LAX01FA055

After being cleared for a VOR/DME Runway 29 instrument approach in actual instrument meteorological conditions, the pilot failed to align the airplane onto the required 276-degree final approach course and descended beneath the 1,120-foot msl minimum descent altitude. The airplane impacted rising hilly terrain about 3.5 miles northeast of the airport at 1,020 feet msl, while tracking 291 degrees. Although the pilot had been cleared to perform a VOR/DME approach, an operating handheld GPS receiver (not approved for IFR navigation) was found in the airplane, and a GPS Runway 29 approach plate was found on the pilot's kneeboard. The GPS's final approach course was 290 degrees, and the airplane was tracking 291 degrees at the time of impact. Also, during the last 2 minutes of flight, the pilot had performed a stabilized descent from approximately 2,000 to 1,000 feet. The pilot was issued an instrument rating about 6 months before the accident. He had indicated to an acquaintance that he planned to practice instrument flying on the day of the crash. Toxicological tests on blood from the pilot detected a very high level of paroxetine (a prescription antidepressant) and an elevated level of mirtazapine (a prescription antidepressant with substantial sedative effects). The pilot did not indicate the use of these drugs on his last application for the medical certificate.

History of flight

On December 9, 2000, about 1927 Pacific standard time, a Cessna TR182, N739HB, descended into rising hilly terrain about 3.5 nautical miles (nm) east-northeast of the uncontrolled Petaluma Municipal Airport, Petaluma, California. The airplane was destroyed. The instrument rated private pilot, who owned and operated the airplane, was fatally injured. Instrument meteorological conditions prevailed, and an instrument flight plan had been filed. The personal flight was performed under 14 CFR Part 91, and it originated from San Carlos, California, about 1803.

An acquaintance of the pilot reported to the National Transportation Safety Board investigator that during the accident flight the pilot had planned to practice instrument flying. The Federal Aviation Administration (FAA) reported that the pilot departed from San Carlos on an instrument flight rules (IFR) flight plan and flew to the Napa County Airport.

About 1916, the pilot departed Napa on an IFR flight plan to Petaluma. The pilot was cleared to cross over the Scaggs Island navigation aid (VORTAC) at 3,000 feet msl, and thereafter, proceed via the Scaggs Island 276-degree radial directly to the AFTIN Intersection (final approach fix) and then to the Petaluma Airport.

At 1919, the radar controller issued the pilot an IFR clearance to perform the VOR/DME Runway 29 approach to Petaluma. The pilot acknowledged the clearance by stating "...cleared for the approach." Also, the pilot stated that he planned to make a full stop landing.

As the airplane approached Petaluma at 1923, the controller terminated radar services and advised the pilot to change to the airport's advisory frequency. The controller advised the pilot that no other traffic was observed in the area. The pilot acknowledged the instruction. There were no further communications recorded from the pilot. No witnesses reported observing the airplane accident.

Personnel information

In 1960, the pilot was issued a private pilot certificate with the following ratings and limitations: airplane single engine land. In June, 2000, the pilot was issued an instrument rating.

Based upon a review of the pilot's aviation medical record application forms and partial flight logbook records, by the accident date his total flight time was approximately 975 hours. His total dual instruction received was 325 hours, his total simulated and actual instrument flight times were 146 and 86 hours, respectively. The pilot's estimated total experience flying the accident make and model airplane was 519 hours.

Aircraft information

The airplane was equipped for flight under IFR. During the accident flight, the pilot had with him a "handheld" GPS receiver. The FAA had not approved its use for navigation under IFR.

An examination of the airplane's maintenance records did not reveal any discrepancies, according to the FAA participant. The airplane's VOR navigation receiver was last checked for accuracy on June 10, 2000.

Meteorological information

Petaluma's airport manager described the local weather conditions between 1930 and 2130 as being "pea-soup drippy fog." He additionally stated that there was an indefinite ceiling with visibility between 1/4 and 1/2 mile and no wind during that time.

A certified flight instructor, who was speaking at an airport function that evening from approximately 2030 to 2130, recalled the weather as being misty to rainy. An airline pilot speaking at the same function described the weather on her arrival at 2050 as misty with light drizzle. She also stated that it was raining on her departure at 2130.

Aviation weather observation stations located at Santa Rosa, elevation 125 feet msl, and Napa, elevation 35 feet msl, reported the following weather conditions:

At 1933, Santa Rosa reported its surface wind was calm; visibility was 2 1/2 miles in mist; broken ceiling at 700 feet above ground level (agl); overcast at 1,600 feet agl; temperature/dew point of 11/11 degrees Celsius; and altimeter 30.04 inHg.

At 1854, Napa reported its surface wind was 260 degrees at 5 knots; visibility was 3 miles in mist; scattered clouds at 1,500 feet agl; overcast ceiling at 3,000 feet agl; temperature/dew point of 12/11 degrees Celsius; and altimeter 30.04 inHg.

Aids to navigation

According to the FAA, all electronic aids to navigation pertinent to the airplane's route of flight were functional on the day of the accident.

Airport, ground facilities and instrument approach information

According to the Petaluma Airport manager, on the evening of the accident, the airport's runway lights and rotating beacon were operating. The manager reported that these lights operate continuously between dust and dawn.

The airport's elevation is 87 feet msl. In addition to the VOR/DME Runway 29 instrument approach procedure (IAP) that the FAA published for use at the airport, the FAA also published a GPS Runway 29 IAP, and a couple of other approach procedures.

According to the VOR/DME Runway 29 IAP chart, the minimum descent altitude (MDA) for a straight-in approach is 1,120 feet msl. The prescribed course from the initial approach fix at the Scaggs Island VORTAC to the final approach fix (AFTIN intersection), and then to the airport, is 276 degrees. The minimum altitude crossing the final approach fix is 1,900 feet msl.

Regarding the GPS approach, the MDA is 900 feet msl. The final approach course between the IPARY waypoint and the airport is 290 degrees.

Wreckage and impact information

The crash site was located about 3.48 nm and 240 degrees, magnetic, from the Petaluma Airport, at an estimated elevation of 1,020 feet mean sea level (msl). The global positioning satellite (GPS) coordinates for the crash site are 38 degrees 16.338 minutes north latitude by 122 degrees 32.043 minutes west longitude. This location corresponds to the airplane being on the 291-degree radial and about 9.43 nm from the Scaggs Island VORTAC navigational aid, which serves as the initial approach fix.

The airplane was found on (estimated) 30-degree upsloping, grass-covered hillside in an upside down attitude, on a magnetic heading of about 035 degrees. The entire airplane was found at the accident site. There was no evidence of fire.

The principle axis of the wreckage distribution path was about 291 degrees. The first airplane component found along the wreckage distribution path was the nose strut's shimmy dampener. The remainder of the nose gear and wheel assembly was found separated from the airplane and was located a few yards downslope. The airplane's marker beacon antenna was found in the initial point of impact (IPI) crater several feet northwest of the shimmy dampener. The distance between the IPI and the main wreckage was about 43 feet.

The leading edges of both wings were crushed in an aft direction. All flight control surfaces were found attached. The upper portion of the right wing lift strut was found separated from the wing. The three other lift strut attachment points were found intact. The cockpit was crushed.

Over 5 gallons (estimated) of fuel was found in the right wing. Rescue personnel who were first responders to the scene verbally reported observing fuel dripping from the airplane. The airplane's altimeter was observed set to 30.02 inHg.

Two IAP charts were found on the pilot's kneeboard, according to law enforcement personnel. The charts were the Petaluma GPS Runway 29 approach and the Petaluma VOR Runway 29 approach. The same personnel reported that the GPS approach plate was the one visible on top of the kneeboard.

Medical and pathological information

On December 11, 2000, an autopsy was performed on the pilot by the Sheriff-Coroner in Sonoma County, California. Toxicological tests were performed on specimens from the pilot by the FAA's Bioaeronautical Sciences Research Laboratory, in Oklahoma City,