NTSB CAROL · Event
Event LAX06FA031
Aircraft involved
Probable cause & findings
the pilot's failure to maintain an adequate terrain clearance altitude profile during the descent that resulted in controlled flight into terrain.
Factual narrative
HISTORY OF FLIGHT
On November 9, 2005, about 1834 Pacific standard time, a single engine Beech F33A, N9204Q, impacted mountainous terrain near Geyserville, California. The private pilot/owner operated the airplane under the provisions of 14 CFR Part 91. The airplane was destroyed. The pilot, the sole occupant, was fatally injured. The personal local cross-country flight departed Benton Field Airport (O85), Redding, California, about 1730, en route to Charles M. Schulz/Sonoma County Airport (STS), Santa Rosa, California. Night visual meteorological conditions prevailed, and no flight plan had been filed. The airplane became a subject of a family concerned alert notification (ALNOT) the following morning when the pilot missed a business appointment. The airplane was located that afternoon at 1427, by the Sonoma County Sheriff's Department (Henry One) air unit. The deputies (pilot and tactical flight officer) flying Henry One the night of the accident reported that in the general area there was a patchy and broken cloud layer with mountain obscuration. The deputies also stated that it was a very dark night. According to family members, the pilot flew from STS to the Redding area weekly for business purposes and was very familiar with the route.
PERSONNEL INFORMATION
A review of Federal Aviation Administration (FAA) airman records revealed the pilot held a private pilot certificate with airplane single engine land and instrument airplane ratings. The pilot held a third-class medical certificate issued on September 27, 2004. It had the limitations that the pilot "must wear correction for distant vision." According to the pilot's last application for a medical certificate, he reported a total time of 2,300 hours, with 65 hours flown in the past 6 months. At that time, the pilot reported that he was currently taking Zyrtec, and that he had previously reported its usage on the previous medical application. The pilot also reported that he had seasonal hay fever. An examination of the pilot's logbook indicated an estimated total flight time of 2,469.0 hours. He logged 26.0 hours in the last 90 days, 11.0 hours in the last 30 days, and about 2.0 hours in the past 24 hours. According to the pilot's logbook and the Aircraft Flight Record, the pilot had accrued about 66.0 hours in the accident airplane since March 23, 2000. His logbook also revealed an estimated total hours of night flight as 367 hours.
AIRCRAFT INFORMATION
The airplane was a 1971 Beech Aircraft Corporation F33A, serial number CE-341. Logbooks for the airplane were not recovered. Paperwork invoices inside the airplane revealed that an annual inspection had been completed on September 6, 2004. The airplane was equipped with a Teledyne Continental Motors IO-520-BB engine, serial number 578867. The pilot maintained an Aircraft Flight Record. On the day of the accident, he recorded an "hour meter out" time of 3,809.2 hours. Based on the pilots entries, investigators estimated that the flight from O85 to STS took about an hour. The airframe total time was estimated at 3,810.2 hours, with 19 hours since a field major overhaul had been completed. An overhauled engine was installed on the accident airplane on August 30, 2005. Fueling records obtained from APEX Aviation at STS showed the airplane was fueled on November 3, 2005, with 33.8 gallons of 100LL aviation fuel. Examination of maintenance records revealed no unresolved maintenance discrepancies against the airplane prior to departure.
METEOROLOGICAL INFORMATION
A staff meteorologist for the National Transporation Safety Board prepared a factual report (the report is appended to this report). The routine aviation weather report (METAR) for Sonoma County Airport at 1753 reported weather as visibilities 10 statute miles (sm); calm winds; a broken cloud layer at 6,000 feet above ground level (agl); temperature 57 degrees Fahrenheit; dew point 50 degrees Fahrenheit; and altimeter 30.07 inches of mercury (inHg). In the remarks section it reported thunderstorms in the distance south-southeast. At 1853, STS METAR reported visibilities 10 sm; winds 340 degrees at 4 knots; clear skies; temperature 57 degrees Fahrenheit; dew point 48 degrees Fahrenheit; altimeter 30.06 inHg.
COMMUNICATIONS
Information obtained from Oakland Air Route Traffic Control Center (ZOA) controllers indicated that at 1804, the pilot contacted ZOA for visual flight rules (VFR) advisories. The pilot was issued a discrete beacon code, and about 16 minutes later, was handed off to another ZOA sector controller. The pilot checked in with the new ZOA sector controller and indicated he was VFR at 7,500 feet. At 1833, the pilot reported that he had the airport in sight and wanted to cancel VFR services. The ZOA controller terminated radar services, the pilot was instructed to squawk a 1200 beacon code, and the pilot's frequency change was approved. No further radio transmissions were received from the pilot. Information obtained from the FAA accident coordinator indicated that the flight was a GPS direct flight from O85 to STS. The FAA coordinator reviewed radio communications between the ZOA controller and the pilot. The pilot cancelled his flight following with the controller and thanked them for the "light show" (lightning) down in the Bay Area. The Safety Board investigator-in-charge (IIC) reviewed radar data from ZOA. Two minutes before the accident the airplane was radar identified via a discrete beacon code. At 1832, the altitude was recorded as 5,500 feet. At 1833, the discrete beacon code was terminated and the pilot switched to a 1200 VFR beacon code. The ensuing 1200 beacon code radar target return matched the projected flight path of the accident airplane. Over the last minute of flight, radar data indicated that the radar target was descending from 4,200 feet, through 4,000 feet. The last recorded radar return at 1834 showed an altitude of 3,500 feet about 4 miles northeast of the accident site.
WRECKAGE AND IMPACT INFORMATION
Investigators from the Safety Board, the FAA, Raytheon Aircraft Company (Beech), and Teledyne Continental Motors (TCM) examined the wreckage at the accident scene. The main wreckage came to rest on Black Mountain at an elevation of 2,834 feet mean sea level (msl), on a 10-degree slope in heavy brush and tree-covered terrain. The airplane wreckage was on an approximate heading of 220 degrees magnetic, and at global positioning system (GPS) coordinates of 38 degrees 44.34.8 minutes north latitude and 122 degrees 49.10.00 minutes west longitude. The accident site was about 15 miles north of STS. The first identified point of contact (FIPC) was along a ridgeline of Black Mountain at 3,031 feet msl, 197 feet above the main wreckage. The FIPC was a set of tracks in the heavy brush and trees that was about 100 feet in length. The distance between the two tracks was similar in dimension to the distance between the main landing gear on the airplane. The tracks traveled in a northeasterly to southwesterly direction towards the airport, along a magnetic heading of 186 degrees. Plexiglass fragments identified as part of the right wing landing light lens cover were found at the ridgeline, as well as some paint chips. Midway down the mountain a small structural piece of the right wing spar was found. About 10 feet north of the accident site, investigators noted young sapling tree trunks that had been newly cut. The cut surfaces were angular in appearance. The propeller assembly separated from the crankshaft flange and remained in buried in the impact crater. All of the propeller blades exhibited S-bending, leading and trailing edge gouging, and chordwise scratches. Both wings exhibited leading edge damage and both wing tips were deformed. The wings remained connected to the airframe via the carry through spar. The left wing fuel cell had been breached hydrostatically. The ring fuel cell remained attached. Investigators noted that the fuel selector valve was selected to the right fuel tank. The airframe representative blew through the fuel line from the engine driven fuel pump for the right tank and noted no obstructions. To aid with the recovery process, the flight control cables were marked and cut. The left wing flight control cables remained attached to the bellcrank. The fuselage came to rest parallel to the wings. The rear portion of the fuselage separated aft of the carry through structure. The landing gear was partially extended with perpendicular brown dirt noted around the circumference of the tires. Investigators also found tree branches in the landing gear struts. According to responding deputies, the pilot and pilot seat had been ejected from the airplane and were found about 5 feet west of the main wreckage. The pilot remained attached to his seat via the lap and shoulder harness restraints.
MEDICAL AND PATHOLOGICAL INFORMATION
The Forensic Medical Group, Inc., Fairfield, California, conducted an autopsy on the pilot on November 11, 2005. The TC FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed a toxicological analysis from samples obtained during the autopsy. The results of the analysis of the specimens were negative for carbon monoxide, cyanide, and volatiles. The report contained the following positive results for tested drugs: Cetirizine detected in urine Cetirizine not detected in blood Diphenhydramine present in urine 0.041 (ug/ml, ug/g) Diphenhydramine detected in blood. Diphenhydramine is commonly known by the trade name Benadryl. Benadryl is an over-the-counter antihistamine with sedative effects, which is most commonly used to treat allergy symptoms. Cetirizine is also known by the trade name Zyrtec. Zyrtec is a prescription antihistamine.
TESTS AND RESEARCH
Investigators examined the airframe and engine at Plain Parts, Sacramento, California, on November 15 and 16, 2005. The airframe examination revealed no pre-existing impact anomalies. Investigators noted that the engine had separated from the engine mounts, with impact damage toward the forward portion of the engine. All of the tubes, lines, and engine control cables remained attached, with the exception of a fuel line. There were no obvious visual mechanical anomalies noted with the engine during the external examination. Investigators removed the top and bottom spark plugs. The Nos. 1 and 3 spark plugs were oil soaked due to how the airplane came to rest. The remaining spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. An inspection of the cylinders revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head. Both the left and right magnetos were manually actuated. Both rotated freely with no binding and spark was obtained through all ignition leads. All of the vacuum pump vanes were whole, in position, and moved freely. The oil pump drive remained intact with normal operating signatures noted in the cavity and gear teeth. The oil sump screen was clean and open. The fuel pump rotated freely with no binding. The drive coupling remained intact and undamaged. Fuel was found in the fuel manifold valve and the fuel screen was clear of debris. Landing Lights and Circuit Breakers The following components were removed and shipped to the Safety Board Materials Laboratory, Washington, D.C., for further examination Four indicator lights (landing gear - Right, Left, Transit, and Nose) Two circuit breakers (Landing Gear and Alternator Field) The Safety Board chemist noted that the filaments for the transit and nose bulbs showed no sign of stretching. The filaments for the right and left bulbs were broken, but showed no sign of stretching. The landing gear and alternator field circuit breakers were examined for arcing. The landing gear circuit breaker was not damaged and showed no sign of arcing, and had not been tripped. The alternator field circuit breakers' case had been cracked. One electrical connection that remained with the circuit breaker assembly showed no signs of arcing. A voltmeter was utilized to determine the circuit breakers position; which was closed.
ADDITIONAL INFORMATION
The IIC released the wreckage to the owner's representative. After visually identifying his home base airport on a night VFR approach, the pilot initiated a descent and the airplane struck the top of a ridgeline at the 2,834-foot level. The pilot was en route home from a trip between two airports that he made often. He had been receiving VFR flight following services from ARTCC and had cancelled when he reported the airport in sight. Recorded radar data showed the airplane descending from its cruise altitude in a straight line toward the airport and the accident site. Investigators identified two marks along the ridgeline that were similar in dimension to the distance between the main landing gear on the airplane. The airframe and engine examinations revealed no preimpact anomalies that would have precluded normal operation. Two drug substances were found in toxicological tests of the pilot's specimens, Diphenhydramine and Cetirizine. Diphenhydramine was found at a level that indicates usage within the past 8 hours of the accident flight. The Cetirizine that was found in the urine, but not the blood, and indicated that the pilot more than likely ingested the drug within the previous 48 hours, but not within the previous 12 hours of the accident. Diphenhydramine can result in drowsiness, and has measurable effects on performance of cognitive and motor tasks. Studies have shown that individuals' performance of tasks has been degraded even though they feel normal after ingesting the drug; however, in this case it is unclear the extent to which the pilot may have been sedated and/or impaired. Studies of individuals taking Cetirizine have not found any significant impairment from the medication. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2005_LAX06FA031.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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