LAX03FA037

NTSB accident investigation · Beech B36TC · Union City, CA · November 25, 2002

Accident · FatalField investigationFinal report
Date
November 24, 2002, 18:00 local (Nov 25, 2002, 02:00 UTC)
Place
Union City, CA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N3242QBeech B36TC
Weather
Instrument (IMC) · Night/dark
Status
Completed · report October 27, 2005
Report
Approved by Office Director
Parties
Federal Aviation Administration, Raytheon (Beech) Aircraft Company, Teledyne Continental Motors
FAA report
20021124034979A
Case key
56129

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the pilot's failure to maintain an adequate terrain clearance altitude, which resulted in controlled flight into rising mountainous terrain. Contributing factors were the pilot's loss of situational awareness to his terrain proximity, the dark night, and the localized low clouds that obscured the terrain.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterApproach
Light condition - dark nightFactor
Weather condition - fogFactor
Terrain condition - risingFactor
Terrain condition - mountainous/hillyFactor
Altitude/clearance - not maintainedPilot in commandCause
Other psychological conditionPilot in commandFactor

Analysis

The airplane collided with rising mountainous terrain while descending toward the destination during a dark, nighttime VFR approach to the airport about 12 miles south of the accident site. The pilot had requested and was receiving radar flight following service, but he had not requested minimum safe altitude warnings, and that service was not provided. At 1752:55, the pilot contacted the TRACON radar facility and told the controller he was descending out of 5,800 feet inbound to the airport. The controller told the pilot to fly his own navigation to the airport and to maintain VFR. The controller terminated radar flight following service about 1 minute prior to the accident. The airplane was last recorded on radar at 1759:30. At this time, its ground speed had decreased to about 130 knots, its altitude had decreased to 1,700 feet, and the airplane's ground track was about 167 degrees, magnetic. Two ground witnesses were about 1/3 mile from the crash site and reported observing the accident airplane fly by their position; however, their view of the airplane was restricted due to the presence of localized fog, and they had only observed the illumination of the airplane's flashing white strobe light as it flew past their location. Minutes later, they observed the glow of a ground fire in the direction the airplane had been flying. The three closest airports to the accident site that reported their weather conditions were, respectively, 7 miles west-southwest, 8 miles northeast, and 12 miles south-southwest from the accident site. Within 15 minutes of the accident, these three airports reported a clear sky, 5- to 10-mile visibility, and surface wind between 6 and 7 knots. At 1755, the closest airport, which was northeast of the accident site, reported 5 miles visibility, mist, and a temperature/dew point of 9 and 8 degrees, respectively. The on-scene accident investigation revealed that the airplane cruised into 28-degree upsloping terrain, and it was destroyed by impact forces and a post impact fire. The initial impact point was at 1,660 feet mean sea level (msl), about 60 feet below the hilltop south of the site. The bearing between the initial impact point and the main wreckage was 163 degrees. No evidence of a preimpact mechanical malfunction was found during the wreckage examination. The Safety Board investigator noted that when located on the hilltop south of the impact site, the pilot's destination was visible. No higher elevation exists between the accident site hilltop and the airport.

Factual narrative

History of flight

On November 24, 2002, about 1800 Pacific standard time, a Beech B36TC, N3242Q, cruised into upsloping mountainous terrain about 3 miles north of Union City, California. At the time of the accident, dark nighttime conditions existed, and the airplane was approaching the Palo Alto Airport of Santa Clara County, located about 12 nautical miles (nm) south of the crash site. Impact forces and a postcrash ground fire destroyed the airplane. The commercial certificated pilot, who was the sole occupant in the airplane, was fatally injured. Instrument meteorological conditions prevailed in the vicinity of the accident site. No flight plan was filed for the personal flight, which was performed under the provisions of 14 CFR Part 91. The Federal Aviation Administration (FAA) had been providing the pilot with en route radar flight-following service, but that service was terminated by the FAA seconds prior to the accident. The pilot's wife reported that the round trip flight originated about 0800 from the Palo Alto Airport, the pilot's home base. Thereafter, the pilot flew to an undetermined airport near Boise, Idaho. The accident occurred during the pilot's return flight home.

After departing from near Boise, the pilot flew to the Ontario Municipal Airport, an uncontrolled airport located in Ontario, Oregon. According to a representative from Ontario Aviation, Inc., its records indicated that on November 24, a purchase transaction was completed with the pilot's credit card for 64.47 gallons of 100 LL aviation fuel. The representative indicated that the self-service fuel pumps were unattended at the time. The airport's Unicom was not in operation.

The pilot's departure time from Ontario was not determined, but the pilot's wife estimated it was between 1500 and 1530. Prior to taking off, the pilot telephoned his wife and indicated that he anticipated returning to Palo Alto about 1800.

According to the FAA's Western-Pacific Regional quality assurance staff (AWP-505), en route to Palo Alto a radar controller from the Northern California Terminal Radar Approach Control facility (NCT) provided the pilot flying N3242Q with radar flight-following service. The pilot/airplane was assigned a discrete transponder code and was identified on radar. The pilot had not requested minimum safe altitude (terrain proximity) warning (MSAW) advisories, and that additional service was not provided.

The FAA reported that, about the time of the accident, the MSAW system was functional at NCT. No outages were reported.

Regarding the last few minutes of the airplane's flight, at 1752:55, the southbound pilot contacted NCT. The pilot stated "approach good evening bonanza three two four two quebec's with you five thousand eight hundred descending into palo alto." The controller replied, "three two four two quebec bay approach own navigation to palo alto maintain vfr." ("Maintain vfr" means that the pilot was directed to maintain flight in accordance with visual flight rules.)

Three seconds earlier, at 1752:52, recorded radar data indicated that the airplane was descending through 5,800 feet, as indicated by the airplane's Mode C altitude reporting transponder. The airplane's ground speed was about 179 knots, and its magnetic track was about 187 degrees.

Three minutes later, the controller contacted the pilot and provided traffic information. The pilot responded by stating "yeah we have both traffic in sight...." The radar data indicates that between 1752:52 and 1758:52, the southbound airplane's altitude decreased to 2,000 feet, and its ground speed decreased to 158 knots.

At 1758:56, the NCT controller made his last radio transmission to the pilot. The controller stated "...no other traffic between you and palo alto remain on your...present beacon code radar service terminated contact tower one one eight point six." Ten seconds thereafter, at 1759:06, the pilot replied with his last recorded transmission by stating "...roger." During this time interval, the airplane's altitude was about 2,100 feet.

The airplane was last recorded on radar at 1759:30. At this time, its position was about 37 degrees 38.200 minutes north latitude by 121 degrees 58.833 minutes west longitude. The airplane's altitude had decreased to 1,700 feet, and its ground speed had slowed to 130 knots. The airplane's last recorded ground track was about 167 degrees, magnetic.

The distance between the airplane's last recorded radar position and the initial point of ground impact (IPI) is about 1/10-mile. The approximate distance and magnetic bearing between the IPI and the Palo Alto Airport is 12.4 nm and 197 degrees.

Two persons reported to the National Transportation Safety Board investigator that about 1800 they observed what they have subsequently learned was the accident airplane flying near their position. The witnesses determined that, at the time of their observations, they were approximately 1/3 mile from the accident site. In summary, the witnesses indicated that their view of the airplane had been restricted due to the presence of fog, and they had only observed the illumination of the airplane's flashing white strobe light as it flew past their location. Minutes later, they observed the glow of a ground fire in the direction the airplane had been flying.

Personnel information

The pilot's wife reported that her husband recorded his flight time in his personal flight record logbook. She provided the Safety Board investigator with her husband's most current logbook for review.

A review of the logbook (number two) and FAA records indicates that the pilot was issued a private pilot certificate in 1993, an instrument rating in 1995, and a commercial pilot certificate and multiengine rating in September 1997. Also, the logbook review indicates that the pilot last accomplished an instrument proficiency check and flight review on March 14, 2000, about 2 2/3 years before the accident flight.

The logbook indicates that by November 17, 2002, the pilot's total logged flight time was about 951 hours. The pilot's wife reported that she believes her husband had not flown during the interval between November 18 and 23. During the 12-month period immediately preceding the accident, the pilot flew the accident airplane for approximately 256 hours.

Aircraft information

Regarding the airplane's lights, the airplane was equipped with red, green, and white navigation lights, along with an upper fuselage rotating beacon. The airplane also was equipped with wing tip flashing strobe lights.

Family members reported that the pilot owned, and was the exclusive pilot, of the accident airplane. The airplane was maintained on an annual inspection basis. The last entry in the airframe logbook was dated June 1, 2002, and it indicated that an annual inspection had been accomplished.

On December 11, 2002, the Safety Board investigator interviewed the mechanic who had performed the last annual inspection on the airplane. The mechanic reported that the pilot was not present at the time he had performed the inspection. As best he could recall, at the start of the inspection the airplane appeared in good condition, and there were no outstanding squawks. Following the annual inspection, the mechanic signed the airplane's logbook and returned the airplane to the pilot. The mechanic had no further contact with the airplane or the pilot. The mechanic additionally stated that he recalled the pilot was very particular about his airplane, and anything needing repair was fixed.

During the Safety Board investigator's wreckage examination, remnants from the airplane's flight manual were observed in the ashes of the destroyed airplane. During the subsequent inspection of the pilot's hangar, no evidence of a maintenance-related squawk sheet was found. However, a white (chalk) board was observed o

Aircraft

Registration
N3242Q
Reported as
Beech B36TC
Category
Airplane
Serial number
EA-405
Airframe hours
2,253
Engine
Continental TSIO-520-UB, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Robert A. Dowlett
Registered owner
Peninsula Transport Equipment
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · June 1, 2002 · 53 hours before
Departed
ONO · Ontario, OR
Destination
PAO · Palo Alto, CA
Airport
PAO · Palo Alto

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
34
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2
Last flight review
March 1, 2000
Seat
Left
Toxicology
Performed
Flight hours
957 total · 262 in this make and model · 729 as pilot in command · 43 in the last 90 days · 19 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Visibility
5 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 46 °F
Altimeter
30.17 inHg
Observed at
LVK, 8 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.