NTSB Factual Report

HISTORY OF FLIGHT

On May 31, 2000, at 1209 hours Pacific daylight time, a Cessna 152, N5538M, was destroyed when the aircraft dove to the ground from approximately 300 feet agl while on left base leg for landing on runway 13R at the Palm Springs International Airport, Palm Springs, California. The commercial certificated flight instructor and the student pilot were fatally injured. Visual meteorological conditions prevailed for the instructional flight, which was operated under 14 CFR Part 91 by The Flight School At Palm Springs. The flight departed from Thermal Airport about 1150. No flight plan was filed.

According to recorded continuous data recording (CDR) radar data provided by the Palm Springs Air Traffic Control Tower, the aircraft departed Palm Springs at 1037 and performed some turning maneuvers, arriving in the area south of Thermal at 1126. The aircraft then proceeded to Thermal Airport where three touch-and-go landings were performed before proceeding to the area of Bermuda Dunes Airport. Without landing at Bermuda Dunes, the pilot contacted Palm Springs Terminal Radar Approach Control at 1157 for arrival sequencing back to Palm Springs. The flight was handed off to Palm Springs tower at 1202. The last six radar returns were recorded between 1209:05 and 1209:33 in the area about 1 mile north of Palm Springs airport. The decoded altitude was 800 feet msl and the course was approximately 220 degrees (airport elevation is 462 feet msl).

According to the supervisor at the Palm Springs Air Traffic Control Tower, when the aircraft was on base leg, the pilot was authorized to make s-turns for spacing on his landing approach due to another aircraft that was on the runway starting its takeoff. The accident aircraft was observed to start a left turn and then dive to the ground as it was on final approach.

Several witnesses reported observing the aircraft make an abrupt turn at 250 to 300 feet above ground level (agl) (some reported a left turn and some a right turn). The turn continued for 360 or 720 degrees rotation, then the nose dropped and the aircraft dove to the ground in a residential street.

One witness, who heard the aircraft from his residence about 1/2 block south of the accident site, reported that the engine was "sputtering" and then stopped entirely 1 or 2 seconds before it dove to the ground. The sound was "like it was running out of gas." He reported there was no wind. He added, "You remember that because this is the windy end of town."

Another witness observed the aircraft from 2 blocks east of the accident site. He said his attention was drawn to the aircraft because of its low altitude, which he estimated at 250 - 300 feet agl with no engine noise. He thought the position was normal for a landing aircraft but too low. As he watched the aircraft proceed on a northwest-bound heading, then did a 720-degree left turn, then the nose dropped, and the aircraft went straight down. He reported the wind at his location was calm but volunteered that the wind varies greatly in the area where the accident occurred.

Still another witness, who lives about 2 blocks north of the accident site, reported that the wind was blowing hard in the area of her residence on the morning of the accident. The wind was calm until about 0800 but then the wind came up and blew hard. She estimated 40 miles per hour. She was cutting her lawn and the wind was blowing the cuttings into her swimming pool. The wind was coming from the west out of the Banning Pass. At the time of the accident this witness was driving south on Farrell at Via Escuela, the first cross-street north of the accident site. Her Jeep didn't have air conditioning so she had the windows open. She heard the airplane approach from behind her on the left. Her attention was drawn to it because it sounded lower than normal. As it passed over her she thought it was lower and slower than normal. She estimated it was "half a block high." The engine sounded uneven but she said the wind in the desert does that. As she watched, the planes wings tilted to the left until they were perpendicular to the ground. Then the airplane rolled abruptly to the right until the wings were perpendicular the other direction, then it turned a full circle, and the nose went straight down and the airplane crashed. She got out of her car and called 911. As she got out of her car, the wind blew her hat off and blew it across the street into the yard of a house. About 10 minutes later, the wind stopped and it became completely still.

PERSONNEL INFORMATION

According to records provided by the Federal Aviation Administration (FAA), the pilot was issued a flight instructor, airplane, single engine, land, certificate on April 4, 2000. FAA records show that the pilot was previously issued "Notice[s] of Disapproval of Application" for the flight instructor certificate on March 10, 2000, February 21, 2000, and January 3, 2000. According to the owner of The Flight School at Palm Springs, the pilot was hired May 1, 2000.

According to the flight instructor's logbook, he had 363 hours total flying time at the date of the accident. He had 248 hours on April 4, 2000, when the flight instructor certificate was issued and had no additional flying time until May 2, 2000. During the month of May the pilot flew 103.3 hours, of which 97.9 were logged as instruction given.

The pilot's girlfriend reported that they went out the night before and met the student who had arrived that day from Italy. The pilot slept from about 0030 to 0800 the next morning. He was well and healthy and was not taking any medications.

According to another flight instructor at The Flight School at Palm Springs, the student was an Italian citizen who had arrived in the United States the previous day for the purpose of receiving fixed wing flight training. The student reportedly had about 60 hours of helicopter flight time acquired from an aviation college in Italy. He held the Italian equivalent of a private pilot's certificate in rotorcraft.

AIRCRAFT INFORMATION

A flight instructor who flew the previous flight of the aircraft on the morning of the accident reported that flight, with a student, remained in the traffic pattern and consisted of four takeoffs and landings. It lasted 0.6 hours (hour meter time). The aircraft was full of fuel when they departed and was not refueled after their flight. He said there were no deferred maintenance items on the aircraft (squawks), and the run-up was normal with slight spark plug fouling on one magneto that they were able to burn off by leaning the mixture. The aircraft flew normally throughout the flight and the instruments remained in the normal range. During at least one landing they slowed the aircraft sufficiently that the stall warning horn sounded. He didn't recall the "inoperative" placard found in the wreckage but thinks it may have been on the clock. This aircraft was only used for VFR instruction and the clock was not required.

According to the aircraft logbooks, the last maintenance performed on the airplane was an annual inspection on April 13, 2000. The aircraft had flown 57 hours since the annual inspection and the engine had accumulated 102 hours since overhaul.

The flight instructor who flew the previous flight also reported observing the instructor and student involved in the accident do a detailed preflight examination of the aircraft since this was the student's first fixed wing aircraft flight.

According to the aircraft charge sheet found in the wreckage, at the start of the above, 0.6-hour flight, the recording tachometer read 5,727.27 hours and the hour meter read 2,901.9. At the end of the 0.6-hour flight, the hour meter read 2,902.5 hours and the recording tachometer read 5,727.64 hours. At the accident site, the hour meter read 2,904.4 hours and the tachometer read 5,729.26 hours. A weight and balance calculation, based upon assumptions developed by the Safety Board investigator (attached), showed the aircraft to have been within approved weight and center-of-gravity limits at the time of the accident.

METEOROLOGICAL CONDITIONS

Surface weather observations taken at the Palm Springs airport between 0953 and 1353, reported clear skies and 10 statute mile visibility. At 0953, the surface wind was calm; at 1053, it was from 140 degrees at 6 knots; at 1153, it was variable at 3 knots; at 1241 and 1242, it was from 140 degrees at 8 and 10 knots respectively; at 1253, it was variable at 5 knots; and at 1353, it was from 340 degrees at 7 knots. In the same time period the altimeter setting dropped from 29.75 to 29.70 inHg, and the temperature increased from 88 to 97 degrees Fahrenheit.

According to correspondence from the Palm Springs Air Traffic Control Tower (attached), the airport does not have a low-level wind shear alert system (LLWAS). There were no reports (from pilots) of wind shear in the hour preceding the accident. There was one pilot report of wind shear at 1305 (about 56 minutes after the accident) by the pilot of an Embraer 120 aircraft. The report was: "Tailwind crossing the threshold, right down in the touchdown zone. Once we touched down it sheared right to a headwind." The Embraer was landing on runway 31L.

A retired FAA Flight Standards District Office inspector, who, after retirement from the FAA, worked several years as a pilot examiner in Palm Springs, reported that wind shear is common near Palm Springs in summer. He recalled one incident that took place during a pilot check ride. He and the applicant were returning to Palm Springs from Thermal in a Cessna 150. Because it was windy and turbulent they had been using 80 knots for approach and no flaps. While on final approach to runway 31L, about 1/4 to 1/2 mile from the runway, they encountered a strong downdraft. He took control of the aircraft and added full engine power. The airspeed dropped from 80 to 50 knots and he had to give up altitude to maintain airspeed. They "barely cleared the fence" and landed short of the runway in the overrun. He said there were no thunderstorms in the area. He attributed the turbulence to an eddy off the mountains west of the airport and the northwesterly surface wind. In the course of the investigation, two other private pilots came forward to report similar experiences with wind shear near Palm Springs airport.

COMMUNICATIONS

The FAA's Southwest Region Quality Assurance Office provided transcripts of communications between the accident aircraft and Palm Springs Terminal Radar Approach Control and Palm Springs Air Traffic Control Tower. The transcripts are attached.

The pilot contacted Palm Springs Approach Control at 1156 and reported his position was 2 miles east of Bermuda Dunes, inbound with recorded airport information hotel. The aircraft was issued a transponder code and then instructed to "continue over the freeway at or above two thousand five hundred [feet] for left traffic runway one three right." At 1201, the aircraft was instructed to contact Palm Springs tower.

The Safety Board investigator listened to a re-recording of communications for the portion of the flight at the Palm Springs Air Traffic Control Tower local control position between 1158 and 1220. At 1202, the pilot contacted the tower over interstate highway 10, inbound to land on runway 13R. The voice of the pilot exhibited good English language diction. The tower instructed the pilot to continue inbound to the airport and the pilot acknowledged. At 1204, the tower controller instructed the pilot to "start your forty five to downwind now," and asked where the aircraft intended to park after landing. After the pilot replied, the tower transmitted "cessna three eight mike roger runway one three right cleared to land wind is one two zero at one two." It was still 1204 when the pilot acknowledged the clearance.

At 1205, the tower cleared American Airlines flight 1726, a McDonnell Douglas MD-80 aircraft, for takeoff on runway 13R. Approximately at 1207, the tower instructed flight 1726 to contact departure control. At 1208, the tower cleared Morning Star 125, a Beechcraft Hawker 125 aircraft, for takeoff on runway 13R. Also at 1208, the tower transmitted "cessna three eight mike hawker departing prior to your arrival caution wake turbulence wind is one two zero at two." The pilot of the accident aircraft acknowledged that he had the traffic in sight.

At 1209, the pilot transmitted "ahh palm springs tower cessna five five three eight mike are we cleared for the left or the right," and the tower controller replied "cessna three eight mike runway one three right - uh - cleared to land make a slight s turn out there for spacing." There was no further communication with the aircraft.

In the time period between 1158 and 1210, the Safety Board investigator heard no other arriving aircraft in communication with the tower and only the two departing aircraft mentioned above.

The facility chief at Palm Springs Air Traffic Control Tower reported that 13R was used in order to minimize taxiing distance for the aircraft after landing, and because traffic volume was very light. While the accident aircraft was on left base leg, the Hawker 125 aircraft was in position on runway 13R. As he turned final, the pilot asked the tower whether they wanted him to land on the left runway or the right, and was told to continue for the right and that S-turns were approved. While on final, the aircraft started a left turn and spun to the ground.

WRECKAGE AND IMPACT INFORMATION

The accident location was in a residential area approximately 1/2 mile northwest of the paved end of runway 13R (runway 13R has a displaced threshold of 2518 feet). The wreckage was in the street and driveway of a residence at 2012 N. Farrell Drive. The latitude was 33 degrees 50.850 minutes north and the longitude was 116 degrees 31.170 minutes west (GPS). The elevation was approximately 500 feet. All of the aircraft was present at the site and there was no fire.

Farrell Drive is a wide, two-lane road aligned north south. There are two 12-foot-wide traffic lanes and a 20-foot-wide paved shoulder on each side. The wreckage came to rest facing west on the eastern extremity of the shoulder with the engine and cockpit in the asphalt portion of the road; the main landing gear in the drainage gutter; and the tail cone/empennage in the driveway of the residence. The wings were aligned northwest-southeast across the cockpit.

The component parts of the aircraft remained attached with two exceptions. The upper engine cowling was laying in the street adjacent to the engine to the south and the propeller, which separated from the crankshaft propeller flange at the bolting interface, was laying in the street about 5 feet southwest of the engine. The right and left wings remained attached to the fuselage by means of the cabin ceiling carry-through structure and the wing struts; however, the wing as an assembly was skewed about 20 degrees with respect to the fuselage in a left-wing-aft, right-wing-forward direction. There was a linear crushing plane from the nose of the fuselage along the leading edge of the left wing. The leading edge of the left wing was crushed aft to the forward spar at the root end and aft to the aileron at the wing tip. Laterally, the plane of the crushing was linear and vertically, the plane of the crushing was flat and at right angles to the wing chord. The right wing exhibited more modest crushing damage to the leading edge outboard of the wing strut attachment.

When viewed from the rear, the tail section of the fuselage was deformed about 20 degrees to the left with respect to the cockpit area. There was a large compression wrinkle on the left side of the fuselage aft of the baggage compartment, but only a modest compression wrinkle on the right side. The flange of the left main landing gear wheel was broken over about 1/2 its circumference, while the corresponding part on the right main landing gear was visibly undamaged.

Flight control and flap cable continuity was verified. The flaps were extended about 30 degrees and the elevator trim was neutral. Early responders reported that at l

NTSB Probable Cause

The failure of the pilot/flight instructor to maintain sufficient airspeed to prevent the aircraft stalling and spinning. Factors in the accident were terrain induced windshear and sudden wind shift and the pilot/flight instructor's lack of total experience.