Aviation Accident Summaries

Aviation Accident Summary LAX06FA222

Somis, CA, USA

Aircraft #1

N615M

Raytheon Aircraft Company A36

Analysis

The pilot was departing on a cross-country flight when he advised an air traffic controller that he needed to land at the nearest airport. The pilot did not specify why he needed to land. An air traffic controller initially cleared him to one airport, and then the pilot asked for a clearance to closer airport. Multiple controllers were in contact with the pilot after his initial call that he needed to land. During the first call, the initial controller and a second controller had a discussion about what the nature of the problem was, and if the pilot was declaring an emergency. The primary controller reported that he thought the pilot was having an engine problem, and he was not declaring an emergency. Once the pilot was handed off to the second controller, the pilot was asked if he had an engine problem and if wanted to declare an emergency. The pilot replied negatively to both questions. The pilot was then handed off to the final controller at the airport where he wanted to land. The pilot was unable to advise the air traffic controller at the landing airport of his position. The pilot was cleared to land, but then he reported an unspecified emergency and collided with terrain approximately 3 miles north of the airport. The airplane came to rest straddling a ditch, adjacent to a road, and was mostly consumed in the post-impact fire. The engine came to rest at the top of the ditch on the south side, and the tail section came to rest on top of the ditch on the north side. An engine inspection and teardown were conducted, with no mechanical anomalies noted that would have precluded normal operation. No evidence was found of any airframe system malfunction or flight control problem. To date, the pilot has not responded to requests from the investigator-in-charge for a statement as to the source of the problem and subsequent emergency. The investigation determined that the pilot was taking a prescription antidepressant, a metabolite of which was detected on post-accident toxicology testing. He was also reported to have recently begun using a prescription anti-anxiety medication, not detected on post-accident toxicology testing, but for which therapeutic levels are below the detection threshold on such testing. Neither medication would have been approved for use by the FAA. The pilot had not reported any mental conditions or use of medications at the time of his most recent application for airman medical certificate nearly 2 years prior to the accident.

Factual Information

HISTORY OF FLIGHT On July 1, 2006, about 1140 Pacific daylight time, a Raytheon Aircraft Company A36, N615M, impacted level terrain near Somis, California. The pilot/owner operated the airplane under the provisions of 14 Code of Federal Regulations Part 91. The private pilot and one passenger sustained serious injuries, two other passengers were killed. A majority of the airplane was thermally consumed in the post impact fire. The personal cross-country flight departed Santa Barbara Municipal Airport (SBA), Santa Barbara, California, at 1100 en route to Wiley Post Airport, Bethany, Oklahoma. Day visual meteorological conditions prevailed, and no flight plan had been filed. The manager at the Hawthorne Automated Flight Service Station (AFSS), Hawthorne, California, reported that the pilot received an abbreviated weather briefing the morning of the accident, but did not file a flight plan. The pilot indicated his destination for the day was Wiley Post Airport via Prescott, Arizona, and New Mexico. The following morning (July 2) the route of flight was through Indiana and New England, with an ultimate destination of New Hampshire. According to a Federal Aviation Administration (FAA) Quality Assurance specialist (AWP 505), the flight departed SBA about 1100. The pilot requested a direct flight at 9,500 feet to Prescott. At 1129, Southern California Terminal Radar Approach Control (SCT) radar identified the accident airplane 20 nautical miles (nm) southeast of SBA. The SCT controller was in contact with the pilot for 3.5 minutes. During this time the pilot indicated that he wanted to divert to Oxnard Airport (OXR), Oxnard, California, to "check a few things out." The SCT controller reported that he did not hear any alarm in the pilot's voice, nor did the pilot report any major problems. The SCT controller then handed the pilot off to a controller at Point Mugu Approach (NDT). During the frequency change, the SCT controller reported to the NDT controller that the pilot was turning back to OXR with engine problems. At no time had the pilot specified what the nature of the problem was. The NDT controller asked if the pilot wanted to declare an emergency, to which the pilot replied negatively. Shortly thereafter the pilot indicated that he wanted to divert to Camarillo Airport (CMA), Camarillo, California. At 1137, the pilot was given a frequency change to CMA tower. When the pilot contacted the CMA controller, he was not able to provide his current location. While the controller was attempting to locate the airplane, the pilot selected the "identify" feature of the transponder enabling the controller to radar identify the airplane 3 miles north of the airport at 1,000 feet; the controller then cleared the pilot for landing. The pilot's last transmission was that he was not going to make the airport, and declared an unspecified emergency. Camarillo tower Automated Weather Observation System (AWOS) reported weather at 1155 as winds from 260 degrees at 8 knots; visibility 10 statute miles; clear sky conditions; temperature 24 degrees Celsius; dew point 12 degrees Celsius; and altimeter setting 29.89 inches of Mercury (InHg). A friend of the family stated that she spoke to the accident pilot while he was in the hospital. He told her that they were supposed to leave on June 29, in order to get their children to camp by July 3. He also told her that the seating arrangement was as follows: Books in the right front seat Pilot in the left front seat One child seated directly behind the pilot His spouse in the right forward facing seat The other child in the rear right seat The dog in the back on the left side Luggage spread out on the floor underneath the passengers' feet To date, the pilot has not returned the National Transportation Safety Board Pilot/Operator Aircraft Accident Report Form 6120.1/2, nor has he responded to numerous follow-up attempts by the Investigator-In-Charge to make a statement as to what the problem was that he was having during the flight. The surviving passenger, a young child, was not able to provide a statement. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the 44 year old pilot held a private pilot certificate with an airplane single-land rating. The pilot held a third-class medical certificate issued on December 01, 2004. It had no limitations or waivers. No personal flight records were made available by the pilot to the National Transportation Safety Board. The aeronautical experience listed in this report was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. On the pilot's December 1, 2004, medical application, he reported a total time of 2,200 hours. AIRCRAFT INFORMATION The airplane was a 2000 Raytheon Aircraft Company A36, serial number E-3344. A review of the airplane's logbooks revealed a total airframe time of 151.0 hours at the last annual inspection. An annual inspection was completed by Preferred Aviation Company, Goleta, California, and returned to service on February 10, 2006. The airplane was equipped with a Teledyne Continental Motors IO-550-B (39) engine, serial number 684144. The last annual inspection performed on the engine was February 10, 2006, by Preferred Aviation Company, at a total time of 151.0 hours. A Hartzell propeller model PHC-C3YF-1RF, serial number EE3524 was installed on the engine new on August 30, 2000, by Cutter Aviation Deer Valley Inc., Phoenix, Arizona. An annual inspection had been completed on January 01, 2004, with a total time of 66.2 hours. Fueling records obtained from Mercury Air Center - Santa Barbara, Inc., Goleta, California, established that the airplane was last fueled on June 30, 2004, with the addition of 49.40 gallons of 100 LL-octane aviation fuel. COMMUNICATIONS The airplane was in contact with the following radar facilities: Santa Barbara Approach Control (SBA), Southern California Terminal (SCT) radar Approach Burbank Sector (BUR), and Departure Sector (LAX), Point Mugu Approach (NDT), and Camarillo Tower. At 1838Z, CMA received a radio transmission from the pilot of N615M that reported he was inbound for landing. He reported north of the airport, and was then instructed to proceed eastbound and report a four-mile final for runway 26. At 1839Z, the pilot stated that he needed to make an emergency landing. The controller cleared him to land on runway 26. The pilot reported that he would not be able to make the airport. At 1840Z, the pilot reported that he was over a "bunch of nurseries." There were no additional transmissions received from the pilot. According to the CMA controller personnel statements, the pilot was unsure of his position when he checked in. He initially reported that he was northwest of the field, and then north of the airport. He was then cleared to land on runway 26. In the next transmission, the pilot requested to land immediately, and then reported that he could not make the airport. Coordinating transmissions between BUR and NDT: At 18:34:27, the BUR controller reported to the NDT controller that he thought he was having some "engine problems or something." The airplane was 5 miles North West of the Fillmore VOR, wanting to land at Oxnard and "check some things out." The NDT controller asked if the pilot was declaring an emergency. The BUR controller reported that the pilot was not declaring an emergency. At 18:37:00, The NDT controller asked if the pilot had information "echo" at Oxnard, and if he was declaring an emergency. The pilot stated that he was not declaring an emergency, and they just "would like to land" at Oxnard. The NDT controller reported that the BUR controller had made it seem like he (the accident pilot) was having some kind of a problem. At 18:37:29, the NDT controller asked if the pilot was familiar with the area. The pilot reported that he had never landed at Oxnard before. The controller told the pilot that the airport was at his twelve o'clock, about 12 miles away. The pilot then asked if the airport was "…right over here? Or is this Camarillo?" At 18:37:49 the NDT controller answered back, that there was an airport at the pilot's ten o'clock position at 7 miles, after Camarillo airport, and that Oxnard airport was closer to the shoreline. At 18:37:55, the pilot requested to land at Camarillo. The NDT controller acknowledged the request. The controller then gave the pilot the current weather information (X-ray) for Camarillo. At 18:38:29, the pilot was provided with Camarillo Tower's frequency. The last contact that NDT had with the accident pilot was at 18:38:35, when the pilot said "Thank you." RADAR INFORMATION The Safety Board IIC reviewed Pt. Mugu Approach's recorded radar data for the period of 18:27:20 until 18:40:45. At the initial contact time (18:27:20), radar identified the accident airplane at 9,000 feet at a groundspeed of 120 knots. At 18:30:30, the airplane was 7.5 miles from the Fillmore VOR at 9,700 feet at a groundspeed of 130 knots. For about 7 seconds the altitude fluctuated between 9,000 feet to 9,700 feet, and then down to 7,900 feet. The airplane's groundspeed fluctuated between 120 knots to 150 knots, and then down to 80 knots. At 18:34:42, (controller coordination between BUR and NDT) the radar target return was at 7,500 feet at a groundspeed of 90 knots. For the next second, the airplane descended down to 6,900 feet, and the groundspeed remained at 90 knots. From 18:35:17 until 18:37:57, the airplane descended to 3,400 feet, with the groundspeed fluctuating between 100, 110, and 120 knots. The last 3 seconds between 18:38:31 to18:40:45, the airplane descended from 2,200 feet to 600 feet, with no recorded groundspeed. Radar data recorded the airplane's last position as 45 miles east of SBA, about 5 miles north of CMA. It should be noted that the last radar return was within a ½ mile south of Santa Paula Airport (SZP), Santa Paula, California. WRECKAGE AND IMPACT INFORMATION The airplane came to rest upright in a drainage ditch adjacent to an asphalt road located between two lemon orchards. The road (Center Street) and the drainage ditch were oriented along an east/west direction. The entire fuselage of the airplane was located in the drainage ditch; the empennage came to rest on the north side of the drainage ditch on a magnetic bearing of 250 degrees, and the engine came to rest on the south side of the drainage ditch on a magnetic bearing of 160 degrees, both in their relative normal position. The airframe was examined on scene, as well as, a visual inspection of the engine. Both examinations revealed no obvious preimpact mechanical malfunctions. The engine had separated from the airframe. All three propeller blades remained connected to the propeller hub; two of the blades were undamaged and straight, the third blade was bent 1-foot outboard of the hub with chordwise scratching evident on the propeller blade tip. MEDICAL AND PATHOLOGICAL INFORMATION The FAA, Forensic Toxicology Research Team, Oklahoma City, performed a toxicological analysis from samples obtained during the pilot's admission to the hospital. Tests for carbon monoxide, cyanide, and volatiles were not performed. Limited testing performed on the small amount of submitted specimens revealed N-desmethylcitalopram detected in serum. A review of the pilot's December 1, 2004, airman medical application revealed that the pilot had reported that he was not currently using any medication, and he responded "no" to the question "mental disorders of any sort; depression, anxiety, etc." Records from the pilot's hospitalization following the accident reported under the MEDICAL HISTORY section that the pilot was currently taking Lexapro (escitalopram), and his past history included depression. Burned medical records located in the airplane from March and July 2005, showed a prescription for Lexapro. A friend of the family reported that the pilot had been taking Lexapro for 2 years, and that he had recently begun a prescription for Xanax (alprazolam). She asked him if he had flown since he had started taking the Xanax, to which he replied negatively. The friend categorized the accident pilot's general demeanor the week before the accident as sleep deprived and exhausted. TESTS AND RESEARCH Investigators examined the engine at Ray's Aircraft in Santa Paula, California, on July 3, 2006. The engine was shipped to Teledyne Continental Motors, Mobile, Alabama, for further inspection on February 12, 2007. Examination of the recovered engine and system components revealed no evidence of any preimpact mechanical malfunctions that would have precluded normal operation.

Probable Cause and Findings

a ground collision during an emergency landing for undetermined reasons.

 

Source: NTSB Aviation Accident Database

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