LAX06FA066

The airplane collided with terrain 9 miles from the destination airport. The pilot was cleared for the instrument landing system approach into the airport. During the descent, the airplane was below the glideslope but tracking the localizer. The pilot contacted the air traffic control tower controller and was cleared to land. The last recorded radar target for the airplane was at 1,600 feet mean sea level (msl) and the initial impact occurred at 1,400 feet msl. The radar data indicated that the target maintained a descent rate of about 1,100 feet per minute during the last minute of flight and was flying at a radar derived ground speed of approximately 112 knots. Though the en route controller received a minimum safe altitude alert (MSAW), he had transferred control of the airplane 1 minute prior to the receipt of the initial MSAW alert. However, the airplane crossed a named intersection at 3,300 feet msl after it was cleared to cross the intersection at 4,000 feet msl while under the en route controller's control. The en route controller did not advise the pilot of the altitude deviation. The air traffic control tower controller did not issue an MSAW to the pilot, even though the equipment was configured to receive MSAW alerts. The tower controller said that he did not recall receiving the alerts and no recording was available to indicate whether or not an aural MSAW alert was received. An evaluation of the operation of the MSAW alerting system following the accident showed that it was functional. Examination of the airframe and engine did not reveal any mechanical anomalies to preclude normal operation. Metallurgical examination of the altimeter showed that the 10,000-foot pointer was not at its correct position at the time of impact and at an undetermined time prior to the accident, moved aft on its shaft and became loose. The effect of the 10,000-foot pointer on the pilot's flight performance could not be ascertained with the available evidence.

1.1 History of the Flight

On December 23, 2005, at 1520 Pacific standard time, a Beech 36, N5942S, collided with hilly terrain 9 nautical miles east of the Livermore Municipal Airport, Livermore, California. The pilot was operating the airplane, which was registered to a private company, under the provisions of 14 CFR Part 91. The private pilot and passenger sustained fatal injuries. The airplane sustained substantial damage. Instrument meteorological conditions prevailed and the pilot requested and received a pop-up instrument flight rules (IFR) clearance about 1500. The flight originated from Santa Barbara Municipal Airport, Santa Barbara, California, at 1342, and was destined for Livermore.

1.1.1 Air Traffic Control History and Radar Information

Information obtained from Lockheed Martin Services, Inc. indicated that the pilot received an abbreviated weather briefing at 1002 from the Prescott Flight Service Station (FSS). After departing Santa Barbara, the pilot requested an additional abbreviated weather briefing via Flight Watch at 1439. The specialist advised the pilot that he should plan on an IFR approach to very low conditions at Livermore.

About 1500, the pilot requested an IFR clearance into the Livermore airport from Oakland Air Route Traffic Control Center (ZOA). The center controller issued the clearance and handed the aircraft off to the Northern California Terminal Radar Approach Control (NCT).

The pilot's first contact with NCT occurred at 1441, when the ZOA sector 10 controller contacted the NCT Morgan sector controller to coordinate an IFR clearance to Livermore. After some discussion, the controllers agreed that ZOA sector 10 would clear N5942S to Livermore via direct to Manteca vhf omni-directional range (VOR) at 8,000 feet. At 1443, the pilot contacted the Morgan controller and reported level at 8,000 feet. The controller acknowledged and issued the Salinas altimeter setting. The Morgan controller then advised the pilot that automatic terminal information service (ATIS) information "Uniform" was current at Livermore, showing wind 190 degrees at 4 knots, visibility 3 miles in mist, ceiling 600 feet overcast, temperature 60 degrees Fahrenheit, altimeter 30.23 inches of Mercury, and that the instrument landing system (ILS) approach to runway 25R was in use. The pilot acknowledged.

At 1448, N5942S was transferred to the NCT Castle sector. The pilot checked in and reported, "…level at 8,000." The controller asked the pilot to advise when he had information "Uniform" and the pilot replied that he had it.

At 1459, the pilot contacted the NCT Sunol sector, again reporting level at 8,000 feet. The controller advised the pilot of N5942S that information "Victor" was current at Livermore, and asked if the pilot had it. The pilot responded negative, and that he had information "Uniform." The controller provided the "Victor" weather information, reporting that Livermore was indicating wind calm, visibility 3 miles in mist, ceiling 600 feet overcast, altimeter 30.22 inches of Mercury, ILS runway 25R approach in use. The pilot acknowledged. At 1506, the pilot was instructed to contact NCT on 123.85, the Tracy sector frequency.

At 1507, the pilot contacted the Tracy sector and reported level at 8,000 feet. The controller acknowledged. At 1510, N5942S was cleared to descend to 7,000 feet and the pilot acknowledged. At 1511, the controller instructed the pilot of N5942S to turn left, heading 280 degrees, to join the localizer and report established. The pilot read back the heading. At 1513, the controller cleared N5942S to descend to 4,000 feet and the pilot acknowledged. At 1514:28, the controller again cleared N5942S to 4,000 feet and the pilot acknowledged. At 1514:35, the Tracy controller transmitted, "November 42S is one-zero miles from FOOTO, fly heading 280, cross FOOTO at 4,000, cleared ILS runway 25R approach." The pilot responded, "Cleared at 4,000, cleared for the approach." At 1515, the controller asked the pilot to verify that he had information "Victor" at Livermore and the pilot responded that he did. At 1517, the controller issued a traffic advisory to N5942S for an aircraft that was eastbound at 12 o'clock and 7 miles, altitude indicating 5,400 feet. The pilot responded that he was looking. At 1519:58 the controller transmitted, "N42S radar service terminated, contact Livermore tower 118.1, traffic no factor." The pilot acknowledged.

At 1520:07, the pilot contacted the Livermore tower and was cleared to land. The pilot's readback was unintelligible. There were no further transmissions from the airplane. At 1524:36, the local control (LC) controller made the first of four unsuccessful attempts to contact N5942S. At 1525:37, the controller advised the NCT Tracy sector that he had lost radio and radar contact with N5942S. Following that call, the controller made two more attempts to contact the aircraft with no response.

The ATCT personnel notified search and rescue personnel of a possible downed airplane and their reception of an electronic locator transmitter at 1529. The wreckage was located at 1800 at an elevation of 1,400 feet msl.

Radar data for the accident flight was reviewed by an NTSB air traffic control specialist. One track was consistent with the airplane's route of flight and identified by the airplane's discrete transponder code of 2040. N5942S was established at a mode C derived altitude of 8,100 feet and was cleared to descend to 7,000 feet. Radar data showed the target N5942S descended to 7,200 feet. At 1514, N5942S was cleared to descend to 4,000 feet and the descent of the identified target continued until impact with terrain. The radar data indicated that the target maintained a descent rate of about 1,100 feet per minute during the last minute of flight at a radar derived ground speed of approximately 112 knots.

During the approach into Livermore, the pilot was cleared to cross FOOTO intersection at 4,000 feet mean sea level (msl). Instead, radar targets indicated that the airplane crossed FOOTO at 3,300 feet msl at 1519:22 while established on the localizer course. At 1520:07, the pilot contacted Livermore ATCT and was cleared to land by the controller at 1520:11. At 1520:16, the last transmission was received from the airplane. The last radar target for the airplane was at 1521:08 at 1,600 feet msl, approximately 9 miles east of Livermore airport.

1.2 Personnel Information

1.2.1 Pilot Information

The pilot held a private pilot certificate with an instrument rating. The pilot's most recent third-class medical certificate was issued in July of 2004. It held the limitations that required the pilot to wear corrective lenses.

The pilot's personal flight time logbooks were not located. On the pilot's last medical certification application, he noted a total flight time of 1,200 hours.

An airplane logbook, that served as a record of the flights taken in the airplane, was recovered from the accident site. The logbook showed that the pilot had accrued approximately 88 hours since November of 2003 (the date of his first entry in the logbook). In 2004 he logged approximately 62 flight hours and in 2005 he logged approximately 20 flight hours. The last entry from the pilot was dated for a time period from November 23 through 27, 2005.

1.3 Aircraft Information

1.3.1 General Aircraft History

The airplane was manufactured in 1968 and was powered by a Continental IO-520-BA engine equipped with a two-bladed McCauley propeller, model 2A36C23. On August 4, 2005, the airplane underwent an annual inspection at a total airframe time of 8,358 hours. At the time of the accident, the airplane had accrued 8,395 hours. The engine had accrued 1,415 hours since major overhaul and the propeller accrued 1,415 hours since overhaul. The pitot static system and transponder check was completed on August 3, 2005 (the logbook