NTSB Factual Report

HISTORY OF FLIGHT

On June 9, 1996, about 0846 hours Pacific daylight time, a Cessna 172N, N734FB, collided with terrain and a railroad track while on climb out from Bermuda Dunes airport, Bermuda Dunes, California. The aircraft was destroyed and the private pilot and his two passengers received fatal injuries. The aircraft was being operated by Bermuda Air Service, Inc., and rented by the pilot when the accident occurred. The flight originated in Bermuda Dunes about 0804. Visual meteorological conditions prevailed at the time and no flight plan was filed.

A witness reported seeing the aircraft landing and then taking off from runway 28. She watched the aircraft as it climbed out, then as the nose pitched up, and finally as it pitched down and disappeared behind a tree line. A second witness reported seeing the aircraft accelerating in level flight, about 30 to 35 feet above the runway. He continued to watch the aircraft as its nose pitched up about 75 to 80 degrees and it climbed to about 600 feet agl. He then saw the aircraft suddenly roll to its right and then drop out of sight behind a tree line. A third witness reported seeing the aircraft on a steep climb out from runway 28. He stated that while the aircraft was still in an extremely nose high attitude it pitched forward and descended behind a tree line in a near vertical, nose-down attitude. He estimated the aircraft's altitude about 300 feet agl at the time it pitched forward. (Copies of the witness' statements are appended to this report.)

The aircraft was located on the Southern Pacific Lines railroad right-of-way approximately 0.15 miles from the departure end of runway 28.

A Riverside county coroner's investigator reported finding what he believed to be controlled substances in the pockets of the front seat passenger. A 35 mm metal film canister contained a green leafy material, while a matchbox was found to contain a bundle of a white powdery substance. Neither substance was subjected to chemical identification.

PILOT INFORMATION

A review of the operator's records revealed that the pilot had been checked out in a Cessna 172 on June 15, 1994. The information was last updated on May 24, 1995. The pilot's logbooks were not located; however, the CFI employed by the operator stated that the pilot flew about twice a week. The pilot's private pilot certificate was issued on June 10, 1994. (A copy of the operator's form is appended to this report.)

According to FAA inspectors, the pilot was scheduled to have surrendered his pilot's certificate for a 120-day suspension on June 11, 1996. The suspension was the result of his second violation of FAR 61.15. The regulation requires that a pilot provide the FAA administrator a written report within 60 days of any motor vehicle conviction involving drugs or alcohol. The same regulation provides for the suspension or revocation of the pilot's certificate if a subsequent conviction occurs within 3 years. The pilot's first violation, which occurred on August 26, 1995, resulted from his failure to notify the FAA of a conviction for driving under the influence (DUI). That violation had been resolved administratively with the pilot being issued a warning letter as a final action on November 11, 1995. The pilot's second violation occurred on October 23, 1995.

A flight instructor employed by the operator said in a written statement that he had observed the pilot flying "in a reckless manner while doing touch and goes at Bermuda Dunes on runway 28." He said the pilot repeatedly pulled the nose up to almost stall angle and then leveled the aircraft. He warned the pilot over the radio that what he was doing was unsafe but that he replied that he had only slowed to 50 knots.

On the day of the accident, the instructor was in the run-up area when the pilot "taxied up excessively fast." (A copy of the instructor's statement is appended to this report.)

AIRCRAFT INFORMATION

The aircraft was modified in accordance with STC SA2196CE that increased the maximum certificated takeoff weight to 2,400 pounds and limits flap travel to 30 degrees. (A copy of the STC is appended to this report.)

A maintenance squawk sheet showed that on April 30, 1996, and on May 27, 1996, the aircraft was reported to have had a problem with the "flaps not retracting every time." The Safety Board found the flaps in the fully retracted position during the postaccident inspection of the aircraft. (A copy of the "Maintenance Squawks" is appended to this report.)

The aircraft had been serviced with 20.5 gallons of 100 LL aviation fuel on the day preceding the accident. (A copy of the Bermuda Air Service Gas Log is appended to this report.)

WRECKAGE AND IMPACT INFORMATION

All structural components of the aircraft were located at the accident site. Control continuity was established to all flight control surfaces. The flaps were found in a fully retracted position. The elevator trim indicator was nose up; however, the control wheel was destroyed. The left and right control columns were bent downward. The right horn on the left control wheel was fractured, as was the left horn on the right wheel.

The left front seat base remained attached to the seat rails; however, the seat base was broken. The forward right foot of the left front seat was fractured and separated from the base. The left front seat feet remained attached to the rail. The left front seat locking pin was found in the 5th hole from the rear of the seat rail. The right locking pin was found in the 8th hole from the rear. The left pin was intact, but the right pin was fractured at the cotter pin hole.

Both sets of front seat belts remained attached to the airframe. The left shoulder harness was attached to the left seat belt. Safety wire was wrapped around the shoulder harness locking stud in place of the nylon grommet. Both front seat belts were found unlatched; however, rescue personnel had previously removed both front seat occupants.

Both propeller blades exhibited leading edge nicks and gouges and polishing in the outboard sections. Chordwise scratches appeared near the last 2 inches of one blade with no perceptible bending or twisting. The second blade exhibited S-bending and twisting along with chordwise and diagonal scratching and polishing. The crankshaft flange was bent aft.

The fuel selector handle was found in the 'both' position, while the fuel valve was found between "right" and "both". The carburetor was separated at its mounting flange; however, the throttle/mixture controls remained attached with continuity to the cockpit. Fuel was found in the float bowl and accelerator pump well. The main jet, composite floats, and 2-piece venturi were intact and seated. The fuel inlet screen was clean and in place. All engine compartment fuel lines were secure and in place.

The vacuum pump was removed and the engine was hand rotated through drive pad. Thumb compression was established at each cylinder and valve train continuity was established. The cylinders were observed with a bore scope and did not exhibit any evidence of internal damage. The oil suction screen was found securely installed. It was removed and found to be free of any contamination. The oil filter was crushed and separated. It was cut open and found to be free of contamination.

The air intake was clean and unobstructed. The inner surface of the exhaust manifold was clean and light colored. The muffler was crushed and bent aft. It was sectioned with a carbide saw and found to be free of obstructions.

The single drive, dual magneto sparked at all leads during hand rotation of the crankshaft and the impulse coupler could be heard to snap during rotation. All eight spark plugs were found installed with all leads securely connected. According to the Champion "check-a-plug" guide AV-27, all the spark plugs electrodes displayed signatures consistent with normal operation.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed on all occupants on June 12, 1996. Toxicological samples were obtained from both front seat occupants and sent to the FAA Civil Aeromedical Institute for screening.

The pilot was found positive for ethanol, tetrahydrocannabinol carboxylic acid, methamphetamine and amphetamine. The front seat passenger was also found to be positive for tetrahydrocannabinol carboxlic acid, methamphetamine and amphetamine. (Copies of the FAA Forensic Toxicology Fatal Accident Reports are appended to this report.)

ADDITIONAL INFORMATION

The aircraft was recovered by National Aircraft Salvage and stored at their Long Beach airport facility. On June 11, 1996, the wreckage was released to a representative of the registered owner. (A copy of the release of aircraft wreckage is appended to this report.)

NTSB Probable Cause

the pilot's impairment of judgment and performance due to alcohol and drugs (methamphetamine, amphetamine, & marijuana), his excessive maneuvering (pull-up) after making a touch-and-go landing, and his failure to maintain sufficient airspeed, which resulted in a stall and subsequent collision with the terrain.