CERES, CA, USA
N560LM
PIPER PA-32R-301T
THE PILOT EXECUTED A MISSED APPROACH IN INSTRUMENT METEOROLOGICAL CONDITIONS. A GROUND WITNESS BRIEFLY OBSERVED THE AIRPLANE PROCEEDING IN AN OPPOSITE DIRECTION OF THE FINAL APPROACH COURSE ON A FLIGHT PATH NOT IN ACCORDANCE WITH THE MISSED APPROACH. THE AIRPLANE ABRUPTLY ENTERED INTO A 90-DEGREE BANKING TURN AND DISAPPEARED INTO THE CLOUDS. THE AIRPLANE CRASHED IN A NEAR-VERTICAL DESCENT ATTITUDE MOMENTS LATER. THE PILOT'S LAST COMMUNICATIONS TO THE LOCAL CONTROLLER WERE UNINTELLIGIBLE. THE WRECKAGE EXAMINATION SHOWED THAT THE MAIN LANDING GEARS WERE IN TRANSIT. THERE WAS NO EVIDENCE OF ANY AIRPLANE OR ENGINE PREEXISTING MALFUNCTIONS OR FAILURES.
HISTORY OF FLIGHT On February 10, 1995, at 1954 hours Pst (all times in this report are Pacific standard time based on the 24-hour clock), a Piper PA-32R-301T, N560LM, crashed in an almond grove in Ceres, California. The crash site is about 3 miles southeast of Harry Sham Field, Modesto, California. The pilot obtained an instrument flight rules (IFR) clearance and was executing an instrument landing system (ILS) approach to Harry Sham Field, runway 28R. The airplane, registered to and operated by the pilot, was destroyed by impact forces and the resulting postcrash fire; several almond trees were destroyed. The certificated private pilot and his passenger sustained fatal injuries. Instrument meteorological conditions prevailed. The flight departed Phoenix, Arizona, metropolitan area from an undetermined airport at an undetermined time. The pilot's family told National Transportation Safety Board investigators that he and his wife departed Modesto for Phoenix on February 6, 1995. On February 10, 1995, the pilot called his secretary and told her that he would be returning to Modesto that day, but he was intending to stop in the Los Angeles, California, area and conduct some business. The Federal Aviation Administration (FAA) air traffic division records show that the pilot obtained a weather briefing from Prescott (Arizona) Flight Service Station at 0614 hours. At 1607 hours, the pilot contacted the Luke Air Force Base (AFB) radar approach control. The sector controller had received an automated handoff from the Phoenix Terminal Radar Approach Control (TRACON) at 1604 hours. Later, the pilot requested and received VFR flight following to Modesto, California. The pilot received subsequent radar flight following services from Albuquerque (New Mexico) Air Route Traffic Control Center (ARTCC), Los Angeles ARTCC, Joshua Approach Control (formally Edwards AFB Approach Control), High Desert TRACON, Bakersfield (California) Approach Control and the Lemoore Naval Air Station Approach Control. At 1847 hours, the pilot requested and received an IFR clearance to Modesto from the Lemoore sector controller. At 1904 hours, the Lemoore sector controller handed off the flight to the Oakland ARTCC sector 22 controller. At 1911 hours, the pilot informed the sector 22 controller that he was beginning a descent to 6,000 feet (all altitudes, unless otherwise noted, are mean sea level altitudes). At 1911 hours, the sector 22 controller advised the pilot to contact Castle AFB approach control. The pilot acknowledged and complied with the instructions. At 1924 hours, the controller instructed the pilot to maintain 3,000 feet. The controller then provided the pilot with multiple radar vectors to the Modesto (Harry Sham Field) runway 28 ILS final approach course. At 1947 hours, the controller cleared the flight for an approach and instructed the pilot to contact Modesto tower. At 1950:46 hours, the pilot initially contacted the Modesto tower local controller and said that he was over the ILS outer marker. The controller responded, in part, " . . . saratoga zero lima mike (0LM), runway 28R, cleared to land." The pilot did not respond. At 1953:30 hours, the local controller instructed the pilot to report the field in sight. The pilot response (at 1953:34 hours) was unintelligible. There were no other communications between the pilot and the local controller. The local controller told investigators that he did not observe the postcrash fireball. A ground witness told Stanislaus County Sheriff's deputies that he heard an airplane, looked up, and saw the beacon light of a small airplane flying in an easterly direction. The airplane suddenly made a 90-degree left banking turn and that the engine sounds diminished during the turn. The airplane disappeared in the fog and he could no longer see the airplane's rotating beacon or navigation lights. About 10 seconds after the airplane made the sudden left turn, the witness said he felt the ground shake followed by a " . . . ball of flames . . . ." PERSONNEL INFORMATION The pilot held a private pilot certificate with airplane single- engine land and instrument airplane ratings. He also held an unrestricted third-class medical certificate issued by an FAA designated airman medical examiner on November 1, 1993. Safety Board investigators recovered remnants of the pilot's flight hours logbook(s). The logbook(s) condition prevented investigators from determining the pilot's total flight hours or his recency of instrument flight experience. Current federal air regulations require that a pilot accrues 6 instrument flight hours within the preceding 6 months of any instrument flight. Three hours of the required instrument flight experience can be flown in a simulator. The Modesto Flight Center provided flight training for the pilot. The pilot's initial instrument flight instructor said that she provided flight instruction between 6 and 7 years before the accident. She had not flown with the pilot for about 3 years. Another flight instructor gave the pilot a biennial flight review about 18 months before the accident. This was the last instruction that the pilot received from Modesto Flight Center. AIRCRAFT INFORMATION The FAA records show that the airplane was initially registered to the pilot on May 24, 1989. According to the pilot's family, Jolliff Aviation, Modesto Airport, maintained the airplane. The family said that Jolliff Aviation accomplished an annual inspection on the airplane before the pilot departed on the accident flight. The owner of Jolliff Aviation told investigators that the pilot retained him to pick up the airplane from his hangar for an annual inspection on February 3, 1995. On February 6, 1995, the pilot called the owner and told him he was going on a trip and that he would need the airplane. The owner told the pilot that he was just beginning the inspection, but he would end the inspection and return the airplane to service. The owner also said that he accomplished the airplane/engine last annual inspection " . . . sometime in February 1994." Jolliff Aviation records, however, show the airplane's initial annual inspection was initiated on January 20, 1994. The owner could not provide any records showing the date the annual inspection was done. The annual inspection work order does not show that the inspection was delayed due to parts back order or any other reason. At the time of the last recorded inspection, the airplane accrued 1,302 hours. AIDS TO NAVIGATION On February 11, 1995, the FAA Airways Facilities Division conducted an operational check on the Modesto Airport instrument landing system. The instrument landing system was found within the specified operational limitations. The pilot of Sundance flight 874, which preceded the accident airplane on the ILS, reported that his ILS approach " . . . was made with no abnormal deviations in electronic guidance, or adverse weather . . . ." The FAA, Western-Pacific Region Air Traffic Division, AWP-505, provided the Safety Board with radar data (National Track Analysis Program (NTAP)) from the Oakland (California) Air Route Traffic Control Center (ARTCC). Review of the data showed that the last radar hit on the airplane was at 1916:46 hours and about 51 nautical miles southeast of the accident site. The FAA quality assurance specialist said that the Oakland radar specialist provided the radar information for the airplane's specific discrete transponder code while being provided radar flight following services by Oakland ARTCC. The Castle AFB radar controller changed the transponder code on the airplane, but this code was not entered into the computer during the data retrieval. Unfortunately, the radar tape was returned to service and further radar data on the accident airplane is no longer available. WRECKAGE AND IMPACT INFORMATION The airplane crashed into an almond grove about a 1/2 mile south of the runway 28R localizer course. One almond tree sustained airplane impact damage; several other trees sustained extensive postfire impact damage. Pieces of the red navigation light were found laying near the almond tree that was initially struck by the airplane wing. Ground scars, broken tree limbs, and the wreckage examination showed the airplane left wing struck the tree in a nose-down attitude with the top of the cabin facing southwest. After impact, the airplane fuselage rotated to the right and came to rest right-side-up about 4 feet southeast of the initial impact crater. The nose of the airplane was facing 310 degrees. Scattered debris and the postcrash fire patterns were oriented in an easterly direction. All of the airplane major components and flight controls were found at the main wreckage area. The right wing remained attached at its respective wing-to-fuselage attach fitting and sustained extensive postimpact fire damage. The right wing aileron and flap assembly remained connected to their respective attach fittings. The right flap appeared to be extended about 20 degrees. The left wing separated from its wing-to-fuselage attach fittings and was found folded rearward and laying against the empennage. The left aileron and flap assembly separated from their respective attach fittings and were found near the left wing. The right main landing gear hydraulic cylinder actuator was found extended about 4.875 inches; the left main gear hydraulic cylinder actuator was found extended 7.875 inches. The left main gear down lock was not engaged. The damage to both wheel wells was consistent with the main landing gear being between the retracted and extended position. The nose gear hydraulic cylinder actuator was found extended 6 inches and was bent 180 degrees. This setting corresponds to a nose gear extended when the actuating rod was bent due to impact forces. The rudder remained connected to the vertical stabilizer and both units sustained extensive fire damage. The horizontal stabilator leading edge sustained impact damage. The stabilator trim jackscrew was found extended 1 inch (seven threads exposed). According to a Piper Aircraft Company engineer, the stabilator trim setting was near the neutral position. The cabin/cockpit area was incinerated by the postimpact fire. Safety Board investigators established continuity of the rudder and elevator cables to the cabin area. Most of the airplane instruments were destroyed by impact. The engine came to rest southeast of the initial impact crater. The propeller assembly separated from the engine crankshaft and was found imbedded in the crater with the crankshaft side facing toward the west. All three blades were found. One blade separated from the hub assembly. Two blades exhibited extensive "S" twisting, tip curling, and chordwise score marks; the remaining blade was bent toward the camber side about 40 degrees about 20 inches outboard of the hub assembly. Safety Board investigators examined the engine on February 28, 1995, at Plain Parts, Pleasant Grove, California. EXTERNAL EXAMINATION The entire accessory section sustained high temperature distress. All of the accessories were destroyed and could not be tested. The manual waste gate lever was found 3/4 inch off the stop. The fuel servo throttle and mixture arms were broken. The vacuum pump drive gear was missing; however, melted remnants of the drive gear were found in the drive gear spline. The rotor sustained rotational damage; all of the vanes were found intact. The upper spark plugs displayed normal operating signatures. The left magneto impulse coupling was found intact. The engine was seized and could not be turned. The No. 1 cylinder was removed and the internal examination showed no fractures of the cam or crankshafts. The connecting rods were found connected to their respective components. MEDICAL AND PATHOLOGICAL INFORMATION The Stanislaus County Coroner's Office conducted the post mortem examination on the pilot. Toxicological examinations were conducted by the FAA, Civil Aeromedical Institute, Oklahoma City, Oklahoma. The examinations were negative for alcohol or drugs. TESTS AND RESEARCH According to the United States Terminal Procedures, Southwest (SW) Vol. 2 of 2, effective January 6, 1994, the missed approach procedure requires the pilot to: Climb (straight on the localizer inbound course) to 700 (feet msl), then (execute a) climbing right turn to 1800 (feet msl and proceed) direct to the MOD VOR/DME (Modesto very high frequency range/distance measuring equipment) and hold. The holding pattern is depicted to hold southeast (left turns) of the Modesto VOR and proceed inbound on the 105-degree radial. ADDITIONAL INFORMATION The Safety Board released the wreckage to the registered owner's insurers on March 3, 1995. The wreckage was at Plain Parts, Pleasant Grove, California, when it was released.
the pilot inadvertently becoming lost/disoriented during a missed approach, his failure to follow the proper missed approach procedure, and his failure to maintain control of the aircraft due to spatial disorientation.
Source: NTSB Aviation Accident Database
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