LAX07FA059

NTSB accident investigation · Piper PA-46-350P · Concord, CA · December 21, 2006

Accident · FatalField investigationFinal report
Date
December 21, 2006, 11:01 local (19:01 UTC)
Place
Concord, CA
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N1AMPiper PA-46-350P
Weather
Instrument (IMC) · Day
Status
Completed · report July 30, 2008
Report
Approved by Office Director
Parties
Pratt and Whitney - Canada, Hartzell Propeller Inc., Federal Aviation Administration, Piper Aircraft
FAA report
20061221027769A
Case key
65054

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

Failure of the pilot to follow the prescribed instrument approach procedures and to maintain an adequate airspeed while maneuvering in the airport environment that led to a stall.

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.

Loss of control - in flightCircling (ifr)
Ifr procedure - not followedPilot in commandCause
Airspeed - not maintainedCause
Stall - encounteredPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

While on an instrument approach for landing, the local tower air traffic controller observed on the BRITE radar repeater scope that the airplane passed the outer marker (OM), 600 feet below the permissible crossing altitude. The controller issued a low altitude alert to the pilot and cleared him to land. The controller also reminded the pilot that the minimum descent altitude for the Localizer Directional Aid (LDA) approach was 440 feet, and provided instructions for the missed approach. At that point the pilot reported that he had the airport in sight and acknowledged the landing instructions. The controller again cleared the pilot to land on the prescribed runway for the instrument approach, and the pilot acknowledged the landing clearance. Shortly thereafter the controller instructed the pilot to execute the missed approach as the radar track showed that the airplane was off course. The pilot was instructed to initiate a climbing left turn to the VOR. The pilot said he had the airport in sight and that he saw one of the cross runways and wanted to land. The controller told the pilot that circling to that runway was not an authorized procedure for the LDA approach and again instructed the pilot to perform the missed approach. A witness stated that he was working on a storage container, about 50 feet in height, when the airplane passed overhead. He estimated the airplane to be about 50 feet higher than the storage container. The airplane made a turn westbound and the witness looked away for a second. When he looked back the airplane was in a nose and left wing down attitude and then it impacted the ground. Another witness located on the airport's north-northeast corner also observed the airplane flying toward the airport. He reported simultaneously hearing the engine power up and observed the left wing stall prior to it impacting the ground. Both witnesses reported that they did not hear anything wrong with the engine. Examination of the airframe, power plant, and propeller revealed no mechanical anomalies that would have precluded normal operation. Internal damage signatures in the engine and propeller were consistent with the production of significant power at the time of impact. A review of the weather in the area revealed that while light rain and mist were occurring near the accident site, no meteorological phenomena existed that would have adversely affected the flight.

Factual narrative

History of flight

On December 21, 2006, at 1101 Pacific standard time, a Piper PA-46-350P, N1AM, collided with flat terrain about 200 yards northwest of the approach end of runways 14 Left and Right, at Buchanan Field (CCR), Concord, California. The pilot/owner operated the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Impact forces and a post-impact fire destroyed the airplane. The commercial multiengine instrument rated pilot, and three passengers were killed. The personal cross-country flight departed Montgomery Field (MYF), San Diego, California, at 0847, with a planned destination of CCR. Day instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed.

According to a California Highway Patrol (CHP) officer, Highway 4 is oriented along an east/west bound direction. The CHP officer reported that the weather after the accident was light rain with cloudy conditions, and an estimated ceiling of 2,000 feet.

The last few seconds of the accident flight were captured by a security video camera from Kinder Morgan Energy Partners located less than a mile northeast of the accident site. The video showed the airplane enter the upper right-hand corner of the video frame. It then enters a left wing-nose low attitude with the top portion of the airframe facing toward the video camera.

A witness from Kinder Morgan reported observing the accident airplane as it passed over his location. The witness was on top of one of the natural gas storage containers, container 20, when the airplane passed over him on a southbound heading toward the airport. The airplane then made a slight right turn westbound. He looked away for a second and when he looked back, the airplane was in a nose down attitude, and then it impacted the ground. The witness reported that the storage container was about 50 feet in height. He estimated the airplane to be about 50 feet above him.

Another witness located on the north-northeast corner of the airport between the approach end of runways 19R and 14L stated that he could see across the airport, but with a cloud layer and poor visibility above the ground. He observed the airplane make a turn to the west parallel to highway 4 and then make a left turn southbound. As the airplane continued to make the left turn, the left wing dropped, which "stalled" the airplane. The airplane started to spin prior to impacting the ground in a nose down attitude. He also reported that he heard the engine power up as the left wing stalled.

Both witnesses reported that the airplane was flying low and appeared to be at a slow airspeed. They did not hear anything wrong with the engine.

Personnel information

A review of Federal Aviation Administration (FAA) airman records revealed that the 78-year-old pilot held a commercial pilot certificate with airplane single, multi-engine land, and instrument airplane ratings. The pilot's instrument rating had been issued on June 15, 1984.

The pilot was issued a second-class medical certificate on August 22, 2006. The medical certificate contained the limitations that the pilot must wear corrective lenses and possess glasses for near and interim vision.

The pilot was issued a mechanic certificate with airframe and power plant ratings on August 23, 1995.

An examination of the pilot's logbook indicated an estimated total flight time of 3,628.17 hours. The pilot flew an estimated 93.0 hours from March 2006, until December 20, 2006, (the last entry in the logbook) in the accident airplane. He logged an estimated 25.0 hours in the last 90 days, and 6.0 hours in the last 30 days. The pilot's personal logbook contained an entry that indicated that a biennial flight review had been completed on May 5, 2006. The 5.4-hour flight review included an instrument proficiency check.

On June 24 and 25, 2006, the pilot logbook indicated that he had attended a 2-day National Check Pilot Standardization course (Flight Instructor Refresher Clinic). The pilot was not a certificated flight instructor.

Aircraft information

The airplane was a 1989 six-seat, pressurized, Piper PA-46-350P, serial number 4622061. A review of the airplane's logbooks showed that on June 2, 1999, the original Lycoming TIO-540-AE2A engine had been replaced with a Pratt and Whitney Canada (PWC) PT6A-34 engine. On September 12, 2002, the engine was converted to a PWC PT6A-35 engine, serial number PEC-RR009. In both instances, the PWC engine had been modified under a supplemental type certificate (STC) by JetProp LLC, Spokane, Washington. The turboprop engine was installed under STC ST00541SE.

The annual/100-hour inspection had been completed on May 11, 2006, with a total airframe time of 2,170.6 hours, and a total engine time of 486 hours. A Hartzell HC-E4N-3I, serial number HH1482, propeller had been installed on the airplane as part of STC ST00541SE on September 12, 2002. At the last annual/100-hour inspection, the recorded total time was 486.1 hours.

The pilot maintained a flight log for the airplane. On October 3, 2006, the Pitot/Static system check was performed with no discrepancies noted. On October 23, 2006, he received, and had installed, a VistaNAV unit. The unit was test flown on October 29. The entry for November 7, 2006, indicated that the VistaNAV had failed, but no reason was provided in any of the subsequent entries. The entry for December 20, 2006, showed the airplane's total time as 2,244.29 hours. There were no further entries in the flight log.

Fueling records obtained from Gibbs Flying Service established that the airplane was last fueled on December 20, 2006, with the addition of 52 gallons of Jet A fuel.

Meteorological conditions

The aviation routine weather report (METAR) issued for CCR at 0953 reported winds from 330 degrees at 3 knots; visibility 3 statute miles with light rain, a broken cloud layer at 5,000 feet and an overcast cloud layer at 6,000 feet; temperature 07 degrees Celsius, dew point 04 degrees Celsius; altimeter setting of 30.29 inches of Mercury (inHg).

The METAR issued for CCR at 1053 reported winds from 100 degrees at 5 knots; visibility 2 statute miles with light rain and mist, an overcast cloud layer at 3,200 feet; temperature 07 degrees Celsius, dew point 04 degrees Celsius; altimeter setting of 30.28 inHg.

The METAR issued for CCR at 1111 reported winds from 070 degrees at 4 knots; visibility 2.5 statute miles with light rain and mist, a broken cloud layer at 2,900 feet and an overcast cloud layer at 3,400 feet; temperature 07 degrees Celsius, dew point 04 degrees Celsius; altimeter setting of 30.27 inHg.

A staff meteorologist for the National Transportation Safety Board reported that the surface analysis chart for 1000 depicted a low-pressure system over Alberta, Canada, with a cold front that extended south-southwest across Alberta, western Montana, northern Idaho, eastern Oregon, and northern California to the Pacific Ocean.

The accident site was located ahead of the cold front. Station models also depicted winds from the southeast at 10 knots or less ahead of the cold front, calm winds near the front, and no apparent wind shift north of the cold front. Rain, fog, and haze restricted visibility in the vicinity of the front, with broken to overcast clouds. The weather stations in the vicinity of the accident site reported marginal VFR (MVFR) conditions with visibilities that ranged from 3 to 5 miles in continuous rain, and overcast skies between 2,000 and 4,300 feet, with a freezing level at 8,500 feet over the accident area.

Communications

Audio Transmissions

The Safety Board investigator-in-charge (IIC) reviewed recorded audio transmissions between the pilot and CCR tower personnel. After passing the outer marker (OM), tower personnel asked the pilot to report the airplane's altitude. The pilot reported

Aircraft

Registration
N1AM
Reported as
Piper PA-46-350P
Category
Airplane
Serial number
4622061
Airframe hours
2,470.6
Engine
Pratt & Whitney Canada PT6A-35, 350 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
John Frank Mauricio Trustee
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 1, 2006
Departed
MYF · San Diego, CA
Destination
CCR · Concord, CA
Flight plan
IFR
Airport
CCR · Buchanan Field, runway 19R, 5,001 × 150 ft, asphalt

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
78
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2
Last flight review
May 1, 2006
Seat
Left
Toxicology
Performed
Flight hours
3,628 total · 25 in the last 90 days · 6 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
70° at 4 knots
Visibility
2.5 statute miles
Lowest ceiling
2,900 ft broken
Temperature
45 °F, dew point 39 °F
Altimeter
30.27 inHg
Observed at
CCR

Docket · 39

The files NTSB released with the investigation on July 9, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 76.8 MB in all.

Meteorology 5 - Factual Report of Group ChairmanItem 1 · .PDF · 2.6 MBController StatementsItem 2 · .PDF · 256 KBCHP Witness ReportItem 3 · .PDF · 14 KBWreckage Diagram (CHP)Item 4 · .PDF · 3.4 MBWitness Wreckage DiagramsItem 5 · .PDF · 951 KBPhoto 1. Aerial of Accident Site (CHP)Item 6 · .PDF · 2.4 MBPhoto 2. Aerial of Accident Site (CHP)Item 7 · .PDF · 2.5 MBPhoto 3. Aerial of Accident Site (CHP)Item 8 · .PDF · 2.6 MBPhoto 4. Aerial of Accident Site (CHP)Item 9 · .PDF · 2.5 MBPhoto 5. Accident Area (CHP)Item 10 · .PDF · 3.7 MBPhoto 6. Debris Across Highway (CHP)Item 11 · .PDF · 4.1 MBPhoto 7. Initial Impact (CHP)Item 12 · .PDF · 5.1 MBPhoto 8. Initial Impact Area Looking at Main Wreckage and Airport (CHP)Item 13 · .PDF · 4.9 MBPhoto 9. Main Wreckage (CHP)Item 14 · .PDF · 3.8 MBPhoto 10. Main Wreckage Left Side (CHP)Item 15 · .PDF · 4.2 MBPhoto 11. Main Wreckage (CHP)Item 16 · .PDF · 4.6 MBPhoto 12. Main Wreckage (CHP)Item 17 · .PDF · 4.8 MBPhoto 13. Propeller (CHP)Item 18 · .PDF · 4.7 MBPhoto 14. Propeller (CHP)Item 19 · .PDF · 5.0 MBPhoto 15. Main Wreckage (NTSB)Item 20 · .PDF · 1.4 MBPhoto 16. Aft View of Airplane (NTSB)Item 21 · .PDF · 1.2 MBPhoto 17. Side View with Kinder Morgan in background (NTSB)Item 22 · .PDF · 1.4 MBPhoto 18. Kinder Morgan Facility Looking Toward the Airport (NTSB)Item 23 · .PDF · 1.5 MBPhoto 19. Accident Site from Kinder Morgan (NTSB)Item 24 · .PDF · 1.6 MBExcerpt of Air Traffic Official Package (Lockheed Martin)Item 25 · .PDF · 1.6 MBReport from Piper AircraftItem 26 · .PDF · 695 KBHartzell ReportItem 27 · .PDF · 394 KBAircraft LogItem 28 · .PDF · 717 KBExcerpt from Engine Log (Aircraft Flight Log)Item 29 · .PDF · 813 KBExcerpt from Engine LogbookItem 30 · .PDF · 1.1 MBLDA 19R ApproachItem 31 · .PDF · 220 KBLDA APP from Aircraft (pilot)Item 32 · .PDF · 514 KBProp LogItem 33 · .PDF · 383 KBWeight and BalanceItem 34 · .PDF · 23 KBToxicological ReportItem 35 · .PDF · 58 KBStatement of Party Representatives to NTSB InvestigationItem 36 · .PDF · 525 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 37 · .PDF · 89 KBAudio TapeItem 38 · .PDF · 10 KBVideo TapeItem 39 · .PDF · 10 KB

FAA reports on this event · 1

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