Morongo Valley, CA, USA
N4972J
PIPER PA 28R-180
The non-instrument rated private pilot and his passenger completed a cross-country flight from their home base to another airport in the airplane earlier that day. They delayed their initial planned departure time for that flight due to weather concerns, ultimately arriving 3 hours later than planned. During that flight, they flew over a high mountain range and through a mountain pass. For the return (accident) flight a few hours later, the weather had deteriorated, resulting in low ceilings along the original route (including in the pass), with high cloud tops and rapidly building cloud formations west and north of the departure airport in the intended direction of the return flight. However, there is no record that the pilot obtained weather information before departing on the return flight. While on the ground, the pilot reported to air traffic control that he was planning to take a "northern route," which would have taken them around the north side of the east-west mountain range that they had crossed on the inbound leg. Shortly after takeoff, the pilot reported to air traffic control that, due to clouds, he would need to climb to an altitude of 9,000 ft mean sea level (msl), which was almost twice as high as originally requested. The request was most likely because, once airborne, the pilot could see the full extent of the building cloud formations to the north along his route, as well as the formations building just west of the departure airport. As the flight proceeded, the air traffic controller began the first of what would become a series of warnings to the pilot about mountainous terrain. The pilot responded that he was aware of the terrain. He then began a series of six climbing 360° turns, rolling out on a west heading directly toward, and about 700 ft lower than, the mountain peak. The controller warned the pilot of the peak several times, and the pilot responded, sounding confused, stating that he was still climbing. Now cruising at an altitude of about 11,000 ft msl, the airplane's climb capabilities had diminished. Furthermore, the pilot did not appear to be flying the airplane at a speed that would have resulted in optimal climb performance. The airplane continued heading west, now no longer climbing and most likely just above the cloud tops. With high and ominous-looking cloud formations now building to the left and right of the flight track, the pilot most likely opted to continue on his homeward westerly track, while attempting to climb over the terrain and clouds ahead. The airplane then suddenly reversed course and rapidly descended. It then transitioned to a fast spiraling descent, and, when challenged by the controller as to whether he had the terrain in sight, the pilot exclaimed, "Negative! Negative!" The turn rate increased as the airplane descended to about 7,500 ft msl and then impacted mountainous terrain just below the cloud bases. Examination of the accident site indicated that the airplane struck the ground in a wings-level attitude at a high forward speed. Damage patterns indicated that the engine was producing power at impact. It is likely that, unable to outclimb the terrain and the cloud tops, the airplane entered the clouds and thus instrument meteorological conditions during the final portion of the flight, and the pilot then experienced spatial disorientation and lost control of the airplane, which resulted in the rapid descent. Additionally, prior to the descent into clouds, he was flying almost directly towards the sun, which could have been a further distraction and additional source of stress. Many of the 71-year-old pilot's medical conditions, including hypertension, low testosterone, Barrett's esophagus, chronic obstructive pulmonary disease, deafness, chronic neck pain, vitamin D deficiency, and prediabetes, were unlikely to cause acute symptoms or be chronically impairing. Similarly, his blood pressure medication, cholesterol medication, testosterone, and prostate medication would not have impaired judgement, decision-making, or flight skills. However, several medications that the pilot was using would have impairing effects. Hydrocodone, which was detected in the toxicology testing, is an impairing opiate pain medication and carries warnings regarding hazards while driving or operating machinery; however, with regular use, a chronic user may appear to function normally, so the pilot may not have been impaired by his use of opiods. Quetiapine, also detected during toxicology testing, is an antipsychotic indicated for the treatment of schizophrenia and bipolar syndrome and carries warnings for an increased risk of seizures and somnolence. It can also impair judgment, thinking, or motor skills, and may have impaired the pilot's performance during the accident flight. The pilot's medical records revealed that he had required years of ongoing psychotherapeutic support to manage the combined symptoms of PTSD and depression; at the time of the accident he had been experiencing an exacerbation of those symptoms for several months, and it did not appear that the symptoms had been completely resolved. Patients with PTSD experience marked cognitive, affective, and behavioral responses to stimuli. These symptoms are likely to occur in stressful situations and may have contributed to his confusion during the high workload period while attempting to ascend above mountain peaks. Further, depression is associated with cognitive degradation, particularly in executive functioning. Therefore, under the stressful conditions of this flight, the combined effects of impairing medications, depression, and PTSD likely resulted in the pilot experiencing significant cognitive degradation.
HISTORY OF FLIGHTOn October 17, 2015, at 1552 Pacific daylight time, a Piper PA28R-180, N4972J, impacted mountainous terrain near Morongo Valley, California. The private pilot and passenger sustained fatal injuries; the airplane was destroyed. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The cross-country personal flight departed Palm Springs International Airport (PSP), Palm Springs, California, at 1513, with a planned destination of Santa Barbara Municipal Airport, Santa Barbara, California. Visual meteorological conditions prevailed at the departure airport, and no flight plan had been filed. Earlier on the day of the accident, the pilot and passenger flew the airplane from their home base of Santa Barbara to Palm Springs in order to visit a museum. According to friends, the original planned departure time for the flight to Palm Springs was 0900; however, due to weather conditions, they departed just before noon and arrived about 1330. Radar data revealed that the route of the outbound flight was via Santa Paula, Valencia, and Acton, then across the east-west mountain range of the Angeles National Forest, across the Los Angeles Basin, and through the Banning Pass to Palm Springs. For the return trip, the pilot requested visual flight rules (VFR) flight following from the clearance delivery controller at Palm Springs and reported that his route of flight back to Santa Barbara would be along a northern route via Palmdale. He initially requested an altitude of 7,500 ft mean sea level (msl) and then immediately corrected himself, requesting 5,500 ft msl. The controller responded, telling the pilot to squawk VFR and to expect a northbound departure with an unrestricted climb. Radar and audio data provided by the Federal Aviation Administration (FAA) captured the entire flight sequence, beginning with the departure from runway 31R at PSP. Following takeoff, the airplane began a climb to the north, and, about 6 minutes later, the pilot initiated radio contact with Southern California Terminal Radar Approach Control, stating that he was 6 miles northeast of Palm Springs. He requested VFR flight following to Santa Barbara and, during the exchange, stated, "It looks like we might have to get up to 9,000 ft with the clouds." The air traffic controller responded, providing the pilot with a squawk code, altimeter setting, and instructions to maintain VFR at an altitude at the pilot's discretion. The pilot confirmed the instructions, and, a short time later, the controller responded that he had obtained radar contact with the airplane. The airplane continued to climb, and, about 4 minutes later, after it reached an altitude of about 5,200 ft msl, the controller communicated, "just to be clear you do have the terrain in sight to your left, right?" The pilot responded in the affirmative and added that he was going to perform a 360° turn to gain altitude. The controller responded, "Ok, just wanted to make sure we are on the same page." The controller then transmitted, "Are you guessing you are going to wind up north of Big Bear or do you think you're going to be able to get up through the Banning Pass, is that what your intents are?" The pilot responded, "I'm going to try to go through San Bernardino and out to the desert then out by General Fox." The airplane then began a left 270° turn, rolling out on a northeast heading by which time it had reached an altitude of 7,000 ft msl. Over the next 14 minutes, the airplane conducted a series of 6 climbing 360° turns, eventually rolling out on a west heading, at an altitude of 10,800 ft msl. By that time, the airplane was about 14 miles east of, and heading directly toward, the 11,500 ft peak of San Gorgonio Mountain. The pilot reported that he was now travelling west, and the controller transmitted, "So you're going to go north side of the peak then, there, correct?" The pilot reported, "Um, say again," and the controller responded, "N72J are you going to go north side of the peak there or south side there?" The pilot responded, "Umm, I show that we're heading right to San Bernardino." The controller retorted, "Ok, I show an eleven seven peak between you and San Bernardino." The pilot responded, "Um, I'm at um, one zero thousand six hundred." The controller responded, "Roger," and, after a brief pause, the pilot continued, "and I'm still climbing." The airplane maintained the west heading and continued to climb at ground speeds varying between 60 and 70 knots, reaching 11,100 ft msl about 3 minutes later. It then conducted another 360° left turn but had not gained significant altitude once it rolled out about 2 minutes later. The westbound track continued at similar speeds toward the peak for the next 4 minutes, as the airplane climbed 200 ft to 11,300 ft. The next radar target appeared 15 seconds later, indicating the airplane had rapidly reversed course and descended to 9,700 ft msl. The airplane then began a spiraling descent, and the controller transmitted, "Piper 72J you are descending once again in an area of higher terrain just west of you, I have a peak that I show to be at eleven thousand seven hundred feet, just west of your position...72J you cut me out, verify you still have the terrain in sight." The pilot then transmitted, "Negative! Negative!," and in the background the passenger could be heard expressing significant alarm. The controller continued issuing instructions, "N72J remain calm, if you are able proceed eastbound, remain VFR proceed eastbound, hold your altitude if you are able I see you are descending - repeat, eastbound, VFR, hold your altitude if you are able you are in an area of higher terrain." The pilot did not respond, and, over the next 45 seconds, the airplane continued to perform two more spiraling turns, with radiuses of about 1,200 and 700 ft, respectively, to the last recorded radar position, at an altitude of 7,500 ft. Over the next few minutes, the controller tried reestablishing communication with the pilot but did not receive a response. A Riverside County Sheriff's Department helicopter was flying in the vicinity, so the controller provided the helicopter's crew with vectors to the airplane's last radar location and asked if they could establish radio communication. They attempted to do so, but no response was received. They reported that the search area was mountainous and obscured by clouds, and, after multiple approach attempts, they located burning wreckage along a ridge, about 100 ft below the base of the clouds. The following three figures show the airplane's radar track. Figure 1 - Route of Flight Figure 2 - Excerpts of Pilot and Air Traffic Control Communications Figure 3 - Radar Data Covering Final Two Minutes of Flight PERSONNEL INFORMATIONThe 71-year-old pilot held a third-class medical certificate limited by a requirement that he must wear corrective lenses for near and distant vision. He was issued a private pilot certificate on September 9, 2014, at which time he reported a total flight experience of 85 hours of which 15 hours were as pilot in command. All the reported flight experience was in a Cessna 172. The pilot did not hold an instrument rating. The pilot was the general manager for a repair station at Santa Barbara Airport. The airplane was maintained at the repair station, and the passenger worked at the repair station. No personal flight records were recovered; however, the repair station's chief inspector stated that the pilot had flown regularly in the airplane, taking multiple trips to Oregon and the Mojave area during the period between receiving his private certificate and the accident. He stated that the reason for the flight was to drop off memorabilia at the flight museum in Palm Springs, and he was not aware of any pressing reason for the pilot and passenger to return promptly that night. AIRCRAFT INFORMATIONThe single-engine, retractable-landing-gear airplane was manufactured in 1968 and powered by a fuel-injected Lycoming IO-360-B1E engine. An annual inspection was performed on May 27, 2015. At that time, the airframe had accrued 3,704.90 total flight hours, and the engine had accrued 1,308.0 hours since overhaul. An avionics upgrade was performed following the May 2015 annual inspection and was completed on August 17, 2015. The upgrade included the installation of a Garmin GTN 650 touchscreen GPS/Nav/Comm and a Garmin GDL 88 ADS-B transceiver. In combination, the pairing provided the pilot with terrain mapping, graphical NEXRAD radar, and weather data on the GTN 650 screen. The chief inspector stated that the pilot was still gaining familiarity with the system and was not fully proficient with its use and features. The chief inspector also reported that the pilot kept an iPad tablet computer onboard for weather and navigation and that the airplane was equipped with a portable oxygen system. Due to fire damage, neither of these systems could be positively identified in the debris; therefore, their operational status could not be determined. Photographs posted by the passenger on a social media website after the flight to Palm Springs indicated that the pilot had mounted the iPad on the control yoke. METEOROLOGICAL INFORMATIONThe pilot did not call Lockheed Martin Flight Service for a telephone weather briefing either the day before or the day of the accident, and there was no record of him downloading an official weather briefing from any DUAT vendor. Satellite Data Geostationary Operational Environmental Satellite number 15 (GOES-15) imagery taken at 1545 and 1600 indicated an area of low- to mid-level clouds over the accident site, with cloud tops near 11,000 ft (figure 4). During that period, an area of clouds was observed developing near Big Bear, California, 12 miles northwest of the accident site, along with rapidly developing enhanced clouds (tops near 33,000 ft) between the accident site and Palm Springs. Multiple layers of clouds extended from west of Palm Springs through to the accident site and obscured Banning Pass to the south. The Riverside County Sheriff's Department helicopter crew reported cloud bases of about 1,500 ft above ground level (agl) in Banning Pass. Figure 4 - GOES-15 Visible Image at 1600 Base Reflectivity An image from Edwards Air Force Base WSR-88D radar (NEXRAD) at 1552 revealed several developing echoes north and south of the accident location. Some very light intensity echoes were identified immediately west of the accident location, consistent with cloud buildups immediately ahead of the airplane's westbound track and over the higher terrain. Upper Air Data The NOAA Air Resource Laboratory North American Mesoscale numerical model over the accident site location depicted a conditional unstable atmosphere with an expected cloud base at 2,196 feet agl, cloud tops near 11,000 ft msl, and potential convective cloud tops near 40,000 ft. The freezing level was identified at 14,776 ft. The wind profile indicated southerly winds veering to the west with height; the average wind from 0 ft to 18,000 ft was from 250° at 9 knots. No significant turbulence or mountain wave activity was noted in the model sounding through 18,000 ft. Area Forecast An area forecast issued at 1245 and valid to 0100 the following morning indicated cloud tops in the Los Angeles Basin area varying between 3,000 and 4,000 ft, with an outlook for marginal VFR. Surface Observations The closest weather reporting facility to the accident location was at Big Bear City Airport, about 11 miles north-northwest of the accident site at an elevation of 6,752 ft. At 1535, an automated report indicated wind from 080° at 3 knots, visibility 10 miles, ceiling broken at 2,100 ft, broken at 2,600 ft, and overcast at 3,500 ft, temperature 13°C, dew point 9°C, altimeter 30.15 inches of mercury. At 1552, similar conditions existed with the addition of light rain. At 1553, PSP reported wind from 140° at 4 knots, visibility unrestricted at 10 miles, scattered clouds at 7,000 ft, temperature 32°C, dew point temperature 15°C, and altimeter 29.82 inches of mercury. At 1447, San Bernardino International Airport, about 26 miles west of the accident site, at an elevation of 1,159 ft, reported wind from 240° at 10 knots, visibility 7 miles, scattered clouds at 6,000 ft, temperature 29°C, dew point 14°C, altimeter 29.87 inches of mercury. At 1556, Yucca Valley Airport, about 17 miles east of the accident site, reported wind from 110° at 8 knots, visibility 10 miles, with scattered clouds at 8,000, 15,000, and 20,000 ft. Astronomical Data In Palm Springs at the time of the accident, the sun was 26° above the horizon at an azimuth of 236°. Sunset was at 1810, with the end of civil twilight at 1835. AIRPORT INFORMATIONThe single-engine, retractable-landing-gear airplane was manufactured in 1968 and powered by a fuel-injected Lycoming IO-360-B1E engine. An annual inspection was performed on May 27, 2015. At that time, the airframe had accrued 3,704.90 total flight hours, and the engine had accrued 1,308.0 hours since overhaul. An avionics upgrade was performed following the May 2015 annual inspection and was completed on August 17, 2015. The upgrade included the installation of a Garmin GTN 650 touchscreen GPS/Nav/Comm and a Garmin GDL 88 ADS-B transceiver. In combination, the pairing provided the pilot with terrain mapping, graphical NEXRAD radar, and weather data on the GTN 650 screen. The chief inspector stated that the pilot was still gaining familiarity with the system and was not fully proficient with its use and features. The chief inspector also reported that the pilot kept an iPad tablet computer onboard for weather and navigation and that the airplane was equipped with a portable oxygen system. Due to fire damage, neither of these systems could be positively identified in the debris; therefore, their operational status could not be determined. Photographs posted by the passenger on a social media website after the flight to Palm Springs indicated that the pilot had mounted the iPad on the control yoke. WRECKAGE AND IMPACT INFORMATIONThe wreckage was located at an elevation of 7,222 ft msl on the eastern flank of the San Bernardino Mountain range, 24 miles north-northwest of PSP, 6 miles east of the San Gorgonio Mountain peak, and about 200 ft northeast of the last recorded radar target. The airplane came to rest upright on a heading of 330° magnetic, on the 25° uphill slope of a boulder-strewn ridge (Photo 1). The entire cabin forward of the baggage door was consumed by fire. Both wings sustained crush damage through to their main spars, and the empennage had folded up over the tailcone. Fragments of the cabin structure and engine cowling had been propelled forward, creating a debris field about 60 ft long. Figure 5 - Wreckage Viewed to the North ADDITIONAL INFORMATIONRegarding supplemental oxygen requirements, 14 CFR 91.211 states: "No person may operate a civil aircraft of U.S. registry - (1) At cabin pressure altitudes above 12,500 feet (MSL) up to and including 14,000 feet (MSL) unless the required minimum flight crew is provided with and uses supplemental oxygen for that part of the flight at those altitudes that is of more than 30 minutes duration; (2) At cabin pressure altitudes above 14,000 feet (MSL) unless the required minimum flight crew is provided with and uses supplemental oxygen during the entire flight time at those altitudes; and (3) At cabin pressure altitudes above 15,000 feet (MSL) unless each occupant of the aircraft is provided with supplemental oxygen." The flight from Santa Barbara to Palm Springs lasted about 1 hour 40 minutes and was flown primarily at an average altitude of about 7,500 ft, except for a 20-minute period in the middle of the flight when the altitude was between 10,000 and 11,700 ft. MEDICAL AND PATHOLOGICAL INFORMATIONFAA Medical Records At the time of the pilot's most recent FAA medical examination, he was 70 inches tall, weighed 157 pounds, and reported hypertension treated with atenolol and amlodipine (prescription blood pressure medications often marketed with the names Tenormin and Norvas
The non-instrument rated pilot's improper inflight decision-making to attempt to outclimb clouds along his planned route rather than reverse course, which resulted in his inadvertent entry into instrument meteorological conditions, spatial disorientation, and a resultant loss of control. The pilot's preexisting medical conditions and his use of impairing medications contributed to his degraded performance.
Source: NTSB Aviation Accident Database
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