N9904ECessna (Textron Aviation) 182P2006-08-04 NTSB Accident Report

Substantial
Fatal

Cessna (Textron Aviation) 182PS/N: 18263964

Summary

On August 04, 2006, a Cessna 182P (N9904E) was involved in an accident near Whitethorn, CA. The accident resulted in 2 fatal injuries. The aircraft sustained substantial damage.

The National Transportation Safety Board determined the probable cause of this accident to be: The pilot's loss of situational awareness with regard to the airplane's proximity to mountainous terrain, and her failure to maintain an adequate terrain clearance altitude or flight path, which resulted in an in-flight collision with the terrain.

HISTORY OF FLIGHT

On August 04, 2006, about 1100 Pacific daylight time, a Cessna 182P, N9904E, impacted a mountain shortly after departing from Shelter Cove Airport, Whitethorn, California. The two pilots, who were partial owners, were operating the airplane under the provisions of 14 CFR Part 91. The two occupants, both private pilots, were fatally injured; the airplane sustained substantial damage. The personal cross-country flight was originating from Shelter Cove Airport, with a planned destination of Ukiah, California. Instrument meteorological conditions prevailed in the area surrounding the accident site.

This accident is documented in NTSB report LAX06FA256. AviatorDB cross-references NTSB investigation data with FAA registry records to provide comprehensive safety information for aircraft N9904E.

Accident Details

Date
Friday, August 4, 2006
NTSB Number
LAX06FA256
Location
Whitethorn, CA
Event ID
20060814X01161
Coordinates
40.024444, -124.048057
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
2
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
2

Probable Cause and Findings

The pilot's loss of situational awareness with regard to the airplane's proximity to mountainous terrain, and her failure to maintain an adequate terrain clearance altitude or flight path, which resulted in an in-flight collision with the terrain.

Aircraft Information

Registration
Make
Cessna (Textron Aviation)
Serial Number
18263964
Engine Type
Reciprocating
Year Built
1975
Model / ICAO
182PC182
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
ZERO FOUR ECHO INC
Address
PO BOX 830
AIR CENTER HANGAR R-Z
Status
Deregistered
City
ACTON
State / Zip Code
CA 93510-0830
Country
United States

Analysis

HISTORY OF FLIGHT

On August 04, 2006, about 1100 Pacific daylight time, a Cessna 182P, N9904E, impacted a mountain shortly after departing from Shelter Cove Airport, Whitethorn, California. The two pilots, who were partial owners, were operating the airplane under the provisions of 14 CFR Part 91. The two occupants, both private pilots, were fatally injured; the airplane sustained substantial damage. The personal cross-country flight was originating from Shelter Cove Airport, with a planned destination of Ukiah, California. Instrument meteorological conditions prevailed in the area surrounding the accident site. An instrument flight rules (IFR) flight plan had been filed and a clearance had been issued; however, the flight plan was never activated.

On August 05, 2006, paragliders spotted the wreckage while operating in the area. Local authorities were notified of the accident, and located the wreckage about 1900.

Investigators conducted an interview with a witness who resided in a trailer located on a campground adjacent to airport property at the end of runway 12. He recalled observing the accident airplane depart on August 04, 2006. He stated that sometime after 0900, he took his dog for a walk [he was unclear of the exact time]. He noted that there was a dense fog surrounding the airport and the entire Shelter Cove area, which provided less than 1/4-mile visibility. He witnessed the airplane takeoff heading in a southerly direction along the coastline. The witness noted that the direction of flight was unusual, as a majority of the time, airplanes depart to the north. The airplane headed toward a dark cloud to the south and entered the fog layer.

Although he could only discern the airplane's silhouette after it entered the fog, the witness stated that he observed it climb to about 500 to 700 feet above ground level (agl). The airplane subsequently made a 90-degree turn to the left. He heard the engine momentarily increase in revolutions per minute (rpm) as if it were revving. The engine noise ceased and he believed that he heard a faint sound akin to the collapsing of an aluminum can.

During a telephone conversation with the National Transportation Safety Board investigator-in-charge (IIC), an airplane mechanic based in Ukiah stated that the right-seated pilot contacted him about 1500 the day prior to the accident via telephone. He noted that the pilot was utilizing a cell phone during their conversations and the reception was poor, making it difficult to communicate. The pilot stated that he was attempting to troubleshoot an oil leak, as he had previously experienced oil residue covering the cowling and windshield area. The pilot speculated that the oil was originating from the filler cap area. After attempting to find the leak and subsequently performing engine runs, the pilot still could not precisely identify the source of the leak. The mechanic told the pilot to bring the airplane to his facilities in Ukiah where he could attempt to troubleshoot the problem. The pilot agreed, but stated that he would have to wait for the fog to lift before he could depart from Shelter Cove.

The mechanic further stated that the pilot reported that he had "lost 4 quarts" of oil during his pervious flight from Van Nuys, California, to Shelter Cove. The pilot added 3 quarts of oil when he arrived in Shelter Cove, at which point the engine indicated it contained a total of 8 quarts. The pilot also expressed concern that there was no place in the area where he would be able to purchase additional oil.

PERSONNEL INFORMATION

Left-seated Pilot

A review of the airmen records maintained by the Federal Aviation Administration (FAA) disclosed that the left-seated pilot held a private pilot certificate with airplane ratings for single engine and instrument flight. Her most recent third-class medical certificate was issued on March 20, 2005, with a limitation that she "must have available glasses for near vision."

The Safety Board IIC reviewed copies of the left-seated pilot's personal flight logbooks. According to the logbook entries, she first received her private pilot license in March 1990, followed by her instrument rating in May 1992. The records indicated that her total flight experience equated to 709.6 hours, with 588.5 hours logged as pilot-in-command. She had amassed 149.2 hours under simulated instrument meteorological conditions (IMC), and had acquired 38.7 hours of actual time operating in IMC.

The logbooks additionally revealed that the left-seated pilot had accumulated a majority of her flight time prior to 1998 (650 hours). The entries indicated that she accrued 33.2 hours from April 2005 to July 24, 2006 (the last entry), all of which were performed in the accident airplane. Within that time frame only two flights were noted as being conducted under simulated instrument meteorological conditions, one of which was on June 22, 2005 (1.3 hours) and the other on July 01, 2006 (1.7 hours). The last flight recorded was the only logbook entry that indicated the pilot had flown to an airport near the accident site. The entry showed that she had logged 3.3 hours from Van Nuys to Ukiah; no instrument meteorological conditions were noted for that flight.

The last two entries in the endorsement section of her logbook were dated July 20, 2006, and were signed by the same certificated flight instructor (CFI). One of the entries noted that the pilot had satisfactorily completed a biennial flight review, and the other stated that the pilot had satisfactorily completed an instrument competency check.

Right-seated Pilot

According to the FAA airmen records, the right-seated pilot held a private pilot certificate with an airplane rating for single engine land. His most recent third-class medical certificate was issued without limitations on June 20, 2005.

The pilot's personal flight records were not recovered. On his last application for a medical certificate, he reported a total flight time 670 hours.

Accident Aircraft Pilot Logbook Entries

Within the wreckage, investigators found an airplane log with numerous entries containing both pilots' names. According to the other owners of the airplane, the log was utilized as a means to track the airplane usage by each owner/pilot. The first flight entry listing the accident pilots was dated on March 07, 2006. In pertinent part, the left-seated pilot's name was recorded on an entry dated July 24, indicating that on that date she had flown the airplane 3.3 hours from Van Nuys to Ukiah. The following entry indicated that the right-seated pilot had flown a 3.5-hour flight from Ukiah back to Van Nuys.

The left-seated pilot's next, and final entry, was dated August 02, where she logged 3.6 hours from Van Nuys to Shelter Cove. The following entry contained the right-seated pilot's name and the airplane's starting tachometer reading; no other information was written in that entry.

AIRCRAFT INFORMATION

The Cessna 182P, serial number 18263964, was manufactured in 1975. A review of the logbooks revealed that the most recent annual inspection were performed on August 12, 2005, at a total time of 4,206.5 hours, corresponding to 110.3 flight hours prior to the accident.

The powerplant, a Teledyne Continental Motors O-470-S, serial number 226420-R, was last overhauled on February 05, 1996, equating to about 1170 hours prior to the accident. The maintenance records listed the last maintenance as occurring on April 20, 2006, where the airplane underwent a 50-hour inspection, which included an oil change.

A review of the voice recordings from the McMinnville, Oregon, Automated Flight Service Station (AFSS) disclosed that the left-seated pilot filed an instrument flight rules (IFR) flight plan indicating that at the time of departure the airplane had 3 hours of fuel on board. The recordings further revealed that the left-seated pilot requested her intentions of making an instrument landing system (ILS) approach at Ukiah, to which the briefer asked, "Is that just for practice?" She replied, "No we have got some problems with our aircraft."

METEOROLOGICAL INFORMATION

Numerous Whitethorn residents reported that the morning of the accident a dense fog surrounded the airport and the Shelter Cove area. One witness stated that he drove his automobile from Shelter Cove to Garberville around the time of the accident. He reported that as he ascended up the mountain out of Shelter Cove he came out of the clouds around 1,300 feet.

The Safety Board IIC reviewed the Geostationary Operational Environmental Satellite (GOES)-11 satellite imagery for the following times: 1015, 1030, and 1045. An examination of the images revealed coastal stratus and fog along the Pacific coast with the accident area obscured by clouds and fog. The infrared satellite imagery indicated a radiative cloud top temperature of 283.3 degrees Kelvin (10.17 degrees Celsius), which corresponded to cloud tops near 9,400 feet mean sea level (msl).

The closest weather observation station was near Garberville, California, about 15 nautical miles from the accident site on a magnetic bearing of about 076 degrees. At 1030, it recorded the temperature at 21.2 degrees Celsius; dew point 12.1 degrees Celsius; wind west-northwest at 2 miles per hours; altimeter 29.91 inHg; sky conditions clear.

A routine aviation weather report (METAR) generated by an Automated Surface Observation System (ASOS) in Arcata/Eureka, California (located 57 nautical miles north of the accident site), reported that at 0953 there was an overcast cloud layer at 400 feet above ground level (agl) with mist. An updated weather report at 1053 reported a broken cloud layer at 400 feet agl with haze.

Records maintained at the McMinnville AFSS disclosed that the left-seated pilot (using the accident airplane's registration number) contacted the facility twice for weather information. The first call, at 0800, was a request for a weather briefing for a flight from Shelter Cove to Ukiah at an altitude of 7,500 feet msl. The briefer advised that an AIRMET (Airman's Meteorological Information) for instrument flight rule (IFR) conditions was current for the coast and encompassed the departure airport. He then queried her, "how does it look outside?" The left-seated pilot responded by saying, "It's foggy probably visibility is less than 2." The briefer indicated that between 1100 and 1300, the instrument meteorological conditions (IMC) "may lift," but indicated that at the time visual flight rules (VFR) was "not recommended." She stated that she intended to file an IFR flight plan "a little later."

The left-seated pilot made a second telephone call at 0941 to the AFSS requesting an "IFR weather update." The briefer informed her of the AIRMET for IFR in the coastal areas, additionally stating that there was stratus, but it was "burning off." She filed an IFR flight plan that said she would be operating at 6,000 feet msl and wanted a direct route from Shelter Cove to Ukiah, rather than following along victor airway V494.

COMMUNICATIONS

Safety Board investigators reviewed recordings from McMinnville AFSS and Oakland Air Route Traffic Control Center (ARTCC). The tape recordings revealed that following the left-seated pilot's telephone request to file a flight plan, an AFSS specialist contacted the D42 controller at ARTCC. The specialist requested an IFR clearance for N9904E from 0Q5 (Shelter Cove) to Ukiah. The D42 controller acknowledged the request and stated that he had a flight progress strip for the airplane, stating, "N9904E is cleared to cleared from the Shelter Cove Airport to the Ukiah Airport, climb and maintain climb and maintain 7,000. Squawk 4235. Clearance void if not off [the ground] by 1755. If not off by 1755 advise Oakland Center not later than 1800 of intentions. Departure frequency will be 132.2." The AFSS specialist verified the departure frequency and asked whether the flight was "cleared as filed" or via any other point. The D42 controller advised the flight was "cleared as filed." The call was terminated with the operating initials of both employees.

Radar data supplied by the United States Air Force from the RBR and RBL long-range radar sites and radar data from the FAA did not show any radar returns in the Shelter Cove area between 1030 and 1130. FAA radar data obtained from Oakland ARTCC did not include any information for transponder code 4235. There were no recorded voice communications between the pilots of N9904E and the Oakland ARTCC R42 sector controller on August 4, 2006, between 1042 and 1105.

AERODROME INFORMATION

The Airport/ Facility Directory (AFD), Southwest U. S., indicated Shelter Cove Airport (0Q5) runway 12/30 was 3,400 feet long and 75 feet wide. The runway surface was composed of asphalt. The airport elevation was 69 feet msl. The non-towered airport was situated in class "G" airspace. A note in the remarks section of the AFD stated, "Expect crosswinds, downdrafts, and extended periods of fog year round."

The airport was situated on the only stretch of flat terrain in the immediate vicinity that was adjacent to the ocean. The runway was nearly centered on the rectangular shaped flat area, which dimensions were about 1 mile in length (north-south) and 1,400 feet in width. The terrain just east of the flat stretch was mountainous with peaks reaching about 2,000 feet msl. To both the north and south of the flat land was open ocean.

Locals to the area reported that the standard procedures for departing aircraft were to takeoff to the north using runway 30 and shortly thereafter turn left away from the adjacent terrain. If the aircraft's destination were to the south, a 180-degree turn would be initiated until the desired heading was reached.

WRECKAGE AND IMPACT

The accident site was located in the costal hills about 1 nautical mile (nm) east of the departure end of runway 12 at Shelter Cove. In character, the hills were steeply slopped, averaging between 70 to 80 degrees, and populated by scattered mature fir trees and manzanita scrub brush typical of the mid to northern California coastal region. The main wreckage was located at an estimated 40 degrees 01.469 minutes north latitude and 124 degrees 02.880 minutes west longitude, at an elevation of about 960 feet msl.

The main wreckage came to rest inverted on the southern side of a 1,350-foot steep hill, with the right wing and tail section attached to the fuselage. The left wing separated at the wing root and was the farthest debris found from the main wreckage; it was located upslope about 150 feet on a median magnetic bearing of about 305 degrees. All control surfaces were accounted for at the accident site.

Trees were located between the left wing and the main wreckage that appeared to have been recently broken and cut, with freshly severed limbs. One tree branch, about 4 inches in diameter was identified immediately east of the left wing that had a diagonal cut, consistent in appearance to a propeller severing it. Brush with lacerated branches was found on the slope leading down to the main wreckage.

The front of the airplane (nose section) was upslope of the fuselage on a measured magnetic bearing of about 060 degrees. The right main landing gear was still affixed, while the nose gear and left main landing gear had separated from the airframe. The tail section was bent aft of station 134 where the aluminum structure had crumpled leaving an angle of about 55 degrees between the tail structure and fuselage. The fuselage had sustained vertical crush deformation, with the forward cockpit area crushed inward and forward toward the engine. The left cabin door was separated from the fuselage and the aft left baggage door was ajar.

The engine and right wing remained attached to the fuselage. The propeller hub, with two propeller blades, was attached to the engine and imbedded within the soil of the slope. The right wing was inverted with the wing flap visually in the retracted position and the strut was still attached. The aileron had separated from the outboard hinges, but remained attached by a forward hinge; the control surface was deformed in with two s-bends. The outboard leading edge of the wing was crushed aft about 1-foot inboard.

The left wing was in two main sections that were located on opposite sides of a mature fir tree on a ridge of a slope to the west of the main wreckage. The larger section was located on the north side of the tree and consisted of a majority of the wing, including the tip inboard to about the mid flap area. The other main section of the left wing was not accessible to investigators on scene, but appeared to consist of the inboard wing with partial attachment of the flap.

The horizontal stabilizers, with elevator control surfaces, were still attached to the fuselage. The leading edge of the left horizontal stabilizer was crushed aft. The elevator remained partially attached at the inboard hinges. The right side was not accessible. The vertical stabilizer and rudder were intact.

MEDICAL AND PATHOLOGICAL INFORMATION

The Humboldt County Coroner's Office completed an autopsy of both pilots. The FAA Toxicology and Accident Research Laboratory performed toxicological testing on specimens of both pilots. The reports for both pilots revealed their specimen tests were negative for carbon monoxide, cyanide, ethanol, and drugs.

TESTS AND RESEARCH

Investigators from the Safety Board, FAA, Cessna Aircraft Company, and Teledyne Continental Motors (TCM) examined the wreckage on September 22, 2006, at the facilities of Plain Parts, Pleasant Grove, California.

Engine

An external visual examination of the engine revealed that it had broken from its mounts, consistent with impact damage. There was a puncture in the crankcase measuring 0.75 inches in diameter located above the number 2 cylinder. Holes were observed on the number 1 and number 2 cylinder rocker box covers. The oil sump was crushed. The bottom of all the exhaust tubing was crushed and the intake pipes were separated from cylinders 4, 5, and 6.

The cylinder mounting flange stamps did not coincide with their respective positions. The sequence was as follows:

Accident Engine- 2, 6, 6, 3, 3, 2

TCM Specified- 1, 2, 3, 4, 5, 6

The TCM representative stated that this would not affect the functionality of the engine.

Investigators removed all cylinder rocker box covers and noted a light blue iridescent coating/film on the valve stems and surrounding cylinder casing. The spark plugs were all removed and photographed. The spark plug faces and electrodes were all dark gray and similar in appearance; the bottom spark plugs for cylinder numbers 2, 3, and 5 were soaked in a substance similar in appearance to oil. The TCM representative stated that the signatures on the spark plugs were consistent with normal operation.

The crankshaft was rotated by means of investigators turning the crankshaft propeller flange. Thumb compression was established in all cylinders. Valve train continuity was observed, with equal lift action at each rocker arm assembly.

The ignition harnesses remained attached to their respective magnetos, and investigators observed that the magnetos had separated from their respective mounting pads. The right and left magneto were rotated by hand and appeared to function normally, producing spark at each terminal.

The cylinders' combustion chambers were examined through the spark plug holes utilizing a lighted borescope. The combustion chambers remained mechanically undamaged, and there was no evidence of foreign object ingestion or detonation. The valves were intact and undamaged. There was no evidence of valve to piston face contact observed. The gas path and combustion signatures observed at the spark plugs, combustion chambers, and exhaust system components displayed coloration that the TCM representative said was consistent with normal operation. There was no oil residue observed in the exhaust system gas path. The number 2 and 5 cylinders were removed. No evidence of mechanical malfunction was found; the oil rings were intact.

The carburetor was detached from the engine and found within the wreckage. Disassembly of the carburetor revealed that the brass floats were intact. The bowl was clean with no debris. The oil pump was disassembled and found free of contaminants. The engine was equipped with a 90-degree oil filter adapter with a Champion spin-on filter. The oil filter was removed and cut open disclosing an oil coated debris-free paper filter.

The vacuum pump was removed; the vanes were all intact. The vanes were removed and found to have a grooved appearance on the outward half of each vane. The grooves were akin to a washboard appearance and the depth of the individual grooves could be felt when investigators ran their fingers over the surface area of the vane. The adjacent rotor areas had a similar appearance.

The muffler was disassembled; it was uniformly black in appearance on the outside and the inside was coated with a white residue.

Airframe

The left horizontal stabilizer was not attached (recovery personnel stated it was removed from the empennage during recovery efforts enabling them to place the airframe on a trailer). Adjacent to the wing root, the stabilizer was intact; the cord measured 28 inches. The surface was progressively crushed aft further outboard where the most outboard cord measured 12 inches; the tip was separated. Two feet of the most inboard portion of the elevator control remained and was attached to one hinge on the horizontal stabilizer.

The right horizontal stabilizer and respective elevator control were intact and attached to the empennage. The aft hinge of the elevator had a static grounding wire attached that was located on the outside of the airframe skin, wedged between the flight control surface and horizontal stabilizer. The surrounding wire's plastic housing was intact with no apparent wear marks. The right and left elevator control arms were disconnected at the torque tube and sheared from their rivets.

The left wing was separated into two main sections. The inboard section measured about 6 feet 2 inches. A semicircular indentation was located about 2 feet outboard from the wing root, with the skin crushed about 1 foot aft at the most significant point of deformation; the diameter of the indentation measured about 1.5 feet. The entire flap had remained attached to the inboard portion of the wing. The outboard wing section, about 9 feet in length, still had the aileron attached at its respective hinges. The hinges were a gold coloration, consistent with the hinges being replaced since original manufacture. The leading edge additionally had a circular shape, with a more hook-like appearance. The inboard crush was circular and the outboard edge curved and was more diagonal to the leading edge. The crush stretched aft about 2 feet, corresponding to a diameter of about 1.5 feet. The left wing aileron balance cable was intact outboard to the control surface; the cable ends were broom-strawed. The forward cable was manipulated by investigators and appeared to be continuous to the control surface on the outboard section. The fuel cap was secured and the seal was intact and pliable. The wing tip was still attached to the outboard section of the wing.

The right wing was relatively intact, with several divots on the leading edge, all of which are consistent with impact damage. The outboard 4.5-foot of the aileron was separated. The wing tip was missing. The rear aileron balance cable was intact and continuity was established by investigators via manipulation of the cable and the observation of the respective control surface movement. The cable end was disconnected at the wing root and had a broom-strawed appearance, consistent with overload.

The empennage was separated at the aft bulkhead. The vertical stabilizer and rudder were intact; flight control continuity was established.

Trace amounts of fuel were found in the gascolator. The primer fuel line additionally contained fuel. The primer knob was found in the "out" position and was not locked. The fuel selector was removed and examined; according to the Cessna representative, the fuel selector was in the "both" position.

The airplane's bottom skin (belly) contained a light dirt layer with no substantial oil traces noted.

One propeller blade was bent aft, with slight s-bending and was broken out of the hub. The other blade was bent slightly aft with the tip curled.

Vacuum Pump

The vacuum pump was examined at the facilities of RAPCO, Inc., the instrument's manufacturer, under the supervision of the Safety Board IIC. The vacuum pump appeared to have sustained post-impact damage and was separated from its respective flange. The external drive spline was absent. Six of the external gear prongs (alignment dowels) remained inside their respective holes of the shear coupler. The shear coupler was intact, though offset; the drive spline prongs were only partially aligned and not directly opposite one another. The shear coupler had a yellow coloration, which according to the RAPCO representative, was indicative of it being exposed to engine oil over time.

The internal drive spline was still affixed to the shear coupler. The sponge-like compression seal was still attached to the internal drive spline and had an appearance consistent with being soaked in an oil-type substance. The ceramic seal was shattered though remained partially in place on the internal drive spline.

Examination of the front housing revealed a circumferential wear pattern on the internal face. The RAPCO representative noted that such wear patterns were a result of a restricted discharge, where the rotor is subsequently pressed toward the front end of the pump (toward the flange) and will make repetitive contact against the internal face. Investigators removed the inlet fitting, which still attached to the front-end housing. It appeared to be overextended and was bent about 100 degrees, as opposed to the normal 90-degree orientation. A visual external examination of the fitting revealed a copper appearance on the upper half, as opposed to its normal brass/gold coloration. The threads of the fitting contained a film of a substance consistent to oil and the internal wall of the fitting was coated in a black residue.

The three-finger drive was removed from the front housing, revealing an intact carbon drive bushing. Investigators additionally noted black carbon-like debris, about 0.25 inches in diameter on the faceplate where the three-finger drive mated against the plate. A black outline of the vane slots were noted on the face of the three-finger drive, consistent to the rotor and vanes being pushed toward the front end. A piece of carbon was lodged inside a forward port of the front-end housing.

The center carbon rotor was shattered into several pieces. The chamfer on the outboard edge of the vane slot displayed a build-up akin to that of vane carbon debris, and consistent with repetitive rub. Investigators measured a portion, which had a height of 1.309 inches. The cavity (stator) displayed evidence of circumferential wear with small grooves visible. The cavity height measured 1.313 inches, equating to 0.004 inches higher than the rotor. The representative stated that a new pump assembly is required to have a variance of 0.002 inches between the cavity and rotor. Both the pressure and inlet ports in the cavity were coated in a residue consistent with that of oil.

All of the six carbon vanes were individually wrapped (for the purpose of transport) and appeared to be intact. The vanes had a grooved appearance; more defined on the outboard half. The grooves were akin to a washboard appearance and the depth of the individual groves could be felt when investigators ran the fingers over the surface area of the vane. The adjacent rotors had a similar appearance. Each vane was measured and compared to the FAA certified blueprints. Investigators additionally measured the one intact vane slot and two intact three-finger holes. The RAPCO representative stated that all measurements were consistent with normal wear.

The end housing contained a residue inside the ports consistent with that of oil. The outlet (pressure) fitting was removed and contained a thick film of the same oil-type residue along the internal walls. The fitting had sustained crush deformation and was bent inward. The RAPCO representative noted that it did not appear to be a standard fitting.

The damage the vacuum pump sustained prohibited investigators from conclusively determining if it was functioning normally at the time of impact. According to the RAPCO representative, all signatures were consistent with the unit producing vacuum. He added that it appeared that the vacuum pump had been ingesting engine oil over a long duration and was most likely discharging oil at the pressure-fitting outlet.

Cockpit

The impact damaged Bendix/King KX165 navigation and communication radio was recovered from the wreckage. The Safety Board IIC applied power to the unit in an avionics shop in an effort to retrieve the frequency data. The communication frequencies were 122.9 on the active and 122.35 on the standby. The navigation frequencies were 109.1 on the active and 116.1 on the standby.

The Common Traffic Advisory Frequency (CTAF) for Shelter Cove was 122.9, with the applicable Flight Service Station (FSS) frequency listed on the San Francisco sectional aeronautical chart as 122.3. There are no frequencies in the area that coincide with 109.1; however, the Gorman Very High Frequency Omni-directional Radio-range (VOR) near Van Nuys has the frequency of 116.1.

The horizontal situational indicator (HSI) had sustained impact damage, but appeared intact on its face. The heading select bug was positioned about 333 degrees and the course indicating arrow was positioned around 140 degrees. The course deviation indicator (CDI) appeared aligned or centered; the "NAV" flag was fully visible. The lubber line displayed a heading of about 045 degrees.

The clock in the cockpit had come to rest displaying a time of 1039.

ADDITIONAL INFORMATION

Regulations

In pertinent part, FAA Order 7110.65, "Air Traffic Control," Paragraph 4-3-4, "Departure Restrictions, Clearance Void Times, Hold for Release, and Release Times" states:

Assign departure restrictions, clearance void times, hold for release, or release times when necessary to separate departures from other traffic or to restrict or regulate the departure flow.

a. Clearance Void Times.

1. When issuing clearance void times at airports not served by control towers, provide alternative instructions requiring the pilots to advise ATC of their intentions no later than 30 minutes after the clearance void time if not airborne.

2. The facility delivering a clearance void time to a pilot shall issue a time check.

Paragraph 10-3-1 "Overdue Aircraft" states in part:

a. Consider an aircraft to be overdue, initiate the procedures stated in this section and issue an ALNOT when neither communications nor radar contact can be established and 30 minutes have passed since:

NOTE-

The procedures in this section also apply to an aircraft referred to as "missing" or "unreported."

1. Its ETA over a specified or compulsory reporting point or at a clearance limit in your area.

2. Its clearance void time.

b. If you have reason to believe that an aircraft is overdue prior to 30 minutes, take the appropriate action immediately.

c. The center in whose area the aircraft is first unreported or overdue will make these determinations and takes any subsequent action required.

Oakland Center (ZOA) 7231.10E, Appendix 104 dated August 3, 2006, states in part:

The purpose of the order establishes standard operating procedures, which are necessary for maintaining a safe and efficient operation within Oakland ARTCC. This order is supplemental to FAA Orders 7110.65, "Air Traffic Control", 7210.3, "Facility Operation and Administration"; and 3120.4, Air Traffic Control Training."

Appendix 104. Area D Front Line Manager Information Binder states in part:

5. Overdue Aircraft. FAA Order 7110.65 addresses overdue aircraft. When there is an overdue aircraft, the supervisor should make the initial call to the airport to determine if the aircraft has landed safely; however, the OMIC will make any subsequent phone calls.

Supervisors are expected to do the following:

a. Obtain the last position of radar contact (fix/radial/distance and/or lat/long).

b. Have the controller mark the last point of radar contact on the MDM using the "draw" feature.

c. Have aircraft in the vicinity (lower altitudes) listen for ELTs.

d. Have the sector and surrounding sectors monitor 121.5/243.0.

e. Print a flight progress strip, if possible.

f. Give the OMIC any information about the aircraft, local weather conditions, etc.

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX06FA256