Aircraft Accident/Incident Report

Lee Vining, California 93541
Monday, February 19, 1996 13:15 PST

NTSB Narrative Summary Released at Completion of Accident

There was no evidence of a preflight weather briefing. Weather forecasts noted cloud bases and tops of 6,000 (less than 1,000 agl) and 25,000 feet, respectively. AIRMETS predicted mountain obscuration, moderate mixed icing conditions, and moderate to severe turbulence from the 7,000-foot freezing level to 26,000 feet. Winds aloft were out of the west at 65 to 70 knots over the mountains. About 1 hour into the flight the pilot air-filed an IFR flight plan and requested 13,000 feet. He was subsequently given 16,000 feet. 10 minutes later the pilot made the first of many subsequent requests for a clearance to a lower altitude. The controller responded that 16,000 feet was the lowest MVA for the next 60 miles or more. 2 hours and 22 minutes from departure the pilot declared an emergency due to an engine failure. The controllers provided vectors to the closest airport, which was behind the aircraft at 9 miles. The aircraft collided with a mountain at the 10,900-foot level. The pilot had only recently moved to the west coast and had limited experience flying over the Sierra Nevada Mountains. No oxygen tubes were found plugged into the cabin side wall regulator panel, and the main supply tank in the aircraft empennage was in the off position. The fuel selector was found selected to the left main tank. Hydraulic fuel cell bladder rupture and deformation to the surrounding containment structures was noted to the right main and fuselage auxiliary tanks. No such evidence was found to the left main tank bladder or surrounding structures. No evidence of preimpact malfunction or failure was found during examination of the engine. Review of the flight timing elements reveals that the pilot operated at msl altitudes above 12,000 feet in excess of 1 hour 50 minutes, with about 1 hour of that time spent between 15,000 and 16,000 feet. Section 8-1-2 of the AIM states in part that due to hypoxia pilot performance and judgment can seriously deteriorate within 15 minutes at 15,000 feet.

NTSB Probable Cause Narrative

Fuel starvation due to the pilot's failure to adequate monitor the aircraft's fuel system and select a tank containing fuel in a timely manner. The pilot's failure to monitor the fuel system was due to the effects of hypoxia. Factors in the accident were the pilot's failure to obtain a preflight weather briefing, his inadequate preflight planning/in-flight decisions, and his lack of familiarity with the mountains.

Event Information

Type of Event Accident
Event Date 2/19/1996
Event Day of the Week Monday
Time of Event 1315
Event Time Zone Pacific Standard Time
Event City LEE VINING
Event State CALIFORNIA
Event Country --
Zipcode of the event site 93541
Event Date Year 1996
Event Date Month 2
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Partial - limited by pilot
Investigator's weather source Weather Observation Facility
Time of the weather observation 1259 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 132
Weather Observation Facility ID MMH
Elevation of weather observation facility 7128
Distance of event from weather observation facility (units?) 28
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height 600
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Partial Obscuration
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 2
Air Temperature at event time (in degrees celsius) 12
Dew Point at event time (in degress fahrenheit) 1
Wind Direction (degrees magnetic) 180
Variable Wind Indicator Unknown
Wind Speed (knots) 4
Wind Velocity Indicator Unknown
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 29
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 1862
NTSB Notification Source --
NTSB Notification Date Feb 19 1996 12:00AM
NTSB Notification Time 1700
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 8 2000 9:51AM
User who most recently changed record dbo
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N2PA
NTSB Number LAX96FA119
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage Destroyed
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Beech
Aircraft Model C35
Aircraft Series Identifier C35
Aircraft Serial Number D-3091
Certified Max Gross Weight 2700
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 4
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Oct 18 1995 12:00AM
Airframe hours since last inspection 45
Airframe Hours 5556
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Yes
ELT Type --
Aircraft Owner Name JEFFREY A. MALM
Aircraft Owner Street Address 9871 E. SELLAROLE ROAD
Aircraft Owner City TUCSON
Aircraft Owner State AZ
Aircraft Owner Country
Aircraft Owner Zipcode 85730
Operator is an individual? --
Operator Name
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address
Operator City
Operator State
Operator Country
Operator Zip code
Operator Code
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code LAS
Departure City LAS VEGAS
Departure State NV
Departure Country
Departure Time 1050
Departure Time Zone PST
Destination Same as Local Flt --
Destination Airport Code OAK
Destination City OAKLAND
Destination State CA
Destination Country
Specific Phase of Flight Cruise
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:34AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --