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An Unfortunate Chain of Events
Examining the first Matrix fatal accident
by David McVinnie
Accident research allows us to look at past events
in the hope of preventing them in the future. It’s not about assigning blame; it’s about identifying potential risk factors and affecting change. Oftentimes, no specific cause is obvious but multiple risks contribute to an event. CBS correspondent Jeff Pegues asked Mark Rosenker, a former NTSB Chairman, “How often is weather a factor
in plane crashes?” He responded “Weather can be a serious factor, but it is never the single cause of what ultimately created the accident. Accidents are always a chain of events.”
I’m going to examine an accident involving N40TS, a 2010 Piper Matrix that went down on February 13th, 2021. This
is the first Matrix fatal accident in the United States and only the second in the Matrix production history. Hopefully, it’s the last and our thoughts go out to the families. The
pilot was not an MMOPA member, and we don’t know if he trained beyond the FAA minimums. That may come to light at a later date.
The details are sparse, and all my information comes from publicly available sources (and the accuracy it implies). There were no witnesses or survivors so a factual determination may never be possible. There are several risk factors to examine, and I’ll use the FAA’s PAVE process as details are too few to take advantage of the MMOPA FRAT.
P: the Pilot
FAA records report the 56-year-old pilot held a Private Pilot certificate with Rotorcraft and Airplane Single Engine
ratings. He was not instrument rated. He presided over several businesses in the Los Angeles area and also had a residence in Mammoth Lakes. The aircraft was registered to one of his companies in 2011 so he was likely the original owner. His training history is not publicly available. The available flight history averages a couple of flights a month.
A: the Aircraft:
N40TS, 4692156, was an early Garmin G1000 Matrix. It was FIKI equipped (some Matrix were not). As most know, the G1000 is capable of displaying synthetic vision and it would be reasonable to assume it was enabled.
enVironment: (The FAA was hard-up for a “V”)
The aircraft left Camarillo, CA (KCMA) at approximately 3:55 p.m. on a planned flight to Mammoth Lakes, CA (KMMH). A direct route would involve altitudes well above 12,500 feet and require the use of oxygen, which explains the lower altitude/route selection. The flight typically took about 1.5 hours and it’s one he appears to have made regularly.
The accident occurred about 32 minutes into the flight and FlightAware ground speeds indicate the aircraft experienced an updraft at about 21-minutes in. As a VFR pilot, the route seems to use easily identifiable visual checkpoints and remains below 12,500 feet MSL. The plan kept him south of some medium peaks (~8,000 feet MSL) and east of the southern Sierra Nevada Mountains. The Sespe Condor Sanctuary is also under the route with an overflight minimum altitude of 9,000 feet MSL. The Sierra chain runs north/south for more than 100 nm, with peaks topping 14,000 feet MSL. The northwest portion of the route runs
up the Owens River Valley (~3,500 feet to 4,000 feet MSL) and stays west of the Inyo Mountain chain. It’s only 15-20 nm wide at some points. The Inyo ridges contain peaks in the 11,000 feet range. The northern half of the route easily qualifies as wilderness/mountainous terrain.
Airspace played a significant part in the planning. The route is a maze of wilderness areas, military MOAs, and restricted areas. Most of the MOA’s are Monday-Friday and run 200 feet AGL and up. The MOA airspace over the Sierras has exclusions below 3,000 feet over the wilderness areas but pilots are supposed to maintain at least 2,000 feet above them
26 MMOPA MAGAZINE MAY / JUNE 2021