LLANO, CA, USA
N1142W
Simons LANCAIR 235
The non-instrument rated pilot received a weather briefing for his original route of flight the morning of the accident and was advised that IFR conditions existed along that route but that VFR conditions existed through the desert areas. The briefer told the pilot that mid level broken to scattered cloud layers were forecasted and that no thunderstorm activity was expected until after 1100. About 40 minutes into his flight, a pilot friend in a second airplane that was traveling to the same destination caught up with the pilot and they conversed via radio. The second pilot indicated that he filed an IFR flight plan due to the uncertain nature of the weather forecasts. The second pilot stated that the weather started to turn bad, and the accident pilot told him that he was going to turn back. The second pilot saw him make a 180-degree turn and descend into clouds; he did not receive any further communication from the accident pilot. Witnesses at the accident site stated that it had been raining and the clouds were all the way down to the ground, with one witness saying she could not see the neighbor's house 1/4-mile away. One witness stated that the airplane flew directly over her house no higher than 75 feet, made a tight right turn, and then crashed to the ground with a loud bang. The extensively fragmented wreckage was distributed over a distance of 718 feet. Examination of the airframe, engine, propeller, and avionics revealed no discrepancies. Review of the pilot's logbook revealed no evidence of instrument flight experience since 1958.
HISTORY OF FLIGHT On September 4, 1998, at 0758 hours Pacific daylight time, a Simons Lancair 235, N1142W, collided with desert terrain under unknown circumstances in Llano, California. The experimental airplane, operated under the provisions of 14 CFR Part 91 by the owner, was destroyed. The private pilot, the sole occupant who was also the builder of the airplane, was fatally injured. Instrument meteorological conditions existed at the accident site. The personal flight departed the Chino, California, airport at 0707 with an intended destination of Redmond, Oregon. No flight plan was filed. The aviation surface weather report from nearby Palmdale, California, at the time of the accident was: visibility 1 1/4 mile with rain showers; the lowest cloud condition was reported as few clouds at 700 feet mean sea level (msl); and the lowest ceiling was reported as 2,600 feet msl. Another airplane took off from Chino approximately 30 minutes after the accident airplane, and filed an Instrument Flight Rules (IFR) flight plan for the same destination. Approximately 10 minutes after takeoff the second airplane caught up with the accident airplane. The pilot of the second airplane stated that he spoke to the pilot of N1142W and said that he sounded in good spirits, but was disappointed because he had to turn around and go back to Chino due to the weather conditions. He stated that he saw N1142W make a 180-degree turn and descend into the clouds, and that was the last that he saw or heard of him. Recorded radar data for the area was reviewed, with a primary 1200 VFR beacon code noted in the vicinity of the accident location from 0736:03 to 0755:56. During this time frame, the target was established on V137 traveling towards Palmdale, California. The target made a 180-degree turn heading in a southwesterly direction. The target then made a 540-degree turn near Crystal airport and continued on a south bound heading before initiating a 180-degree turn to the north. The target again crossed over V137 at 0750:54. For the next 2 minutes, the target was in a turn to the north-northwest with mode C reported altitudes varying from 10,500 feet to 10,100 feet. At 0752:06, a turn to the west was initiated with a loss in mode C reported altitude from 10,500 feet to 9,000 feet. From 0752:06 to 0753:31, the target made two 360-degree turns with altitudes ranging from 9,200 feet at 0752:06 to 7,800 feet at 0753:31. From 0753:31 to the last recorded radar return at 0754:31, the target was on a southwesterly direction, then turned to a northwest heading, initiated a turn to the east, and the last recorded heading was northwest. During this time the altitude ranged from 8,700 feet to 7,300 feet. One witness, who lives approximately 10 miles east of the accident site, stated that about 0800 that morning she watched a red airplane fly over. What drew her attention was the sound of the airplane. It sounded like the engine was "racing," and she expected it to be moving "really fast." When she looked up, it was moving very slowly. She stated that the airplane was in straight and level flight, with no erratic movements or swerving. She further reported that it was very cloudy and overcast, but not windy. Two witnesses that live next to the accident site reported a loud noise overhead. One of the witnesses stated that he only heard the airplane fly overhead. He stated that it sounded like it was flying low, close to the roof. Due to the sound, he thought that the airplane turned to the southwest and then the southeast, and then it was quiet. The other witness was outside of her house at the time of the accident. She saw the airplane make a tight right turn to reverse direction, right next to her house. She reported that the turn was made over telephone poles that she estimated to be about 75 feet tall. She then heard a loud impact and turned around and saw pieces of airplane and papers falling to the ground. She stated that her neighbor's house, about 1/4-mile away from her house, was not visible at the time of the accident due to clouds and rain. PERSONNEL INFORMATION The pilot's logbook was reviewed by a Safety Board investigator, who estimated the pilot's total flight time to be 243.4 hours. Review of the logbook revealed that the pilot received a foreign certificate from Denmark in 1958, and received his United States private pilot certificate in August 1970. His logbook indicated that there were no flights from May 1983, until June 1996. The last flight prior to the accident flight was on September 1, 1998. Based on entries in the logbook, it was estimated that he had approximately 57.3 hours in the accident airplane. Other than 2.0 hours of experience that he had accrued during his foreign certification in 1958, no other instrument flight time was found from 1958 to the day of the accident. AIRCRAFT INFORMATION The airplane was built by the owner from a Lancair 235 kit, serial number 235-114, purchased from Lancair International, Inc., in Redmond, Oregon in July 1996. Review of the aircraft maintenance records disclosed that the initial Experimental Category airworthiness certificate was issued under 14 CFR 21.191(g) on September 26, 1997, and the maiden flight occurred on October 2, 1997. The initial 40-hour test period was completed on May 11, 1997. On August 19, 1998, the airplane was issued a Special Airworthiness Certificate in the Amateur-built Experimental Category. The next condition inspection was due in August of 1999. A representative of the kit manufacturer stated that after the Federal Aviation Administration (FAA) and the Experimental Aircraft Association (EAA) has approved the airplane as being airworthy, upon the request of the owner, they will conduct an inspection on the airplane, and test fly it for the owner. In November 1997, this representative conducted the kit manufacturer's inspection of the airplane at the owner's request. He stated that he found a number of things still wrong with the airplane after it had been approved by the FAA and EAA (checklist appended to report). He stated that the pilot informed him that he accrued approximately 170 hours over the past 20 years. The kit manufacturer stated that he flew with the pilot in the accident airplane, and felt that the pilot was "behind the aircraft." He reported that he "recommended/urged" the pilot to locate a flight instructor to provide him with extra training. He attempted to do some follow-up work with the pilot, but did not receive any response from the pilot. METEOROLOGICAL INFORMATION Witnesses at the accident site reported that visibility the morning of the accident was poor. They could not see mountains located about 5 miles to the west of the accident site. They stated that it had been raining and the clouds were down to the ground. Review of FAA records disclosed that the pilot received a weather briefing from the San Diego Flight Service Station (FSS) at 0540 the morning of the accident. According to a transcript of the recorded briefing, the pilot indicated that he wanted a weather briefing from Chino to Bakersfield via Van Nuys, California. The FSS briefer indicated that there were weather advisories for icing at 15,000 to 25,000 feet along the immediate coastal range, and Instrument Flight Rules (IFR) conditions existed due to low ceilings, stratus, and fog along his planned route. He further reported that between Chino and the Grapevine (a mountain pass) midlevel clouds existed between 8,000 feet to 12,000 feet and were broken to overcast. The briefer indicated that Palmdale had visibility of 10 miles, with few clouds at 8,000, while the neighboring airport at Lancaster was reporting a broken layer at 10,000. The briefer stated that he should have enough clearance over the mountains if he wanted to depart VFR from Chino and go through Palmdale, because the other route would have lower clouds that would be "skimming the top of the mountains." He further indicated that no thunderstorm activity was expected until after 1100, so if the pilot was going to "go VFR, now was the time." A staff meteorologist for the Safety Board prepared a meteorological factual report, which included the following information on the weather for the departure area, anticipated route of flight, and the accident location. The route of flight was from Chino, through the Cajon Pass, over Palmdale, and thence to Bakersfield. At the time of departure from the Chino airport, visual meteorological conditions existed. Chino airport, located approximately 167 degrees at 37 nautical miles from the accident location was listed at a field elevation of 650 feet mean sea level (msl). The Chino (KCNO) aviation routine weather repot (METAR) issued at 0653 reported visibility as 4 miles, with haze. Sky conditions were few clouds at 8,500 feet, overcast at 11,000 feet and wind from 330 degrees at 5 knots. A Safety Board software package determined the sunrise was at 0626 and there was 96 percent illumination of the moon. Ontario, California, elevation 943 feet msl, is located about 162 degrees at 32 nautical miles from the accident location. METAR information issued for Ontario-International Airport (KONT) at 0653 indicated that visibility was 5 miles with mist; sky condition was 1,200 feet broken, 7,500 feet overcast; temperature 72 degrees Fahrenheit; dew point 68 degrees Fahrenheit; and altimeter 29.83 inHg. Reported winds were from 240 degrees at 6 knots. Palmdale, elevation 2,543 feet msl, is located about 288 degrees at 15 nautical miles from the accident location. A special METAR was issued for Palmdale (KPMD) at 0739, which indicated that visibility was 5 miles with light rain and mist; sky condition was broken at 2,200 feet, overcast at 2,900 feet; temperature 68 degrees Fahrenheit; dew point 64 degrees Fahrenheit; and altimeter 29.94 inHg. Reported winds were from 030 degrees at 9 knots. At 0753, KPMD issued another METAR indicating that the visibility was 2-1/2 miles with light rain and mist; overcast at 2,600 feet; temperature/dew point were both 66 degrees Fahrenheit; and altimeter 29.95 inHg. At 0809, KPMD issued another METAR indicating visibility was 1-1/4 miles with heavy rain and mist; few clouds at 700 feet, 2,600 feet broken, 3,300 feet overcast; temperature/dew point were both 66 degrees Fahrenheit. A Terminal Aerodrome Forecast (TAF) for KCNO, issued by the Los Angeles National Weather Service (NWS), was valid beginning 0500. It stated that visibility was greater than 6 miles with broken clouds at 15,000 feet. Temporary conditions expected from 0500 to 0800 included light rain showers and broken clouds at 6,000 feet. The TAF for KPMD was valid beginning 0500. It indicated visibility greater than 6 miles, with showers expected in the vicinity, and scattered clouds at 6,000 feet with a broken layer at 12,000 feet. An amendment was issued at 0800 predicting a general lowering of the clouds to a scattered layer at 700 feet and a broken layer at 2,500 feet. AIRMET SIERRA for IFR conditions and mountain obscuration was issued for September 4, at 0345, and was valid until 2200. For the inland area, scattered to broken clouds were forecast from 5,000 through 10,000 feet, with tops at 20,000 feet. Widely scattered light rain showers were predicted, with the outlook for conditions to be VFR. The interior mountains and desert (northern portion) were forecast to be broken at 8,000 and 12,000 feet, with tops to 28,000 feet. Scattered light rain showers were also predicted, with the outlook for conditions to be VFR. WRECKAGE AND IMPACT The accident location was in an open flat desert field, with scrub brush vegetation near Palmdale. The latitude was 34 degrees 33.04 minutes north, and longitude was 117 degrees 48.10 minutes west. The elevation was approximately 2,700 feet. The accident site was located on private property behind houses, and was accessible via a dirt road. The wreckage was distributed along a linear path approximately 718 feet long, oriented on a magnetic bearing of approximately 114 degrees. The first identified point of contact was 30 feet in length, 7 feet wide, and 3 feet deep. Debris was scattered between this ground scar and the farthest piece, identified as a main wheel and brake. Both wings were found approximately 200 feet from the first ground scar and on the right side of the median wreckage distribution line. Fragments of green navigation light lens were located in the initial ground scar. The engine was found approximately 180 feet from the initial ground scar on the left side of the median wreckage distribution line. The horizontal stabilizer was located approximately 200 feet on the left side from the initial scar. The seats and bottom portion of the fuselage were located approximately 350 feet from the initial scar. TESTS AND RESEARCH The airframe and powerplant examination were conducted under the supervision of a Safety Board investigator with representatives from Lancair International, Inc., and Textron-Lycoming engines who were parties to the investigation. The examinations took place at Aircraft Recovery Services located in Compton, California, on September 16, 1998. The control system utilizes push/pull and torque tubes. Control continuity was established from the control stick to both ailerons with compressive failures exhibited throughout the entire system's length. Rudder continuity was established from the rudder to the rudder pedals. Elevator continuity to the elevators was established from the control stick through the intermediate bellcrank to the elevator. The flap and landing gear actuators were in the up position. According to the airplane manufacturer, there were no apparent bond failures of the composite structure or skin laminations. No further discrepancies were noted with the airframe. External examination of the powerplant revealed damage to the Nos. 1 and 3 cylinders. Crankshaft rotation could not be established due to the damage. Mechanical continuity of the rotating group and the internal mechanisms were visually established during the disassembly of the engine. No evidence of lubrication depravation or contamination was found. The camshaft was broken near the gear, with bending evident at the fracture, and each of the cam lobes appeared normal in shape. The accessory gears, including the crankshaft gear and dowel pin, were intact and found undamaged. According to Champion Aviation Check-A-Plug chart AV-27, the spark plugs displayed coloration consistent with normal operation. No evidence of valve to piston face contact or valve stem peening was observed. Internal examination of the oil pump revealed that the impeller gears were undamaged and oil was present in the housing. Magneto to engine timing could not be ascertained due to postimpact damage. The left and right magnetos were found detached from the engine at the mounting pad; however, both sides had a piece of magneto mounting flange that remained under the clamps, and were found secure at the mounting pads. The impulse coupler drive of the left magneto was hand rotated and produced spark at the four leads. The left magneto was disassembled and no anomalies were noted. The right magneto could not be tested due to postimpact damage. It was noted that the drive gear was securely mounted. The engine driven fuel pump was disassembled and the diaphragm was noted to have a tear that propagated from the actuation stem bore out towards the edge of the diaphragm. According to the engine manufacturer, the tear was a result of overload forces applied to the pump plunger during separation of the fuel pump during the accident sequence. No further discrepancies were noted. The propeller examination took place on December 4, 1998, at Aircraft Recovery Services under the supervision of a Safety Board investigator with assistance from a representative from IVOPROP Corp., the propeller manufacturer. Composite material was removed from the blades and the pitch change jackscrew was found in a cruise position. The manufacturer's representative noted that there appeared to be no evidence of a preimpact failure. He further stated that produ
Pilot's inadvertent VFR flight into instrument meteorological conditions , which resulted in spatial disorientation and a subsequent loss of aircraft control.
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