NTSB CAROL · Event
Event WPR15FA227
Aircraft involved
Probable cause & findings
The noninstrument-rated pilot's decision to conduct a visual flight in instrument meteorological conditions, which resulted in controlled flight into mountainous terrain.
Factual narrative
HISTORY OF FLIGHTOn August 1, 2015, about 0905 Pacific daylight time, a Cessna P337G, N4CU, impacted mountainous terrain about 2.8 miles east of Santa Paula Airport, Santa Paula, California. The commercial pilot was fatally injured and the airplane was substantially damaged. The airplane was registered to the pilot and operated under the provisions of 14 Code of Federal Regulations, Part 91. Instrument meteorological conditions prevailed for the flight and no flight plan had been filed. The flight originated at Santa Paula Airport and was destined for California City, California. Airplane wreckage was located by California Resources Corporation employee who was working at the South Mountain Booster Plant. He located the wreckage about 1400 PDT on August 1. A witness reported seeing the airplane takeoff at 0902 from runway 22 at Santa Paula Airport. The airplane disappeared into a 300 foot above ground level (agl) overcast then reemerged after turning 180 degrees on a close downwind to the runway. It then departed on the downwind to the east. The wreckage was located on the north side of South Mountain on a 40 degree slope populated with scrub trees at an elevation of 1,223 feet mean sea level (msl), 2.8 miles east of the departure airport. The initial point of impact was the left wingtip identified by wingtip fairing fragments and topped-off small trees/brush next to the main impact ground scar. Contained within the ground scar was the landing gear door. Clipped brush and ground scar evidence is consistent with a level attitude at time of impact. The airplane traveled upslope 20-30 feet beyond the initial impact point, along a 205° magnetic bearing direction. PERSONNEL INFORMATIONThe pilot, age 82, held a commercial pilot certificate with ratings for airplane single-engine land and sea, and multiengine land issued June 11, 1995. He held a third-class medical certificate issued February 1, 2008, with the limitation that he must have glasses available for near vision. Additionally the pilot held a mechanic airframe and powerplant certificate, issued on August 7, 2008. The pilot's logbook was not located for examination. On the pilot's February 1, 2008, application for his medical certificate he reported total flight time of 3,290 hours. AIRCRAFT INFORMATIONThe six-seat, high-wing, twin engine, retractable landing gear airplane, serial number P3370065, was manufactured in 1973. It was powered by a Rolls Royce TSIO-360D in the front, and a Continental Motors TSIO-360C(5B) in the rear, both capable of producing 225 horsepower. Both engines were equipped with McCaulley constant speed, two bladed, propellers. A review of the airplane's maintenance logbooks showed that an annual inspection was performed on July 31, 2014. At the time of the inspection the documented total time on the airframe was 2,246.7 hours. The front engine logbook documented that a 100 hour inspection had been completed on July 31, 2015, time since overhaul (TSOH) of 921.7 hours. The rear engine logbook showed that a 100 hour inspection had been completed on July 31, 2015, at 1,403.0 hours TSOH. Both engine inspections were signed by the pilot, who held a mechanic airframe and powerplant certificate. Family members of the pilot stated that the intention of the flight was to travel to California City, California, where a mechanic was going to finish the annual inspection. METEOROLOGICAL INFORMATIONThe nearest weather reporting station was Camarillo Airport, located about 10 miles southwest of the accident site. At 0855 the automatic surface observation system (ASOS) recorded calm wind, 5 statute mile visibility in haze, a 700 foot agl overcast, temperature was 21 degrees Celsius, the dew point was 18 degrees Celsius, and the atmospheric pressure was 29.99 inches of mercury. The GOES-15 satellite visible image at 0900 depicts an area of low stratiform clouds and/or fog over the accident site and the departure airport, and generally hugging the California coastal sections. The San Diego upper air sounding plot supports cloud or stratus layer with tops to only 2,000 feet agl with a defined temperature inversion from 2,000 to 4,000 feet, stable atmosphere and light winds. The radiative cloud top temperature over the accident site was 292° Kelvin or 18.8° Celsius (C), which corresponded to cloud tops at 2,152 ft msl.
WRECKAGE & IMPACT INFORMATION
The wreckage was located on a 40° slope upright with the wings and tail sections intact, on a 137° magnetic bearing, and 20-30 foot ground scar oriented along 205°. The wings had separated at the wing roots but remained next to their approximate location along the fuselage. The forward firewall was displaced aft into the cockpit instrument panel and the cockpit floor was displaced upward into the cabin. The left tail boom remained attached to the left wing and extended aft. The stabilizer and elevator remained attached to the tail booms. Both vertical fins and rudders remained attached to the tailbooms. The forward engine was displaced down and to the left, the propeller had separated from the crank shaft behind the propeller flange. The aft engine remained attached to the aft engine mount and was displaced to the right. The propeller remained attached to the engine. All flight control surfaces were present, and the flight control cables were traced and found continuous. Fuel was confirmed present in the left wing fuel tank and in each of the engine distribution valves. Both engine crankshafts were rotated manually and thumb compression achieved on all cylinders. Both propellers exhibited leading edge damage and blade tip damage consistent with power application.
MEDICAL & PATHOLOGICAL INFORMATION
An autopsy was performed on the pilot by the Ventura County Medical Examiner-Coroner, Ventura, California, on August 3, 2015. The cause of death was listed as "blunt force trauma." The Federal Aviation Administration's Civil Aerospace Medical Institute (CAMI), Forensic Toxicology Research Team performed toxicology on specimens from the pilot with negative results for ethanol and listed drugs. Tests for carbon monoxide and cyanide was not performed. AIRPORT INFORMATIONThe six-seat, high-wing, twin engine, retractable landing gear airplane, serial number P3370065, was manufactured in 1973. It was powered by a Rolls Royce TSIO-360D in the front, and a Continental Motors TSIO-360C(5B) in the rear, both capable of producing 225 horsepower. Both engines were equipped with McCaulley constant speed, two bladed, propellers. A review of the airplane's maintenance logbooks showed that an annual inspection was performed on July 31, 2014. At the time of the inspection the documented total time on the airframe was 2,246.7 hours. The front engine logbook documented that a 100 hour inspection had been completed on July 31, 2015, time since overhaul (TSOH) of 921.7 hours. The rear engine logbook showed that a 100 hour inspection had been completed on July 31, 2015, at 1,403.0 hours TSOH. Both engine inspections were signed by the pilot, who held a mechanic airframe and powerplant certificate. Family members of the pilot stated that the intention of the flight was to travel to California City, California, where a mechanic was going to finish the annual inspection. The noninstrument-rated commercial pilot departed for the cross-country flight over mountainous terrain in instrument meteorological conditions. A witness observed the airplane take off from runway 22, disappear into an overcast layer at 300 ft above ground level (about 550 ft mean sea level [msl]), and then reappear heading in the opposite direction. The witness reported that the airplane departed the traffic pattern heading northeast. The wreckage was located in mountainous terrain at an elevation of 1,223 ft msl, 2.8 mi east of the departure airport. Meteorological data indicated that, at the time of the accident, a cloud layer extended over the accident site from about 550 ft msl to about 2,100 ft msl, and, at the elevation of the accident site, the terrain would have been obscured by clouds. Examination of the wreckage did not reveal evidence of any preimpact mechanical malfunctions or anomalies that would have precluded normal operation of the airframe or engine. The orientation of the wreckage indicated that, at impact, the airplane was heading south and traveling at a ground speed consistent with normal traffic pattern speeds. The damage to the airplane was consistent with controlled flight into the terrain, and the airplane's impact heading was consistent with the pilot attempting to return to the airport when the airplane collided with the rising terrain. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Below VFR minima-Effect on personnel - C
- C Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - C
- C Environmental issues-Physical environment-Terrain-Mountainous/hilly terrain-Contributed to outcome - C
Verbatim from NTSB's published report. Source file
NTSB_2015_WPR15FA227.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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