CESSNA 172S

Full Narrative

HISTORY OF FLIGHTOn April 29, 2023, about 1950 Pacific daylight time, a Cessna 172S, N575ND, was substantially damaged when it was involved in an accident in Los Angeles, California. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The pilot was renting the airplane from a flight school at Camarillo Airport (CMA). He had approached the school in early April 2023 for a flight review, having last flown July 2022 in the Bay Area of Northern California. The flight review was performed in the accident airplane and was completed two days before the accident.

For the outbound flight, the pilot departed CMA about 1340, and arrived at Bermuda Dunes Airport (UDD), Palms Springs, about 1500. The route was to the north of the LAX Class B airspace and over the Class C and D airspace of the airports that lined the foothills of the San Garbriel Mountains. After arrival at UDD, the airplane was serviced with fuel. According to a family friend, the flight was for pleasure and the pilot planned to have lunch in the area then return to CMA later in the day.

While in Palm Springs, the pilot sent a text message to his wife stating that he was going to be late due to weather, and the flight school’s scheduling software showed that he changed the airplane’s return time from 1800 to 2000. He did not have any meetings or appointments that would have necessitated being back that night.

For the return flight, the airplane departed UDD at 1848 and flew on a northwest track, reaching an altitude of about 7,000 ft mean sea level (msl) once it reached the Banning Pass. The airplane then changed course to the west, where for the next 70 miles it flew a reciprocal route within the Los Angeles Basin as the outbound journey. For most of that portion of the flight, it maintained an altitude of about 6,500 ft msl, with ground speeds ranging between 110 and 125 kts. Having reached the western edge of the Ontario Airport (ONT) Class C airspace, the airplane began a gradual descent, while maintaining separation from the northern boundary of the upper segment of LAX Class B airspace.

At 1943, the airplane had reached the southeastern edge of the BUR Class C airspace, flying just below its 3,000 ft shelf at an altitude of 2,725 ft. The airplane continued to pass through and below a 1-mile-wide corridor between the LAX (lower shelf 5,000 ft) and BUR airspace (figure 1).


Figure 1- Accident flight track
About 4 minutes later, having descended to about 2,000 ft msl, the pilot contacted the tower controller at Van Nuys Airport (VNY), and reported that he was 9 miles southeast, and had the most current weather observation. Another airplane then made a radio transmission, and the pilot of the accident airplane responded that he could not clearly hear the transmission and asked if it was intended for him. The VNY controller then responded and provided instructions for the accident airplane to make left traffic for runway 16L. The pilot replied with the correct readback, and the controller provided him with a transponder code and stated that in the future, based on his approach to the airport, he should contact BUR tower before contacting VNY.

The controller then asked for the aircraft type, and with no response from the pilot, he asked a second time, following which the pilot reported that it was a Cessna 172. With the airplane now at an altitude of about 1,900 ft, the controller provided the pilot with an instruction to turn right and fly direct to the I-405 and US 101 interchange. The pilot responded, “again sorry” and the controller replied with a suggested heading of 305°.

The pilot responded and the airplane then began a descending right turn toward VNY. About 40 seconds later, the controller asked the pilot to confirm he had the most current weather, and the pilot replied that he did. By this time the airplane was traveling at about 117 kts, and on a track of 320° toward VNY, but had descended to 1,600 ft (about 700 agl) and was on a trajectory toward hilly terrain. The pilot did not make any further transmissions, and the airplane maintained the same heading while descending to 1,375 ft. The VNY controller then transmitted that the airplane had dropped off his radar and asked the pilot to confirm he was approaching the interchange. The pilot did not respond, and the controller continued with multiple transmissions to reach the pilot, all with no response.

An alert notice (ALNOT) was issued after the airplane did not land at VNY, and the airplane wreckage was eventually located later that night after a multi-agency search that was hindered by dense fog.

The pilot did not request visual flight rules (VFR) traffic advisories (flight following) from any en route air traffic control facility during the flight. PERSONNEL INFORMATIONThe 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. AIRCRAFT INFORMATIONThe 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. METEOROLOGICAL INFORMATIONSunset 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. AIRPORT INFORMATIONThe 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. WRECKAGE AND IMPACT INFORMATIONThe 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 path


Figure 3 - Final flight path

The first identified point of impact was a level cut swath through a 5 ft wide bush, 100 ft west of the final ADS-B target (figure 4). From there, a fresh ground scar contained fragments of the right-wing tip, right main landing gear, right door and window, propeller and hub, and remnants of the instrument panel; the scar continued on a heading of 285° to the main wreckage.

The airplane came to rest nose-down on a heading of about 100° at the base of a tree, 150 ft west of the first impact point (figure 4). The airframe sustained significant impact damage, crushing the firewall and forward cabin structure, and exposing the front left (pilot) seat. The right wing remained partially attached to the fuselage, and the left wing was detached and folded over the right wing. The tail section was upright and resting against the top of the tree. The left-seat airbag had deployed.


Figure 4 - Swath cut through bush, with the airplane and Van Nuys Airport (beyond the mist and behind the hill) in the background.

Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. Fuel was found in both fuel tanks and the fuel lines through to the engine fuel servo. The propeller blades exhibited damage consistent with rotation at impact. The flap actuator was intact and in the fully retracted position. The elevator trim tab actuator length corresponded to 5° trim tab up, which would have been a position consistent with cruise flight.

All flight instruments, including both Garmin G1000 displays, sustained crush and fragmentation damage; the SD card (which typically stores flight data) for the G1000 units was not located. The backup attitude indicator and altimeter sustained crush damage, and the face of the altimeter’s Kollsman window showed a value of 29.8 inHg. MEDICAL AND PATHOLOGICAL INFORMATIONThe 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.