S. LAKE TAHOE, CA, USA
N64845
Cessna 152
The student pilot was on an authorized round-robin cross-country flight with several intermediate landings. He had made 1 landing at the first airport, and 3 landings at the second airport, having a density altitude of about 6,700 feet. He then took off but did not follow the published (recommended) departure procedures for gaining altitude. He did, however, proceed along his flight plan route directly toward the next authorized landing site. The route was over terrain which required the airplane to climb at a rate which exceeded its published maximum performance. After climbing about 4 minutes the airplane collided with trees and impacted the snow covered mountainside about 7,840 feet msl. The CFI reported that he had personally authorized his student to make the flight, but told him to change the route from what the student had initially selected (accident route) to one over lower terrain. The CFI had not flown with the student in 3 months nor had he provided dual cross-country training in nearly 6 months. Also, the CFI had not provided his student with high density altitude flight training in the geographical area flown. Prior to the student's departure, the CFI had not reviewed with him the latest forecast weather conditions or ensured that the pencil line depicting the route of flight was drawn away from the higher elevation mountainous terrain.
HISTORY OF FLIGHT On April 6, 1997, at 1528 hours Pacific daylight time, a Cessna 152, N64845, operated by Fallon Airmotive, Inc., collided with upsloping mountainous terrain approximately 3.76 nautical miles (nm) east-southeast (116 degrees magnetic) from the Lake Tahoe Airport, South Lake Tahoe, California. Visual meteorological conditions prevailed at the time of the solo instructional flight. The student pilot had filed a visual flight rules flight plan, but it was not activated. The airplane was found destroyed and the student pilot was fatally injured. The round robin flight originated from Fallon, Nevada, about 1255. The pilot's certified flight instructor (CFI) provided a written statement to the National Transportation Safety Board indicating that he had personally reviewed his student's flight planning and had authorized the cross-country flight. The pilot's flight plan form (as found in the airplane wreckage along with the corresponding sectional aeronautical chart) indicated a round robin flight with his first landing at the uncontrolled Gansner Field (201), Quincy, California. Thereafter, he planned to proceed to the controlled Lake Tahoe Airport (TVL). At Lake Tahoe the pilot planned to perform three takeoffs and landings. Then, he planned to fly to and land at the uncontrolled Hawthorne Municipal Airport (HTH), Hawthorne, Nevada, before returning to the uncontrolled Fallon Municipal Airport (FLX). The Federal Aviation Administration (FAA) did not report receiving any communications with the airplane during its en route cruise flight. The FAA coordinator reported that the airplane was observed landing at the Gasner Field, and thereafter the airplane departed the area. The first recorded radio communications with the airplane occurred as it approached Lake Tahoe for landing. At 1502, the pilot was issued a clearance to land on runway 18. Thereafter, the pilot indicated to the controllers that he desired to perform additional takeoffs and landings. The pilot taxied back to runway 18, and at 1506, was issued a takeoff clearance. The airplane departed but remained in the traffic pattern. At 1509, the pilot was again cleared to land. The pilot landed and taxied back for another takeoff. At 1514, the pilot was cleared for his second takeoff. At 1516, the pilot was cleared to land, again on runway 18. After landing he taxied back for takeoff, and the Lake Tahoe controller directed the pilot to taxi into position on runway 18 and hold. The pilot acknowledged the clearance. At 1523:16, the controller issued the following clearance to the pilot: "Cleared for takeoff left or right downwind departure approved." Seven seconds later, at 1523:23, the pilot stated ". . .roger thanks for your help." This was the last recorded voice communication from the pilot. The controllers described the traffic conditions as light, and did not report observing anything unusual as the airplane took off for the third time and departed the area. The controllers did not recall the airplane's direction of flight. About 4:29 minutes later, at 1527:52, the brief transmission of an emergency locator transmitter (ELT) signal was recorded in the control tower. PERSONNEL AND TRAINING INFORMATION Pilot-in-Command Based upon entries contained in the pilot's flight training logbook, the pilot commenced primary flight training at Fallon on May 16, 1996. After receiving 20.1 hours of dual flight instruction, the pilot accomplished his first solo flight on July 22. The flight was performed in a Cessna 172. About 2 weeks later, on August 7, the pilot soloed in a Cessna 152. This flight, and the remainder of all the pilot's flights, were performed in the same Cessna 152, N64845. Regarding cross-country flight training, the pilot's first dual cross-country flight was performed on August 27, during which he flew between Fallon and the Douglas County Airport (MEV), Minden, Nevada. The pilot's next cross-country flight occurred on September 17, and was flown between Fallon and Hawthorne. The pilot's final dual cross-country flight was performed on October 14, 1996, and was flown to Douglas and Hawthorne from Fallon. Thereafter, between October 17 and November 27, the pilot performed a series of four solo cross-country flights with landings authorized by his CFI in Nevada at Fallon, Douglas, Hawthorne, and the Dixie Valley airports (elevation 3,963, 4,718, 4,215, and 3,443 feet mean sea level (msl), respectively). The CFI authorized landings in California at the Herlong and Bishop airports (elevation 4,055 and 4,120 feet msl, respectively). A further review of the pilot's logbook and flight records indicates that the last four flights prior to the accident consisted of a dual lesson on January 7, 1997, and solo flights on January 21, February 6, and March 17. All flight instruction was provided by the same CFI. The CFI endorsed the student pilot's certificate for the fifth time on January 7, which was 89 days prior to the accident flight. On April 4, 1997, the CFI wrote in his student's pilot logbook that he had reviewed the student's preflight planning, and he was prepared to make a solo cross-country flight from Fallon to the following airports: 201, TVL, and HTH (Gasner, Lake Tahoe, and Hawthorne, respectively.) The Safety Board found no evidence indicating that the student had previously landed at Lake Tahoe, or that the CFI had provided his student with dual flight instruction regarding departure and climb out procedures from Lake Tahoe, a high density altitude airport partly surrounded by higher mountainous terrain. Certified Flight Instructor The FAA reported that the pilot's CFI holds a commercial pilot certificate with airplane single engine land, multiengine land, and instrument airplane ratings. The multiengine land rating is limited to flight only under visual flight rules (VFR). On June 2, 1997, the CFI reported to the FAA that his total flight time was 7,000 hours. He had flown 400 hours during the previous 6 months. The CFI's instructor certificate was originally issued in November 1985. On the accident date the CFI was privileged to instruct in single engine land airplanes and instruments. AIRCRAFT INFORMATION The airplane last received an annual inspection on October 23, 1996, at an airframe total time of 5,877 hours, and an engine total time of 990.5 hours. At the accident site the recording tachometer was found registering 5,979.7 hours, about 102.7 hours since its last inspection. No outstanding maintenance discrepancies were found in the maintenance records or logbooks. Weight and balance records found in the airplane indicated that on December 6, 1990, the airplane's empty weight was revised. Its new empty weight was listed as 1,149.3 pounds, and the new useful load was 520.7 pounds. METEOROLOGICAL INFORMATION At 1447, Lake Tahoe reported its surface wind was from 180 degrees at 10 knots, and the temperature was 50 degrees Fahrenheit. About 1521, controllers reported that the wind was from 230 degrees at 5 knots, and the altimeter was 30.06 inHg. At 1547, Lake Tahoe reported its surface wind was from 220 degrees at 5 knots, and the temperature was 46 degrees Fahrenheit. The Safety Board estimated that the density altitude was approximately 6,700 feet. AIRPORT INFORMATION The following remarks are written for Lake Tahoe, elevation 6,264 feet msl, in the government publication entitled "Airport/Facility Directory Southwest U.S.:" "Normal dep Rwy 18 is a wide left downwind dep, left crosswind turn should not be made until reaching the south arpt boundary and 7500'. If sufficient altitude is not reached after tkf for crosswind turn to a downwind departure with safety approximately 1.5 miles south is a golf course where you may circle to gain altitude; advise twr of intentions ... TPA--7500." Upon request, the Lake Tahoe airport director provides pilots with free information sheets containing an airport diagram and text which describes departure procedures. In pertinent part, pilots departing using runway 18 are requested not to turn left (eastbound) until reaching 7,500 feet msl. No evidence was found indicating that the pilot had received this information sheet. WRECKAGE AND IMPACT INFORMATION The main wreckage was located on United States Forest Service land known as the Tahoe Basin Management Unit, about 38 degrees 51.14 minutes north latitude, by 119 degrees 56.10 minutes west longitude. The terrain elevation is approximately 7,840 feet msl. Within 2 miles south through northeast of the accident site, the mountain elevation increases from approximately 8,800 to over 9,800 feet msl. Based upon the on-scene examination of the accident site and airplane wreckage, the airplane was found to have initially collided with several estimated 90-foot-tall trees before coming to rest in an inverted attitude partially wrapped around an estimated 2.5-foot diameter tree trunk in the snow covered terrain. Numerous felled branches were observed surrounding the trees at the initial point of impact (IPI). Fragmented portions of the airplane's right wing tip and rudder were found suspended from branches 80 to 90 feet above ground level. Additional portions of airplane structure were found along a magnetic track of 117 degrees and consisted of the severed outboard portion of the left wing and the right elevator with attached trim tab. The distance between the IPI and the main wreckage was approximately 170 feet. The cockpit was found crushed, and the wings were observed broken from the fuselage structure. Both wing tanks were observed ruptured. The left wing was observed resting on its leading edge, and fuel was observed pooled inside. Slight evidence of chordwise abrasions were noted on the propeller's cambered surface. All of the airplane's flight control surfaces were accounted for at the accident site, and all major airframe components were located on scene. No evidence was found indicating there was any preimpact failure of the flight control system. There was no evidence of fire. The engine was found without evidence of case rupture. Thumb compression was verified in all cylinders upon rotation of the crankshaft through 720 degrees. Magneto spark was observed from all eight leads, and evidence of fuel was observed upon inspecting the line between the carburetor and the gascolator bowl. The fuel screen was clear. The alternator drive belt and the vacuum pump drive gears were found intact; the oil dipstick was observed seated; and the throttle and carburetor heat controls were found connected at the engine fittings. MEDICAL AND PATHOLOGICAL INFORMATION On April 8, 1997, an autopsy was performed by the County of El Dorado, South Lake Tahoe. Results of the FAA's toxicology tests on the pilot were negative for ethanol, carbon monoxide, and pertinent drugs. TESTS AND RESEARCH Endorsements and Flight Training No evidence was found in the pilot's logbook of a 90-day flight endorsement which matched the FAA's recommendations pursuant to Advisory Circular number 61.65C and the regulatory flight training requirements for solo flight. According to the pilot's logbook and flight records, during the preceding 2 months he had flown an airplane on one occasion in solo flight on 3/17/97. He had not received dual instruction since 1/7/97, and he had not received dual cross-country flight instruction since 10/14/96. The CFI endorsed the pilot's logbook for the cross-country (accident) flight on 4/4/97. The pilot received a predeparture weather briefing from flight service for the flight on 4/6/97. The CFI reported that he did not review the contents of this weather briefing with his student. Navigation Chart, Weather, and Flight Plan Log Sheet The pilot's San Francisco sectional aeronautical chart, flight plan form, and log sheet were found in the wreckage. The following note was printed on the chart: "Obsolete for use in navigation . . . [on] October 10, 1996." Flight service station personnel informed the pilot during his predeparture briefing to expect a head wind along certain portions of the en route flight. Also, the terminal weather forecast indicated that at Lake Tahoe the surface winds were expected to be from 200 degrees at 10 knots, with gusts to 21 knots. No compensation for the winds aloft was evident on the flight plan log sheet. The same airspeed was listed for all route segments, and the wind correction angle was not indicated. The log did not include information about fuel burn off. Fuel Consumption Based upon Cessna's performance data, the existing weather conditions, and the approximate 2.6 hour long period of engine operation during the flight, at the time of the crash the calculated quantity of fuel which remained in the airplane's fuel tanks was between 8.5 and 11.5 gallons. The distance between the crash site and the remainder of the planned flight to Fallon, the pilot's home base airport, was about 123 nm. According to the pilot's flight log, en route to Fallon he planned to land at Hawthorne. The pilot listed the flight duration as 3:45 hours, and indicated that the airplane carried 4:00 hours of fuel. The pilot did not indicate he anticipated stopping for fuel. Flight Planning and Route Selection The CFI reported to the Safety Board that he noticed his student had planned to depart Lake Tahoe and travel south over Luther Pass and then proceed east to Hawthorne. According to the CFI, he had "suggested" to his student that due to the high terrain, it would be "more prudent" for him to depart Lake Tahoe and fly in a northerly direction before heading east toward Hawthorne. The CFI further reported that the student had agreed to change his plan. In a subsequent statement the CFI reported that, prior to his student's flight, he had observed the student's sectional chart. The chart was marked with a pencil line indicating a direct route of flight was planned between Lake Tahoe and Hawthorne. The CFI stated that he recognized the chart as the same one which his student had used on previous training flights. The Safety Board observed the aforementioned straight route line on the sectional chart. The route line was oriented along a 092 degree course. The corresponding route segment observed written on the student's flight log sheet similarly indicated that the pilot intended to fly along a direct 092 degree course between Lake Tahoe and Hawthorne. The listed cruise altitude was 9,500 feet msl. (See the CFI's written statement and the Safety Board's interview for additional details.) The Safety Board's examination of the sectional chart and the flight log revealed no evidence of the pilot having drawn any route line between Lake Tahoe and Hawthorne other than along the aforementioned 092 degree direct course. No marks were apparent in the Luther Pass area. Also, no evidence was observed on the flight log sheet indicating that the pilot had planned to fly along any course other than a direct easterly course between Lake Tahoe and Hawthorne. (See the photographs of the flight log and the sectional chart.) Route of Flight and Climb Performance The Safety Board measured the approximate (flight) distance from the middle of the Lake Tahoe Airport to the departure end of runway 18, and then directly to the crash site. The distance was about 4.55 nm based upon a left crosswind turn upon reaching the runway's end. (See the accident site maps and the Climb Performance calculation exhibit.) About 4:22 minutes elapsed between the estimated time of liftoff and when the ELT signal was recorded. Based upon these figures, the airplane's calculated ground speed was 62.5 knots. The Cessna Aircraft Company reported that the maximum rate of climb at a 7,000 foot pressure altitude is achieved when maintaining a speed of 62.5 knots. (See the Extract from the Cessna POH.) The observed pencil route line segment between Lake Tahoe and Hawthorne passed within 1/3 mile of the top of Freel Peak, elevation 10,881 feet msl. The airplane collided with terrain in a mountain pass area about 1 2/3 miles west-sou
The pilot's collision with mountainous terrain due to his failure to follow published high density altitude departure procedures during climb out, and route selection which exceeded the airplane's maximum climb performance specifications. Also causal was the CFI's inadequate flight supervision and improper approval of his student's preflight preparation and route selection. Factors were: the pilot's inadequate preflight planning, his lack of high density altitude training for the area flown, and the high density altitude.
Source: NTSB Aviation Accident Database
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