NTSB Factual Report

HISTORY OF FLIGHT

On December 21, 2005, at 2046 Pacific standard time, a Cessna 172, N7383A, impacted terrain following a loss of control near Gilroy, California. The non-instrument rated private pilot and his three passengers were fatally injured. The pilot operated the airplane under the provisions of 14 CFR Part 91 as a personal flight. Night instrument meteorological conditions prevailed and a flight plan was not filed for the cross-country flight, which departed the South County Airport (E16), San Martin, California, around 2035. The flight was destined for Fresno, California.

According to a friend of the pilot, who was also the owner of the airplane, the pilot flew from Fresno to E16 because he had a business in San Jose, California, and was dropping off some parts for that business. He brought along members of his family, and they stayed in San Martin for a couple of hours and went to a movie while waiting for some weather to clear before returning to Fresno. The friend asked the pilot to stay at his place for the night since the weather had not improved much, but the pilot declined the offer.

The following information was obtained from the Oakland Flight Service Station (FSS) weather briefing given to the pilot between 1908 and 1923. The pilot called the FSS indicating that he wanted to know if "conditions are good for a flight from South County to Fresno Chandler." The pilot informed the briefer that he was flying a Cessna 172 and it would be a visual flight rules (VFR) flight. The controller informed the pilot that VFR flight was not recommended, as there were widespread rain showers for the northern half of the route almost all the way to Fresno. He added that AIRMETS (Airman's Meteorological Information) were still in effect for the northern half of the route for IFR (instrument flight rules) conditions, mountain obscuration, and, for the entire route, for occasional moderate turbulence, as well as moderate rime or mixed icing above 9,500 feet. The briefer added that there were reports of marginal VFR conditions around the Monterey Bay and the southern part of the San Francisco Bay, with the worst of it being at Watsonville, California, where the ceiling was reported as 200 feet overcast.

The briefer further stated that the ceiling at Reid Hillview, California, was broken at 2,200 feet and overcast at 8,000 feet. The briefer stated that the conditions improved near the San Joaquin Valley, with the lowest ceiling in that area being reported over Merced, California, as 7,500 feet. Weather in the Fresno area was provided as 5 miles in haze with a few clouds at 10,000 feet, broken clouds at 13,000 feet, and overcast at 20,000 feet. He then provided the pilot with a pilot report (PIREP) indicating that the flight crew of a Boeing 737 reported low-level wind shear (LLWS) at San Jose, California. The pilot asked what altitude the LLWS was reported, and was informed it was between 600 and 400 feet above ground level (agl). The pilot responded by indicating that he didn't think the LLWS would apply to his flight since he was "too far south."

The briefer then informed the pilot that the weather radar data depicted a "bit of a break right there near South County, but more light to moderate precip[itation] [was] spreading out just west of Merced, then a solid area of light precip[itation] [was] between Merced and Fresno, right below the mountain." The pilot responded by indicating that, "Yeah, um it seems like it's...it seems like...it's pretty good. The visibility where I'm at is pretty close." He then asked what the overcast cloud elevation was for E16. The briefer responded by indicating he did not have a PIREP for E16 and that it was difficult to say since the weather reports depicted the clouds at 200 feet overcast at Watsonville and 2,200 feet broken at Reid Hillview. The pilot then asked about Salinas. The briefer informed the pilot that the weather reports at Salinas indicated 10 statute miles visibility in light rain, a few clouds at 1,500 feet, and a broken ceiling at 2,400 feet, and an overcast ceiling at 3,300 feet.

The pilot responded with, "So, I'm not going to be able to go over that hump" and then asked what the outlook was for the next day. The briefer informed the pilot that the forecast for the next morning was for marginal VFR conditions with multiple cloud layers between 2,000 and 3,000 feet with visibility between 3 and 5 miles in light rain and mist. He then informed the pilot that, "if anything, it might be a little bit worse out toward Fresno tomorrow." The pilot said, "Okay, but definitely not further south. So the conditions aren't as bad actually further north closer to Reid Hillview than it is to Salinas." The briefer responded with, "right", and the pilot ended the conversation.

The pilot departed South County (an uncontrolled airport) after obtaining 19.43 gallons of 100 low-lead aviation gasoline from a self-service fuel pump (the time on the fuel receipt was 1942:03). After departing, the pilot attempted to contact the San Jose control tower to request flight following. San Jose was unable to make radar contact with the airplane and suggested the Northern California Terminal Radar Approach Control (NorCal TRACON). The pilot contacted NorCal TRACON at 2041:07, and said he had a problem. He then said that he would "like to land at 290 or uh E16, but uh I'm having trouble. I'm trying to fly VFR and I've lost my bearings." The controller asked the pilot to squawk 0342, ident, and to say his altitude. The pilot repeated the transponder code and informed the controller that he was at 2,800 feet.

At 2042:13, the pilot said, "approach request assistance now, I have a problem." The controller informed the pilot that he did not know where he was and again asked the pilot to squawk 0342. He then asked the pilot if he was about 2 miles east of South County, to which the pilot responded, "Correct, that is my position." The controller then asked the pilot what he could do for him, and the pilot responded, "(unintelligible) find my place and my uh, my uh, um attitude indicator is messed up." The controller asked the pilot if he was in IFR or VFR conditions, and the pilot informed him that he was IFR. At 2042:53, the controller reported to the pilot that South County was west of his position, about 2 miles. The pilot then requested a bearing. The controller informed him that he could not confirm the pilot's position, but believed he was 2 miles east of South County and suggested a westbound heading and informed the pilot that the MVA (minimum vectoring altitude) in his area was 4,000 feet.

At 2043:46, the controller asked the pilot if he was making left hand turns, "three sixties?" The pilot responded that he was and the controller asked him what he would like the controller to do. The pilot responded, "Um little excited up here. Losing, uh, I, I do not have my turn coordinator. It, it has gone out so I can't tell if I'm (unintelligible) wings level." The controller offered a no-gyro-vector, to which the pilot responded, "Anything that you could do, I would help. I am going up and I am going down. I have no control." The controller asked if the pilot's electrical system was working, and the pilot responded, "I do not [have] a directional gyro. I do not have at attitude indicator." At 2044:55, the controller instructed the pilot that if he was able, he was to stop his turn. The pilot responded with "please", which was the last communication received from the pilot.

A police helicopter had been flying in the area around the time of the accident and contacted the air traffic controller asking if they wanted him to look for the airplane. The controller said yes, and at 2057:29 asked the police helicopter pilot to report the weather when he got near South County. The police helicopter pilot informed the controller that he was "under it about nine hundred feet" and that there was a cloud in front of him. At 2101:53, the police helicopter pilot informed the NorCal controller that the "weather is really down low here at a couple hundred feet." The controller asked him to confirm that the clouds were at 1,200 feet, and the police pilot informed him that it was "200 feet off the deck at best."

The NTSB investigator-in-charge (IIC) requested radar data from the NorCal TRACON and was given a verbal briefing within a few hours following the accident. According to the controller providing the briefing, the radar data depicted the airplane entering a series of turns before they lost radar contact at an altitude of 2,300 feet mean sea level (msl).

About 2045, a park ranger at home in the area heard an aircraft engine making a straining sound and then saw a flashing glow type of light in the overcast clouds outside of his window. At 2047, the ranger called the Santa Clara County Sheriff Communications Center to report what he heard and saw. Other persons in the area of the accident site described the weather as poor, with rain, mist, fog and low clouds present around the time of the accident.

Search and rescue efforts were initiated but weather and the dark night conditions hampered the efforts. The airplane was located the following morning on the southern end of the Coyote Lake Park about one mile south of the lake. A global position system (GPS) receiver marked the wreckage location at 37 degrees 04 minutes north latitude and 121 degrees 31 minutes west longitude, at an elevation of 1,181 feet msl.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with a single-engine airplane rating. He was not instrument rated. He obtained his private pilot certificate on November 14, 2005. He was issued a third-class medical certificate, which was issued in July 2003, with limitations.

According to his last flight instructor, the accident pilot indicated an interest in completing the three hours of instruction needed to obtain his private pilot certificate. The instructor agreed to work with the pilot and finish his private pilot training. They flew in the accident airplane and the instructor described the pilot as "a very good stick". The instructor flew 6.5 hours with the accident pilot and logged 1.5 hours of ground instruction, though he believed there was more ground instruction that just was not logged. He added that he had flown 0.5 hours at night with the accident pilot. When asked if the instructor conducted training on recovery from inadvertent instrument conditions, the instructor responded that he had done unusual attitude recoveries with the pilot and the accident pilot logged about 0.6 hours of flight time with a view limiting device. He added that the flight examiner, who provided the accident pilot's private pilot check ride, indicated that the accident pilot had stumbled on some aspects of the aeromedical factors, airspace system, lost communications procedures, preparing for a night cross-country, planning for unforeseen delays, and unusual attitude recoveries. When asked if the instructor ever discussed go/no-go decision making or personal minimums with the pilot, the instructor said he had not.

According to the instructor, the accident pilot had an estimated total flight experience of 80 hours around the time of the check ride. A friend of the pilot's indicated that he believed the accident pilot accumulated around 120 hours of flight time.

AIRCRAFT INFORMATION

The 1957-model Cessna 172 (serial number 29483) was equipped with a Continental O-300B engine (serial number 12009-D-6-B). According to the registered owner of the airplane, he was in the process of selling the airplane to the accident pilot, but they had not completed the transaction and the airplane was still registered to him. The owner indicated that the accident pilot had taken custody of the airplane about 2.0 to 2.5 months prior to the accident and when he did so, the owner provided him with the airframe and engine logbooks, which the pilot usually carried in a duffle bag located in the airplane.

When asked if there were any mechanical problems with the airplane that he was aware of, the owner indicated that the airplane ran perfect and there were no problems. He did indicate that prior to the flight from Fresno to San Martin, a maintenance facility in Fresno changed the tachometer.

The owner indicated that the airplane had accrued about 1,930 hours of total time. The owner provided a receipt from the last annual inspection, which took place on February 24, 2005, at a tachometer time of 1,920.9 hours. According to the receipt, the #2 cylinder was replaced due to low cylinder compression. The owner added that the #5 cylinder was replaced about 4 to 6 months prior to the accident because the "engine would not produce full power."

When asked what instruments the airplane was equipped with, the owner indicated that it had the basic VFR instruments and an automatic direction finder (ADF) and a GPS. The owner reported that the accident pilot intended to convert the airplane to an instrument approved aircraft, but hadn't done so as of the time of the accident.

According to the pilot's last flight instructor, the airplane was not equipped with gyro instruments or a vacuum pump. He added that, "it didn't even have the venturis that were available on some models." The airplane instrument panel was equipped with a DC powered turn coordinator, a vertical card magnetic compass, a vertical speed indicator, an airspeed indicator, altimeter, a very high omni-directional range navigation instrument (VOR), and a hand-held GPS.

Review of the Cessna 172 owner's manual revealed that the instrument panel was not organized with today's standard primary flight instruments (two rows of three instruments, which include the airspeed indicator, attitude indicator, altimeter, turn coordinator, heading indicator, and vertical speed indicator). The accident airplane did have a needle and ball, electrically operated, turn coordinator.

METEOROLOGICAL INFORMATION

At 2253, the weather observation facility at Watsonville, California (15 nautical miles southwest of the accident site) reported the wind from 220 degrees at 10 knots, visibility 5 statute miles in mist, overcast clouds at 200 feet above the ground, temperature 16 degrees Celsius, dew point 15 degrees Celsius, and an altimeter setting of 30.12 inches of mercury.

A witness to the weather conditions on the night of the accident indicated that he was leaving the Home Depot (near Highway 101) in San Martin and heard an airplane fly over. The witness was shocked to hear the airplane, as the weather was "bad enough that [he] couldn't believe anyone was flying." He reported the weather as rainy, cloudy, and dark, and estimated the cloud bases to be between 400 and 500 feet above the ground.

WRECKAGE AND IMPACT INFORMATION

First responders described the terrain at the accident site as steep and treacherous. The airplane sustained significant impact and fire damage. A Federal Aviation Administration (FAA) inspector from the San Jose Flight Standards District Office (FSDO) responded to the accident site and documented the wreckage. The wreckage was then transported to Plain Parts in Sacramento, California, for further examination.

TESTS AND RESEARCH

On January 9, 2006, the NTSB IIC, along with the FSDO inspector and investigators from Cessna Aircraft Company and Teledyne Continental Motors, examined the wreckage at Plain Parts. The engine, cockpit/cabin, and inboard wing sections sustained severe fire damage. The vertical stabilizer/rudder and right side horizontal stabilizer/elevator remained intact and attached to the empennage. The left side horizontal stabilizer, with its elevator attached, separated from the empennage. Both horizontal stabilizers sustained leading edge deformation. Control continuity could not be confirmed due to the extensive damage and cable separations; however, all cable separations displayed a broom-straw appearance and did not show evidence of fatigue. All control surfaces were accounted for during the examination. The right wing leading edge displayed three rounded impact marks on the leading edge. The right horizontal stabili

NTSB Probable Cause

The non-instrument rated pilot's poor judgment to fly in dark night instrument conditions, which resulted in his spatial disorientation and loss of aircraft control while maneuvering. Contributing factors were the dark night light condition and the low ceiling.