Livermore, CA, USA
N5942S
Beech 36
The airplane collided with terrain 9 miles from the destination airport. The pilot was cleared for the instrument landing system approach into the airport. During the descent, the airplane was below the glideslope but tracking the localizer. The pilot contacted the air traffic control tower controller and was cleared to land. The last recorded radar target for the airplane was at 1,600 feet mean sea level (msl) and the initial impact occurred at 1,400 feet msl. The radar data indicated that the target maintained a descent rate of about 1,100 feet per minute during the last minute of flight and was flying at a radar derived ground speed of approximately 112 knots. Though the en route controller received a minimum safe altitude alert (MSAW), he had transferred control of the airplane 1 minute prior to the receipt of the initial MSAW alert. However, the airplane crossed a named intersection at 3,300 feet msl after it was cleared to cross the intersection at 4,000 feet msl while under the en route controller's control. The en route controller did not advise the pilot of the altitude deviation. The air traffic control tower controller did not issue an MSAW to the pilot, even though the equipment was configured to receive MSAW alerts. The tower controller said that he did not recall receiving the alerts and no recording was available to indicate whether or not an aural MSAW alert was received. An evaluation of the operation of the MSAW alerting system following the accident showed that it was functional. Examination of the airframe and engine did not reveal any mechanical anomalies to preclude normal operation. Metallurgical examination of the altimeter showed that the 10,000-foot pointer was not at its correct position at the time of impact and at an undetermined time prior to the accident, moved aft on its shaft and became loose. The effect of the 10,000-foot pointer on the pilot's flight performance could not be ascertained with the available evidence.
1.1 History of the Flight On December 23, 2005, at 1520 Pacific standard time, a Beech 36, N5942S, collided with hilly terrain 9 nautical miles east of the Livermore Municipal Airport, Livermore, California. The pilot was operating the airplane, which was registered to a private company, under the provisions of 14 CFR Part 91. The private pilot and passenger sustained fatal injuries. The airplane sustained substantial damage. Instrument meteorological conditions prevailed and the pilot requested and received a pop-up instrument flight rules (IFR) clearance about 1500. The flight originated from Santa Barbara Municipal Airport, Santa Barbara, California, at 1342, and was destined for Livermore. 1.1.1 Air Traffic Control History and Radar Information Information obtained from Lockheed Martin Services, Inc. indicated that the pilot received an abbreviated weather briefing at 1002 from the Prescott Flight Service Station (FSS). After departing Santa Barbara, the pilot requested an additional abbreviated weather briefing via Flight Watch at 1439. The specialist advised the pilot that he should plan on an IFR approach to very low conditions at Livermore. About 1500, the pilot requested an IFR clearance into the Livermore airport from Oakland Air Route Traffic Control Center (ZOA). The center controller issued the clearance and handed the aircraft off to the Northern California Terminal Radar Approach Control (NCT). The pilot's first contact with NCT occurred at 1441, when the ZOA sector 10 controller contacted the NCT Morgan sector controller to coordinate an IFR clearance to Livermore. After some discussion, the controllers agreed that ZOA sector 10 would clear N5942S to Livermore via direct to Manteca vhf omni-directional range (VOR) at 8,000 feet. At 1443, the pilot contacted the Morgan controller and reported level at 8,000 feet. The controller acknowledged and issued the Salinas altimeter setting. The Morgan controller then advised the pilot that automatic terminal information service (ATIS) information "Uniform" was current at Livermore, showing wind 190 degrees at 4 knots, visibility 3 miles in mist, ceiling 600 feet overcast, temperature 60 degrees Fahrenheit, altimeter 30.23 inches of Mercury, and that the instrument landing system (ILS) approach to runway 25R was in use. The pilot acknowledged. At 1448, N5942S was transferred to the NCT Castle sector. The pilot checked in and reported, "…level at 8,000." The controller asked the pilot to advise when he had information "Uniform" and the pilot replied that he had it. At 1459, the pilot contacted the NCT Sunol sector, again reporting level at 8,000 feet. The controller advised the pilot of N5942S that information "Victor" was current at Livermore, and asked if the pilot had it. The pilot responded negative, and that he had information "Uniform." The controller provided the "Victor" weather information, reporting that Livermore was indicating wind calm, visibility 3 miles in mist, ceiling 600 feet overcast, altimeter 30.22 inches of Mercury, ILS runway 25R approach in use. The pilot acknowledged. At 1506, the pilot was instructed to contact NCT on 123.85, the Tracy sector frequency. At 1507, the pilot contacted the Tracy sector and reported level at 8,000 feet. The controller acknowledged. At 1510, N5942S was cleared to descend to 7,000 feet and the pilot acknowledged. At 1511, the controller instructed the pilot of N5942S to turn left, heading 280 degrees, to join the localizer and report established. The pilot read back the heading. At 1513, the controller cleared N5942S to descend to 4,000 feet and the pilot acknowledged. At 1514:28, the controller again cleared N5942S to 4,000 feet and the pilot acknowledged. At 1514:35, the Tracy controller transmitted, "November 42S is one-zero miles from FOOTO, fly heading 280, cross FOOTO at 4,000, cleared ILS runway 25R approach." The pilot responded, "Cleared at 4,000, cleared for the approach." At 1515, the controller asked the pilot to verify that he had information "Victor" at Livermore and the pilot responded that he did. At 1517, the controller issued a traffic advisory to N5942S for an aircraft that was eastbound at 12 o'clock and 7 miles, altitude indicating 5,400 feet. The pilot responded that he was looking. At 1519:58 the controller transmitted, "N42S radar service terminated, contact Livermore tower 118.1, traffic no factor." The pilot acknowledged. At 1520:07, the pilot contacted the Livermore tower and was cleared to land. The pilot's readback was unintelligible. There were no further transmissions from the airplane. At 1524:36, the local control (LC) controller made the first of four unsuccessful attempts to contact N5942S. At 1525:37, the controller advised the NCT Tracy sector that he had lost radio and radar contact with N5942S. Following that call, the controller made two more attempts to contact the aircraft with no response. The ATCT personnel notified search and rescue personnel of a possible downed airplane and their reception of an electronic locator transmitter at 1529. The wreckage was located at 1800 at an elevation of 1,400 feet msl. Radar data for the accident flight was reviewed by an NTSB air traffic control specialist. One track was consistent with the airplane's route of flight and identified by the airplane's discrete transponder code of 2040. N5942S was established at a mode C derived altitude of 8,100 feet and was cleared to descend to 7,000 feet. Radar data showed the target N5942S descended to 7,200 feet. At 1514, N5942S was cleared to descend to 4,000 feet and the descent of the identified target continued until impact with terrain. The radar data indicated that the target maintained a descent rate of about 1,100 feet per minute during the last minute of flight at a radar derived ground speed of approximately 112 knots. During the approach into Livermore, the pilot was cleared to cross FOOTO intersection at 4,000 feet mean sea level (msl). Instead, radar targets indicated that the airplane crossed FOOTO at 3,300 feet msl at 1519:22 while established on the localizer course. At 1520:07, the pilot contacted Livermore ATCT and was cleared to land by the controller at 1520:11. At 1520:16, the last transmission was received from the airplane. The last radar target for the airplane was at 1521:08 at 1,600 feet msl, approximately 9 miles east of Livermore airport. 1.2 Personnel Information 1.2.1 Pilot Information The pilot held a private pilot certificate with an instrument rating. The pilot's most recent third-class medical certificate was issued in July of 2004. It held the limitations that required the pilot to wear corrective lenses. The pilot's personal flight time logbooks were not located. On the pilot's last medical certification application, he noted a total flight time of 1,200 hours. An airplane logbook, that served as a record of the flights taken in the airplane, was recovered from the accident site. The logbook showed that the pilot had accrued approximately 88 hours since November of 2003 (the date of his first entry in the logbook). In 2004 he logged approximately 62 flight hours and in 2005 he logged approximately 20 flight hours. The last entry from the pilot was dated for a time period from November 23 through 27, 2005. 1.3 Aircraft Information 1.3.1 General Aircraft History The airplane was manufactured in 1968 and was powered by a Continental IO-520-BA engine equipped with a two-bladed McCauley propeller, model 2A36C23. On August 4, 2005, the airplane underwent an annual inspection at a total airframe time of 8,358 hours. At the time of the accident, the airplane had accrued 8,395 hours. The engine had accrued 1,415 hours since major overhaul and the propeller accrued 1,415 hours since overhaul. The pitot static system and transponder check was completed on August 3, 2005 (the logbook entry was incorrectly dated August 3, 2007). The onboard logbook for the airplane noted that an ILS approach was flown on August 12, 2005. The last flight prior to the accident flight was logged on December 15, 2005, ending at a tachometer time of 64.3. Co-owners of the airplane flew both of these flights. 1.3.2 Fueling The airplane was topped off with 100 low lead (LL) fuel on December 23 (the day of the accident) at Santa Barbara, California. 1.4 Meteorological Information The automated weather surface observation system (METAR) for Livermore reported the following at 1453: winds calm; visibility 3 miles with mist; ceiling 600 feet overcast, temperature 61 degrees Fahrenheit; dewpoint 57 degrees Fahrenheit; altimeter 30.22 inches of Mercury. Geostationary Operational Environmental Satellite (GOES)-10 data for 1515 was reviewed and showed that there were clouds in the accident area. The GOES-10 infrared image showed a radiative temperature of about 37 degrees Fahrenheit. Comparing this data with the Oakland, California, upper air data for December 23 at 1600, this temperature resulted in cloud tops of about 12,000 feet. 1.5 Aids to Navigation and Communications The pilot was conducting the instrument landing system (ILS) approach to runway 25R. FAA operational check of the ILS revealed no operational anomalies during the accident time frame. The ILS approach chart for runway 25R indicated that the final approach course was 225 degrees, and the compass locator at the outer marker (LOM) was 6.1 nautical miles from the runway. The crossing altitude over the outer marker was 2,409 feet msl. The approach chart noted that an automatic direction finder (ADF) was required and autopilot coupled approaches were not authorized below 1,700 feet. The pilot was in contact with the Livermore ATCT when the accident occurred. 1.6 Wreckage and Impact Information The National Transportation Safety Board investigator, the FAA accident coordinator, and a representative from Raytheon Aircraft Company, a party to the investigation, responded to the accident scene on December 24, 2005. The airplane came to rest on hilly, grass-covered terrain used for cattle pasture. There was no evidence of fire. The initial impact point at 1,400 feet msl, was on a 20-degree slope; three separate holes, the approximate distance between the landing gear of the airplane were present in the soft, muddy soil. Just above these three holes was a large area of disrupted and churned soil, and the step of the airplane, normally located just aft of the right wing, was on the top surface of the soil. To the immediate left and right of this large disrupted area there were two rectangular shapes imprinted into the earth similar in shape and size to the leading edges of the wings. The nose gear was near this impact area. From this point, the debris path continued upslope in the agitated soil where the propeller hub, with one blade still attached, and the bottom strobe light were identified. The blade was bent slightly aft at the tip. Moving up the terrain on a magnetic heading of 258 degrees, the soil was less disrupted, although the grass was bent uphill and various cockpit components, the upper engine cowling, and the main landing gear, marked the wreckage path. The main wreckage came to rest 168 feet from the initial impact point and was at an approximate altitude of 1,467 feet mean sea level. The fuselage structure of the airplane was compressed downward from the cockpit area aft to the baggage area. At this point, the fuselage was circumferentially buckled and bent forward. The elevator and rudder control cable continuity was obtained from the empennage to the carry through structure. Cable continuity from the right aileron to the carry through structure was confirmed. Full travel of the left aileron cable was restricted due to a pinch of the cable within the deformed wing structure. The left and right elevator trim actuators were measured at 1 10/16 inches and 1 7/16 inches, respectively. Manual actuation of the elevator trim cable showed associated movement to the actuator screws. According to the airframe representative, the left flap actuator measurement indicated that the left flap was retracted. Due to the deformity of the structure from the main landing gear struts pulling aft through the wing during the impact sequence, an accurate measurement for the right flap actuator was not obtained. The separated propeller blade was located about 500 feet forward and slightly north of the main wreckage several months following the accident. The blade was twisted and gouged outboard near the tip. 1.7 Medical and Pathological Information The Alameda County Sheriff's Office performed autopsies on the pilot and passenger. Both deaths were attributed to injuries sustained during the accident sequence. The Federal Aviation Administration Bioaeronautical Research Laboratory completed toxicological testing on specimens of the pilot and passenger. The results were negative for carbon monoxide, cyanide, volatiles, and all tested drugs (no volatile or drug testing were performed on the passenger). 1.8 Tests and Research On January 10, 2006, the Safety Board investigator, and representatives from Teledyne Continental Motors and Raytheon Aircraft Company, further examined the wreckage at Plain Parts, located in Pleasant Grove, California. 1.8.1 Airframe The control cables extending up to the rudder pedals and the control yoke were uncovered in the crushed and deformed forward fuselage. Access to the rudder and elevator controls was obtained from the interior of the fuselage and manual actuation was obtained. The rudder pedal crossover tube was fractured in the center section of the fuselage so movement was obtained to the left rudder pedals only. To gain access to the aileron control cables, the nose of the airplane was elevated and investigators were able to actuate the cables from that vantage point. Movement was obtained throughout all of the control systems. The static and pitot systems were traced throughout the airplane. The static line was uncovered from the rear ports, along the left side of the fuselage, up to the cockpit instrumentation. Visual examination of the static lines to the instrumentation showed that they were free from obstruction. Investigators blew air into the static line connection based at the left lower cockpit. Air was transferred through the line to the right port, left port, and autopilot port, respectively. The static lines were traced from the static air source to the instrumentation. A line leading from the altimeter to the vertical speed indicator (VSI) was fractured at its plastic fitting. The VSI was destroyed during the impact sequence. A t-fitting from the mode-C encoder was also severed but its adjoining part was identified behind the instrument panel and a tape identification tag showed that the adjoining part was a static test line. The test line was sealed. The other end of the t-fitting connected by design, to a line from the altimeter. The line from the altimeter fit over the tube on the mode-C encoder. The pitot air line was traced from the cockpit instrumentation, outboard to the wing where the line had been cut during recovery. Investigators blew air through this line at an attach point in the lower cockpit and airflow was evident. Investigators located the remaining line which led to the pitot tube mounting point on the left wing and airflow was successful. The pitot tube had been severed from the wing during the accident sequence but was unobstructed. The alternate air source lever was found in the closed (OFF) position. 1.8.2 Engine The Teledyne Continental Motors IO-520-BA engine was detached from the wreckage, slung from a hoist, and examined. The propeller had separated from the crankshaft and only residual oil was present in the engine during the examination. Thumb compression was obtained on all six cylinders and the magneto leads produced spark in the appropriate firing order for the engine. Rotation was observed from the rear of the engine at the accessory case. The top spark plugs were removed from the engine and showed similar wear and coloration signatures. When compared to a Champion A
The pilot's failure to maintain the appropriate glidepath alignment during an instrument landing system approach, resulting in collision with terrain. A contributing factor to the accident was the failure of the air traffic controllers to issue a minimum safe altitude warning (MSAW) alert.
Source: NTSB Aviation Accident Database
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