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L-19 Crash Documents

Here are several documents that explain the L-19 crash causes in greater detail.  All documents provided by John Youngs.


Document #1 -- The tragic tale of the missing Cessna L-19E

 Cessna serial number 24527 - FAA Reg. Number N4584A - January, 2009 Intended Flight Route: Granby, Colorado to (Jeffco County) Denver, Colorado. Lost: August 10th, 1984 at approx. 13:00 hours Found: August 23rd, 1987, near Tabernash, Colorado

It’s a very tragic tale – unwittingly caught on film by the gentleman who died in the crash along with a friend riding in the back seat. It was first shown to me (along with many others) at an FIRC (Flight Instructor Renewal Clinic) over 20 years ago.

The family of the deceased had put a 20-year moratorium (via the FAA) on the release of the film to the general public with the only stipulation that it (at the FAA’s request to the family of the deceased) be shown ONLY to Flight Instructors at FIRC’s and workshops such as the ones I attend every two years (for the purpose of renewing my flight instructor’s license; along with discussing the lessons learned herein with private & commercial pilot applicants so that the knowledge gleaned from the tape could be used and disseminated to help prevent this kind of thing from happening to someone else). Last year the moratorium was up and not renewed – so it effectively became “public domain”.

Here’s what happened: The gentleman flying this aircraft (a restored single-engine Cessna L-19E “Bird Dog” - commonly used by the US Army (beginning in 1962, it was also known as the “O-1” during the Vietnam War – the last one retiring from active service in 1974) & the USAF in Korea & Vietnam for general spotting (F.A.C.) & liaison duties as well as a basic training airplane in the US) had been offered a contract by the Colorado Dept. of Forestry to videotape a particularly nasty type of beetle infestation that had been ravaging hundreds of acres of Colorado forest in and around some of the higher-elevation foothills surrounding some of the Rockies. One thing that was unique about this particular flight was that the pilot had mounted a VHS video camcorder atop the instrument panel for the purpose of visually recording any beetle infestation that was observed along the flight route. The pilot started the camera shortly after takeoff and it ran until the aircraft crashed down through the trees – approx. 6-1/2 minutes later.

The problem, as you’ll see in this (approx.) 6-1/2 minute video, was that he was flying into what can be clearly seen as gradually ever-ascending terrain altitude. However, because of the density altitude conditions which existed at the time of the accident (remember, this was in August), he was already at or above the airplane’s effective “service ceiling” – the point at which a plane cannot maintain at least a minimum of a 100 foot-per-minute rate of climb – in this case, he was flying a normally-aspirated (meaning no turbocharger or supercharger on the engine) single-engine plane at or above it’s normal level of (density) altitude for which it was capable of maintaining – again, considering the abrupt bank angle attempted at the end of the flight which culminated in the crash itself.

As he flew along – with his friend in the back seat (this being a “tandem-seat” aircraft - fore-and-aft seating – like a Piper Super Cub), you can see the terrain continually slowly increase in altitude, until right at the very end of the tape, when he makes his second – and fatal – error. He makes a moderately steep turn to the right (in excess of 45 to 50 degrees angle of bank) in an attempt to turn around quickly – the plane loses considerable lift and initially stalls twice; then on the 3rd stall (with the stall warning horn blaring in the background), enters the traditional “stall/spin” syndrome and flips upside down as the left (up-wing) wing stalls completely and the plane, flipping over on it’s back, plunges straight down through the trees – but not before capturing the pilot’s last mournful cry to his friend in the back seat: “Damn, hang on Ronnie!!”; the plane smashes downwards through the thick tree branches (you can hear the heavy “thuds” as the plane’s wings smash into these while heading for the ground); it crashes & burns – killing both the pilot and back-seat passenger.

There is a small fire which consumes some of the wreckage but no forest fire is started and since the plane plunged straight down through the trees to the ground, there was no visible tree damage for any would-be rescuers to use to spot the wreckage or crash location. One additional important factor that added to the delay of the discovery of the wreckage was the fact that the fuselage (the main body) of the plane came to rest upside down – on top of the ELT (Emergency Locator Transmitter) antenna, effectively silencing its emergency signal to satellites and other would-be rescue aircraft.

Note: The above photo text is wrong in that it was just over three (3) years from the crash date of Aug. 10th, 1984 until its initial discovery on Aug. 23rd, 1987.

The wreckage laid there for approximately 3 years (Aug. 10th, 1984 to Aug. 23rd, 1987) until it was found by a pair of backpackers hiking through that particular location. The wreckage was removed and after the NTSB & the FAA released their findings (based on both crash evidence as well as lack of prior logged maintenance problems with the plane); the wreckage was then released to the family of the deceased pilot as the plane had belonged to him. The family kept what they wanted and gave the rest to a scrap yard for final disposition.

Dale Wood, a Colorado deputy sheriff investigating the wreckage and the crash scene, discovered the shattered video recorder within the wreckage and “rebuilt” the tape (which was in pieces and had been exposed to the elements for 3 years – some of it hanging from tree branches during that 3 year period of time!!) and turned it over to the NTSB for final review. The end result was what you see here – the pilot had recorded, on video tape, his “…continued flight into rising terrain – combined with a high density altitude condition existing at that time – along with an abrupt maneuver (approx. 45 - 50+ degrees angle of bank) resulting in a fatal “stall/spin” accident…” – he had unwittingly recorded his own death.

The fire had warped and partially melted the VHS recorder into a misshapen hunk of plastic that no one at the NTSB or FAA could recognize, so they initially passed on a closer examination – thinking it was apparently some sort of item that could not be attributed to playing any conceivable role in the accident.

This is that tape – converted to DVD/WMV file format. The intermittent gaps in the “engine rumbling noises” and the electronic “glitches” in the video and audio portions of the tape were caused by tree and ground impact damage along with heat from the fire as well as exposure to the elements for three years – I saw this tape approx. 20 years ago and its exactly as I saw it back then. - Finis -

(Scroll down for further information about the Cessna L-19E aircraft)

The Cessna L-19E “Bird Dog” – 2-seat (“tandem” – fore & aft seating) spotter (F.A.C.) and general-duty liaison aircraft used extensively in both the Korean and Vietnam Wars as well as in the US as a US Army and USAF basic training aircraft. Engine: Continental O-470-11, 6-cylinder, 213 hp.

Introduced in the very early 1950’s (around the start of the Korean War), this aircraft is the “forerunner” of what eventually became the Cessna 170 series of civilian light planes. There are approximately 120 Cessna L-19’s (also known as “O-1’s”) still registered & flying in the US today.


Document #2 -- Enjoy the Experience of Mountain Flying - But Get the Proper Training First...

(A follow-on lecture dealing with the Cessna L-19 crash in Colorado, Aug. 10th, 1984)

Story by Dan Sobczak

I once sat inside the cockpit of a Cessna L-19, a two-seater with a big engine and a climb rate more than double that of a Cessna 172. The aircraft was being flown in the Colorado Mountains on what appeared to be a perfect flying day: calm conditions and severe clear. The Cessna's flight ended prematurely, however, going down vertically into gradually rising terrain, fatally injuring the pilot and passenger onboard. But I survived the two-seater's crash.

How is it possible that I could have been onboard this two-seater's flight and survived such a crash in the mountains? It was possible because I was watching the final 20 seconds of this flight on videotape from the perspective of someone inside the cockpit. The souls onboard happened to be capturing their flight on videotape by a cockpit-mounted camera when a rather pleasant scenic flight turned tragic in just a matter of moments. Three years after the crash (Aug. 10th, 1984 – the date of the crash, to Aug. 23rd, 1987 – date of initial discovery of the wreckage), a pair of backpackers accidentally discovered the Cessna's wreckage. The videotape onboard captured the entire accident.

On the tape, the pilot and passenger make sundry comments concerning the beautiful scenery, while the terrain below gradually rises. Moments later, the pilot is aware of the steeper terrain, but by now it's too late. All of his escape routes are closed. At nearly treetop level, he attempts an escape from the rising earth by banking hard to the right. You hear the stall warning horn go off. The plane stalls three separate times – its nose bobbing down then up with each stall. You see the left wing drop. The aircraft enters a stall/spin. The last thing you hear is the pilot scream “Damn, hang on Ronnie…!!!” Seconds later, it's all over. It is very chilling to watch this tape.

But it is even more chilling to realize how easily you, as a pilot, can get into such a situation if you have not prepared in advance, and how difficult it is to get out once all your escape routes have expired. Certainly the best escape route is to avoid getting your airplane into such a situation to begin with. As a safety-conscious pilot, how do you prepare? There are many good articles and books written on mountain flying techniques, and it would be well worth your time to read a few of these texts to increase your aviation knowledge. But knowledge alone may not be enough to save you. Not one of these books can give you what you really need to fly the mountains: experience.

No matter how many hours you may have logged as a pilot, until you experience mountain flying and the related effects of density altitude on a light aircraft's performance, it is difficult to appreciate how remarkably different it is compared to the performance your airplane achieves at lower elevations.

As a student pilot, my limited knowledge of density altitude may have been slightly better than the average student because I learned about this phenomenon very early in my training from a meteorologist who is also a pilot. He introduced me to the three Hs of density altitude: height, heat and humidity. As altitude (height), temperature (heat), and humidity increase, so does density altitude, or the altitude the airplane thinks it is at, and performs in accordance with. As density altitude increases, your airplane's performance decreases.

But my knowledge alone was not enough. I had an excellent flight instructor during my private pilot training, but one flight we never undertook was that of heading north to the mountains of Arizona for a lesson in density altitude to experience decreased aircraft performance.

As a result of my student training experience, shortly after I passed my check ride I made the decision that the northern half of Arizona, with all its tempting, beautiful mountain scenery, was off-limits to my flying until I received mountain-flying instruction. Thankfully, I didn't have to wait very long. Westwind School of Aeronautics, based at Deer Valley Airport in Phoenix, recently launched a new FAA-sanctioned Arizona Mountain Flying Safety Course. Their one-day course (which is also part of the WINGS pilot proficiency award program) includes 2.5 hours of thorough ground instruction and 3.0 hours of flight training to three of northern Arizona's most popular, and potentially dangerous, airports: Flagstaff, Sedona and Payson.

I enrolled in the course and scheduled it for a Saturday. After preparing my own flight planning prior to the class, I walked into the briefing room where the usual hangar flying conversation transpired among the other five pilots who also enrolled in the course. The ground school, taught by Westwind's Chief Flight Instructor Jim Pitman (who also helped develop the course), soon began with an introduction which described what mountain flying has to offer pilots: great flying, fantastic scenery, and, as we all discovered upon watching the Cessna L-19 video clip, the tragic consequences of not being prepared for it.

The ground instruction covered a lot of material, including density altitude and related aircraft performance, proper mixture leaning procedures for various phases of flight (emphasizing the use of maximum lean for taxi operations), the importance of flying the same indicated airspeed you would normally fly at lower elevations, the effects of weight and balance on a mountain flight, and of course, weather and mountain waves.

After the ground instruction was complete, I was teamed up with a Westwind flight instructor, grabbed a plane and headed up north to begin my flight experience. However, on this particular day, it was apparent we would not be making our flights to the north country due to thunderstorms enroute and snowy conditions at Flagstaff, only 89 nautical miles north, despite the sunny and clear morning weather in Phoenix. Although I was somewhat disappointed at not being able to make the flight this day, it was a good lesson in obtaining detailed weather briefings before venturing into the mountains. Weather can change quickly in the high country and often has much more localized weather phenomena than do the flatlands, so obtaining a thorough and detailed weather briefing is key in making your go/no-go decision.

I rescheduled my flight, and two weeks later it was time to fly. This day, the weather was cooperating relatively nicely despite gusty winds up north, so Jim and I climbed aboard the school's Cessna 172S and took off for the high country. Launching from Deer Valley at an elevation of 1,478' MSL, I took note of our C-172's familiar 500 fpm climb rate and we flew direct to Flagstaff Pulliam, elevation 7,011' MSL, about a 50-minute flight. As our flight progressed, Jim and I discussed each topic we had gone over in class as it came up during the flight: route selection, proper methods of crossing ridge lines, determining the effects of wind against terrain, and engine performance.

As I quickly learned during my flight, one of many keys to successful mountain flying is knowing the winds aloft. Knowing how the wind is affected by the mountainous terrain below and visualizing what the wind is doing when it comes in contact with terrain is paramount. As Jim illustrated, to help visualize this, a pilot should think of the wind as water flowing over rocks. Flowing water is smooth when running over a flat, even surface. Once the water flows over jagged rocks, it flows like rapids in a raging river where turbulent waves are created, often lasting far downstream. Similarly, as airflow passes over a ridge, mountain waves form, while underneath and often invisible to the pilot are severe rotor waves, which frequently have downdrafts in excess of 1,000 fpm, far exceeding the climb ability of any normally aspirated light aircraft.

But how do you determine winds aloft during your flight? Often while flying over the mountains, you may be out of communication range and unable to obtain enroute weather briefings from a nearby flight service station or an air traffic control center. If this is the case, then your next best tool is the weather itself. Remember the old standby "see and avoid" for traffic avoidance? In this case, it's "see and observe." If there is visible moisture in the air in the form of clouds, then you have another source of information about winds aloft right at your disposal. All you need to do is decipher the message. Every cloud tells a story about its adjacent wind patterns. It's up to you as the pilot to read what the clouds are telling you about potential winds that may affect your flight.

As we made our approach into Flagstaff, a perfect example of a lenticular cloud resulting from the mountain wave over the peaks that day appeared to rest comfortably over the tip of Humphrey's Peak, the highest point in Arizona at 12,633' MSL (a mere five miles northwest of the Flagstaff runway). Of course, we knew the wind currents running through and below that lenticular cloud were anything but restful.

We flew a low-pass over the Flagstaff runway to experience what a go-around would feel like at our now-diminished and sluggish climb rate of 200 fpm, flew the traffic pattern, performed a full-stop taxi back, then launched for Sedona, elevation 4,827' MSL, about 10 minutes to the southwest. After a brief stop at Sedona to stretch our legs and check in with Prescott Flight Service once more for an updated weather briefing, we launched for Payson, elevation 5,157' MSL where we performed another full-stop taxi back, and then launched for home. Three hours exactly had ticked off on the Hobbs meter when we shut down back at Deer Valley, after which Jim and I discussed the flight in detail in our debriefing.

There are, however, plenty of other aspects about mountain flying pilots must understand than simply density altitude and weather patterns. Westwind's course also details other important keys. Many mountain airports have their own visual illusions due to varying circumstances, such as sloping terrain. Nightfall can cause the headlights of cars on nearby highways to appear as a false horizon. Interstate-17, just a few miles off the departure end of runway 21 in Flagstaff, can be a dangerous false horizon if conditions are just right, especially with the fast-rising terrain not far beyond the interstate. In addition, each mountain airport has its own unique weather phenomena due to surrounding terrain, as I learned at Sedona with its cliffs and jagged rock formations all around the immediate vicinity of the runway. And don't forget that some mountain airports have obstructions at the end of a runway which may be impossible to clear in a single engine light aircraft, such as the 7,903' MSL peak just 12 nautical miles southwest of Payson. A thorough pre-flight before launching is key to knowing the complexities of your route over the mountains and the conditions at your destination airport.

The videotape of the Cessna L-19 crash that was part of the Westwind ground school depicts many light aircraft mountain accidents, but no flight needs to end tragically like that. It's up to you as the pilot-in-command to determine the outcome of your mountain flight. Arizona mountain flying offers pilots rewarding flying experiences and fantastic views, but it also raises significant safety challenges that have led to many unfortunate and fatal crashes. As one flight instructor who has years of instruction experience told me, mountain flying and related density altitude topics may be the most consistently under-trained and poorly understood operations in general aviation. Jim Pitman and his team at Westwind have put together a thorough course to address the topic, enhance your aviation knowledge, and most importantly, give you the experience you need to safely fly the mountains. You owe it to yourself, your family, and your friends to receive the proper training experience before flying the mountains.

For more information on Westwind's course, visit them online at www.iflywestwind.com/azmfsc.php.


Document #3 -- The NTSB Report

NTSB Identification: DEN84FA308. The docket is stored on NTSB microfiche number 25894.

Accident occurred Friday, August 10, 1984 in TABERNASH, CO Probable Cause Approval Date: 12/14/1992 Aircraft: CESSNA L-19E, registration: N4584A Injuries: 2 Fatal.

THE AIRPLANE DEPARTED GRANDBY 8/10/84 AND FAILED TO ARRIVE AT ITS DESTINATION. ON 8/23/87, IT WAS FOUND ON THE SLOPE OF A HIGH TREE-COVERED RIDGE. VIDEO TAPE RECOVERED FROM THE WRECKAGE PROVIDED A VISUAL AND AUDIO RECORD OF THE FLIGHT FROM TAKEOFF TO IMPACT. COMPARING THE RECORDING TO A TOPOGRAPHICAL MAP, THE FLIGHT WAS SLOWLY CLIMBING BUT ITS ALTITUDE ABOVE THE GROUND WAS DECREASING WHEN IT CRASHED AT THE 10,200-FT LEVEL. DURING THE LAST FEW SECONDS OF THE TAPE, THE TERRAIN DOMINATED THE VIEW THROUGH THE COCKPIT WINDOW. THE PILOT MADE AN APPROXIMATELY 45 to 55-DEG ANGLE BANK TO THE RIGHT, AND THE STALL WARNING HORN COULD BE HEARD 3 TIMES DURING THE APRX. 180 DEG OF TURN. THE AIRPLANE SUBSEQUENTLY STALLED 3 TIMES, SPUN, FLIPPED OVER, AND ENTERED THE TREES. THE DENSITY ALTITUDE WAS JUST ABOVE 13,000 FT.**

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: IN-FLIGHT PLANNING/DECISION, IMPROPER...PILOT IN COMMAND AIRSPEED...NOT MAINTAINED...PILOT IN COMMAND…DENSITY ALTITUDE NOT TAKEN INTO CONSIDERATION WHILE ATTEMPTING 180-DEGREE RIGHT TURN AT APPROX. 45 to 55 DEGREES OF BANK ANGLE...PILOT IN COMMAND INSUFFICIENT LIFT AVAILABLE TO COMPLETE THIS MANEUVER SAFELY.

Contributing Factors: WEATHER CONDITION...SUNNY AND HOT…HIGH DENSITY ALTITUDE CONDITIONS… TERRAIN CONDITION...MOUNTAINOUS/HILLY…FLIGHT INTO CONTINOUSLY ASCENDING TERRAIN…HIGH DEGREE OF BANK ANGLE RESULTING IN LOSS OF POSITIVE AERODYNAMIC LIFT…AIRCRAFT UNABLE TO MAINTAIN LEVEL FLIGHT…

NOTE: The Cessna manual for the L-19E lists the service ceiling for this make/model as 20,300 feet. Under “optimum” conditions (less density altitude), and/or with a much gentler bank angle, the pilot should’ve been able to safely complete this turn. By banking at 45 to 55-degrees under existing temperature conditions at the time of the crash, he effectively put the performance ceiling for completing this maneuver well below that altitude.

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