Aircraft Accident/Incident Report

Oak Glen, California 92399
Tuesady, March 28, 2006 16:55 PST

NTSB Narrative Summary Released at Completion of Accident

The airplane was operated by the manufacturer and was on a sales demonstration itinerary. On the accident flight the airplane was being repositioned following a demonstration and the two pilots included a commercially licensed manufacturer's sales pilot and a private licensed regional sales distributor. One of the two pilots onboard requested, and received, an abbreviated weather briefing prior to departure, the details of which included an airman's meteorological information notice (AIRMET) for occasional moderate rime ice. He then filed an instrument flight rules flight plan for a route passing over mountainous terrain, with a published Minimum En route Altitude (MEA) for the airway that was above the predicted icing level. The flight plan was not activated and the pilots told a TRACON controller who was providing VFR advisories that they intended to continue under visual flight rules through a mountain pass and open their IFR flight plan after reaching the other side of the pass where the MEA was lower. A review of the mode C reported altitudes flown by the pilots and an analysis of the cloud bases and tops revealed that the flight was likely in at least intermittent, if not mostly solid, instrument meteorological conditions as it flew through the pass. As the flight approached the other end of the pass, the controller advised the pilots that the radar showed they were heading into rising terrain. The controller asked, "Do you have the terrain in sight?" One of the pilots responded, "we're maneuvering away from the terrain right now." After that, radar contact was lost. Recorded radar data showed that the airplane made a right-hand turn toward rising terrain while continuing to climb to an approximate altitude of 8,800 feet mean sea level (msl). The last minute of radar data showed the airplane at altitudes of 8,000 feet msl, 8,800 feet msl, and 8,600 feet msl. The last radar return was at an altitude of 7,300 feet msl. An aircraft performance study was accomplished using recorded radar data and aerodynamic data provided by Cessna. Based on the radar data and other relevant information, as the aircraft turned toward the rising terrain, the bank angle steadily increased, until a very abrupt change in pitch consistent with a stall occurred, and the airplane departed controlled flight and descended at a very steep nose down attitude into the mountainous terrain. The airplane wreckage was subsequently located at an elevation of 6,073 feet. Nearby ground witnesses first noticed the sound of the airplane, that then suddenly changed to a high-pitched increasing rpm. Witnesses then saw the accident airplane coming out of the clouds almost straight nose down. The witnesses described the weather as cold with drizzling rain and reduced visibility due to the clouds. Examination of the wreckage revealed no evidence of mechanical malfunction or failure.

NTSB Probable Cause Narrative

The pilot's continued flight into instrument meteorological weather conditions and his subsequent failure to maintain an adequate airspeed while maneuvering, that led to a stall/spin.

Event Information

Type of Event Accident
Event Date 3/28/2006
Event Day of the Week Tuesday
Time of Event 1655
Event Time Zone Pacific Standard Time
Event City Oak Glen
Event State CALIFORNIA
Event Country --
Zipcode of the event site 92399
Event Date Year 2006
Event Date Month 3
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 340240N
Event Location Longitude 1165359W
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 --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1655 Pacific Standard Time
Direction of event from weather observation facility (degrees) 220
Weather Observation Facility ID RIV
Elevation of weather observation facility 1535
Distance of event from weather observation facility (units?) 20
Time Zone of the weather observation PST
Lighting Conditions Day
Lowest Ceiling Height 2300
Lowest Non-Ceiling Height 1200
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 20
Air Temperature at event time (in degrees celsius) 12
Dew Point at event time (in degress fahrenheit) 5
Wind Direction (degrees magnetic) 170
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 8
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.87
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 2
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 23652
NTSB Notification Source FAA
NTSB Notification Date Mar 28 2006 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record May 28 2008 12:03PM
User who most recently changed record NTSB\johb
Basic weather conditions Instrument Meteorological Cond
FAA District Office FAA HQ- AAI-100

Aircraft Involved

Aircraft #1

Aircraft Registration Number N208WE
NTSB Number LAX06FA131
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? No
Damage Destroyed
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Cessna
Aircraft Model 208B
Aircraft Series Identifier --
Aircraft Serial Number 208B1171
Certified Max Gross Weight 8750
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 10
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Jan 1 2006 12:00AM
Airframe hours since last inspection 50.4
Airframe Hours 52
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Cessna Aircraft Company
Aircraft Owner Street Address PO Box 7704
Aircraft Owner City Wichita
Aircraft Owner State KS
Aircraft Owner Country USA
Aircraft Owner Zipcode 67277
Operator is an individual? No
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? --
Certified for Part 133 or 137 Operation --
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) Business
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code TRM
Departure City Thermal
Departure State CA
Departure Country USA
Departure Time 1635
Departure Time Zone PST
Destination Same as Local Flt --
Destination Airport Code ONT
Destination City Ontario
Destination State CA
Destination Country USA
Specific Phase of Flight Climb - to cruise
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record May 19 2008 5:17PM
User who most recently changed record COOS
Since inspection or accident Time of Accident
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --