# NTSB LAX03FA076: Piper PA-60-601P, N3636Q, Scottsdale, AZ, January 27, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 26, 2003, 20:23 local (Jan 27, 2003, 03:23 UTC) - Place: Scottsdale, AZ - Coordinates: 33.665832, -111.831108 - Nearby events: https://openairdocs.org/map.md?lat=33.6658&lon=-111.8311&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 28, 2004 - Report: Approved by Office Director - Parties: The New Piper Aircraft Company, Federal Aviation Administration, Textron Lycoming, Hartzell Propeller, Inc. - NTSB case key (mKey): 56401 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03FA076 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56401/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56401 - Page: https://openairdocs.org/ntsb/LAX03FA076 ## Probable cause the pilot's failure to maintain an adequate altitude clearance from mountainous terrain. Contributing factors were dark night conditions, mountainous terrain, and the pilot's diverted attention. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, takeoff - initial climb - light condition - dark night (contributing factor) - terrain condition - mountainous/hilly (contributing factor) - altitude/clearance - not maintained, pilot in command (cause) - diverted attention, pilot in command (contributing factor) ## Analysis The airplane collided with mountainous terrain 5 miles from the departure airport during a dark night takeoff. Review of recorded radar data found a secondary beacon code 7267 (the code assigned to the airplane's earlier inbound arrival ) on the runway at 2021:08, with a mode C report consistent with the airport elevation. Two more secondary beacon returns were noted on/over the runway at 2021:12 and 2021:19, reporting mode C altitudes of 1,600 and 1,700 feet, respectively. Between 2021:08 and 2021:38, the secondary beacon target (still on code 7267) proceeded on a northeasterly heading of 035 degrees (runway heading) as the mode C reported altitude climbed to 2,000 feet and the computed ground speed increased to 120 knots. Between 2021:38 and 2021:52, the heading changed from an average 035 to 055 degrees as the mode C reports continued to climb at a mathematically derived 1,300 feet per minute and the ground speed increased to average of 170 knots. At 2022:23, the code 7267 target disappeared and was replaced by a 1200 code target. The mode C reports continued to climb at a mathematically derived rate of 1,200 feet per minute as the ground speed increased to the 180-knot average range. The computed average heading of 055 degrees was maintained until the last target return at 2022:53, which showed a mode C reported altitude of 3,500 feet. The accident site elevation was 3,710 feet and was 0.1 miles from the last target return. The direct point to point magnetic course between Scottsdale and Santa Fe was found to be 055 degrees. Numerous ground witnesses living at the base of the mountain where the accident occurred reported hearing the airplane and observing the aircraft's lights. The witnesses reported observations consistent with the airplane beginning a right turn when a large fireball erupted coincident with the airplane's collision with the mountain. No preimpact mechanical malfunctions or failures were found during an examination of the wreckage. The radar data establishes that the pilot changed the transponder code from his arrival IFR assignment to the VFR code 30 seconds before impact and this may have been a distraction. ## Factual narrative 1.1 History of Flight On January 26, 2003, at 2023 mountain standard time, a Piper PA-60-601P, N3636Q, collided with mountainous terrain after takeoff from the Scottsdale, Arizona, airport. The airplane was owned and operated by the pilot under the provisions of 14 CFR Part 91 of the Federal Aviation Regulations. The airplane was destroyed in the impact and post crash fire sequence. The instrument rated private pilot and one passenger sustained fatal injuries. Night visual meteorological conditions prevailed with unrestricted visibility; however, the moon was not above the horizon. No flight plan was filed for the personal cross-country flight that originated in San Diego, California, at 1500 Pacific standard time as a flight to Santa Fe, New Mexico, with a planned stop in Scottsdale. According to a Safety Board Sun and Moon location program for the geographic coordinates and altitude of Scottsdale, sunset occurred at 1758, and nautical twilight ended at 1854. At the time of the accident, the moon was 75 degrees below the northeastern horizon. Information was obtained from the following Federal Aviation Administration (FAA) facilities: Western Pacific Air Traffic Quality Assurance Division, San Diego Automated Flight Service Station (AFSS), Phoenix Terminal Radar Approach Control (PHX TRACON), and Scottsdale Air Traffic Control Tower (ATCT). The pilot requested and received a preflight weather briefing for the flight from San Diego AFSS and filed an instrument flight rules flight plan from San Diego to Scottsdale. According to the facilities who worked the flight, the instrument arrival into Scottsdale was routine and the airplane landed at 1811. The flight's inbound assigned discrete transponder code was 7267. At 2016, the pilot contacted Scottsdale ATCT clearance delivery and requested VFR flight following to Santa Fe. The controller denied the pilot's request and advised him to contact Phoenix TRACON after he was airborne. The pilot contacted ground control at 2017, advising that he was ready to taxi for takeoff, and the flight was cleared to runway 03. At 2020, the pilot advised the local controller that he was ready for takeoff and asked for a right turn. The controller then cleared the flight for takeoff. Recorded radar data from the FAA's Phoenix Terminal Radar Approach Control (TRACON) ARTS IIIA radar system was obtained and reviewed. At 2021:08, a secondary beacon code 7267 was observed on the runway at the Scottsdale airport with a mode C report of 1,500 feet. Two more secondary beacon returns were noted on/over the runway at 21:12 and 21:19, reporting mode C altitudes of 1,600 and 1,700 feet respectively. Between 21:08 and 21:38, the secondary beacon target (still on code 7267) proceeded on a northeasterly heading computed by the ARTS IIIA system of 035 degrees as the mode C reported altitude climbed to 2,000 feet and the computed ground speed increased to 120 knots. Between 21:38 and 21:52, the computed heading changed from an average 035 to 055 degrees as the mode C reports continued to climb at a mathematically derived 1,300 feet per minute and the ground speed increased to average of 170 knots. At 22:23, the code 7267 target disappeared and was replaced by a 1200 code target. The mode C reports continued to climb at a mathematically derived rate of 1,200 feet per minute as the ground speed increased to the 180-knot average range. The computed average heading of 055 degrees was maintained until the last target return at 22:53, which showed a mode C reported altitude of 3,500 feet. The accident site elevation was 3,710 feet and was 0.1 miles from the last target return. The direct point-to-point magnetic course between Scottsdale and Santa Fe was found to be 055 degrees. Numerous ground witnesses living at the base of the mountain where the accident occurred reported hearing the airplane and observing the aircraft's lights. The witnesses reported observations consistent with the airplane beginning a right turn when a large fireball erupted coincident with the airplane's collision with the mountain. 1.2 Pilot Information Review of the FAA airman and medical certification files disclosed that the pilot held a private pilot certificate with airplane ratings for single engine land, multiengine land and instruments. The most recent issuance of his certificate was dated May 2, 2000. A second-class medical certificate was issued to the pilot on May 3, 2002, and contained the limitation that correcting lenses be worn and that glasses for near and intermediate vision be carried. The pilot's personal flight records were not recovered. On the May 3, 2002 application for his medical certificate, the pilot listed his total flight time as 1,450 hours. On an application for insurance coverage dated July 2, 2001, the pilot reported a total time of 1,400 hours, with 160 accrued in the accident airplane. Contained in the insurance file was a certificate that showed the pilot had completed ground and flight recurrency training in the accident airplane on August 9, 2001. 1.3 Aircraft Information The aircraft, a Piper PA-60-601P, serial number 61P07858063398, was manufactured in 1980. The maintenance logbooks for the aircraft, engines, and propellers were not located. The investigation obtained and reviewed a certified copy of the registration and airworthiness files maintained by the FAA Civil Aircraft Registry office in Oklahoma City, Oklahoma. In addition, the investigation was able to identify an aircraft maintenance shop in Brigham City, Utah, that performed maintenance on the aircraft, and copies of the recent work orders for maintenance performed were obtained. With these sources, the maintenance and modification history of the airplane was partially reconstructed. In 1996 the aircraft was acquired by the Machen Corporation and several modifications were performed under FAA approved Supplemental Type Certificates to convert the airplane to what is popularly known as a "Machen conversion." In pertinent part, the modifications included the removal of the original 290-horsepower Lycoming IO-540-S1A5 engines and installation of Lycoming TSIO-540-U2A engines that develop 350 horsepower. The Aerostar Corporation acquired the airplane in 1998 and used the airplane as a factory demonstrator and test bed for various avionic system approvals by the FAA. During this time, a Bendix-King KFC255 auto pilot and flight director system was installed. Other modifications performed at various times included the installation of a fuselage mounted auxiliary fuel tank and a GPS navigation system. The GPS system was approved for navigation in VFR and IFR conditions in the en route, terminal, and approach environments. The steering signal output of the GPS was channeled to the horizontal situation indicator (HSI). The last work order from The Flight Shop, Inc., Brigham City, Utah, was dated June 21, 2002, and listed the completion of an annual inspection. The total time on the airframe at the time of the annual was 2,574 hours. According to the firm's personnel, at the time of the annual a complete Airworthiness directive (AD) listing was performed, with all AD's applicable to the airplanes serial number accomplished. Based on references in the FAA airworthiness files, the engines and propellers are estimated to have accrued between 800 and 900 hours since installation in the airframe. No information was available to determine the overhaul status of the engines. The airplane was parked at a FBO on the Scottsdale airport for 2 hours following the flight's arrival at 1811. Interviews with ground service personnel at the Scottsdale FBO where the airplane was parked revealed that no services were provided. Review of a FAA approved Pilot Operating Handbook for a Piper PA-60-601P applicable to the serial number of the accident airplane disclosed that at the ambient atmospheri ## Aircraft - Registration: [N3636Q](https://openairdocs.org/deregistered/N3636Q-2014-10-02), registration cancelled 2014-10-02, S/N 61P07858063398, built 1980 (OpenAirDocs) - Reported make and model: Piper PA-60-601P - Registry model: [Piper AEROSTAR 601P](https://openairdocs.org/model/piper-aerostar-601p) (registry code 7106012) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 61P07858063398 - Airframe hours: 2574 - Engines: Lycoming TSIO-540-U2A 350 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Duane E. Shrontz - Registered owner: NDB Equipment Finance, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 21, 2002 - Departed: SDL, Scottsdale, AZ - Destination: SAF, Santa Fe, NM - Airport: SDL, Scottsdale, runway 3, 8,249 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review August 9, 2001; seat: left; toxicology performed; flight hours: 1,450 total, 160 in this make and model ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 10° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 32 °F - Altimeter: 30.18 inHg - Observed at: SDL, 5 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 (OpenAirDocs). - [Accident 20030126001009A](https://openairdocs.org/incident/20030126001009A), Jan 26, 2003: Piper PA60601P, Scottsdale, AZ, Destroyed, 2 fatal. (-23) Airman departed runway 3 from the sdl airport for santa fe, NM. Controlled flight into terrain occurred shortly after takeoff in the mcdowell mountains,… ## Docket (24 files) The files NTSB released with the investigation on October 23, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56401. 4.3 MB in all. - Weather Reports and Records (item 1, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216400&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Sun Moon Position Data (item 2, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216401&FileExtension=.PDF&FileName=Sun%20Moon%20Position%20Data-Master.PDF - Maps or Charts of Accident Area, VFR Aeronautical Chart (item 3, .PDF, 599 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216402&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20VFR%20Aeronautical%20Chart-Master.PDF - Maps or Charts of Accident Area, IFR Approach & Departure (item 4, .PDF, 274 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216404&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20IFR%20Approach%20%26%20Departure-Master.PDF - Radar Target Plots (item 5, .PDF, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216406&FileExtension=.PDF&FileName=Radar%20Target%20Plots-Master.PDF - Radar Data (item 6, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216407&FileExtension=.PDF&FileName=Radar%20Data-Master.PDF - Aircraft Climb Performance Char (item 7, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216409&FileExtension=.PDF&FileName=Aircraft%20Climb%20Performance%20Char-Master.PDF - Aircraft Maintenance Work Orders (item 8, .PDF, 523 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216410&FileExtension=.PDF&FileName=Aircraft%20Maintenance%20Work%20Orders-Master.PDF - Reports from Parties to the Investigation, Textron Lycoming (item 9, .PDF, 401 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216412&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation,%20Textron%20Lycoming-Master.PDF - Reports from Parties to the Investigation, Hartzell Propellers (item 10, .PDF, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216415&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation,%20Hartzell%20Propellers-Master.PDF - Pilot Recurrent Training Proficiency Certificate (item 11, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216418&FileExtension=.PDF&FileName=Pilot%20Recurrent%20Training%20Proficiency%20Certificate-Master.PDF - Toxicological Report (item 12, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216419&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 330 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216422&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Photo 1. View of accident site from recovery staging area at base of mountains (item 14, .PDF, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216429&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20accident%20site%20from%20recovery%20staging%20area%20at%20base%20of%20mountains-Master.PDF - Photo 2. View from above accident site looking back along flight path to airport (item 15, .PDF, 169 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216436&FileExtension=.PDF&FileName=Photo%202.%20%20View%20from%20above%20accident%20site%20looking%20back%20along%20flight%20path%20to%20airport-Master.PDF - Photo 3. View of airport location from accident site. (item 16, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216438&FileExtension=.PDF&FileName=Photo%203.%20%20View%20of%20airport%20location%20from%20accident%20site.-Master.PDF - Photo 4. Overall view of accident site. Impact scar starts at the left edge middle and goes roughly to center of frame (item 17, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216442&FileExtension=.PDF&FileName=Photo%204.%20%20Overall%20view%20of%20accident%20site.%20%20Impact%20scar%20starts%20at%20the%20left%20edge%20middle%20and%20goes%20roughly%20to%20center%20of%20frame-Master.PDF - Photo 5. Detail view of part of main wreckage mass (item 18, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216444&FileExtension=.PDF&FileName=Photo%205.%20%20Detail%20view%20of%20part%20of%20main%20wreckage%20mass-Master.PDF - Photo 6. Detail view of balance of main wreckage mass (item 19, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216445&FileExtension=.PDF&FileName=Photo%206.%20%20Detail%20view%20of%20balance%20of%20main%20wreckage%20mass-Master.PDF - Photo 7. Reconstructed left propeller (item 20, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216447&FileExtension=.PDF&FileName=Photo%207.%20%20Reconstructed%20left%20propeller-Master.PDF - Photo 8. Reconstructed right propeller (item 21, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216449&FileExtension=.PDF&FileName=Photo%208.%20%20Reconstructed%20right%20propeller-Master.PDF - Photo 9. General view of reconstructed wreckage (item 22, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216452&FileExtension=.PDF&FileName=Photo%209.%20%20General%20view%20of%20reconstructed%20wreckage-Master.PDF - Photo 10. Additional reconstructed wreckage (item 23, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216454&FileExtension=.PDF&FileName=Photo%2010.%20Additional%20reconstructed%20wreckage-Master.PDF - Photo 11. More reconstructed wreckage (item 24, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216455&FileExtension=.PDF&FileName=Photo%2011.%20More%20reconstructed%20wreckage-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.