BANGOR, CA, USA
N9703C
Piper PA-28-181
The pilot had logged 1,600 total flight hours, of which 1,100 hours were flown in his autopilot equipped airplane. The pilot and his passenger/wife, also a pilot with over 300 flight hours, planned to fly northward from Lincoln, California, to Bend, Oregon. Neither pilot was instrument rated. FSS provided the pilot with a weather briefing indicating flight precautions for mountain obscurement and thunderstorms. Weather conditions along the planned route included multiple cloud layers at 2,000 and 4,000 feet msl, and light rain showers. The pilot informed the FSS briefer that he could fly in IMC. After a 0740 takeoff the pilot requested and received VFR radar flight following service, encountered the clouds, and commenced flight in IMC while continuing toward his intended destination. At 0759:28, the pilot advised the Oakland ARTCC controller that he was in the clouds and on autopilot. The controller advised the pilot to 'use caution and maintain VFR.' The pilot again informed the controller that he was in the clouds and VFR flight was not possible, to which the controller responded at 0800:51 by stating 'maintain VFR.' Then, the controller provided the pilot with directions to an airport ahead with unknown weather conditions. The controller observed the airplane's 2,400-foot altitude and was aware that the minimum instrument altitude for the area was at least 5,000 feet. Contrary to requirements specified in the FAA's Air Traffic Control Order 7110.65, the controller failed to perform his first duty priority by not properly assisting the pilot in an emergency. The controller provided the pilot with a bearing to an airport south of his position necessitating a course reversal turn while proceeding in IMC, and he neglected to issue a safety alert for terrain proximity or give climb instructions to an area where flight under VFR was likely possible. Seconds after the pilot received the turn instructions he became disoriented, lost control of the airplane, and in an inverted attitude impacted the underlying hilly terrain. About 8 months prior to the accident flight the 78-year-old pilot's high blood pressure (180/90) was reduced with prescription drug treatment. Insufficient specimens remained for definitive autopsies or toxicological tests. No mechanical malfunctions were found with the airplane.
HISTORY OF FLIGHT On June 8, 1998, at 0804 hours Pacific daylight time, a Piper PA-28-181, N9703C, impacted hilly terrain near Bangor, California. The airplane, owned and operated by the pilot, cruised into instrument meteorological conditions during the personal flight conducted under the provisions of 14 CFR Part 91. Instrument meteorological conditions existed in the vicinity of the accident site, and no flight plan was filed. The airplane was destroyed, and the private pilot was fatally injured. The passenger, who also held a private pilot certificate, and the family dog were also fatally injured. Neither pilot was instrument rated. The planned nonstop flight to Bend, Oregon, originated from Lincoln, California, about 0740. A review of the recorded radar data, and the pilot and controller statements, indicated that after takeoff the pilot requested and received radar flight following service. At 0759, while proceeding north-northwest bound between 2,000 and 2,100 feet mean sea level (msl) as indicated by the airplane's Mode C transponder, the pilot established contact with the Federal Aviation Administration (FAA) Oakland Air Route Traffic Control Center (ARTCC) Sector D42 radar controller. At 0759:28, the pilot advised the controller that he was not flying in visual meteorological conditions (VMC), was in the clouds, and was on autopilot. The controller acknowledged the transmission and asked the pilot "what will be the route of flight?" The pilot responded "three four zero." The controller stated "use caution and maintain VFR" (visual flight rules). At 0800:06, the pilot again informed the controller that he was in the clouds and could not maintain flight under VFR. The controller responded at 0800:51 by stating "maintain VFR." The controller then provided the pilot with heading instructions to the Oroville Airport, located 10 nautical miles (nmi) north-northwest of his position, and the following exchange of communications occurred: At 0801:06, the pilot asked "what's the conditions at Oroville?" The controller replied at 0801:11 by stating "Cherokee zero three Oroville does not have weather reporting." At 0801:17, the pilot said "How about Chico?" (The Chico Airport is located about 22 nmi northwest of Oroville.) The controller replied "Cherokee zero three charlie the Chico ah one three five three observation visibility four and mist fifteen hundred overcast." The controller next informed the northwest bound pilot, at 0801:52, of the weather conditions at an airport located approximately 20 nmi south of his position by stating "Cherokee zero three charlie the Marysville ah airport is reporting visibility ten miles scattered clouds at two thousand broken clouds at three thousand and six thousand overcast." The pilot responded with "Can you ah give me a bearing to ah Marysville please?" The controller replied "Cherokee zero three charlie suggest heading of one niner five vectors Marysville." The pilot's last recorded transmission was at 0802:15 when he replied "one niner five thank you." The airplane's last recorded position by the radar facility at the Beale Air Force Base was at 0803:34, and by the Oakland ARTCC at 0803:38. At this time, the airplane was about 39 degrees 24 minutes 52 seconds north latitude, by 121 degrees 24 minutes 50 seconds west longitude. The airplane descended from 2,500 to 2,100 feet during the last 1/4 minute of recorded flight. About 0803 a witness, who was located within about 2 miles of the crash site, telephoned the Butte County Sheriff to inform them that he had heard the sound of an airplane's engine rev up and then suddenly stop with the sound of a "thump." The witness indicated it sounded as though an airplane had crashed. Another witness, who resides in Bangor, similarly reported hearing the sound of a rapidly descending airplane with its engine running at a very high speed. The witness said the sound terminated with a "thud," and he assumed the airplane had crashed. PERSONNEL INFORMATION Pilot. No flights were observed recorded in the pilot's personal flight record logbook since December 1, 1997, and this last entry listed a local flight from Palm Springs, California. The pilot's total logged flight time was indicated as approximately 1,589 hours. The flight times shown in the "Flight Time Matrix" portion of the National Transportation Safety Board's factual report core form are estimates. The times are based upon a combination of the pilot's logbook data, FAA files, and an application for insurance dated January 20, 1997. On that date, the pilot reported his flight experience consisted of 1,325 hours, of which 1,050 hours were in the Piper PA-28-181 airplane. The pilot's logbook indicated that he had flown over 1,167 hours on cross-country trips, which included several flights between California and Oregon. During the past 13 years, the only airplane listed as having been flown was the accident airplane. In December 1997, the pilot reported to his insurance company that he never flies without his wife (the passenger onboard). A comparison between the pilot and passenger's logbooks revealed that most of their flights were performed together in the accident airplane. The pilot did not possess an instrument rating. His total logged instrument flight experience was 6 hours. Passenger. A review of the passenger's personal flight record logbook revealed she acquired all of her flight training in the accident airplane. She was issued a private pilot certificate in September 1994, after obtaining about 96 hours of dual flight instruction, and had a total flight time of 216 hours. Since certification, all of her logged flights were flown in the accident airplane. The last flight listed in her logbook was dated November 16, 1997, and was flown from Palm Springs. On that date, her total recorded flight time was about 313 hours. The passenger did not possess an instrument rating. Her total logged instrument flight time was 4 hours. Air Traffic Controller. During the on-scene phase of the accident investigation the FAA's Oakland ARTCC controller, who had been communicating with the pilot during the last few minutes of the airplane's recorded flight, visited the crash site on his own initiative. The controller reported to the Safety Board that all communications with the pilot had been "clear," and the pilot had sounded responsive to his instructions. Nothing unusual was noted in the manner by which the pilot spoke. All communications with the airplane were from the same pilot, who had a male-sounding voice. The controller stated that he recalled the pilot advising him that he was not flying in VFR conditions, was in a cloud, and had the autopilot turned on. The controller further indicated that he last observed the airplane on radar in a descent after the pilot commenced a course reversal turn from 340 degrees to 195 degrees, seconds after he had informed the pilot of the weather at an airport which was located south of his position. The Safety Board's air traffic control group chairman conducted an interview of the controller on June 15, 1998, at the Oakland ARTCC facility, and reviewed the controller's training and personnel records. The air traffic controller was hired by the FAA in 1993, and he was promoted to full performance level in 1996. The controller holds a private pilot certificate (issued in 1990), and he stated that he has flown light airplanes over California's Central Valley. He was aware that terrain elevation increased over the mountainous region east of the valley floor. The controller stated that when the accident pilot told him that he was flying on autopilot in the clouds he was "shocked," but he did not consider the airplane to be an emergency. He recalled that the airplane's altitude fluctuated between 1,700 and 2,400 feet. The controller believed that the pilot was flying in a minimum instrument altitude area of 5,800 feet, and explained that he understood minimum instrument altitudes are established at 2,000 feet above the highest terrain in the boxes drawn on the chart. The controller reported that he did not know how to activate the minimum safe altitude warning (MSAW) feature for VFR airplanes. (Oakland ARTCC management reported that MSAW was available for use with Mode C transponder equipped tracked VFR airplanes.) The records indicated, in summary, that between 1995 and 1998, the controller had received training regarding the handling of lost/disoriented aircraft, radar assistance to VFR aircraft in weather difficulty, minimum IFR altitudes, MSAW and safety alert procedures. The controller had been found responsible for two previous operational errors, in March 1997, and in January 1998. The primary factor related to the first error involved coordination between controllers. The primary factor related to the second error involved the controller's failure to correlate the aircraft's position with the minimum instrument altitude chart. This action resulted in the pilot's operation below the minimum instrument altitude. (See the Safety Board's Group Chairman's Factual Report for additional details.) AIRCRAFT INFORMATION The airplane was equipped with dual flight controls, and was controllable from either front seat location. The rear seats were not located; they had been removed from the airplane. A review of the airframe and engine logbooks indicated that the airplane was maintained on an annual inspection basis. No evidence of outstanding squawks or open maintenance items was located in the recovered and impact damaged records. The airplane was equipped with a Century II autopilot which provided heading, course tracking, and turn functions. No altitude hold capability existed. METEOROLOGICAL INFORMATION Pilot Briefing. At 0618, when the pilot telephoned the FAA's Rancho Murieta, California, Automated Flight Service Station, he informed the specialist that he was located at Lincoln (elevation 119 feet msl) and desired to fly (northbound) to Redmond, Oregon. The specialist asked the pilot "you want to do this IFR right," to which the pilot replied "yeah." The specialist then provided the pilot with a weather briefing. In pertinent part, the specialist informed the pilot that flight precautions for mountain obscurement and thunderstorms were forecast along his planned flight route, and the weather conditions were forecast to improve later during the day. The specialist provided the pilot with weather reports for several airports including the Beale and McClellan Air Force Bases which are located about 15 nmi north and south of the uncontrolled Lincoln Airport. The weather at Beale (elevation 113 feet msl) was reported as few clouds at 2,000 feet, 4,000 overcast, visibility 4 miles in light rain showers and mist. The weather at McClellan (elevation 75 feet msl) was reported as scattered clouds at 3,000 feet, 6,000 broken, 12,000 overcast, with 8 miles visibility. (See the transcript for additional details.) Accident Site Weather. The closest aviation weather observation station to the accident site is located at the Beale Air Force Base, about 16.5 nmi south (168 degrees magnetic) of the site. At 0755, Beale reported the following weather conditions: wind 300 degrees at 3 knots; 5 miles visibility; mist; few clouds at 1,000 feet; 2,000 scattered; 4,000 broken; and overcast clouds at 6,000 feet above ground level (agl). The temperature and dewpoint were both 61 degrees Fahrenheit, and the altimeter was 29.97 inches of mercury. Several witnesses provided statements regarding the weather conditions in the Bangor area. One witness indicated that he could not see ahead 50 feet from his 800-foot msl elevation. He also stated that at 0803, the clouds were at ground level. A fire apparatus engineer, who was based at the Bangor fire station, reported that about 0837 there was an overcast sky condition with an estimated cloud base at 500 feet agl. There was no rain or mist in the area. The visibility was at least 1/2 mile. Bangor's elevation is about 750 feet msl. At 0924, a sheriff's helicopter pilot overflew the accident site and reported that the ceiling was about 250 feet agl. The neighboring mountaintops were obscured. AIDS TO NAVIGATION According to the FAA's records of facility operations, all electronic aids to navigation pertinent to the aircraft's route of flight were functional. WRECKAGE AND IMPACT INFORMATION The accident site and airplane wreckage examination revealed the airplane had descended into approximately 850-foot msl hilly terrain at global positioning satellite coordinates of 39 degrees 24 minutes 36.84 seconds north latitude by 121 degrees 24 minutes 32.28 seconds west longitude. The Safety Board calculates that this location is approximately 0.34 nmi from the airplane's last position as recorded by the Oakland ARTCC. The airplane's wreckage was found fragmented and scattered over an approximate 245-foot-long path that was principally oriented along an east-northeasterly magnetic course of 058 degrees. The initial point of impact (IPI) was noted by the presence of ground scar adjacent to an oval shaped impact crater. Fragmented airframe components associated with the upper surface of the airplane were found in and adjacent to the IPI crater. These components included portions of the rotating beacon and the rudder's counterweight, and were found about 6 inches below ground level. Also located within a few yards from the IPI crater was the red colored (left wing tip) position light lens and its respective housing. The propeller was found about 49 feet northeast of the IPI. The blades were observed torsionally twisted, bent into an "S" shape, with the leading edge gouged and scratched in a chordwise direction. The wings and fuselage were found separated from each other. The fuselage was located partially suspended from tree branches about 118 feet northeast of the propeller. Also observed hanging from the tree branches, about 15 feet agl, were articles of clothing. All of the airplane's flight control surfaces were located at the accident site. Cable ends associated with the flight control system exhibited broomstraw and necking down (tension overload) signatures. The cockpit was found demolished. Both of the control yokes were observed broken from their supporting structure. The engine was located about 78 feet east-northeast of the main wreckage. It was impact damaged and was partially devoid of its airframe mounts and accessories. The crankshaft could not be rotated. No evidence of case rupture was noted. The oil suction screen was clear. The engine driven vacuum pump's drive coupling was found intact. The pump's housing was not located. The directional gyroscope rotor was removed from its case and examined. Circumferentially oriented score marks were noted around the rotor body, and corresponding marks were observed in the case. A few drops of fuel were observed inside the carburetor. The throttle plate was observed in the full open position. The fuel filter screen was devoid of obstructing material. The carburetor's metal floats were found symmetrically compressed. (See the Piper Aircraft and Lycoming Engine participants' reports for additional details.) One of the airplane's tires, and the grass adjacent to the tire, was observed partially destroyed by fire. There was no evidence of fire associated with the main airframe structure. Following the wreckage examination, the left wing was carried over to the IPI ground scar. Wing tip-to-ground matching contact signatures were observed when the wing was positioned such that it was in an attitude consistent with about a left 135-degree bank angle (inverted) and about a 30-degree nose low attitude. (See the wreckage diagram and photographs for additional details.) MEDICAL AND PATHOLOGICAL INFORMATION According to information provided to the FAA in the pilot's January 2, 1997, application for a third-class aviation medical certificate, he had no current history of angina. In the application, it was noted that the pilot no longer had a blood pr
The pilot's attempted flight into instrument meteorological conditions, loss of spatial orientation, and the resultant loss of airplane control. Contributing factors were his improper preflight and in-flight decisions, overconfidence in his personal ability, and the low ceiling. An additional factor was the radar controller's substantial deviation from prescribed procedures for handling VFR aircraft in weather difficulty.
Source: NTSB Aviation Accident Database
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