# NTSB LAX04FA077: Piper PA-34-200T, N3747U, Avalon, CA, December 24, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 24, 2003, 10:20 local (18:20 UTC) - Place: Avalon, CA - Coordinates: 33.376388, -118.419166 - Nearby events: https://openairdocs.org/map.md?lat=33.3764&lon=-118.4192&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 5 fatal - Status: Completed, report October 27, 2005 - Report: Approved by Office Director - Parties: New Piper Aircraft, Teledyne Continental Motors, Federal Aviation Administration - NTSB case key (mKey): 58540 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04FA077 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58540/pdf - Page: https://openairdocs.org/ntsb/LAX04FA077 ## Probable cause The failure of both pilots to properly execute the published missed approach procedure. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, missed approach (ifr) - weather condition - clouds - terrain condition - mountainous/hilly - missed approach - not followed, pilot in command (cause) ## Analysis The twin-engine airplane impacted mountainous terrain during a VOR-B approach in actual instrument weather conditions. The commercial pilot (first pilot) and airline transport pilot (owner/second pilot), were conducting an aircraft checkout flight. The VOR is located on top of a mountain at an elevation of 2,090 feet. The VOR/DME-B approach consists of tracking the 352-degree radial inbound to the VOR from the north descending from 3,200 feet down to the minimum descent altitude of 2,100 feet prior to the Initial Approach Fix (IAF). The IAF is 2.2 nm from the Missed Approach Point (MAP). The MAP is 1.0 nm north of the airport runway and 2.8 nm from the VOR. The published missed approach procedure consists of a climb from 2,100 feet to 3,200 feet direct to the VOR on the 352 radial, then hold at the VOR. Review of the recorded radar data disclosed that while executing the VOR-B approach, the airplane appeared to fly the published approach procedure normally with the exception of paralleling the final approach course (352-degree radial) about 1 mile to the east. The pilots had told the controllers that they were flying the approach with the intentions of executing the missed approach procedure. Once the airplane passed the missed approach point (MAP), the pilots failed to execute the climb portion of the missed approach procedures. The airplane continued to track towards the VOR at the minimum descent altitude until impacting the mountain just below the VOR. ## Factual narrative 1.1 HISTORY OF FLIGHT On December 24, 2003, about 1020 Pacific standard time, a Piper PA-34-200T, N3747U, impacted mountainous terrain while flying the missed approach portion of the (VOR/DME-B) approach to Catalina Airport (AVX), Avalon, California. Long Beach Flying Club was operating the airplane under the provisions of 14 CFR Part 91. The airline transport pilot/certified flight instructor (CFI), the commercial pilot under instruction (PUI), and three passengers sustained fatal injuries; the airplane was destroyed. The local instructional flight departed Long Beach (LGB), California, about 0954, en route to Avalon. Day instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The primary wreckage was at 33 degrees 22.35 minutes north latitude by 118 degrees 25.09 minutes west longitude. Southern California Terminal Radar Approach Control (SCT) Approach control cleared the airplane for the very high frequency omni-directional range/ distance measuring equipment-BRAVO (VOR/NDB-B) approach to AVX, and told the pilots to contact AVX UNICOM. The pilots established radio contact with the UNICOM operator, who advised them that the weather was: wind from 120 degrees at 4 knots; ceiling 100 feet overcast; and visibility 1.25 statute miles. AVX UNICOM received no further radio communication from the accident airplane. The National Transportation Safety Board investigator-in-charge (IIC) reviewed recorded radar data from the Los Angeles Air Route Traffic Control Center (ARTCC) and noted a target identified with the flight's assigned transponder beacon code 4711. Recorded radar data showed that after the radar target departed Long Beach, it gained in altitude on a southerly course until passing the shoreline south of LGB at a mode C reported altitude of 2,900 feet mean sea level (msl). The target continued to gain in altitude to a maximum reported altitude of 4,100 feet msl. The target continued south until passing the Santa Catalina VORTAC (SXC) (very high frequency omni-directional radio range, tactical air navigation). It then started to descend and turned northbound to start the VOR/DME-B approach. The radar track shows the target turning to the south and establishing the approach on a heading of 172 degrees. The airplane continued to descend to the published minimum descent altitude (MDA) of 2,100 feet msl and leveled off. The target crossed the missed approach point (MAFPI) at the MDA of 2,100 feet msl. The missed approach point is 2.8 nautical miles from the SXC VOR. The SXC VOR is located on top of Mount Orizaba at an altitude of 2,090 feet msl. The radar track showed that the target maintained an altitude of 2,100 feet msl after the missed approach point before radar contact was lost. 1.2 PERSONNEL INFORMATION 1.2.1 First Pilot For the purposes of this report the first pilot is identified as the pilot who was occupying the left front seat of the accident airplane. A review of Federal Aviation Administration (FAA) airman records revealed the first pilot held a commercial pilot certificate with ratings for airplane single and multiengine land. He also held a certified flight instructor certificate with ratings for airplane single and multiengine land, and instrument airplane. The first pilot held a second-class medical certificate issued on October 15, 2003. It had no limitations or waivers. No personal flight records were located for the pilot, and the aeronautical experience listed in this report was obtained from a review of the FAA airmen records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated a total time of 730 hours with 200 hours logged in the last 6 months. 1.2.2 Second Pilot For the purposes of this report the second pilot is identified as the pilot who was occupying the right front seat of the accident airplane. A review of FAA airman records revealed the second pilot held an airline transport pilot certificate with ratings for airplane multiengine land rating, and a commercial pilot certificate with an airplane single engine land rating. He also held a certified flight instructor certificate with ratings for airplane single and multiengine land, and instrument airplane. The pilot held a first-class medical certificate issued on January 17, 2003. It had no limitations or waivers. No personal flight records were located for the pilot, and the aeronautical experience listed in this report was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City. These records indicated a total time of 4,500 hours with 300 hours logged in the last 6 months. 1.3 AIRCRAFT INFORMATION The airplane was a Piper PA-34-200T, serial number 34-7570287. A review of the airplane's logbooks revealed a total airframe time of 3,320.1 hours at the last annual inspection. The annual inspection was completed on August 7, 2003. The last recorded maintenance indicated the total airframe time of 3,384.0 hours on December 12, 2003. The airplane had a Teledyne Continental Motors TSIO-360-EB engine, serial number 265612-R, installed on the left side. Engine total time since major overhaul was 1,523.54 hours. The airplane had a Teledyne Continental Motors TSIO-360-EB engine, serial number 266165-R, installed on the right side. Total time on the engine since major overhaul at the last 100-hour inspection was 1,523.54 hours. The airplane was equipped with an inoperative Long Range Radio Aid to Navigation (LORAN) system. The airplane was not equipped with a Global Position System (GPS). Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure. 1.4 METEOROLOGICAL INFORMATION A staff meteorologist for the Safety Board prepared a factual report, which included the following weather for the departure area and destination. 1.4.1 Catalina Airport (KAVX), Avalon, California The closest official weather observation station was a nonaugmented Automated Surface Observing System (ASOS) at, Catalina Airport, Avalon, located 3 miles north of the accident site. The elevation of the weather observation station was 1,610 feet msl. Reported weather at 1022, was winds from 120 degrees at 4 knots; visibility 1 1/4 miles; surface weather- light rain/mist; sky condition overcast 100 feet; temperature 52 degrees Fahrenheit; dew point 50 degrees Fahrenheit; altimeter 30.07; Remarks- rain began at 1015. 1.4.2 Long Beach Airport (KLGB), Long Beach, California The next closest official weather observation station was Long Beach Airport (LGB), Long Beach, located 29 miles northeast of the accident site. The elevation of the weather observation station was 34 feet msl. Reported weather at 0956, was winds from 080-degrees at 4 knots; visibility 10 miles; sky condition overcast at 3,300 feet; temperature 59 degrees Fahrenheit; dew point 52 degrees Fahrenheit; altimeter 30.08 inHg. 1.5 COMMUNICATIONS 1.5.1 Long Beach Airport (Daugherty Field) (LGB)- Airport Traffic Control Tower (ATCT) The IIC reviewed recorded radio communications and official transcripts between LGB tower controllers and the pilot. All communications were read back correctly or acknowledged unless noted otherwise. At 0933, the pilot contacted LGB clearance delivery with information UNIFORM and requested an IFR clearance to AVX. Between the times of 0936 and 0937, the pilot was instructed to contact ground control for taxi instructions, and received taxi instructions to runway 25L at Delta. Between the times of 0950 and 0954, the pilot was issued his IFR clearance, and then cleared for takeoff. At 0956, LGB local control instructed the pilot to contact departure (SCT). 1.5.2 Southern California Terminal Radar Approach Control (S ## Aircraft - Registration: [N3747U](https://openairdocs.org/deregistered/N3747U-2013-09-12), registration cancelled 2013-09-12, S/N 34-7570287 (OpenAirDocs) - Reported make and model: Piper PA-34-200T - Registry model: [Piper PA-34-200T](https://openairdocs.org/model/piper-pa-34-200t) (registry code 7103406) (OpenAirDocs) - Category: Airplane - Serial number: 34-7570287 - Airframe hours: 3320.1 - Engines: Continental TSIO-360-EB 220 horsepower reciprocating; Continental LTSIO-360-EB1 220 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Long Beach Flying Club - Registered owner: Golf Air Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 7, 2003 - Departed: LGB, LONG BEACH, CA - Destination: LGB, LONG BEACH, CA - Flight plan: IFR - Airport: AVX, Catalina ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; last flight review December 18, 2003; seat: left; toxicology performed; flight hours: 609 total, 489 as pilot in command - Flight instructor; age 35; injuries: fatal; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review January 1, 2003; seat: rear; toxicology performed; flight hours: 4,500 total ## Weather - Conditions: Instrument (IMC), Day - Wind: 120° at 4 knots - Visibility: 1.25 statute miles - Lowest ceiling: 100 ft overcast - Temperature: 52 °F, dew point 50 °F - Altimeter: 30.06 inHg - Observed at: AVX, 2 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 20031224034459A](https://openairdocs.org/incident/20031224034459A), Dec 24, 2003: Piper PA34200T, Avalon, CA, Destroyed, 5 fatal. (-23) This flight was a 'checkout' flight conducted by the ATP and CFI rated owner of the aircraft for a commercial and CFI rated potential renter. This check… 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.