NTSB Factual Report

HISTORY OF FLIGHT

On February 15, 2005, about 0925 Pacific standard time, a Beech 95, N8269D, impacted the southeast side of Mount St. Helena while in cruise flight near Calistoga, California. The pilot was operating the airplane under the provisions of 14 CFR Part 91. The private pilot and one passenger sustained fatal injuries; the airplane was destroyed. The personal cross-country flight originated from Oroville Municipal Airport, Oroville, California, at an unknown time, with a planned destination of the Charles M. Schulz- Sonoma County Airport, Santa Rosa, California. Instrument meteorological conditions prevailed in the area surrounding the accident site, and a flight plan had not been filed.

On February 17, 2005, the Federal Aviation Administration (FAA) issued an alert notification (ALNOT) after receiving a notice from a concerned family member that the airplane was missing and overdue. Both the Civil Air Patrol and local authorities were notified of an overdue aircraft; several hours later the airplane wreckage was located.

Family members reported that the purpose of the flight was for the pilot to take his wife (the passenger) to a doctor appointment near Santa Rosa. They did not believe that he had flown her to that airport before, although she did accompany him on trip occasionally. The direct route of flight from Oroville to Santa Rosa is about 81 nautical miles (nm) on a course of 223 degrees true. The terrain during the first half of the flight is level, averaging about 50 feet mean sea level (msl). In the latter portion of the flight there are several mountain ridges that are oriented almost perpendicular to the flight path. The last mountain before reaching Santa Rosa is Mount St. Helena, which summits at 4,339 feet msl.

During the investigation, the recorded voice channels from Oakland Air Route Traffic Control Center and recorded radar data were obtained and reviewed by a National Transportation Safety Board investigator.

While the airplane was en route to Santa Rosa, the pilot was in communication with Oakland Center air traffic controllers receiving radar flight following services. At 0905:22, the pilot made his initial call to Oakland Center, announcing the airplane's altitude to be 6,500 feet. The controller responded, providing the Santa Rosa altimeter setting of 29.97 inches of mercury. At 0908:21, the pilot was instructed to change frequencies.

At 0908:51, the pilot made contact with Oakland Center sector R41 transmitting on a frequency of 125.85, restating that he was at an altitude of 6,500 feet. The controller responded, again providing the current altimeter setting. At 0916:38, about 11 minutes after the initial contact, the pilot made his last transmission stating that he was starting his descent for Santa Rosa. Around 0924, the controller lost radar contact with the airplane. In written statements, controllers at Oakland Center stated that the area where the wreckage was located is a common location to lose radar contact with aircraft.

Recorded radar data covering the area of the accident was examined for the time frame, and a discreet secondary beacon code target was observed that matched the anticipated flight track of the airplane en route from Oroville to Santa Rosa. The data was supplied by the Federal Aviation Administration (FAA) in the form of a National Track Analysis Program (NTAP) printout from Oakland Center.

A review of the data disclosed that the plot stretched over an 18 nm distance throughout a duration of 6 minutes 53 seconds, which equates to a radar derived ground speed of about 157 miles per hour (mph). The target was first identified at 0915:07 as it tracked southwest bound on a Mode C reported altitude of 6,300 feet. After several minutes, radar returns showed a gradual descent toward Santa Rosa. The last 4 nm of the radar plot occurs from 0920:24 to 0922:00, or over the course of 1 minute 36 seconds. During that last section of the plot, the radar returns indicated a varying altitude between 3,100 and 3,300 feet, with a radar derived ground speed of about 150 mph. The last radar return was recorded at 0922:00, at an altitude of 3,300 feet, about 1.45 nm from the accident location on a true course of 196 degrees.

The majority of the radar returns were all spaced uniformly and followed a track of about 228 degrees true. The data plots are contained in the public docket for this report.

The Beech Owner's Manual contains a "Cruising Operation" chart that displays the airplane's performance at a maximum gross weight of 4,000 pounds. The chart indicates that between 3,000 and 4,000 feet msl with the airplane configured at a power setting of 2,300 revolutions per minute (rpm), or 65 percent power, it will cruise at a true airspeed of about 180 mph. At a power setting of 2,200 rpm, or 55 percent power, the airplane will cruise at a true airspeed of about 167 mph.

Based on atmospheric conditions and assuming maximum gross weight conditions, the airplane's single engine service ceiling was estimated to be about 6,000 feet, with an absolute ceiling of about 7,500 feet.

PERSONNEL INFORMATION

A Safety Board investigator conducted a review of the pilot's personal flight records and the FAA airman and medical records files. He held a private pilot certificate with ratings for airplane single engine land and instruments. The pilot's most recent third-class medical certificate was issued without limitations on May 01, 2004.

The pilot's flight records were obtained from the family, and consisted of a bound logbook (dated from May 2002 to December 2003) and a printout of an electronic database (dated April 2004 to August 2004 and November 2004). The summation of flight hours from both log sources revealed that the pilot had accumulated 581.6 hours total time, with 94.1 in multiengine airplanes, and 88.6 hours amassed in the accident airplane. The logs additionally disclosed that he had accrued 18.9 hours of flight time in actual instrument flight conditions, which were completed in a Cessna 172 airplane. The pilot received his instrument rating on February 07, 2003, and recorded 16.9 hours of instrument time (both simulated and actual) after receiving the rating. There was no instrument time recorded on the electronic logs. A majority of the flights recorded throughout the logs were conducted within at least a week duration from the previous entry.

Based on the airport identifiers listed in the logs for flight origin and destination points, the pilot had never completed the same route as the accident flight. However, he had flown into Santa Rosa on two previous occasions, both of which originated from, and terminated in, Sacramento, California. The most recent of the two flights to Santa Rosa was conducted on December 30, 2002. Most of the flight activity recorded in the logs were daily trips between Oroville and Sacramento.

According to family members, the pilot's wife (passenger) did not have any prior aeronautical experience. No record of the individual was found during a review of the FAA airman and medical records database.

A Safety Board investigator conducted a telephone interview with a coworker of the pilot. He stated that about 3 to 4 days a week he and the pilot would commute to work via the accident airplane. They would regularly leave Oroville about 0530 in the morning and arrive in Sacramento about 0600. He recalled many times where the pilot would fly through a layer of clouds in an effort to descend down to the airport.

AIRCRAFT INFORMATION

No airplane or engine maintenance records were located. A review was conducted of the material maintained by the FAA in the Aircraft and Registry files for this airplane. The Beech 95 multiengine airplane, serial number TD-59, was manufactured in 1958, and purchased by the pilot on March 29, 2004. According to the Owner's Manual, the airplane was originally equipped with two a Lycoming O-360-A1A engines.

While no formal maintenance logbooks as such were located, search and rescue personnel found several handwritten sheets of paper in the wreckage that contained notations of maintenance activities. The entries were dated from November 30, 1995 (at a tachometer time of 3112.13), to March 30, 2004. An entry on the log showed an annual inspection was due in May 2003.

METEOROLOGICAL INFORMATION

The closest weather observation station was Santa Rosa, located 14 nm southwest of the accident site and situated on the opposite side of the mountain range. A routine aviation weather report (METAR) for the airport was issued about 30 minutes prior to the accident. It stated: skies 5,000 feet scattered, 7,000 feet overcast. At 0953, the observation updated to: winds 070 degrees at 7 knots; visibility 10 statute miles; skies 7,000 feet broken; 9,000 feet overcast; temperature 12 degrees Celsius; dew point 09 degrees Celsius; altimeter 29.97 inches of mercury. The observation was again updated at 1053 reporting: skies 2,400 feet few, 4,800 feet scattered, 6,500 overcast.

The weather observation station at Sacramento International Airport, Sacramento, California, located about 50 nm east of the accident site, reported conditions at 0953. It stated: winds calm; visibility 3 statute miles; light rain, mist; skies 3,900 feet broken, 4,800 feet overcast; temperature 11 degrees Celsius; dew point 09 degrees Celsius; altimeter 30.06 inches of mercury.

The weather observation station at Ukiah Municipal Airport, Ukiah, California, located about 38 nm northwest of the accident site, report conditions at 0956. It stated: winds calm; visibility 10 statute miles; skies 4,000 feet overcast; temperature 11 degrees Celsius; dew point 08 degrees Celsius; altimeter 29.98 inches of mercury.

The closest Weather Surveillance Radar (WSR-88D), located at Beale Air Force Base, captured radar data at 0950, in areas surrounding the accident site. A review of the data disclosed convective radar returns around the region where the wreckage was located. In addition, there were lines of relectiveness prevalent up to 15 dBZ (color coded light green on the WSR chart and equivalent to precipitation returns).

There was no satellite imagery available surrounding the time of the accident.

The closest upper air sounding to the accident site was from Oakland, California (KOAK), located approximately 59 nm north-northwest of the accident site. The 1200Z sounding, indicated a lifted condensation level at 948 feet and was saturated with relative humidity greater than 75 percent from the surface to 21,000 feet. The freezing level was identified at 7,600 feet msl.

An area forecast for the region was issued by the National Weather Service at 0245 Pacific standard time, with the clouds and weather information valid until 1600. It reported, in part: "Clouds and weather; AIRMET for mountain obscuration. Mountains occasionally obscured in clouds, precipitation, fog and mist. Conditions developing/spreading southward during period." Clouds were forecasted to be: 1,500 feet scattered, 3,000 to 5,000 feet broken, layered to flight level 28,000 feet.

A Safety Board investigator located a pilot who was heard on the Oakland Air Route Traffic Control Center tapes and had landed in Santa Rosa just after the accident. He stated that he was flying on an instrument flight rules (IFR) flight plan from Watts-Woodland Airport, Woodland, California, to Santa Rosa, an estimated 45 nm trip on a true course of about 257 degrees. He recalled that the cloud tops were about 5,000 feet msl and the base was about 3,000 feet. He noted that the mountains in the area were obscured, but did not observe any unusual or hazardous meteorological conditions.

There was no evidence that the pilot ever obtained a weather briefing for the flight from any official FAA or NWS aviation source.

WRECKAGE AND IMPACT

The wreckage was located at an estimated 38 degrees 38 minutes 08.5 seconds north latitude and 122 degrees 36 minutes 57.6 seconds west longitude, and at an elevation of about 3,300 feet msl. The accident site was approximately 14 nautical miles northeast of Santa Rosa.

During a telephone conversation with a Safety Board investigator, a helicopter pilot stated that he spotted the wreckage while practicing maneuvers during a training flight. He noted that the main wreckage, consisting of the fuselage and tail section, had come to rest about 200 to 300 feet below a peak of Mount St. Helena. The debris field stretched over 90 feet of rugged terrain, on a slope of about 70 degrees that was comprised of rock outcroppings and wet terrain; the site appeared inaccessible. While maneuvering above, he located several trees about 150 to 200 feet from the main wreckage that appeared to have been severed at the tops. The wreckage sustained no fire damage. The fuselage was fragmented and both wings were separated, but located in the same general vicinity as the main wreckage. He noted that the impact appeared to be one of high velocity.

The coroner composed a written report of the accident location. He stated that the wreckage was located about 1,100 feet below the eastern summit of Mount St. Helena. The terrain was consisted primarily of pine and bay trees with the accompaniment of brush, rocks, and dirt. The fuselage was situated almost vertical on a slope that is inclined about 70 to 80 degrees. The main portions of the airplane were spread throughout a 10,000-square-foot-area, including the fuselage, wings, engines, and tail. He noted the faint smell of fuel or oil near the engines. He added that the site was extremely difficult to traverse and navigate through safely, as there were no established trails or roads in the surrounding area. There was a presence of dense fog with intermittent downpours making the steep terrain very wet.

MEDICAL AND PATHOLOGICAL INFORMATION

The Napa County Coroner's Office completed an autopsy. The FAA Toxicology and Accident Research Laboratory performed toxicological testing on specimens of the pilot and passenger. The results of analysis of the pilot's specimens revealed putrefaction, and the presence of ethanol which the FAA attributed to sources other than ingestion.

ADDITIONAL INFORMATION

The body recovery entailed a search and rescue team of over 40 people. The corner described the accident site as virtually inaccessible. The search and rescue personnel declined to return to the accident site stating that the terrain was too dangerous for even the most experienced mountaineers.

The wreckage was not recovered at the time of this writing.

NTSB Probable Cause

The pilot's inadequate preflight and in-flight planning/decision, which resulted in continued VFR flight into instrument meteorological conditions at an altitude insufficient to ensure adequate terrain clearance and impact with rising terrain.