WPR23FA172

The pilot’s failure to maintain clearance with the hilly terrain resulting from his loss of situational awareness due to the deteriorating weather conditions as he descended to approach his destination airport.

The non-instrument-rated private pilot rented the airplane from a flight school, where he had just completed a flight review two days before the accident. The flight was for pleasure, with the pilot planning to have lunch in the area and return later in the day. Marine layer weather conditions consisting of low visibilities and low ceiling had been forecast and were being reported at his destination and in the area of the accident around the time the airplane took off from the departure airport for the return flight. Phone records indicate that the pilot checked the weather about the time of departure and would have been aware that his destination airport was already reporting instrument meteorological conditions, and that he would not have been able to land there. Nevertheless, he continued with the departure, taking off about 50 minutes before sunset. All inland airports along the pilot’s route of flight were reporting VFR weather conditions. For the first segment of the flight the airplane flew along a reciprocal route to the outbound journey. The pilot then began a gradual descent, likely in preparation for landing. About an hour after takeoff, the flight reached the congested airspace at the southeastern edge of the Burbank Airport (BUR) Class C airspace and the border of the LAX Class B airspace. By now the sun had set, and the area to the pilot’s left (south) was completely enveloped in clouds. Clouds were likely also intermittently obscuring the surrounding terrain, lighting, and ground features as the marine layer progressed. However, Van Nuys Airport, just 10 miles northwest, was reporting clear skies and unlimited visibility. After descending to about 1,000 ft agl over the Hollywood Hills, the pilot initiated contact with the Van Nuys control tower. He was provided a transponder code and began a series of communications with the tower controller, who gave him instructions to turn toward a highway interchange reference point just south of the airport. He did not appear to understand the reference, so the controller provided him with a northwest heading and the airplane began to turn northwest, toward the airport, while descending. The airplane continued to descend with no further communication from the pilot; a short time later it struck the top of a hilly peak, about 8 miles short of the landing runway. The debris field direction, length, and pattern indicated the airplane was flying straight and level, at a high speed; the airplane impacted in a manner consistent with controlled flight into terrain. During the final segment of the flight the airplane descended so low that it is likely the pilot could no longer distinguish between the lights of the hillside residences and the lights in the valley beyond and ahead where the airport was located. Compounding the visual illusion would have been the rising terrain beyond the airport, the low clouds that were forming in the area, the decreasing light levels, and the fact that the area the airplane struck was unlit and probably not visible to him. He was therefore likely experiencing a visual illusion as he flew toward the airport and lost situational awareness. The weather then deteriorated so rapidly that it hampered the search efforts, even though it was in a densely populated area. The pilot had relatively low time, and did not hold an instrument rating. He learned to fly in another city, and although he had flown in the Los Angeles area about half a dozen times before, those journeys were during daylight hours and avoided most of the congested airspace close to the accident area. It is therefore likely that he was task saturated as he approached the airport through unfamiliar and busy terrain and airspace, and his communication with the control tower appeared to indicate he was slightly confused. Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation, and damage signatures indicated the engine was producing power at impact. The pilot had Type I diabetes mellitus and was using insulin. However, his diabetes was well managed with medication and was therefore not a factor in the accident.

Sunset occurred at 1937, with civil twilight ending at 2004. At 1951, VNY was reporting VFR weather conditions, including 10 miles visibility and clear skies, and an altimeter of 29.94 inches of mercury (inHg). At the same time further west, toward the coast, Santa Monica Airport (SMO) was reporting low instrument flight rules (LIFR) conditions with 7 miles visibility and a 300 ft overcast ceiling. The planned destination airport, CMA, was reporting instrument flight rules conditions (IFR) with 8 miles visibility and a 600 ft overcast ceiling. Phone records indicated that the pilot called the automated surface observation system for CMA about the time of departure. At that time, it was also reporting IFR conditions with 8 miles visibility and 700 ft overcast ceiling. All inland airports along the pilot’s route of flight were reporting VFR weather conditions. Terminal Aerodrome Forecasts The terminal aerodrome forecast (TAF) issued for CMA at 1054 anticipated VFR conditions would prevail through 2000, with visibility 6 miles or more, and scattered clouds at 1,200 ft agl. After 2000 the visibility was expected to deteriorate to 5 miles in mist, with a ceiling broken at 500 ft agl. A second TAF for CMA was issued at 1638, about 2 hours before the pilot departed, and was current at the time of the accident. It indicated IFR conditions due to ceilings broken at 900 ft agl, and after 2000, visibilities of 4 miles in mist with ceilings broken at 500 ft. Pilot Reports Seventeen pilot reports (PIREPs) were disseminated to the FAA for the accident area between 1700 and 2200. All reported low overcast clouds with bases as low as 300 ft and cloud tops from 1,000 to 1,500 ft msl. Satellite Imagery NOAA Geostationary Operational Environmental Satellite number 18 infrared imagery indicated that during the hours leading up to the accident, low stratiform clouds were present along the coastal areas of Los Angeles. By 1951, the clouds had reached the vicinity of the hills in the accident location south of VNY and were encroaching on the airplanes final flight track. The pilot had no contact with the FAA Automated Flight Service Station provider Leidos nor any 3rd party venders utilizing their system on the day of the accident. ForeFlight also had no record of the pilot contacting them for any weather briefing services surrounding the period. The pilot was issued his private pilot certificate in December 2020; he did not hold an instrument rating. His flight training took place in a similarly equipped Cessna 172 at a flight school at Reid-Hillview Airport (RHV), in the Northern California Bay Area. During the flight review at CMA, the pilot told the flight instructor that because of his schedule he had not flown for the last seven months. The instructor met with the pilot on April 7, and 27, providing both ground and 3 hours of flight training in the accident airplane. All flight training took place at CMA and Santa Paula Airport, about 9 miles away. The pilot expressed interest in flying to Catalina Airport, so the instructor included ground training on a simulated cross-country to Catalina, during which they reviewed the airspace within Los Angeles. Review of the pilot’s logbooks showed that at the time of the flight review he had accrued a total flight experience of 180 hours, of which 115 were as pilot-in-command. He had flown in the Los Angeles area 6 times during the 2 years leading up to the accident. For five of those flights, he flew roundtrip journeys from RHV to VNY, and for those flights he approached and departed VNY from the north, avoiding the congested airspace within the Los Angeles Basin and LAX Class B airspace. For one flight on October 19, 2021, he flew a roundtrip journey from RHV to Torrance. For that flight, he avoided the congested airspace by flying along the coast and over LAX via the “Mini Route” defined in the Los Angeles VFR Terminal Area Chart. The airplane was manufactured in 2009 and equipped with a Garmin G1000 “glass cockpit” that included a primary and a multi-function display. The airplane included conventional vacuum-driven instruments for backup. The G1000 series had an optional synthetic vision system, which displayed terrain and obstacle clearance alerts on the primary screen, along with the topography immediately in front of the airplane. The system could provide visual and audible alerts of terrain encounters relative to the projected flight path. However, delivery records provided by Textron Aviation revealed that the airplane was not fitted with the requisite hardware for those options. Nevertheless, the system would still have provided the pilot with a moving map and limited terrain information. The airplane was serviced with the addition of 20 gallons of 100 low-lead aviation gasoline at UDD at 1508. Testing of fuel in the supply tanks revealed that it was clear and bright, with no contaminants. No other customers who serviced their airplanes with the fuel from the same batch and truck reported any fuel problems. The pilot’s last aviation medical examination was September 27, 2019. At that time, he reported having Type I diabetes mellitus treated using insulin lispro and insulin glargine. He was issued a third-class medical certificate on August 15, 2022, by special issuance with the limitation that it was not valid after September 30, 2023. In July 2022, the pilot underwent an ophthalmology exam, which documented 20/20 vision in both eyes, and no evidence of ocular diabetic complications. That month, the pilot also obtained a detailed report from his endocrinologist regarding his diabetes management. In the report, the physician stated that with the use of a continuous glucose monitor (CGM) and an insulin pump, the pilot’s fluctuations in glucose levels had improved and his overall glucose levels were stable (the pilot was transitioned to an insulin pump in February 2022). The pilot’s family provided the historical CGM data recovered from his phone for the 90 days leading up to the accident. The data revealed that the week before the accident, his blood glucose levels ranged from 55 mg/dL to 300 mg/dL. No recorded alarms for low blood sugar levels were noted. On the day of the accident, the pilot’s blood sugars ranged from 60 mg/dL to 215 mg/dL. The last CGM reading was 110 mg/dL, before takeoff at around 1738. The County of Los Angeles Department of Medical Examiner-Coroner performed the pilot’s autopsy. His cause of death was multiple blunt force trauma, and no significant natural disease was identified. The FAA Forensic Sciences Laboratory performed toxicology testing of postmortem specimens from the pilot. Minoxidil was detected in cavity blood and urine. No other tested-for substances were detected. No urine or vitreous glucose was detected. Minoxidil can be used as a prescription oral medication for treatment-resistant high blood pressure, or (at low doses) for hair loss. There are some potential safety concerns with oral minoxidil use, and the drug carries a warning that its use in high blood pressure should be reserved for certain cases where multiple other medications have been ineffective. However, minoxidil also is commonly used in topical products available over the counter to promote hair growth. When used as directed topically, minoxidil is absorbed into circulation to a low extent only and is not typically impairing. According to the FAA, minoxidil is acceptable for pilots to use if the underlying condition is acceptable. The main wreckage was found at an elevation of 1,345 ft msl, on a south-facing 45° slope. The wreckage was about 40 ft below the peak of a hill located just above a residential area in the Hollywood Hills, 6.5 miles South-Southeast of VNY (figures 2, 3). A municipal water storage tank was at the top of the hill, which was surrounded by residences about 50 ft below. Figure 2 - Approach and descent pat