Big Bear City, CA, USA
N291KT
JAHNKE LIONEL G GLASAIR III
The pilot departed on a cross-country flight in the experimental, amateur-built airplane under day visual meteorological conditions. He was reported missing the following day, and the wreckage was subsequently discovered along the route of flight near the summit of a mountain at an elevation about 9,720 ft mean sea level (msl). Automatic dependent surveillance – broadcast (ADS-B) data revealed that the pilot departed and climbed the airplane to an altitude about 9,500 ft msl on an easterly heading and roughly maintained this heading and altitude for the duration of the flight until impact. Both the ADS-B data and distribution of the wreckage were consistent with controlled flight into terrain in a near-level attitude with a high forward velocity and revealed no evidence of evasive action before impact. The scope of the wreckage examination was limited due to the location of the accident site; however, all major components of the airplane were identified at the site. Additionally, ADS-B data was not consistent with the pilot experiencing a flight control or engine anomaly before the accident. Whether the pilot may have experienced physiological incapacitation or impairment during the flight could not be determined based on the available information. No blood samples were available for toxicological testing; therefore, carboxyhemoglobin levels could not be determined. Testing of available muscle tissue indicated the pilot’s use of the sedating antihistamine doxylamine; however, this result could not be used to determine whether the drug had sedating or impairing effects that may have contributed to the accident.
HISTORY OF FLIGHTOn November 20, 2021, about 1656 Pacific standard time, an experimental, amateur-built Glasair III, N291KT, was destroyed when it was involved in an accident near Big Bear City, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A friend of the pilot reported that the pilot commuted to work in the accident airplane between Los Angeles, California, and Phoenix, Arizona, about twice per week. Review of ADS-B data revealed that the airplane departed Camarillo Airport (CMA), Camarillo, California, on the night of the accident. The airplane climbed to an altitude between about 9,500 to 9,600 ft msl on a heading of about 095°. The last 5 minutes of data showed relatively constant parameters in the airplane’s airspeed, altitude, and heading. The last data point indicated that the airplane’s heading was about 095°, and the groundspeed was about 219 knots. The pilot was reported missing the following day, and a search for the airplane was initiated. The wreckage was subsequently located on a mountainside at an elevation about 9,720 ft msl, near the summit of San Bernardino Peak. PERSONNEL INFORMATIONThe pilot held an airline transport pilot certificate with a rating for airplane multiengine land, and commercial privileges for airplane single-engine land. His most recent Federal Aviation Administration (FAA) first-class airman medical certificate was issued on October 21, 2021, without limitations. On the application for that certificate, the pilot reported 18,000 total hours of flight experience and reported his occupation as a pilot for a major airline. AIRCRAFT INFORMATIONThe airplane was a high-performance, low wing, composite monoplane. The airframe and engine maintenance logbooks were not located. An individual who worked on the airplane reported that it was equipped with an autopilot and a Garmin 496 GPS unit. METEOROLOGICAL INFORMATIONVisual flight rules (VFR) conditions were reported over the region. A review of National Composite Radar Mosaic depicted no meteorological echoes over southwestern California. A sounding model over the accident site indicated surface wind from the northeast at 7 knots (kts), and wind at 8,000 ft from 035° at 11 kts. No significant turbulence or mountain wave conditions below 12,000 ft were depicted. The closest weather reporting station to the accident site was Big Bear City Airport (L35), Big Bear City, California, at an elevation of 6,752 ft msl. The 1655 automated observation included calm wind, visibility of 10 statute miles or more, clear skies below 12,000 ft above ground level (agl), and an altimeter setting of 30.26 inches of mercury. There were no pilot reports (or PIREPs) near the accident site. No SIGMETs, convective SIGMETs, or National Weather Service advisories were active for the area of the accident site. AIRMET Sierra was valid for instrument flight rules (IFR) conditions along the Pacific coast and AIRMET Tango was valid for turbulence below 12,000 ft north of the accident site. At the time of the accident, the Sun was 3.8° below the horizon at an azimuth of 248°. Moonrise was at 1739, and the moon was -9.7° below the horizon at an azimuth of 52°. AIRPORT INFORMATIONThe airplane was a high-performance, low wing, composite monoplane. The airframe and engine maintenance logbooks were not located. An individual who worked on the airplane reported that it was equipped with an autopilot and a Garmin 496 GPS unit. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted rocky, tree-covered terrain on a 45° slope about 9,720 ft mean sea level (msl). Fragments of the wings and fuselage were located in this area. The only portion of the airplane that was relatively intact was the tail section, which was also found in this area. All the flight control surfaces on the vertical stabilizer and horizontal stabilizers remained attached. Fragments of the airplane were scattered about 200 ft upslope from the main wreckage and about 100 ft below the site. The engine, which sustained substantial impact damage, separated from the fuselage and was located about 100 ft upslope of the main wreckage. The propeller blades and hub had separated. Damage to the airplane, the debris dispersal pattern, and impact markings, were all consistent with impact in a high-speed, wings-level attitude. The airplane wreckage was located in remote mountainous terrain and was not recovered. ADDITIONAL INFORMATIONADS-B data for the accident flight revealed that, after the time the airplane leveled off between about 9,500 to 9,600 ft, its altitude indicated 8,000 ft on three occasions. The first descent was about 1630 and lasted for a duration of 10 minutes. The second descent was about 1651. Shortly thereafter the airplane was climbed back to 9,000 ft. The last descent was about 1654, and the airplane maintained for the remainder of the data. During these altitude changes, the airplane’s airspeed, vertical velocity, and heading data parameters remained virtually unchanged. In addition, the descents to 8,000 ft took place in less than 1 second. Furthermore, the ADS-B geometric altitude remained unchanged after the airplane initially leveled off and did not reflect any descents in altitude during cruise; all consistent with anomalous data rather than an actual descent to 8,000 ft. The FAA defines controlled flight into terrain (CFIT) as an event that "occurs when an airworthy aircraft is flown, under the control of a qualified pilot, into terrain … with inadequate awareness on the part of the pilot of the impending collision." In April 2003, the FAA published Advisory Circular (AC) 61-134, entitled " General Aviation Controlled Flight Into Terrain Awareness." The AC stated that, "in visual meteorological conditions, the pilot in command (PIC) is responsible for terrain and obstacle clearance (See and Avoid) …" and identified several CFIT risks, including: - Loss of situational awareness - Breakdown in good aeronautical decision making - Failure to comply with appropriate regulations - Failure to comply with minimum safe altitudes The AC recommended that, during VFR flight, pilots maintain a minimum of 1,000 ft above the highest terrain while operating in non-mountainous areas, and 2,000 ft above the highest terrain when operating in mountainous areas. MEDICAL AND PATHOLOGICAL INFORMATIONThe San Bernardino County Sheriff’s Department Coroner Division, San Bernardino, California, conducted an autopsy on the pilot. The medical examiner determined that the cause of death was “multiple blunt force injuries.” Toxicology testing performed by the FAA’s Forensic Sciences Laboratory on the pilot’s muscle specimen detected doxylamine. Doxylamine is a sedating antihistamine medication that is available over-the-counter as a sleep aid and as an ingredient in various cold and allergy products. Sedating antihistamines can cause drowsiness and may have impairing effects on task performance. Doxylamine is acceptable for pilots if used occasionally for a time-limited condition. The FAA states that pilots should not fly within 60 hours of using doxylamine, to allow time for it to be eliminated from circulation.
The pilot’s failure to maintain clearance from mountainous terrain for reasons that could not be determined based on the available information, which resulted in controlled flight into terrain.
Source: NTSB Aviation Accident Database
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