NTSB Factual Report

HISTORY OF FLIGHT

On June 19, 1999, at 1103 hours Pacific daylight time, a Cessna 182A, N4824D, collided with terrain during the takeoff and initial climb from the municipal airport in Paso Robles, California. Blue Sky Adventures was operating the airplane under the provisions of 14 CFR Part 91. The commercial pilot and four skydivers were onboard for the local skydiving flight. The pilot and two passengers sustained fatal injuries in the ground collision sequence. Two passengers sustained serious injuries, but one of these passengers succumbed to her injuries the day after the accident. The airplane was destroyed. Visual meteorological conditions prevailed and no flight plan had been filed.

The Safety Board Investigator-in-Charge (IIC) interviewed the survivor. He said the airplane was configured with one seat for the pilot and a 2-inch foam pad for the skydivers. The survivor, who was in position 2, was facing aft and leaning against a bulkhead in what would normally be the front right seat position. He said two female jumpers occupied the middle section of the cabin and faced aft. The jumper in position 3 was leaning against the back of the pilot's seat and the jumper at position 4, who survived for 1 day, was leaning against the knees of the survivor. He stated that the fourth jumper, who was the owner of the airplane, was facing forward and kneeling in the rear of the cabin. He thought the seat belt was secured under the fourth jumper's leg straps, which he said was a common practice for skydivers. He said the other skydivers had their seat belts fastened.

The survivor stated that he made a jump from the accident airplane earlier in the day. The owner of the airplane was the pilot for that four-person jump. After landing, the survivor was taken to a hangar, where he repacked his parachute. He estimated about 30 minutes passed before he and the other skydivers loaded into a pickup truck to be taken to the airplane for the next jump.

A witness observed the pilot taxi to the fuel pumps, refuel the airplane, open the cowling, and check the oil level. He did not recall observing her drain any fuel from the airplane. A pickup truck delivered the skydivers while the pilot was pushing back from the pumps. The survivor stated that he helped the pilot finish pushing the airplane back from the fuel pumps, and did not recall the pilot draining fuel or completing a preflight inspection in his presence.

Winds were reported from 290 degrees at 11 knots and other airplanes were using either runway 31 or 01. Witnesses observed this airplane taxi to taxiway Charlie and depart midfield on runway 19, with 3,200 feet remaining. Witnesses stated that the initial climb after liftoff appeared extremely steep, and then the airplane descended as steeply as it climbed. Witnesses estimated the peak altitude was between 200 and 800 feet above the terrain.

The survivor stated that as the airplane was getting to speed he felt it go a little left, but that was corrected. Then it felt like the airplane went straight up, climbing on an angle he estimated to be at least 45 degrees.

From the time of liftoff until the ground contact, the survivor remembered the pilot "furiously working" her right hand. His head was level with the pilot's thigh; however, his parachute positioned him away from the instrument panel so he could not see what she was touching. He remembered that she reached to the right, but was vague about whether she was rolling something or working her arm up and down. He detected an expression of concern on the pilot's face. He said she maintained her normal sitting position and her seat definitely did not move forward or aft.

PERSONNEL INFORMATION

Federal Aviation Administration (FAA) records indicated the pilot held a commercial, airplane single land certificate and an instrument airplane rating. FAA records indicated a second-class medical was issued on June 2, 1998, with the restriction the pilot must wear corrective lenses, and possess glasses for near and intermediate vision.

The pilot's family supplied partial pilot logbook records, consisting of copies of the last seven logbook pages, as requested by the Safety Board IIC. On a form supplied to an insurance company dated April 12, 1998, the pilot stated she had 576 hours in a Cessna 177RG. Review of the records supplied revealed a total time of over 1,230 hours as of June 18, 1999, with over 1,170 hours as pilot-in-command. In the records supplied, the first entry noting a flight in the accident airplane was on March 12, 1999. Five subsequent flights were logged in N4824D and one flight in another Cessna 182. In the remarks section, an entry dated June 8 had "solo," and a flight on June 13 had "jumpers." An entry on March 1, 1998, recorded a biennial flight review.

AIRCRAFT INFORMATION

The data plate indicated the airplane was a Cessna 182A, serial number 34924. Family members could not locate the airplane's logbooks. The investigator located a copy of 1 page, which recorded weight and balance information as of November 20, 1992.

The IIC obtained certified copies of the airplane and registration files from the FAA Aircraft Registry in Oklahoma City, Oklahoma. A review of the airplane file revealed an application for standard airworthiness certificate when the airplane returned to United States registry from Canadian registry in 1992. That application listed the total airframe time as 2,998.1 hours. The airplane was registered to the current owner on June 2, 1995.

The 1992 application for the airworthiness certificate listed the engine as a Teledyne Continental Motors (TCM) O-470-L model, serial number 17026. The data plate on the engine at the accident site indicated it was a TCM TSIO-520-R Modified (1). An additional data plate read "Ponk Aviation O-470-50, STC #SE498 8 NM, SER NO 2125." This data plate was also stamped with, "MAX RPM 2700, CID 520, 100 LL, MC 285, MTO 310." Investigators did not find an FAA form 337 (major repair and alteration) in the certified copy of the FAA airplane file, which recorded installation of this engine on this airplane.

The most recent weight and balance information that investigators found was the logbook entry recorded on November 20, 1992. This record noted removal of the front seat and the addition of a jump step and seat belts and brackets. The airplane's total empty weight was 1,684,8 pounds, with a total moment of 59,047.71 inch-pounds at a center of gravity 35.05 inches aft of the datum.

The IIC used the pilot's medical certificate to determine her weight and a police report, which listed the weights of the skydivers as shown on their drivers' licenses. The survivor estimated the weight of each occupant's parachute rig. The IIC assigned the total weight of each skydiver plus their rig to the seat location listed in the airplane's owner's manual.

The left wing fuel tank ruptured and was empty. During recovery, investigators estimated that about 20 gallons of fuel remained in the right wing tank. Fuel receipts from the self-serve fueling station recorded two fuel sales within the hour prior to the accident. One was for 18 gallons and the last sale prior to the accident was for 14.98 gallons. The IIC used 20 gallons for the total amount of fuel on board at the time of the accident.

The IIC computed an estimated total weight at the accident site of 2,729 pounds, and a total moment of 120,498 inch pounds at 44.15 inches aft of the datum. The owner's manual indicated that the maximum certified gross weight of the airplane was 2,650 pounds, and the chart for the center of gravity envelope did not extend above this weight.

A company document found in the airplane indicated maintenance was completed the day before the accident at the airplane's home base in Davis, California. The document indicated the oil and filter were changed, the spark plugs were cleaned and rotated, and a compression check was satisfactory. Tachometer time was listed as 305.0. The next line of the document noted 30 gallons of fuel at Davis. A ferry flight from Davis to Paso Robles was completed on June 19, 1999, at a tachometer time of 306.61. The next entry was "load # 1, alt 13, # jum 4." Investigators read the number 7.23 on the tachometer at the accident site.

METEOROLOGICAL CONDITIONS

An aviation routine weather report (METAR) issued for Paso Robles at 1053 indicated: skies clear; visibility 30 statute miles; temperature 75 degrees Fahrenheit; wind from 290 degrees at 11 knots; and altimeter 29.94.

AERODROME INFORMATION

The Airport/Facility Directory, Southwest U. S., listed Paso Robles Municipal Airport's elevation as 836 feet above mean sea level (msl). It indicated runway 19 was asphalt, 6,009 feet long by 150 feet wide.

WRECKAGE AND IMPACT INFORMATION

The first identified point of ground contact (IPC) was measured on a map and determined to be 1,200 feet from the departure end of runway 19. Two furrows about 4 feet apart were observed in sandy soil. About 4 feet later, a third furrow started 4 feet left of the others. Ground scars were continuous from the IPC to the wreckage along a magnetic bearing of 190 degrees. About 10 feet from its starting point, the center furrow spread to a crater about 4 feet wide, 18 feet long, and 6 inches deep at the deepest point. Part of the nose gear fork was found 1 foot past the end of the crater. Sixty-four feet past the IPC, the ground scar proceeded through a 1-foot high berm and a section of barbed wire fence. The jump step was on centerline 64 feet from the IPC. About 10 feet right and next to a piece of remaining fence was the left wing tip. The ground scaring, debris, and barbed wire then crossed a road and went into a flat field.

The main wreckage was 217 feet from the IPC. The fuselage fractured and separated ahead of the dorsal fin; the fracture was jagged its entire length. The cabin and wings were inverted and twisted; the right wing was on the left side. The cabin was aligned on a magnetic bearing of 210 degrees. The right wing strut was bent up almost 90 degrees and the right main landing gear was deformed up. Both wings exhibited aft and down crush damage on their leading edges. The empennage was upright and was aligned on a magnetic bearing of 300 degrees.

The control yoke fractured at the connecting joint; the fracture surface was irregular and grainy. Control continuity was established from the primary control surfaces to their connections on the bottom of the control yoke. The aileron balance cable fractured in a bomb burst pattern. The degree of fuselage destruction precluded determination of the stabilizer trim position. The flaps were found in the up position.

The engine and propeller separated from the aircraft, and were 293 feet from the IPC, on a magnetic bearing of 130 degrees. Two propeller blades were attached to the hub; the third was 10 feet away. Blade No. 1 had leading edge gouges and dents; it twisted 90 degrees in the fractured hub. Blade No. 2 was curled towards the face side about 150 degrees; it had gouges in the leading edge near the tip and scratches angled to the chord. Blade No. 3, which separated, had leading edge gouges and chordwise scratches. It twisted 90 degrees toward the cambered side. The spinner was flattened in the blade No. 3 attach area.

MEDICAL AND PATHOLOGICAL INFORMATION

The San Luis Obispo County Coroner, completed an autopsy on the pilot with specimens retained for toxicological testing, both by the county laboratory and the FAA Toxicology and Accident Research Laboratory in Oklahoma City. The results of analysis of the specimens were negative for carbon monoxide, cyanide, volatiles, and all screened drug substances.

SURVIVAL ASPECTS

One of the first rescuers to respond on scene reported seeing the pilot and her seat suspended by the seat belt as the airplane lay upside down. This witness also noted that the survivor in position No. 2 was suspended by his seat belt. The rescuer walked around the airplane and checked on the three other occupants, who had been ejected. As he walked around the tail to the south side of the airplane, he saw the survivor crawling onto the wing and assumed he must have unbuckled himself. The rescuer stated that the seat belt behind the pilot was dangling from the inverted floor and was not latched. The rescuer did not recall the position of the other seat belts. The skydiver from position No. 4, who lived for a day, was found several feet south of the tail when the airplane came to rest. The skydiver from position No. 3 was several feet north of the tail, and skydiver from position No. 5 was partially under the left horizontal stabilizer.

Rescue personnel cut the pilot's seat belt during recovery. All of the other seat belts were disconnected and dangling when the IIC arrived on scene. Investigators did not observe any abnormalities with the disconnected seat belt's webbing or buckles. Investigators operated all of the buckles without difficulty.

TESTS AND RESEARCH

Investigator's examined the wreckage at Aircraft Recovery Service in Compton, California, on June 20, 1999. They rotated the engine manually and all the valves moved freely. They obtained thumb compression on all cylinders. They removed the top spark plugs for inspection; the spark plug for cylinder No. 1 fractured during removal. The electrodes exhibited no mechanical damage; however, the plugs in cylinders No. 4 and 6 were wet. Investigators observed spark from the ignition harness leads for each cylinder when they rotated the engine. The carburetor was damaged, but its finger screen was clean. The fuel strainer screen was clean. Investigators disassembled the engine and noted no unusual condition of any internal component.

Section I of the owner's manual described the airplane's systems, including the "Adjustable Stabilizer Control Wheel." It noted that the airplane's design enabled the entire horizontal stabilizer to be trimmed to meet different load and speed conditions. Movement of the adjustable stabilizer control wheel, which was located on the center consul area to the left of the flap handle, adjusted the stabilizer. Forward rotation trimmed the nose down, and backward rotation trimmed the nose up. This section noted, "control wheel loads are very heavy when the stabilizer is not properly set." Takeoff should be made with the trim set in the "TAKEOFF" position. The aircraft was not equipped with an electric trim system.

Investigators measured 7 7/8 inches between the centerline of the mounting bolt of the adjustable horizontal stabilizer and a reference point on the airplane. The manufacturer's representative said this equated to -7 degrees nose down position, and the "TAKEOFF" position was -3 1/2 degrees nose down position.

ADDITIONAL INFORMATION

Section II of the Owner's Manual listed in checklist form the steps necessary to operate the airplane efficiently and safely. Item 4 of the "Before Starting the Engine" check list instructed the pilot to rotate the adjustable stabilizer trim control wheel so that the indicator was in the "TakeOff" range. Item 2 of the "Before TakeOff" checklist instructed the pilot to recheck the adjustable stabilizer trim control wheel setting.

The wreckage was released to the owner's sister.

NTSB Probable Cause

the pilot's failure to set the trim as prescribed by the published check list. This led to a steep climb angle which caused the airspeed to decay, resulting in a stall at an altitude too low to allow recovery.