# NTSB LAX04FA066: Cessna 421C, N6887L, Claremont, CA, December 15, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 14, 2003, 17:23 local (Dec 15, 2003, 01:23 UTC) - Place: Claremont, CA - Coordinates: 34.123054, -117.718887 - Nearby events: https://openairdocs.org/map.md?lat=34.1231&lon=-117.7189&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report May 29, 2007 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Cessna Aircraft Company, Teledyne Continental Motors - NTSB case key (mKey): 58481 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04FA066 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58481/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58481 - Page: https://openairdocs.org/ntsb/LAX04FA066 ## Probable cause the pilot became lost/disoriented during the approach, failed to maintain course alignment with the missed approach procedure, and subsequently lost control of the airplane. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - weather condition - low ceiling - became lost/disoriented - inadvertent, pilot in command (cause) - proper alignment - not maintained, pilot in command (cause) - missed approach - improper, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - In flight collision with object, descent - uncontrolled - object - residence ## Analysis The airplane impacted a residence during a missed approach. After completing the en route portion of the instrument flight, a controller cleared the pilot to proceed direct to the initial approach fix for the global positioning satellite (GPS) approach to the airport. After being cleared for the approach, the airplane continued on a course to the east and at altitudes consistent with flying the GPS published approach procedure. Radar data indicated that at the missed approach point at the minimum descent altitude of 2,000 feet msl, the airplane made a turn to the left, changing course in a northerly direction toward rapidly rising mountainous terrain. The published missed approach specified a climbing right turn to 4,000 feet, and noted that circling north of the airport was not allowed. Remaining in a slight left turn, the airplane climbed to 3,300 feet msl over the duration of 1 minute 9 seconds. The controller advised the pilot that he was flying off course toward mountainous terrain and instructed him to make an immediate left turn heading in a southbound direction. The airplane descended to 3,200 feet msl and made a left turn in a southerly direction. The airplane continued to descend to 2,100 feet msl and the pilot read back the instructions that the controller gave him. The airplane then climbed to 3,300 feet, with an indicated ground speed of 35 knots, and began a sharp left turn. It then descended to impact with a house. At no time during the approach did the pilot indicate that he was experiencing difficulty navigating or request assistance. An examination of the airplane revealed no evidence a mechanical malfunction or failures prior to impact; however, both the cockpit and instrument panel sustained severe thermal damage, precluding any detailed examinations. ## Factual narrative HISTORY OF FLIGHT On December 14, 2003, at 1723 Pacific standard time, a Cessna 421C, N6887L, collided with a residence in Claremont, California, while attempting an instrument approach to Cable Airport, Upland, California. The pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The commercial pilot, the sole occupant, sustained fatal injuries; the airplane was destroyed. The personal cross-country flight originated from Camarillo Airport, Camarillo, California, at 1653. Visual meteorological conditions prevailed at Brackett Field, La Verne, California, the closest official reporting station, which was 4 miles southwest of the accident site. An instrument flight rules (IFR) flight plan had been filed. During the investigation, a National Transportation Safety Board investigator obtained and reviewed the recorded voice channels and radar data from Southern California Terminal Radar Approach Control (SCT). Prior to departure, the pilot received an IFR clearance for radar vectors to the Van Nuys very high frequency omni-directional radio-range (VOR) navigation aid, and then to proceed to the Pomona VOR, via victor airway 186 (095-degree radial) and victor airway 210 (045-degree radial). While en route, the pilot received numerous heading, airspeed, and altitude assignments for traffic avoidance purposes. A review of the radar data disclosed that the pilot complied with all instructions and requests. However, at one point during the en route portion of the flight, while flying on victor airway 210, the target became off course about 1 1/2 miles north of the airway. The controller advised the pilot of the heading deviation, and instructed him to turn right 10 degrees to intercept the airway. After completing the en route portion of the instrument flight, the SCT controller cleared the pilot to proceed direct to COVIN, the initial approach fix (IAP) for the global positioning satellite (GPS) approach to Cable Airport. At 1716:00, the controller cleared the pilot for the GPS RWY 6 approach. Radar data indicated that after being cleared, the target continued on a course and at altitudes consistent with flying the GPS published approach course. Radar data further revealed that the target crossed over the final approach fix (FAF), the Pomona VOR, at 1720:08, and for 1 minute 28 seconds thereafter, remained on a heading consistent with that of the GPS approach course (054 degrees). Throughout that duration, the target descended from 2,900 to 1,900 feet mean seal level (msl) (all radar altitudes are as indicated by the airplane's Mode C-equipped transponder unless otherwise noted). At 1720:13, the controller advised the pilot that he was over Pomona and approved him to change to an advisory frequency, which he followed with instructions on canceling the IFR flight plan. Several seconds later, the pilot responded by reading back the instructions. After this exchange, radar indicated that at 1721:45, at an altitude of 2,000 feet msl, the target made a turn to the left, changing course in a northerly direction, which corresponded to a 45-degree heading change. The target continued in an arc, climbing to 3,300 feet msl over the duration of 1 minute 9 seconds (between 1721:45 and 17:22:54). At 1722:43, 2 minutes 30 seconds after giving the pilot a frequency change approval, the controller queried the pilot if he was still on the frequency. Several seconds later, the pilot confirmed that he was still on frequency by stating, "roger I'm with you." At 1722:47, the controller advised the pilot that he was flying off course, toward mountainous terrain. He instructed the pilot to make an immediate left turn, heading in a southbound direction, and inquired as to what the pilot's intentions were. The controller repeated the instructions 14 seconds later and added that, if able to do so, the pilot should climb to 5,000 feet msl. The recorded radar data revealed that, at 1722:59, the target descended to 3,200 feet msl and made a left turn in a southerly direction. The target began tracking in a southerly direction 4 seconds later and descended to 2,700 feet msl. During the 10 seconds thereafter, the target continued that descent until 2,100 feet msl. The pilot's last recorded radio transmission occurred at 1723:10, when he stated, "i'm southbound turning immediately," and the airplane then climbed to 3,300 feet. The last radar return was at 1723:35, with the target at 2,200 feet msl; it was directly next to the wreckage site During interviews with a Safety Board investigator, several ground witnesses reported hearing a low flying airplane. They recalled hearing the sound of an engine sputtering, followed by it smoothing out, then sputtering again, and subsequently becoming quiet. Some witnesses reported seeing the lights on the airplane descending, and then observing the airplane impact a house. A post crash fire consumed most of the house. Several witnesses further noted that it was dark outside. During an interview with a Safety Board investigator, the pilot's certified flight instructor (CFI) stated that he was waiting at the airport for the pilot to land. As the airplane approached the airport he could hear the airplane, but was unable to obtain visual contact. He reported seeing the runway lights illuminated. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a commercial pilot certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. On June 06, 2003, when the pilot was issued a second-class medical certificate, his reported total flight time was 580 hours. In an interview with a Safety Board investigator, the pilot's CFI stated that he had flown numerous hours with the pilot in the accident airplane. He estimated that the pilot had accumulated 175 hours in it, of which 55 were with him. He further stated that the pilot often flew simulated and actual IFR flights, and that he had made approaches into Cable Airport many times prior. The last time he and the pilot flew on instruments together was in May 2003, at which time the pilot demonstrated proficiency performing GPS approaches using the Garmin GNS 430. He noted that the pilot also was accustomed to using the Garmin GNS 530 in a Cessna P210 that he used to fly regularly. Their last flight together was in October 2003. AIRCRAFT INFORMATION The airplane was a Cessna 421C, serial number 421C1113. A review of the airplane's logbooks revealed that the airplane had undergone an annual inspection on March 01, 2003, at a total time of 3,257.1 hours. The engines were both Teledyne Continental Motors GTSIO-520-N series and underwent annual inspections on March 03, 2003. During the inspections, the mechanic noted that the right engine, serial number 227143-R, accumulated a total time of 2,267.2 hours, and that the left engine, serial number 277151-R, accumulated a total time of 1,604.1 hours. This airplane was delivered with the Cessna 800B Integrated Flight Control System (IFCS). The IFCS had a mode selector, which had annunciation lights for the flight director, autopilot, NAV 1, NAV 2, back course, go-around, glide slope, VOR/ localizer, and altitude hold modes. It had one avionics bus. A Safety Board investigator reviewed the airplane's Major Repair and Alteration FAA 337 forms. The review disclosed that around November 24, 1999, Western Aircraft, Boise, Idaho, repair station personnel installed dual Garmin International, Inc., GNS 430 navigation, communication, and GPS systems on the accident airplane. The systems were certified solely for operation under visual flight rules (VFR). The entry further indicated that the airplane had two avionics buses. Connection to avionics bus one consisted of the number one GNS 430 unit, the directional gyro (KG102A), and the Sandel multi-function display. The ## Aircraft - Registration: [N6887L](https://openairdocs.org/deregistered/N6887L-2004-05-21), registration cancelled 2004-05-21, S/N 421C1113, built 1981 (OpenAirDocs) - Reported make and model: Cessna 421C - Registry model: [Cessna 421C](https://openairdocs.org/model/cessna-421c) (registry code 2076016) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 421C1113 - Airframe hours: 3257 - Engines: Continental GTSIO-540-N 375 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2003 - Departed: CMA, Camarillo, CA - Destination: CCB, Upland, CA - Flight plan: IFR - Airport: CCB, Cable Airport, runway 060, 3,865 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 600 total, 175 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 3 statute miles - Lowest ceiling: 1,400 ft overcast - Temperature: 52 °F, dew point 52 °F - Altimeter: 30.09 inHg - Observed at: POC, 3 nm away ## Docket (40 files) The files NTSB released with the investigation on June 20, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58481. 106 MB in all. - Witness Statements (item 1, .PDF, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274597&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Weather Reports (item 2, .PDF, 283 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40221833&FileExtension=.PDF&FileName=Weather%20Reports%20-Master.PDF - Transcript of Radio Communications (item 3, .PDF, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274599&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - ATC Summary (item 4, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274799&FileExtension=.PDF&FileName=ATC%20Summary-Master.PDF - Photo 1: Accident Site (item 5, .PDF, 405 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40221927&FileExtension=.PDF&FileName=Photo%201%3A%20Accident%20Site-Master.PDF - Photo 2-Right Side of Wreckage (item 6, .PDF, 464 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274601&FileExtension=.PDF&FileName=Photo%202-Right%20Side%20of%20Wreckage-Master.PDF - Photo 3-Left side of wreckage (item 7, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274591&FileExtension=.PDF&FileName=Photo%203-Left%20side%20of%20wreckage-Master.PDF - Video File-Radar Track LAX04FA066 (item 8, .PDF, 8 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274802&FileExtension=.PDF&FileName=Video%20File-Radar%20Track%20LAX04FA066-Master.PDF - Instrument Approach Procedure Chart: GPS Runway 06 (item 9, .PDF, 309 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40222030&FileExtension=.PDF&FileName=Instrument%20Approach%20Procedure%20Chart%3A%20GPS%20Runway%2006-Master.PDF - Sun and Moon Information (item 10, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40221838&FileExtension=.PDF&FileName=Sun%20and%20Moon%20Information%0D%0A-Master.PDF - Reports from Parties to the Investigation-Cessna Radar Plots (item 11, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274603&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation-Cessna%20Radar%20Plots-Master.PDF - Ground Track (item 12, .PDF, 955 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274605&FileExtension=.PDF&FileName=Ground%20Track-Master.PDF - Airplane Logbook Excerpts (item 13, .PDF, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274607&FileExtension=.PDF&FileName=Airplane%20Logbook%20Excerpts-Redacted.PDF - Flight Manual Excerpts (item 14, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274623&FileExtension=.PDF&FileName=Flight%20Manual%20Excerpts-Master.PDF - CD Burbank/Ontario Radar Data (item 15, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278572&FileExtension=.PDF&FileName=CD%20Burbank%2FOntario%20Radar%20Data-Master.PDF - Radar Data Burbank Pages 1-2,900 (item 16, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274749&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20Pages%201-2,900-Master.PDF - Radar Data Burbank Pages 2,901-5,800 (item 17, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274750&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20Pages%202,901-5,800-Master.PDF - Radar Data Burbank Pages 5,801-8,700 (item 18, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274751&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20Pages%205,801-8,700-Master.PDF - Radar Data Burbank Pages 8,701-11,600 (item 19, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274752&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20Pages%208,701-11,600-Master.PDF - Radar Data Burbank Pages 11,601-14,500 (item 20, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274753&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20Pages%2011,601-14,500-Master.PDF - Radar Data Burbank Pages 14,501-17,400 (item 21, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274754&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20Pages%2014,501-17,400-Master.PDF - Radar Data Burbank Pages 17,401-20,300 (item 22, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274755&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20Pages%2017,401-20,300-Master.PDF - Radar Data Burbank Pages 20,301-23,200 (item 23, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274756&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20Pages%2020,301-23,200-Master.PDF - Radar Data Burbank Pages 23,201-26,100 (item 24, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274757&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20Pages%2023,201-26,100-Master.PDF - Radar Data Burbank pages 26,101-29,000 (item 25, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274758&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20pages%2026,101-29,000-Master.PDF - Radar Data Burbank Pages 29,101-31,904 (item 26, .PDF, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274759&FileExtension=.PDF&FileName=Radar%20Data%20Burbank%20Pages%2029,101-31,904-Master.PDF - Radar Data Ontario Pages 1-3,100 (item 27, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274762&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%201-3,100-Master.PDF - Radar Data Ontario Pages 3,101-6,200 (item 28, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274763&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%203,101-6,200-Master.PDF - Radar Data Ontario Pages 6,201-9,300 (item 29, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274764&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%206,201-9,300-Master.PDF - Radar Data Ontario Pages 9,301-12,400 (item 30, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274771&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%209,301-12,400-Master.PDF - Radar Data Ontario Pages 12,401-15,500 (item 31, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274776&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%2012,401-15,500-Master.PDF - Radar Data Ontario Pages 15,501-18,600 (item 32, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274778&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%2015,501-18,600-Master.PDF - Radar Data Ontario Pages 18,601-21,700 (item 33, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274779&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%2018,601-21,700-Master.PDF - Radar Data Ontario Pages 21,701-24,800 (item 34, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274781&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%2021,701-24,800-Master.PDF - Radar Data Ontario Pages 24,801-27,900 (item 35, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274782&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%2024,801-27,900-Master.PDF - Radar Data Ontario Pages 27,901-31,000 (item 36, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274783&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%2027,901-31,000-Master.PDF - Radar Data Ontario Pages 31,001-33,947 (item 37, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274784&FileExtension=.PDF&FileName=Radar%20Data%20Ontario%20Pages%2031,001-33,947-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 38, .PDF, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274608&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 39, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274610&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 40, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353090&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF From the NTSB's public API. 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