Accident Details
Probable Cause and Findings
the pilot's in-flight loss of control due to the flight's encounter with unforecasted localized mountain wave activity with severe to potentially extreme turbulence, downdrafts, and rotors.
Aircraft Information
Registered Owner (Historical)
Analysis
1.1 HISTORY OF FLIGHT
On February 10, 2005, at 2033 Pacific standard time, a Cessna P210N, N432AR, reported severe turbulence while in cruise flight and collided with the ground during a rapid descent 8 nautical miles northeast of Lebec, California. Action Air Express, Inc., was operating the airplane as an on-demand air taxi passenger flight under the provisions of 14 CFR Part 135. The commercial pilot and one passenger sustained fatal injuries. The airplane was destroyed. The airplane departed under visual flight rules (VFR) from Fresno Yosemite International Airport, Fresno, California, at 1935, and received an instrument clearance to Santa Monica Municipal Airport, Santa Monica, California, in flight over the Clovis vhf omni-directional range (VOR). A combination of visual and instrument meteorological conditions prevailed along the route of flight.
The Air Force Rescue and Coordination Center (AFRCC) issued an Alert Notice (ALNOT) at 2230 on February 10, 2005. The wreckage was located at 1000 on February 12, 2005.
According to the operator, the purpose of the flight was to transport the passenger from Fresno to Santa Monica. The passenger was scheduled to depart from Fresno at 1700 but was late to arrive. The pilot waited at a fixed-base-operator (FBO) for the passenger who arrived for the flight about 1915. At 1920, the operator called the pilot to verify that the passenger had arrived. The pilot replied affirmatively, and stated that the passenger was just boarding the airplane for departure to Santa Monica.
While en route, the pilot communicated with several Federal Aviation Administration (FAA) facilities. The National Transportation Safety Board investigator reviewed transcripts for the time period from 2021 through 2030.
At 2026:13, the accident pilot stated, "So Cal, four nine three alpha romeo's checkin with you nine thousand." The controller replied "November four nine three alpha romeo Los Angeles center, roger the uh Burbank altimeter two niner eight eight."
At 2026:21, the pilot radioed "two niner eight eight four three two alpha romeo add uh uh you guys had any reports over uh Lake Hughes for any icing or (did it) pretty much cleared up uh we're getting some uh we got some a little bit south of Shafter."
At 2026:31, the controller stated, "Uh there's been a bunch of icing between Shafter and Lake Hughes I believe it's getting a little better closer to Lake Hughes November one five mike what is your flight conditions sir?"
At 2026:40, N9351M reported, "Uh five one mike is experiencing light rime ice."
At 2026:44, the controller reported, "Okay rog roger that uh November two alpha romeo traffic over Lake Hughes at eleven has some light rime ice traffic overhead at eleven had un had a little bit earlier."
At 2026:54, the pilot stated, "Uh roger four three two alpha romeo and what kind of plane is that we're um a two ten."
At 2027:00, the controller stated, "Uh the traffic over Lake Hughes is a Mooney and uh right overhead is a twin Cessna at eleven."
At 2027:07, the pilot responds, "(thanks) four three two alpha romeo."
At 2029:40, the controller stated, "November two alpha romeo can you maintain your altitude, maintain niner thousand."
At 2029:50, the controller stated, "November four three two alpha romeo LA Center."
At 2030:09, the controller stated, "November four three two alpha romeo LA Center."
At 2030:12, the pilot stated, "Four three two alpha romeo uh we have lower request (unintelligible)."
At 2030:18, the controller stated, "Two alpha romeo you're below my minimum uh altitude do your best to climb can you maintain altitude?"
At 2030:23, the pilot reported, "Four three two alpha romeo extreme turbulence."
No further transmissions were received from the accident pilot.
1.2 PERSONNEL INFORMATION
1.2.1 Pilot
The pilot held a commercial pilot certificate for single and multiengine instrument airplane, and also held a certified flight instructor certificate with ratings for single and multiengine instrument airplane. He held a valid first-class medical certificate issued on October 1, 2004, that did not have any waivers.
The pilot began his flight training on December 5, 2000. He obtained his pilot certificates over a period of 2 years from August 22, 2001, until his last rating, which was a certified flight instructor-instrument on June 24, 2002. During this time period the pilot took seven check rides. He failed the following three check rides on his first attempt: private multiengine; private instrument; and certified flight instructor instrument. Moreover, he took the private instrument check ride two times before passing.
The Safety Board investigator reviewed the pilot's records from Air Action Express, Inc. On May 26, 2004, the pilot satisfactorily completed a 14 CFR Part 135 flight check with an FAA inspector. The flight check satisfied the requirements of 14 CFR 135.293, 135.297, and 135.299.
On December 15, 2004, the pilot failed a 14 CFR 135.297 check. It was noted that item number 1, equipment examination (oral or written), was the reason for disapproval. On December 21, 2004, the pilot received another disapproval. It was noted on FAA Form 8410-3, "Airman Competency and Proficiency Check" that item number 23, holding, was unsatisfactory. Based on the FAA records, all other test areas were completed satisfactorily. On January 26, 2005, the pilot satisfactorily completed the 14 CFR 135.297 check.
Prior to the pilot's initial 14 CFR Part 135 check on May 26, 2004, he had attempted four Part 135 flight checks for the predecessor of Action Air Express, Inc., Peach, Inc. The FAA issued identifier code assigned to both companies was the same (QXNA). On January 30, 2004, the inspector noted, "135.293(a) unsatisfactory." On February 6, 2004, a disapproval was given for item number 1, equipment examination (oral or written). On March 4, 2004, a disapproval noted that item number 10, steep turns were unsatisfactory. On March 9, 2004, a disapproval again indicating item number 10 was unsatisfactory.
Two pilot's logbooks were recovered from the accident site and reviewed by the Safety Board investigator. The first logbook contained entries from December 5, 2000, to December 24, 2002. The second logbook began on May 8, and the last entry was dated October 3, 2004. The entries in the second logbook were intermittent so the times were estimated using the logged flight times. Based on a combination of the recorded flight logbook times and records from Action Air Express, Inc., the pilot's total flight time was estimated to be about 1,850 hours. On the pilot's most recent FAA medical application, the pilot reported a total pilot time of "2,000 est."
1.2.2 Passenger Information
Based on interviews with the passenger's spouse and a review of FAA airman records, the passenger did not hold a pilot certificate nor had he engaged in any flight training. The passenger had flown with the company on previous occasions due to business, and had not reported any complaints regarding Action Air Express, Inc., operations or flights.
1.3 AIRCRAFT INFORMATION
The single engine pressurized airplane was built in 1978. According to the maintenance records, the last annual was performed on July 14, 2004. The last maintenance performed was a 100-hour inspection on November 1, 2004. At the time of the accident, the airplane had accumulated approximately 97 hours since its last inspection.
In the limitations section of the airplane Pilot's Operating Handbook (POH), the following limitation was noted: Flight into known icing conditions is prohibited.
The airplane was equipped with a System Fifty-Five X Autopilot. Pursuant to the operating requirements of the operator, the autopilot was required to be operational for IFR flights. The autopilot could be disconnected during flight through the following methods: turn the autopilot master switch to OFF; press the autopilot disconnect/trim interrupt switch on the aircraft's control wheel; and/or pull the aircraft's AUTOPILOT circuit breaker.
1.4 METEOROLOGICAL INFORMATION
1.4.1 Pilot Weather Briefing
There was neither an FAA Flight Service Station nor Direct User Access Terminal Service record of the pilot receiving a weather briefing the day of the accident; nor was one required. According to the FAA accepted operations specifications for the operator, the pilot "will use National Weather Service (NWS) reports and forecasts or the PIC may use his own observations when operating in Visual Flight Rules."
According to the FBO from which the airplane departed in Fresno, a weather station is setup in a private room in their facility. The pilot was not witnessed utilizing the FBO weather station; however, FBO personnel stated that it would have been possible for the pilot to use the weather station without them witnessing it.
Loose, undated papers were located within the wreckage that contained hand written weather observations for various geographic areas and routes of flight.
1.4.2 Weather Study
A Safety Board meteorologist performed a weather study of the accident area and time.
1.4.2.1 General National Weather Service (NWS) Reports
The southwest section of the NWS Surface Analysis Chart for 1900 on February 10, 2005, depicted three separate high pressure systems with a central pressure of 1034 millibars (mb) extending over western Wyoming and Colorado. A low pressure system with a central pressure of 1002 mb was located to the south of the accident site in the Pacific Ocean off Baja of California, with a trough of low pressure extending northward along the California coast. The location of the pressure systems resulted in a pressure gradient along eastern California and western Nevada with an east to northeast wind flow pattern across southern California and in the vicinity of the accident site.
The NWS observation station at Sandberg, California (KSDB), located approximately 10...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX05FA092