NTSB Factual Report

HISTORY OF FLIGHT

On April 24, 1998, at 1515 hours Pacific daylight time, a Cessna 172, N8364L, pitched down and impacted terrain while on landing approach at the Ramona, California, airport. The commercial licensed flight instructor and the unlicensed student pilot were fatally injured and the aircraft was destroyed. Visual meteorological conditions prevailed for the instructional flight that was performing touch-and-go landings.

Several pilots witnessed the accident and reported that the aircraft was on a stabilized approach to runway 27 approximately 300 feet agl, when the nose of the aircraft abruptly pitched down. In 2 or 3 seconds, the aircraft achieved a near-vertical, nose down attitude that continued to impact.

One witness, a retired Safety Board Air Safety Investigator, observed the accident from the cockpit of another aircraft on the north parallel taxiway near the runway 27 threshold. He said that his aircraft was stopped, heading southeast, and that he was watching the accident aircraft on final as part of clearing traffic in preparation for takeoff. He said that the accident aircraft was perhaps a little high on approach. When at 350 or 400 feet agl, the nose abruptly pitched down and the aircraft dove to the ground in a near vertical attitude. This witness was certain that, as the aircraft pitched over, he saw the elevator control deflected full down. It was not a stall and the pitch-over was instantaneous. The aircraft "pushed right over and stayed that way." (The pilot) "had to be deliberately doing it." In the seconds before the pitch-over the aircraft was on a stable approach, not "bobbling" and there was no perceptible pitch change before the abrupt pitch down. The aircraft was not in a slip prior to the pitch-over maneuver.

A private pilot on the north ramp about 1,000 feet west of the accident site happened to be watching the accident aircraft as it approached runway 27 for landing. He said that the airspeed and altitude looked normal. About 200 feet agl the aircraft pitched nose down in about 2 seconds (maybe a little longer on second thought) and then dove nose first for about 2 or 3 seconds to impact. He said that the wings remained level and "it looked like a controlled pushover." Before the nose dropped, the aircraft was in a nose-low attitude, was not slipping, and the event was not a stall. He was of the opinion that the pilot had enough altitude to recover from a stall. He did not hear the engine or the impact with the ground. He said that the unicom operator told him there were no distress calls from the aircraft.

A mechanic who observed the accident from the same location said that he had watched the aircraft do three touch-and-go's and that the pilot was "obviously a student," the landings were "very sloppy." He said that the aircraft was on a normal approach at normal speed, maybe a little high. In approximately 2 seconds the aircraft nosed down to vertical flight; it was very fast and not a stall maneuver.

A commercial pilot/flight instructor observed the accident from the north ramp approximately 4,000 feet west of the accident location. As he watched the aircraft on final approach he observed 2 seconds of normal flight, then a wings-level pitch-over to vertical nose-down flight in 2 to 3 seconds. He was emphatic that the pitch-over was not a stall event. There was "no stall, no spin, it was flying."

PERSONNEL INFORMATION

The aircraft was rented from an aircraft rental (flying club) operator at Gillespie Field, El Cajon. The operator reported that the student had joined the club and was permitted to bring in a flight instructor of his choice who was current and qualified to instruct him in the aircraft. The pilot/flight instructor was a freelance instructor and was paired with the student by arrangement of the operator.

The pilot's sister reported that the pilot's wife had been fatally injured in an automobile accident in Turkey in November, 1997. He had been devastated and it was a very stressful time in his life. He was still distraught when he visited her in Australia in January, 1998, but she thought he was improved by the time he left in late January. When he visited her in mid-March she believed that "emotionally, he was recovered." He was planning to visit his sister again in mid-May for his daughter's birthday. She last talked with him the day before the accident and said that the conversation was unremarkable. "(H)e was not depressed, he was not suicidal, he loved his daughter."

The fiancee of the pilot reported that after his wife's death he had been very upset for a while, but now they had been dating and he was doing better and they were planning to be married. She said that the pilot had a daughter living in Australia who would be 11 years of age in 3 weeks and that he had planned a trip to Australia in May (1998) for her birthday. She said that he had been eating health foods and would drop her off at the gym while he went running and they often went walking on the beach.

The operator said that the pilot/flight instructor was a talented and skilled man who had been a very successful engineer but agreed that the pilot had been despondent in the weeks following his wife's death and had lost 30 - 40 pounds of weight. By this spring though, the pilot came to him and said he wanted to start doing more flying. To (the operator) it seemed that he was better (over his despondency). In the week before the accident the pilot appeared normal to him.

The student pilot was a citizen of the Federal Republic of Germany and traveled to the United States for the purpose of obtaining a pilot's license. According to the operator, the student signed up to rent aircraft from him on April 19, 1998, and had no prior piloting experience. An U.S. based private pilot arranged for the student's flight instruction in advance of his arrival from Germany. He said that the student pilot had recently received his Ph.D. from the University of Stuttgart, and had come to the United States to get his private pilot license prior to starting work in Luxembourg. He had only 4.5 weeks to complete his training. He was very upbeat and, in this person's opinion, suicide was not an issue. The student did not hold an Airman's Medical Certificate, however, his parents reported that he had no history of incapacitating illness, even as a child.

AIRCRAFT INFORMATION

Pilots who had flown the aircraft before the accident reported there were no maintenance discrepancies. They also commented that it flew like other Cessna 172's and that its stall characteristics were normal.

The engine recording tachometer was destroyed; however, the aircraft owner reported that the aircraft had approximately 1,970 hours total flying time at the accident. At the last annual inspection on January 4, 1998, the tachometer was recorded as 1,917.54 hours. According to the operator, the hour meter operated by an engine oil pressure switch read 324.4 hours on January 6, 1998, when the aircraft returned to service. At the time of the accident the hour meter read 425.2 hours.

METEOROLOGICAL CONDITIONS

At 1555, the automated surface observation at Ramona reported wind from 270 degree at 12 knots, visibility 10 miles with a few clouds at 4,300 feet agl.

WRECKAGE AND IMPACT INFORMATION

The accident location is inside the airport perimeter fence approximately 400 feet from the runway 27 threshold and approximately 25 feet south of the extended runway centerline. The accident site is on a slope approximately 20 feet below the threshold elevation and is covered with natural grasses about 2 feet high. From the accident site, the terrain slopes up approximately 5 degrees to the west to the runway threshold. The accident location is at latitude 33 degrees 02.26 minutes north, and longitude 116 degrees 54.33 minutes west (GPS). The elevation is approximately 1,380 feet msl. Rescue personnel reported there was a strong fuel smell at the site after the accident.

All of the aircraft components were present at the impact location and there was no fire. The aircraft was inverted and exhibited crushing damage as far aft as the mid-chord of the wing. The longitudinal axis of the fuselage was aligned approximately east west and the wings, still attached to the fuselage at the cabin ceiling carry-through structure, were oriented with the left wing pointing to the south and the right wing pointing to the north. The tail cone section of the fuselage exhibited compression buckling aft of the baggage compartment and was bent downward (with respect to the longitudinal axis) and to the left (southwest).

The engine was inverted under the nose of the aircraft with the longitudinal axis at a 45-degree nose down angle with respect to horizontal on a heading of approximately 090 degrees. There was a hole in the soil approximately 4 feet in diameter and 1-foot deep in the area where the propeller attaches to the engine and freshly exposed soil was present around the perimeter of the hole.

According to an inspector from the Federal Aviation Administration (FAA) San Diego Flight Standards District Office (FSDO), who was on-scene on the day of the accident, the right-hand seat belt was observed to be fastened in the wreckage, however, the seat belt was not around the right seat occupant. The FSDO inspector was of the opinion that the loop formed by the fastened seat belt was of a size appropriate for a person of the right seat occupant's size. The left seat occupant was restrained by the seat belt. The aircraft did not have shoulder belts installed.

The fuselage firewall and instrument panel were formed over the accessory section of the engine and most of the instrument panel was destroyed. The forward fuselage was separated from the cabin area at the top of the forward doorpost and from the cabin floor area aft of the wing strut attachment station. Flight control cables remained intact between the two sections. The control wheel on the right side of the instrument panel had both its control grips intact whereas the control wheel on the left-hand side of the instrument panel had both grips broken off at the base where they join the lateral member. There was a loafer-style deck shoe trapped in the wreckage near the right rudder pedal on the right-hand side of the cockpit. There was an open-toe style sandal near the control column vertical post in the center of the cockpit.

The chordwise compression damage to the left wing extended aft to near the aileron spar of the left wing whereas it extended aft to approximately the mid-chord of the right wing. Both fuel tanks exhibited compression damage and were ruptured.

The propeller remained attached to the engine and was stopped in a north-south orientation. The blade oriented to the south was bent aft approximately 80 degrees with a long, smooth bend from the root to the tip. There was a 1/2-inch diameter gouge in the leading edge of this blade approximately 2 inches from the tip. The other blade was almost straight and, when the aircraft was recovered, both blades exhibited chordwise striations on the face.

The carburetor was removed from the engine before the aircraft was recovered and there was approximately 1 tablespoon of fuel in the inlet fuel line and the accelerator pump ejected three squirts of fuel before exhausting its supply.

The aircraft was examined at Ramona Aircraft Salvage on April 26, 1998.

The elevator control cables were continuous from the front bellcrank to the elevator bellcrank (except where marked cut for recovery). The cables were properly routed around pulleys and cable retainers were in place. The maximum elevator up travel was measured to be 29 degrees and the maximum down travel was measured to be 24 degrees. According to the party representative from Cessna Aircraft Company, the manufacturer's specification for up elevator travel is 28 degrees, plus 1, minus 0 degrees. The specification for down elevator travel is 23 degrees, plus 1, minus 0 degrees. The elevator trim tab was deflected approximately 4 degrees nose-down trim.

The aileron and rudder cables were continuous and were routed over their respective control pulleys and retained by cable keepers except for one location at the fuselage station behind the baggage compartment where the left rudder cable keeper was broken in the area of fuselage buckles. According to the Cessna Aircraft party representative, the flap actuator was extended 5.5 inches, which corresponds to 35 degrees of flap deflection. The forward flap balance cable was broken at the right wing root in an area where flap and aileron cables had ripped through the skin of the aircraft. The cable ends were bright and shiny and did not exhibit any longitudinal scrape marks.

The engine was mechanically continuous from the propeller shaft through the accessory case. The valves functioned and there was thumb compression when the engine was rotated. The ignition wires were broken from the magneto cases however, the magnetos both sparked at all four electrodes when turned by hand. The ignition switch, found in the both position, was electrically open to ground. The upper spark plugs were clean, dark gray in color, and unfouled. The lower spark plugs exhibited minor fouling.

ADDITIONAL INFORMATION

The County of San Diego Office of the Medical Examiner performed autopsies and the FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma performed toxicological analyses.

The aircraft was released to Kern and Wooley, agents for the insurer, on June 2, 1998.

NTSB Probable Cause

The loss of control of the aircraft on final approach for undetermined reasons.