NTSB Factual Report

HISTORY OF FLIGHT

On August 7, 2008, approximately 2130 Pacific daylight time, a Cessna 172S, N15963, impacted mountainous terrain during descent near Incline Village, Nevada. The airplane sustained substantial damage, and the student pilot, the sole occupant, was killed. The airplane was registered to, and operated by, Advantage Aviation, Inc., Palo Alto, California. Night visual meteorological conditions (VFR) prevailed at the accident site, and a flight plan was not filed. The 14 Code of Federal Regulations Part 91 personal cross-country flight departed from Palo Alto about 2010, and the intended destination was Reno, Nevada.

An acquaintance of the pilot reported that he had spoken with the pilot by telephone twice on the day of the accident. The pilot told him that he was going to fly from Palo Alto to Reno that evening and planned to arrive at the Reno/Tahoe International Airport about 2130. According to the acquaintance, the pilot intended to gamble at a casino in Reno.

At the time of the accident, the pilot's spouse was out of the country and was not aware that the pilot was going to fly to Reno. After the accident, it was determined that the pilot had a substantial amount of cash with him, and the pilot's spouse stated that the large amount of cash he had with him indicated to her that he was going to Reno to gamble.

Information provided by Federal Aviation Administration Air Traffic Control (FAA ATC) personnel indicates that the airplane departed from Palo Alto Airport and proceeded northeast on a direct course towards Reno, climbing to and leveling out at an altitude of about 11,500 feet mean sea level (msl). The airplane began descending about 2107, and radar contact was lost shortly thereafter when the airplane was about 35 nautical miles southwest of Reno. The last radar data indicated the airplane was descending from 11,200 feet msl on a 045-degree heading. The pilot received VFR flight following services from Northern California approach control and Oakland center. The last radio contact with the pilot was approximately 2115, at which time the pilot was advised to contact Reno approach control for further flight following. The pilot did not check in with Reno approach control.

About 0300 on August 8, 2008, local authorities in Nevada County, California, were notified that an emergency locator transmitter (ELT) signal was being picked up from a location north of Lake Tahoe near the California - Nevada border. A search was initiated, and the wreckage of the airplane was located by a search airplane about 0700 in Washoe County, Nevada, about 2 miles north of Incline Village, in the Mount Rose Wilderness Area at an elevation of approximately 8,600 feet msl.

PERSONNEL INFORMATION

The pilot, age 41, held a third-class medical certificate and student pilot certificate that was issued on December 20, 2007. The certificate was issued with the limitation: holder shall wear corrective lenses. On the back of the certificate, there was an endorsement for solo flight in Cessna 172S airplanes dated April 20, 2008. The section for solo cross-country endorsements was not completed.

Review of the pilot's flight logbook revealed that his total flight time was approximately 97 hours, of which 78 hours were dual instruction and 19 hours were solo. All but 0.5 hours of the pilot's time was in Cessna 172 airplanes. He had received a total of 1.8 hours dual instruction at night, which took place during a single flight on August 6, 2008, the night before the accident. None of the pilot's solo flight time was at night. The pilot had made solo cross-country flights to airports less than 50 nautical miles from Palo Alto. No entries were found in the logbook indicating any flights to Reno.

According to the pilot's flight instructor, the pilot had flown about 10 hours in Garmin G1000 equipped Cessna 172s. Of the 10 hours, about 6 hours were dual instruction and 4 hours were solo flight. The pilot had been taught how to select a destination and fly direct to it using the G1000. The G1000 in the accident airplane did not have a terrain avoidance feature.

The flight instructor reported that the pilot was at the point in his training where he was going to start instructing the pilot in cross-country planning. He had not endorsed the pilot's logbook or student certificate for cross-country flight. According to the operator, the student pilot was not given authorization to conduct the 160-nautical-mile flight.

AIRCRAFT INFORMATION

Examination of the airplane's maintenance records indicated that the 2005 model Cessna Skyhawk SP received its most recent 100-hour inspection on June 10, 2008, at a total time of 1,184.7 hours. As of that date, the engine, a Lycoming IO-360-L2A, had also accumulated 1,184.7 hours. Review of the maintenance records revealed no evidence of any uncorrected maintenance discrepancies.

The airplane was equipped with a Garmin G1000 glass cockpit consisting of Garmin GDU 1040 Primary Flight and Multifunction Displays and a Garmin GMA 1347 Audio Panel. The Garmin units have no non-volatile memory. Additionally, the airplane was equipped with a Bendix/King KAP 140 two axis autopilot. The autopilot has no non-volatile memory, but the autopilot's KCM 100 configuration module does record error faults, including G-loadings and the time of power loss.

According to the operator and the flight instructor, their fueling procedure was to fill the airplane's fuel tanks to the tabs after each flight. When filled to the tabs, the airplane had 35 gallons of usable fuel, enough to fly for about 3 hours with a 1/2 hour reserve. The operator's records showed that the airplane had been flown once earlier on the day of the accident and was fueled back to the tabs before the accident flight.

METEOROLOGICAL INFORMATION

At 2055, the reported weather conditions at Reno/Tahoe International Airport, located 17 nautical miles northeast of the accident site, were wind from 280 degrees at 12 knots gusting to 18 knots; visibility 10 miles; scattered clouds at 14,000 feet; temperature 27 degrees Celsius (C); dew point 5 degrees C; and altimeter setting 29.97 inches of mercury.

According to the U.S. Naval Observatory, the sun set at Incline Village at 2005, and the end of civil twilight was at 2034. The moon was a 40 percent crescent.

WRECKAGE AND IMPACT INFORMATION

Impact site photographs indicate the wreckage path was down slope, approximately 1,760 feet long, on a heading of 065 degrees. The first tree impact was at an elevation of 8,830 feet approximately 50 feet above the ground. The main wreckage was located at an elevation of 8,605 feet. The nose landing gear, right wing, right horizontal stabilizer, and the engine separated from the fuselage. The firewall section above the lower engine mount structure was separated from the fuselage. The lower portion of the firewall and fuselage structure was displaced aft into the cabin, the instrument panel was fragmented, and the cabin doors were separated.

The wreckage was examined after it was recovered under the supervision of the National Transportation Safety Board investigator-in-charge by representatives of the FAA, Cessna, and Lycoming on August 29, 2008. All flight controls remained attached to airframe components. Flight control continuity was established throughout the airplane through cable separations displaying signatures consistent with tension overload and separations created by recovery personnel. Flap actuator measurement indicated a retracted flap position. No preimpact anomalies were noted with the airframe.

The propeller remained attached to the engine. Both propeller blades displayed leading edge damage, twisting, and "S" bending. The propeller, valve covers, spark plugs, and rear mounted accessories were removed from the engine. The crankshaft was rotated by hand using a drive tool inserted into the accessory section, and continuity of the crankshaft, camshaft, valve train, and accessory drives was established. All four cylinders produced thumb compression when the engine was rotated. Borescope examination of the cylinders revealed no anomalies. Both magnetos produced spark from all towers when rotated by hand. No pre-impact anomalies were noted with the engine.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was conducted by the Washoe County Medical Examiner/Coroner, Reno. The cause of death was reported as multiple injuries due to blunt force trauma. Toxicology tests were conducted by the FAA's Toxicology and Accident Research Laboratory. The tests were negative for carbon monoxide, cyanide, and ethanol. The following drugs were detected:

>> 0.02 (ug/ml, ug/g) BENZOYLECGONINE detected in Blood

>> 0.891 (ug/ml, ug/g) BENZOYLECGONINE detected in Urine

>> 0.004 (ug/mL, ug/g) BUPRENORPHINE detected in Blood

>> 0.131 (ug/mL, ug/g) BUPRENORPHINE detected in Liver

>> ECGONINE METHYL ESTER detected in Urine

>> ECGONINE METHYL ESTER NOT detected in Blood

>> 0.013 (ug/mL, ug/g) FLUOXETINE detected in Blood

>> 0.266 (ug/mL, ug/g) FLUOXETINE detected in Liver

>> LAMOTRIGINE detected in Blood

>> LAMOTRIGINE detected in Liver

>> 0.005 (ug/mL, ug/g) NORBUPRENORPHINE detected in Blood

>> 0.075 (ug/mL, ug/g) NORBUPRENORPHINE detected in Liver

>> 0.182 (ug/mL, ug/g) NORFLUOXETINE detected in Blood

>> 3.021 (ug/mL, ug/g) NORFLUOXETINE detected in Liver

>> OXYMETAZOLINE detected in Liver

>> 0.019 (ug/mL, ug/g) QUETIAPINE detected in Blood

>> QUETIAPINE detected in Liver

Review of the pilot's FAA medical records indicated the pilot's only application for a third-class Airman Medical Certificate and Student Pilot Certificate was on December 20, 2007. The application indicates "No" in response to "Do You Currently Use Any Medication." The application notes "Yes" in response to "Admission to Hospital" and "Other illness, disability, or surgery." The application notes "No" to all other items under "Medical History," including specifically "Mental disorders of any sort; depression, anxiety, etc." and "Substance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years," and "Alcohol dependence or abuse." Under "Explanations" is noted, "Appendectomy, Left inguinal hernia repair."

The Executive Director of the Medical Board of California filed an Accusation against the pilot, a physician, on April 22, 2008. The Accusation documented a history of substance dependence and abuse for more than 10 years preceding the accident, involving the misuse of at least 4 different substances (including alcohol) and treatment through at least 6 different programs for substance-related disorders during that period. The pilot's spouse stated he was being treated for "addiction" and "anxiety and depression" at the time of the accident.

TESTS AND RESEARCH

The stored error codes were recovered from the airplane's KCM 100 autopilot configuration module during an examination at the manufacturer's facility under the supervision of an FAA inspector. There was an acceleration reasonability check code that was registered at 1 hour 17 minutes 58 seconds after the avionics power was applied. This code can be logged in turbulent conditions or as a result of impact. The autopilot does not need to be engaged to log this acceleration code, and it cannot be determined from the recorded data if the autopilot was engaged. However, the variations (airspeed, altitude, and displayed track) observed in the flight's radar data are not consistent with autopilot use.

NTSB Probable Cause

The pilot's decision to initiate a flight for which he was neither approved nor qualified and his failure to maintain terrain clearance during the flight. Contributing to the accident were the dark night, the mountainous terrain, and the pilot's medical condition.