot's employer, the pilot worked from 1500 hours to 2230 hours on May 24, 1993.

A witness who works for the Palm Springs Airport Police told Safety Board investigators that he observed the pilot taxiing the airplane away from the Million Air hanger, where the pilot worked, at about 2335 hours.

He said the pilot announced his intentions to depart on runway 31R as he taxied out for departure. The airport policeman called the pilot from a two way radio in his police truck and told him, "31 left is the active runway." He said he received no response. He said he observed the pilot of N4783J depart on 31 right, which is a closed runway from 2200 hours to 0600 hours. The runway has no runway lights on during the closed period of time. The airport policeman said that "it's unusual for him to takeoff on the closed runway...he worked at the airport and knew it was closed." (See items 8.6 and 8.7 for additional information).

There were no eyewitnesses to the actual accident sequence. However, one ear-witness reported that between 0200 to 0215 hours, he heard a noise he could not identify. He said his house is located about 900 feet mean sea level. The ear-witness said, "weather was about one mile in drizzle and light rain, and all mountain tops were obscured with zero visibility."

Another ear-witness said he heard an airplane fly over about 0100 hours. He said it started raining about 1900 hours the day prior to the accident. He estimated that visibility was less than 50 feet with a misting, light rain. He said it was foggy the next morning when he woke up.

On May 25, at about 0930 hours, the Lompoc Sheriff's office received a telephone call from Vandenberg Air Force Base (AFB) informing them that they may have a possible search and rescue mission. The caller told the sheriff's office that they were receiving an emergency locator transmitter (ELT) signal, but had not determined the location of the signals.

At about 1310 hours, the Santa Barbara County Sheriff's Department dispatched officers to Migulito Canyon Park to confirm reports of a downed airplane. According to the Sheriff's report, the peaklocated s of the hills in the area were shrouded in fog. There was an occasional light drizzle. When the fog lifted, a United States Air Force rescue helicopter was dispatched from Vandenberg AFB, and visually sighted the airplane wreckage on a hillside located on the J.P. Larsan Ranch. Fire and Sheriff's units responded and found the airplane wreckage and the remains of the two occupants.

CREW INFORMATION

The pilot held a commercial pilot certificate with airplane single land, multi-engine land, and an airplane - instrument ratings; the multi-engine rating was endorsed for VFR only. The most recent second class medical certificate was issued on January 21, 1993, with no limitations.

Safety Board investigators recovered the pilot's logbooks. The pilot's total aeronautical experience consisted of about 325 hours, with about 70 flight hours in the Cessna 172.

The pilot had accrued about 29 hours of night flight experience, 24 of which were listed as pilot in command. The pilot had logged 2 hours of "actual" instrument flight time, and 50 flight hours of "simulated" instrument flight time. The pilot received an instrument competency check on December 20, 1992.

The pilot had complied with the biennial flight review requirements of the current federal air regulations by receiving his commercial pilot certificate on April 30, 1992.

AIRCRAFT INFORMATION

The operator, Bermuda Air Services, provided the Safety Board with the airplane's maintenance records. The airframe and engine flight hours reflected on page 4 of this report were derived from the maintenance records examination. The records examination disclosed that maintenance personnel completed the last 100 hour inspection on May 21, 1993. The airplane had accrued 7.6 hours since the last inspection.

The pilot rented the accident airplane with a hobbsmeter reading of 460.9 hours. The hobbsmeter indicated 464.6 hours at the accident site.

An examination of the "maintenance squawk sheet" for the accident airplane revealed a write up concerning the "ADF inoperative", written up on April 7, 1993. The co-owner of Bermuda Air Services told Safety Board investigators on June 30, 1993, that he "recalled somebody saying something about the directional gyro processing, but said he had no recollection about the ADF being written up as inoperative."

AIDS TO NAVIGATION

All of the navigational aids along the airplane's flight path were operating. Lompoc Airport is served with a very high frequency omni range (VOR) and a nondirectional beacon (NDB) approach procedure.

Safety Board investigators found the NDB approach plate clipped open in the cockpit area. There is no record that the pilot requested an instrument approach to Lompoc from any FAA air traffic control facility.

METEOROLOGICAL INFORMATION

Instrument meteorological conditions were reported by ear-witnesses near the accident site throughout the evening prior to the accident. Search and Rescue personnel reported that the peaks of the hills in the area were shrouded in fog, and that there was an occasional drizzle. Their observation was taken at 1310 hours, or about 10 1/2 hours after the accident.

The pilot received an abbreviated weather briefing from Riverside Flight Service Station about 2258 hours before departing from the Palm Springs Airport. According to the flight service station, weather at the Lompoc Airport was reported to be: "1500 scattered, 2000 scattered, 2700 scattered, with a flight precaution for turbulence and icing."

Weather was obtained from the National Weather Service in Salt Lake City, Utah, for the Lompoc Airport. At 0215 hours, Lompoc reported "1900 overcast, with 10 miles visibility." At 0235 hours, Lompoc reported "measured 1700 overcast, with 10 miles visibility."

Santa Maria Airport, located about 15 nautical miles north of Lompoc reported the following surface weather observation at 0300 hours: "700 feet scattered clouds, measured ceiling 1200 feet broken clouds, 2500 feet overcast clouds, ten miles visibility with light rain." At 0342 hours, the surface weather observation was: "1400 feet scattered clouds, measured ceiling 1200 feet broken clouds, rain began 19 minutes past the hour."

WRECKAGE AND IMPACT INFORMATION

The accident site is located about 5 miles southeast of the Lompoc, Airport, Lompoc, California. The site is located on a hill with about a 24 degree upward slope. The hill is vegetated with bushes ranging in height to about 3 feet. Additional vegetation consists of small brush, scrub bushes and grass. The general area is rolling hills with higher hills at the crash site area.

The main wreckage was located on the slope of the hill at about the 1487 foot level which is about 50 feet from the top of the hill. The main wreckage consisted of the airplane, both wings, the empennage, and the engine. The wreckage ground path was oriented on a bearing of about 075 degrees, magnetic, beginning about 52 feet west of the main wreckage.

The airplane came to rest, inverted, on a magnetic heading of 272 degrees. Some small fragments of red glass and wing tip material were found about 20 feet from the ground scar on a magnetic bearing of about 325 degrees.

Control continuity was established from the cockpit to the elevator and rudder control surfaces.

The engine remained attached to the airframe. The crankshaft flange separated from the crankshaft, with the propeller attached. Cylinders number 2 and 4 exhaust risers displayed ductile crushing. The exhaust tail pipe was found crushed flat. All intake and exhaust risers remained attached.

Continuity of the gear and valve train assembly was established during the hand crankshaft rotation. Compression was produced in all four cylinders, using a pair of pliers to rotate the crankshaft. No preimpact mechanical failure of any rotating or reciprocating component of the engine was observed during the examination.

The alternator remained attached and sustained minor impact damage. The starter was partially separated from the engine.

Sparking was observed from the bottom numbers 2 and 4 ignition leads at the terminal end during hand crankshaft rotation of the left magneto. An impulse coupler was heard operating during the hand crankshaft rotation. The right magneto could not be tested.

All four bottom spark plugs were removed and visually examined. The electrode wear was normal, according to the Lycoming engine representative. Visual examination of all four plugs revealed that they were dry.

The fuel line from the gascolator to the carburetor was removed and clean, blue fuel was present. The inlet screen and the airplane's gascolator fuel screen was free of any contaminates. The carburetor housings were separated.

The propeller blades remained connected at hub/crankshaft flange. The blades exhibited chord wise scratches, leading edge nicks, and torsional "S" twisting. The spinner assembly displayed extreme aft crushing.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by Dr. R. M. Failing, County of Santa Barbara, on May 26, 1993. The autopsy listed the cause of death for the pilot as "Subarachnoid hemorrhage with concussion due to basal skull fracture". No preexisting physical or disease conditions were noted on the autopsy report which would have affected the pilot's ability to operate an airplane.

Toxicological examinations were performed for the Santa Barbara County Sheriff-Coroner's Office. Negative results for all screened drugs were reported for the pilot. Additional toxicological examinations were performed by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma. The report dated September 8, 1993, revealed that Nizatidine was detected in Urine.

According to the 47th edition of the 1993 Physicians' Desk Reference, "Nizatidine" is a histamine H2-receptor antagonist. It is indicated for the treatment of esophagitis, including erosive ulcerative esophagitis, and associated heartburn due to gastroesophageal reflux disease (GERD).

TESTS AND RESEARCH

The airplane's altimeter and turn and slip indicators were examined by Otto Instrument Service, Ontario, California, on July 7, 1993, under supervision of the Safety Board. The altimeter was pressure tested to 10,000 feet, with no discrepancies noted. Disassembly of the altimeter disclosed no obvious discrepancies which would have prevented the altimeter from working properly prior to impact.

The turn and slip indicator was bench tested and no discrepancies were noted. The ADF was examined by Gunnell Aviation, Santa Monica, California, on August 11, 1993. The avionics manager said the ADF unit and receiver were too severely damaged to be tested.

ADDITIONAL INFORMATION

The Safety Board released the airplane wreckage to Mr. Gary Wayne, insurance adjuster, Inflite Aviation Adjustment Group, Inc., Van Nuys, California, on August 11, 1993. Inflite Aviation Adjustment Group, Inc., represents the insurer's of the registered owner.

NTSB Probable Cause

VFR FLIGHT BY THE PILOT INTO INSTRUMENT METEOROLOGICAL CONDITIONS (IMC), AND HIS FAILURE TO MAINTAIN PROPER ALTITUDE (OR CLEARANCE) FROM MOUNTAINOUS TERRAIN. FACTORS RELATING TO THE ACCIDENT WERE: THE LOW CEILING, FOG, DRIZZLE, OBSCURATION, AND MOUNTAINOUS TERRAIN.