San Dimas, CA, USA
N222ES
Piper PA-34-200
The airplane collided with rising mountainous terrain while executing a missed approach procedure in instrument conditions during an instructional flight. At 1929 the TRACON controller (POMR) cleared the airplane for the VOR-A approach, and advised the pilot to contact the tower. The pilot acknowledged, then contacted the ATCT local controller (LC) and stated they were on the VOR-A approach outside of the final approach fix (FAF). Two minutes later the POMR controller, after observing the aircraft's target off course, contacted the LC to ask why the airplane was circling the airport. The LC stated he would find out and get back to the POMR controller. The LC asked the pilot if he wished to cancel IFR or continue the approach. The pilot replied that he wanted to continue and the LC told him to report the runway in sight. The LC, who was monitoring the flight's target track on the tower's DBRITE radar display, also informed the pilot that they appeared to be west of course. At 1932:20 the LC asked if they had the airport in sight. The pilot replied they had the airport in sight. The LC then contacted POMR and advised that the pilot was canceling IFR and had the airport in sight. The POMR controller then dropped the accident airplane's data block from his radar display. 47 seconds later, the LC asked the pilot to confirm he had the runway in sight. The pilot replied in the negative. The controller then asked if the pilot wanted the missed approach. The pilot replied that he had the ground and a freeway in sight. The pilot was instructed to continue and report the airport in sight. A few seconds later the pilot again reported the airport in sight, and was cleared to land runway 26L. At 1934:25 the LC asked the pilot what he was doing and if he had the airport in sight. The pilot asked if anything was wrong. The controller advised the pilot he was now three miles west of the airport and suggested he turn to a heading of 080-degrees. The controller also told the pilot to maintain visual flight conditions, and to report the runway in sight. At 1936:02 the controller advised the pilot the airport was 1.5 miles at the pilot's 12:00 o'clock position. He also asked if the pilot had the airport in sight. The pilot replied negatively. The controller instructed the pilot to make a 10-degree right turn to enter the downwind. The controller again informed the pilot that the airport was a little over a mile at their 12:00 position. The pilot replied he had the airport in sight. The controller instructed the pilot not to lose sight of the airport again, and cleared him to land. After observing the flight deviate from a track to the airport, at 1939:29 the controller asked the pilot for their current heading. The pilot then requested a missed approach. The controller instructed the pilot to execute the missed approach and to standby for a frequency change. The LC then called the TRACON sector controller and a discussion ensued between the two about the flight's VFR versus IFR status, with the TRACON controller saying that he thought the pilot had cancelled IFR and went VFR. The LC controller stated that "he had cancelled, he had the airport in sight, he lost sight of the airport, and he is asking me now if he can go missed approach so I don't know what to do with him." The Local Controller said he could work the pilot and try and get him back to the airport unless POMR wanted to take him. POMR stated that if the pilot was IMC and did not have the airport in sight that "I would have him turn southbound immediately." The LC then told the pilot to turn south and climb immediately to 5,000 feet. There was no response by the flight. Review of the recorded radar data disclosed that beginning at 1933:10 (about 5 minutes before the accident), the Minimum Safe Altitude Warning (MSAW) system was flashing an alert on both the TRACON controllers display and the DBRITE display in the tower; however, after the TRACON controller dropped the airplane's data tag the MSAW alert was automatically suppressed at the TRACON. Review of the recorded air/ground communications tapes disclosed that at no time did either controller issue an alert advisory for terrain avoidance to the flight.
1.1 HISTORY OF FLIGHT On October 6, 2000, at 1938 Pacific daylight time, a Piper PA-34-200, N222ES, collided with mountainous terrain while executing the missed VOR-A approach procedure at Brackett Field (POC), La Verne, California. Air Desert Pacific operated the airplane under the provisions of 14 CFR Part 91. The airplane was destroyed. The certified flight instructor (CFI) and the commercial single-engine instrument student sustained fatal injuries. The local instructional flight originated at POC about 1830. Instrument meteorological conditions prevailed for the local area instructional flight, that included an approach into the Chino Airport (CNO), Chino, California. An instrument flight rules (IFR) flight plan had been filed. The primary wreckage was at 34 degrees 08.572 minutes north latitude and 117 degrees 47.870 minutes west longitude. The Safety Board investigator-in-charge (IIC) reviewed transcripts of recorded radio transmissions between the pilot's and various FAA Southern California air traffic control (SoCal ATC) facilities. The transcripts indicated that the pilots were in contact with Pomona Associate (POMA), Pomona Radar Sector (POMR), Riverside Radar Sector (RALR), and the POC local controller (LC). No discrepancies were noted with the IFR flight to CNO that culminated in a missed approach or the request for the VOR-A approach to POC. At 1927 POMR radar identified the accident airplane and radar vectors were issued for the VOR-A approach to POC. The POMR controller asked the pilot if he had POC ATIS information "Lima". The pilot acknowledged the call, and then asked if they could have a frequency change to get the ATIS information. The POMR controller issued the ATIS weather and runway information. At 1929 POMR cleared the airplane for the VOR-A approach, and advised the pilot to contact POC. The pilot acknowledged the instructions. The pilot contacted the LC and stated they were on the VOR-A approach outside of GOLDI. The local controller instructed the pilot to report GOLDI. Two minutes later POMR contacted the LC to ask why the airplane was circling the airport. The LC stated he would find out and get back to POMR. Between the times 1932:05 to 1932:20 the LC asked if the pilot wished to cancel IFR or continue the approach. The pilot replied that he wanted to "continue." The LC told him to report the runway in sight, and the pilot acknowledged the request. The LC also informed the pilot that they appeared to be west of course. At 1932:20 the LC asked if they had the airport insight. The pilot replied they had the airport insight. The LC then contacted POMR and advised the pilot was canceling IFR and had the airport insight. POMR dropped the accident airplane's data block from its display. At 1933:07 the controller asked the pilot to confirm he had the runway in sight. The pilot replied in the negative. The controller then asked if the pilot wanted the missed approach. The pilot replied that he had the ground and Interstate-10 in sight. The pilot was instructed to continue, report the airport in sight, and cleared to land runway 26L, which he acknowledged. The pilot reported the airport in sight, and was again cleared to land runway 26L. At 1934:25 the LC asked the pilot what he was doing and if he had the airport in sight. The pilot asked if anything was wrong. The LC asked them their current heading. The pilot stated 280-degrees and then corrected the heading to 250-degrees. The controller advised the pilot he was three miles west of the airport and suggested he turn to a heading of 080-degrees. The controller also instructed the pilot to report he was established on an eastbound heading, to maintain visual flight rules (VFR) flight conditions, and to report the runway in sight. The pilot acknowledged all of the controller's requests. At 1936:02 the controller advised the pilot the airport was 1.5 miles at the pilot's 12:00 o'clock position. He also asked if the pilot had the airport in sight. The pilot replied negatively. The controller instructed the pilot to make a 10-degree right turn to enter the downwind. The controller again informed the pilot that the airport was a little over a mile at their 12:00 position. The pilot replied he had the airport insight. The controller instructed the pilot not to lose sight of the airport again, and cleared him to land. From 1936:46 until 1937:06 the controller was in contact with another airplane that was inbound from GOLDI for landing behind the accident airplane. The controller queried the accident pilot as to their current heading. The pilot requested a missed approach. The controller instructed the pilot to execute the missed approach and to standby for a frequency change. Between the times of 1937:29 to 1937:31 the LC informed POMR that the accident airplane was executing the missed approach. The POMR controller told the LC to instruct the pilot to execute the missed approach and "maintain three thousand, actually have him climb up to four." At 1937:50 the POMR controller commented to the LC that he (POMR) thought the pilot had cancelled IFR and went VFR. The LC controller stated that "he [the pilot] had cancelled, he had the airport in sight, he lost sight of the airport, and he is asking me now if he can go missed approach so I don't know what to do with him." At 1938:00 the LC said he could work the pilot and try and get him back to the airport unless POMR wanted to take him. POMR stated that if the pilot was IMC and did not have the airport insight that "I would have him turn southbound immediately." At 1938:12 the LC instructed the pilot to turn to the south, and stated that he should have been executing the missed approach. The LC then asked if the pilot knew what the missed approach was. The pilot stated they were trying to get back to the VOR and that they were making a turn to a heading of 150-degrees. At 1938:30 the LC instructed the pilot to make an immediate climb to five thousand feet. The controller attempted to reestablish radio communications with the accident pilots. The controller informed POMR a search would have to be initiated. Both the local and POMR controllers stated that the accident airplane had not established radio communications on either frequency. At 1941:40 POMR contacted Pomona Air One and advised them of a missing airplane. The controller stated that the last radar contact with the accident airplane was three miles north of the airport at 1,700 feet. Pomona Air One proceeded to the area to search for the accident airplane. Pomona Air One was unable to continue the search due to a "setting ceiling." A discussion ensued between the LC and POMR. POMR asked if the pilot had cancelled IFR. The LC stated he had cancelled IFR with the airport in sight. POMR asked where the pilot was at when he cancelled IFR. The LC replied he was over KELLOGG, a VFR checkpoint, about a mile and half southwest of the airport. During the ensuing discussion, POMR was informed that the LC had queried the pilot as to what heading was currently being flown. The pilot replied that he was on a heading of 270-degrees. The LC indicated that heading would take him away from the airport. The LC then instructed the pilot to turn to an easterly heading, and to let him know when the pilot had the airport in sight. The pilot stated he had the runway in sight, at which point the LC cleared him to land. He stated that the pilot started to head to the north and didn't answer any transmissions, except to say that he (the pilot) wanted a missed approach. The LC cleared him for the missed approach; however, the airplane continued northbound. He then told the pilot to turn to a southerly heading, and to climb and maintain, what he believed was, five thousand feet. The LC indicated that there were no further transmissions from the pilot. 1.5 PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed the CFI held a commercial certificate with ratings for airplane single-engine land, multi-engine land, and instrument airplane. The CFI also held a certified flight instructor certificate with ratings for airplane single-engine land, multi-engine land, and instrument airplane. The CFI held a first class medical certificate that was issued on April 15, 2000. It had no limitations or waivers. Family members were unable to locate the CFI's personal logbook. A review of the CFI's employee hire record and customer flight report from Air Desert Pacific revealed that the CFI was hired on May 12, 2000. He reported on the PILOT REGISTRATION form a total flight time of 205 hours. The company's customer flight report showed a total flight time of 71.6 hours from the period of May 30, 2000 to October 6, 2000. A review of FAA airman records revealed the student held a commercial certificate with ratings for airplane single-engine land and airplane instrument. The student held a first class medical that was issued on August 25, 2000, with no limitations or waivers. A review of the student's logbook revealed an estimated total flight time of 406 hours. He logged 35 hours in the last 90 days, and 16 in the last 30 days. The estimated total simulated instrument time logged was 58 hours; the estimated total time logged in actual instrument conditions was 3 hours. The pilot had an estimated 9 hours in this make and model. 1.6 AIRCRAFT INFORMATION The airplane was a Piper PA-34-200, serial number 34-7250331. A review of the airplane's logbooks revealed a total airframe time of 7,039 hours at the time of the accident. An annual inspection was completed on September 26, 2000. The tachometer read 4,373 at the last inspection. The tachometer read 4,427.60 at the accident scene. The airplane had a Lycoming IO-360-E1A6 engine, serial number L-9380-51A, installed on the left side. The 100-hour inspection was completed on September 25, 2000, and the total engine time was 6,985 hours. The airplane had a Lycoming LIO-360-E1A6 engine, serial number L-434-67A, installed on the right side. The 100-hour inspection was completed on September 25, 2000, and the total engine time was 6,985 hours. Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure. 1.7 METEOROLOGICAL INFORMATION The routine aviation surface weather (METAR) report from Brackett Field at 1847 reported winds from 260-degrees at 8 knots with 2 miles visibility. Mist obscured 3/8's to 4/8's of the sky, with an overcast ceiling at 1,500 feet above ground level (agl). At 1947, visibility had been reduced to 1 mile. Mist obscured 3/8's to 4/8's of the sky, with an overcast ceiling of 1,000 feet msl. Two AIRMET's (WA's) had been issued for the area for IFR conditions and mountain obscuration. 1.10 AERODROME INFORMATION 1.10.1 Missed Approach Procedure The missed approach procedure for POC was a climbing left turn to 4,000 feet direct to the POM VOR. The MVA in the area of the accident site was about 6,000 feet. 1.10.2 Minimum Safe Altitude Warning (MSAW) At the time of the accident POC tower was not equipped with an audible MSAW warning system. The FAA issued notice 7210.485, "Minimum Safe Altitude Warning for Remote Tower Displays," addressing the installation of aural alarms at "visual flight rules terminal facilities that receive radar information from a host radar control facility and would otherwise receive only a visual MSAW alert." Notice 7210.485 was issued on November 2, 1999. POC was scheduled to receive an aural alarm system by April 2001. The recorded minimum safe altitude warning (MSAW) data from the Southern California (SoCal) Terminal Radar Approach Control (TRACON) showed that MSAW issued an alert beginning at 1933:10 that continued for the remainder of the flight. The alert would have been visually displayed to the local controller on the digital bright radar indicator tower equipment (DBRITE) as a flashing "LA" in the data block that was the accident airplane. The alert would not have been available to POMR controllers, as they had already dropped the data block from their radar due to the cancelled IFR. 1.12 WRECKAGE AND IMPACT INFORMATION The Los Angeles County Sheriff Search and Rescue (SAR) crew located the accident site at 0417 on October 7, 2000, in the Angeles National Forest near Ham and Sycamore Canyons. Investigators from the Safety Board, the FAA, and New Piper Aircraft, a party representative to the accident, examined the wreckage at the accident scene. The airplane came to rest in a ravine on a 50-degree slope, at 2,150 feet. The accident site was located 3.66 miles northwest of POC on a magnetic bearing of 332-degrees, in rugged rising mountainous terrain, with trees and scrub brush. A ground scar was present on the eastern face of the ravine the length of the airplane from wing tip to wing tip. Navigational light lens fragments from each of the wing tips were found embedded on the eastern face of the ravine. All of the airplane's major components were contained at the accident site. The airplane came to rest with the fuselage on a 020-degree magnetic heading. The tail section of the airplane was bent over the fuselage in the direction of the right wing. The right wing was destroyed in the impact sequence; however, it remained partially attached to the fuselage. The aileron was found approximately 1-foot in front of the wing along with a portion of the door. The right fuel tank had ruptured. The right engine separated from the right wing; however, it was located in its approximate location under the wing. The left front seat was ejected from the airplane and located next to the left wing tip. The left wing remained partially attached to the fuselage. It was crushed span wise from leading to trailing edge. The flap and aileron remained attached to the wing. The left engine separated from the left wing; however, it was located in its approximate location under the wing. The empennage partially separated from the fuselage. The stabilator sustained impact damage to the right side. The stabilator control cables remained attached to the control tee-bar assembly, and the rudder cables were separated at the eyebolt attachment point. The trim cable remained attached to the trim drum. 1.13 MEDICAL AND PATHOLOGICAL INFORMATION The Los Angeles County Coroner completed the autopsies. Toxicological analysis was performed by the FAA Civil Aeromedical Institute (CAMI), Oklahoma City, Oklahoma, from samples obtained during the autopsy. The results of the analysis for the CFI were negative for drugs. Carbon monoxide, and cyanide tests were not conducted. The report contained the following positive results: 13 (mg/dL, mg/hg) ethanol detected in Kidney, 4 (mg/dL, mg/hg) acetaldehyde detected in Kidney, 1 (mg/dL, mg/hg) N-Propanol detected in Kidney, 20 (mg/dL, mg/hg) ethanol detected in muscle, 1 (mg/dL, mg/hg), N-Butanol detected in muscle, 1 (mg/dL, mg/hg) N-Propanol detected in muscle. The results of the analysis for the student pilot were negative for drugs. Carbon monoxide and cyanide tests were not conducted. The report contained the following positive results: 10 (mg/dL, mg/hg) ethanol detected in muscle, 54 (mg/dL, mg/hg) ethanol detected in Kidney, 22 (mg/dL, mg/hg) acetaldehyde detected in Kidney, 4 (mg/dL, mg/hg) N-Propanol detected in Kidney. There was a NOTE attached to the VOLATILES section that stated "The ethanol found in this case may potentially be from postmortem ethanol formation and not from the ingestion of ethanol. 1.16 TESTS AND RESEARCH 1.16.1 Air Traffic Control An Air Traffic Control Group was formed on October 14, 2000. A review was conducted of taped air traffic control transmissions, transcripts, airport diagrams and other documentation. The air traffic control tower (ATCT) local controller, the sole occupant in the tower at the time of the accident, was also interviewed, and his training records were examined. On October 24, 2000, controllers from the Southern California Terminal Radar Approach Control (SoCal TRACON) were in
The pilots becoming lost and disoriented during an improperly conducted IFR approach, and subsequent missed approach, that led to a collision with rising mountainous terrain. Also causal was the local controller canceling the IFR approach when the pilot specifically stated he wanted to continue the IFR approach, and the local controller, as well as sector controllers failure to issue a unsafe proximity to terrain safety alert to the pilots (MSAW alert) as required by the Air Traffic Control Handbook.
Source: NTSB Aviation Accident Database
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