San Jacinto, CA, USA
N210RE
Cessna T210L
During a GPS approach, the pilot did not turn onto the prescribed course toward the final approach fix, and he allowed the airplane to prematurely descend below the specified altitude for the route segment until impacting a mountainside in controlled flight. Actual instrument meteorological conditions prevailed, with a low ceiling over the mountains. About 11 minutes before the accident, the radar controller cleared the pilot to perform the GPS approach. The pilot indicated to the controller that he was aware of the initial approach fix's location and crossing altitude. At no time during the approach did the pilot indicate he was experiencing difficulty navigating or request assistance. The pilot initially navigated along the prescribed course. Seconds after passing an intermediate fix where a critical 75-degree course change was required, the controller lost radar and radio contact with the pilot. Rather than proceeding toward the final approach fix along the 153-degree prescribed course, the pilot's track averaged 107 degrees. Also, instead of maintaining the 4,100-foot msl minimum altitude until passing the final approach fix, the pilot descended to 3,550 feet msl. The airplane was equipped with a GPS receiver that had the capability of displaying a "moving" map. The airplane crashed 5.9 nm east of the prescribed course and 550 feet below the authorized altitude. The reason why the pilot lost situational awareness and his track became divergent is unknown.
HISTORY OF FLIGHT On December 14, 2001, about 1528 Pacific standard time, a Cessna T210L, N210RE, collided with rising mountainous terrain during an instrument approach to the Hemet-Ryan (uncontrolled) Airport, about 4 nautical miles (nm) northeast of San Jacinto, California. The airplane was destroyed by impact forces and a postimpact ground fire. The instrument rated private pilot was fatally injured. Instrument meteorological conditions prevailed in the vicinity, and an instrument flight rules (IFR) flight plan was filed. At the time of the accident, the airplane was between the initial and final approach fixes and was approximately 5.9 nm east of the specified southerly approach course. The airplane was being operated as a personal flight under 14 CFR Part 91. Reportedly, the pilot had planned to fly to Hemet-Ryan to pickup relatives and transport them to Santa Monica, California, for a family gathering. The pilot departed from the Santa Monica Municipal Airport about 1446. At 1515, as the airplane was en route to the Hemet-Ryan Airport, a March Air Reserve Base (ARB) air traffic controller (March GCA) established radar contact with the accident airplane's pilot. The following minute the pilot advised the controller that he was descending from 7,000 to 6,000 feet mean sea level (msl). The controller informed the pilot that the altimeter was 29.68 inches of mercury. The pilot indicated that he desired to start the instrument approach to the Hemet-Ryan Airport at Seter. (Seter is the name of an initial approach fix depicted on the GPS-A initial approach procedure (IAP) chart for the airport.) At 1516:39, the controller stated to the pilot "cross Seter at ah five-thousand cleared GPS into Hemet." The pilot responded by asking "...cleared direct Seter right now?" The controller replied "affirmative, you can go direct at this time." The pilot then stated "ok, direct Seter and did you say descend to five-thousand?" The controller replied at 1516:59, and stated "stand by sir, I'm trying to see where the approach starts at, fifty-five or five, stand by." The pilot responded and said "I show it fifty-five on my ah on my chart here." The controller replied "yeah, I believe you're right, yeah you can cross Seter at five-thousand-five hundred cleared GPS into Hemet." Recorded radar data from the Los Angeles Air Route Traffic Control Center (LAX ARTCC) and the Southern California Terminal Radar Approach Control (SOCAL TRACON) indicate that between 1523:27 and 1523:49, the northeast bound accident airplane passed Seter, descended from 5,600 to 5,500 feet (as indicated by the airplane's Mode C-equipped transponder), and began tracking in an easterly direction toward the Kende intersection. For several minutes thereafter, there were no additional recorded communications to or from the accident pilot. Then, at 1525:15, the controller attempted to communicate with the pilot. The controller advised the pilot to report canceling his IFR flight on the current radio frequency, or after landing via telephone. The controller heard no response from the pilot. About this time, the accident airplane was approximately 0.6 nm south of the Kende intersection and was crossing the 153-degree prescribed direct course to the San Jacinto final approach fix. About 12 seconds later, the airplane's 077-degree track had become 092 degrees. At 1525:33, 1525:40, and 1525:47, the controller again attempted to contact the pilot. During the latter effort, the controller stated, "If you hear me ident." At 1526:02, the controller stated, "I copy the ident." The last recorded radar hit occurred 23 seconds earlier, at 1525:39, at which time the airplane had descended to 5,100 feet. The airplane's location at 1526:02 was subsequently recalled by the controller as being southeast of Kende. The pilot's last recorded radio transmission occurred at 1526:05, when he said "ah March, do you read me, zero romeo echo." The controller replied at 1526:08, and stated "OK, I hear you now its, ah when you get behind those mountain ranges over there its ah we usually lose radar and radio back there." At 1526:16 and 1526:26, the controller again transmitted IFR cancellation instructions to the pilot, but no reply was recorded. The controller transmitted "zero romeo echo, radar contact lost" at 1526:51. No witness reported observing the accident. The pilot's route of flight between the location where radar contact was last recorded and the 6.6 nm distance to the crash site is unknown. During the last minute of radar recorded flight, the airplane's average track and ground speed were about 092 degrees and 160 knots. Based on this ground speed, and the 107-degree direct course between the last recorded radar return (hit) and the crash site, the accident occurred about 1528. PERSONNEL INFORMATION The pilot held a private pilot certificate with the following ratings: airplane single and multiengine land, instrument airplane, and rotorcraft helicopter. On February 20, 2001, when the pilot was issued a second-class aviation medical certificate, with the restriction that he must wear corrective lenses, his reported total flight time was 1,150 hours. A relative of the pilot, who completed the National Transportation Safety Board's "Pilot/Operator Aircraft Accident Report" form, indicated that the pilot's experience flying the accident model of airplane was 425 hours. Data extracted from the pilot's flight record logbook indicates that the pilot's total flight time was in excess of 1,215 hours. Also, the pilot's total actual and simulated instrument flying experience was in excess of 39 and 83 hours, respectively. On October 10, 2001, the pilot successfully completed an instrument proficiency check (IPC) in his (accident) airplane. According to the certified flight instructor (CFI) who administered the IPC, during the flight the pilot demonstrated steep turns, unusual attitudes, holding, compass turns, ILS and VOR instrument approaches. The CFI did not report that the pilot demonstrated any proficiency performing GPS approaches. AIRCRAFT INFORMATION GPS Installation and Revision Service Data. According to Able Avionics, Van Nuys, California, about April 23, 2001, its repair station personnel installed a Garmin International Inc. GPS receiver model GNS 530 into the pilot's airplane. The airplane was not equipped with a separate automatic direction finder (ADF receiver) or a secondary GPS receiver. The GNS 530 unit was certificated for instrument en route, terminal, and nonprecision instrument procedures. The GNS 530's serial number was 78401266. The software version in the unit was unchanged since Able's acquisition of the unit from the manufacturer. The pilot was advised to keep the receiver's aviation database current using Jeppesen's revision service. Personnel at Jeppesen verbally reported to the Safety Board investigator that in order to maintain a current database in the GNS 530, the pilot had subscribed to its Skybound Datawriter revision service. This service provides for revisions on a 28-day cycle via internet downloads. Jeppesen reported that the pilot had subscribed to this revision service. However, they were unable to ascertain whether, in fact, the pilot had downloaded the current data. Jeppesen's personnel also noted, however, that there had not been any changes to the Hemet GPS-A approach procedure between the receiver's April installation and the December accident date. Flight Limitation, Equipment Certification, and Maintenance. The Federal Aviation Administration (FAA) certified the airplane for flight into instrument meteorological conditions (IMC). The airplane was not certified for flight into icing conditions. The airplane was equipped with a heated pitot tube and an alternate source for obtaining static atmospheric pressure for emergency use if the primary static port became blocked. The primary static port was not heated. The FAA authorized IFR operation of the GNS 530 under a field approval process following a functional evaluation on May 2, 2001. Also, an (S-TEC-60-2) autopilot having pitch, roll, and altitude hold capability was installed in the airplane. Its installation was accomplished under the provisions of a supplemental type certificate. An FAA avionics inspector reviewed the installation documentation for the GPS and the autopilot, in addition to data associated with the pitot-static system and transponder checks. In summary, the FAA inspector reported that the reviewed documentation included several FAA Form 337s and airplane logbooks. The documents were found satisfactory, and no discrepancies were reported. METEOROLOGICAL INFORMATION About 1530, a person located about 5 miles west of the accident site reported hearing a low flying airplane pass by his location. The person indicated that he did not observe the airplane because there were low clouds in the area. The person's elevation was about 1,500 feet msl, and he estimated the cloud base was about 500 feet above the ground. Weather Briefings. At 1035, the pilot telephoned the Hawthorne, California, Flight Service Station (FSS) and requested a weather briefing for an IFR flight from Santa Monica to Hemet. The FSS briefer informed the pilot, in pertinent part, of the issuance of airmen's meteorological information (AIRMET) for moderate icing and stated that the freezing level was "just under six thousand feet." The forecast condition for 1400 in the vicinity of the March ARB (15 nm west-northwest of the Hemet-Ryan Airport) was for a broken sky condition with clouds based between 2,000 and 3,000 feet above ground level (agl), visibility 3 to 5 miles, light rain showers and mist. After 1600, the March ARB forecast was for scattered to broken clouds based at 4,000 feet agl, with isolated light rain showers, and surface wind from 280 degrees at 25 knots. The FSS briefer stated to the pilot that he did not have any good weather reporting at Hemet. However, Hemet did have an automatic weather observing system (AWOS), but its report was not available in the FAA's computer system. The commercial landline telephone number for the Hemet-Ryan Airport was listed in the FAA's "Airport/Facility Directory (A/FD)." Regarding notices to airmen (NOTAMS), the briefer advised the pilot that there were no NOTAMS for the Hemet-Ryan Airport. Also, all of the navigation aids in the area were operating normally. The pilot did not inform the FSS briefer that during his planned flight GPS navigation would be used. During the standard briefing, there was no discussion regarding the status of GPS receiver autonomous integrity monitoring (RAIM) outages or GPS NOTAMS. At 1150, the pilot telephoned the FSS and obtained an abbreviated briefing for his proposed round robin flight. The pilot indicated he anticipated flying around 1400. In pertinent part, the briefer advised the pilot that there was an AIRMET for icing above 8,000 feet. However, some reports indicated icing existed at 7,000 feet. The weather was forecast to improve first over the Los Angeles basin area, and then later during the afternoon it was forecast to improve over the Ontario area. (Ontario is located 35 nm west-northwest of Hemet.) At 1420, the pilot telephoned the FSS again. The pilot advised the briefer that he was "kind of familiar with the weather" because he had received a couple of briefings and updates. The pilot indicated that he desired to file an IFR flight plan, and he requested a little assistance with the routing. The pilot stated that he desired to "stay low...out of the freezing level." The briefer responded by asking the pilot if he had flown around the Los Angeles basin, or if he was from out of town. The pilot responded by stating "I know the basin." The briefer advised the pilot that the freezing level was 7,000 feet or higher. He then provided the pilot with the established tower en route course (as published in the A/FD) involving flight at 5,000 feet, and using the prescribed route identification of "SCTL26" between the airport pairs of Santa Monica and Hemet. The pilot also informed the FSS briefer that his proposed indicated airspeed was 140 knots, his estimated en route flight time was 45 minutes, and his proposed departure time was 1445. In response to the briefer's question "did you get all the AIRMETS and the weather you need," the pilot said "yes." Destination Weather. In pertinent part, at 1455, March ARB, elevation 1,538 feet msl, reported the following weather conditions: visibility 1 1/4 miles, light rain and mist, and overcast ceiling at 400 feet agl. The temperature and dew point were both 8 degrees Celsius. The altimeter was 29.68 inches of mercury. March ARB is located about 15 nm west-northwest of Hemet. At 1515, Hemet-Ryan Airport, elevation 1,512, reported its surface wind was from 200 degrees at 15 knots with gusts to 20 knots; the visibility was 2 miles; the sky condition was broken at 1,000 feet agl and overcast at 1,600 feet agl. The altimeter was 29.66 inches of mercury. At 1525, Hemet's surface wind was from 200 degrees at 17 knots with gusts to 24 knots; the visibility was 5 miles; and the sky condition was scattered at 1,000 feet agl, broken at 1,800 feet agl, and overcast at 5,000 feet agl. The altimeter was 29.66 inches of mercury. AIDS TO NAVIGATION Navigation Aid Status. According to the FAA, no reports were received from pilots (PIREPS) regarding any navigation anomalies in the vicinity of the Hemet-Ryan Airport. All navigation aids associated with its instrument approaches were operating normally. The FAA's Sacramento, California, Flight Inspection Field Office last flight-tested the Hemet-Ryan instrument approaches in September 2000. No problems were noted. GPS Outages and Availability. The FAA reported that the GPS-A approach to Hemet-Ryan airport was first published in October 1996. The only subsequent change to the procedure occurred in February 2000. Receiver autonomous integrity monitoring (RAIM) allows the GPS receiver to maintain a self-awareness as to whether it has information from enough GPS satellites to reliably calculate position and altitude data. According to the FAA, there were no RAIM availability issues pertinent to the accident flight route. A search for pilot reports regarding GPS anomalies, jamming, and RAIM outages was performed. No evidence was found of pertinent events during the time that the accident airplane was flying in the vicinity of the crash site. No GPS NOTAMS were in effect at the time and location of the accident flight. AIRPORT AND GROUND FACILITIES Several instrument approach procedures (IAPs) exist for use at the Hemet-Ryan Airport. The approach procedure entitled "NDB and GPS-A" has the lowest published landing minima. When performing the GPS-A IAP, the minimum descent altitude is 2,600 feet msl (1,088 feet agl). The listed minimum visibility is 1 1/4 miles. WRECKAGE AND IMPACT INFORMATION The accident site is about 3/4-mile east of a mountain that has a peak elevation of 4,106 feet msl. The on-scene examination of the accident site and airplane wreckage revealed the airplane impacted the north facing slope of an approximately 3,600-foot-high mountain at GPS coordinates of 33 degrees 49.452 minutes north latitude by 116 degrees 53.215 minutes west longitude. This location is about 8.7 nm and 38 degrees from the Hemet-Ryan Airport. The magnetic track of the airplane's impact ground scar was about 127 degrees. The estimated elevation of the initial point of impact (IPI) was 3,550 feet msl, about 50 feet below the mountaintop. The airplane came to rest about 38 feet upslope (slant distance) from the IPI. The IPI was on estimated 30-degree soft dirt and sagebrush covered upsloping terrain. The airplane was found in an upright attitude. A ground fire consumed the inboard portions of both wings, the instrument panel, the entire passenger cabin, and the cockpit. The GPS navigation system components were destroyed. The aft portion of the empennage remained intact with the flight control surfaces attached. T
The pilot's loss of situational awareness and his failure to adhere to the prescribed instrument approach procedures, including the track and altitudes flown. The underlying reasons for the pilot's loss of situational awareness are unknown.
Source: NTSB Aviation Accident Database
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