# NTSB LAX07FA059: Piper PA-46-350P, N1AM, Concord, CA, December 21, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 21, 2006, 11:01 local (19:01 UTC) - Place: Concord, CA - Coordinates: 37.9977777777778, -122.060833333333 - Nearby events: https://openairdocs.org/map.md?lat=37.9978&lon=-122.0608&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report July 30, 2008 - Report: Approved by Office Director - Parties: Pratt and Whitney - Canada, Hartzell Propeller Inc., Federal Aviation Administration, Piper Aircraft - NTSB case key (mKey): 65054 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX07FA059 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/65054/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=65054 - Page: https://openairdocs.org/ntsb/LAX07FA059 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, circling (ifr) - ifr procedure - not followed, pilot in command (cause) - airspeed - not maintained (cause) - stall - encountered, pilot in command (cause) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N1AM-2007-04-24), registration cancelled 2007-04-24, S/N 4622061, built 1989 (OpenAirDocs) - Reported make and model: Piper PA-46-350P - Registry model: [Piper PA 46-350P](https://openairdocs.org/model/piper-pa-46-350p) (registry code 7104620) (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: 4622061 - Airframe hours: 2470.6 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 78; injuries: fatal; 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 ## 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 20061221027769A](https://openairdocs.org/incident/20061221027769A), Dec 21, 2006: Piper PA46350P, Concord, CA, Destroyed, 4 fatal. (-23) On December 21, 2006, at 1101 PST, a Piper PA-46-350P, piloted by [privacy data omitted] departed montgomery airport (myf) heading locally to Buchanan… ## Docket (39 files) The files NTSB released with the investigation on July 9, 2008, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=65054. 76.8 MB in all. - Meteorology 5 - Factual Report of Group Chairman (item 1, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273154&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Controller Statements (item 2, .PDF, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295833&FileExtension=.PDF&FileName=Controller%20Statements-Redacted.PDF - CHP Witness Report (item 3, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295834&FileExtension=.PDF&FileName=CHP%20Witness%20Report-Redacted.PDF - Wreckage Diagram (CHP) (item 4, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295796&FileExtension=.PDF&FileName=Wreckage%20Diagram%20(CHP)-Master.PDF - Witness Wreckage Diagrams (item 5, .PDF, 951 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295835&FileExtension=.PDF&FileName=Witness%20Wreckage%20Diagrams-Master.PDF - Photo 1. Aerial of Accident Site (CHP) (item 6, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295836&FileExtension=.PDF&FileName=Photo%201.%20Aerial%20of%20Accident%20Site%20(CHP)-Master.PDF - Photo 2. Aerial of Accident Site (CHP) (item 7, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295837&FileExtension=.PDF&FileName=Photo%202.%20Aerial%20of%20Accident%20Site%20(CHP)-Master.PDF - Photo 3. Aerial of Accident Site (CHP) (item 8, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295838&FileExtension=.PDF&FileName=Photo%203.%20Aerial%20of%20Accident%20Site%20(CHP)-Master.PDF - Photo 4. Aerial of Accident Site (CHP) (item 9, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295839&FileExtension=.PDF&FileName=Photo%204.%20Aerial%20of%20Accident%20Site%20(CHP)-Master.PDF - Photo 5. Accident Area (CHP) (item 10, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295840&FileExtension=.PDF&FileName=Photo%205.%20Accident%20Area%20(CHP)-Master.PDF - Photo 6. Debris Across Highway (CHP) (item 11, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295841&FileExtension=.PDF&FileName=Photo%206.%20Debris%20Across%20Highway%20(CHP)-Master.PDF - Photo 7. Initial Impact (CHP) (item 12, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295842&FileExtension=.PDF&FileName=Photo%207.%20Initial%20Impact%20(CHP)-Master.PDF - Photo 8. Initial Impact Area Looking at Main Wreckage and Airport (CHP) (item 13, .PDF, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295843&FileExtension=.PDF&FileName=Photo%208.%20Initial%20Impact%20Area%20Looking%20at%20Main%20Wreckage%20and%20Airport%20(CHP)-Master.PDF - Photo 9. Main Wreckage (CHP) (item 14, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295844&FileExtension=.PDF&FileName=Photo%209.%20Main%20Wreckage%20(CHP)-Master.PDF - Photo 10. Main Wreckage Left Side (CHP) (item 15, .PDF, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295845&FileExtension=.PDF&FileName=Photo%2010.%20Main%20Wreckage%20Left%20Side%20(CHP)-Master.PDF - Photo 11. Main Wreckage (CHP) (item 16, .PDF, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295846&FileExtension=.PDF&FileName=Photo%2011.%20Main%20Wreckage%20(CHP)-Master.PDF - Photo 12. Main Wreckage (CHP) (item 17, .PDF, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295847&FileExtension=.PDF&FileName=Photo%2012.%20Main%20Wreckage%20(CHP)-Master.PDF - Photo 13. Propeller (CHP) (item 18, .PDF, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295848&FileExtension=.PDF&FileName=Photo%2013.%20Propeller%20(CHP)-Master.PDF - Photo 14. Propeller (CHP) (item 19, .PDF, 5.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295849&FileExtension=.PDF&FileName=Photo%2014.%20Propeller%20(CHP)-Master.PDF - Photo 15. Main Wreckage (NTSB) (item 20, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40296200&FileExtension=.PDF&FileName=Photo%2015.%20Main%20Wreckage%20(NTSB)-Master.PDF - Photo 16. Aft View of Airplane (NTSB) (item 21, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40296201&FileExtension=.PDF&FileName=Photo%2016.%20Aft%20View%20of%20Airplane%20(NTSB)-Master.PDF - Photo 17. Side View with Kinder Morgan in background (NTSB) (item 22, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40296202&FileExtension=.PDF&FileName=Photo%2017.%20Side%20View%20with%20Kinder%20Morgan%20in%20background%20(NTSB)-Master.PDF - Photo 18. Kinder Morgan Facility Looking Toward the Airport (NTSB) (item 23, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40296203&FileExtension=.PDF&FileName=Photo%2018.%20Kinder%20Morgan%20Facility%20Looking%20Toward%20the%20Airport%20(NTSB)-Master.PDF - Photo 19. Accident Site from Kinder Morgan (NTSB) (item 24, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40296204&FileExtension=.PDF&FileName=Photo%2019.%20Accident%20Site%20from%20Kinder%20Morgan%20(NTSB)-Master.PDF - Excerpt of Air Traffic Official Package (Lockheed Martin) (item 25, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295850&FileExtension=.PDF&FileName=Excerpt%20of%20Air%20Traffic%20Official%20Package%20(Lockheed%20Martin)-Redacted.PDF - Report from Piper Aircraft (item 26, .PDF, 695 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40296239&FileExtension=.PDF&FileName=Report%20from%20Piper%20Aircraft-Redacted.PDF - Hartzell Report (item 27, .PDF, 394 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295853&FileExtension=.PDF&FileName=Hartzell%20Report-Redacted.PDF - Aircraft Log (item 28, .PDF, 717 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295854&FileExtension=.PDF&FileName=Aircraft%20Log-Redacted.PDF - Excerpt from Engine Log (Aircraft Flight Log) (item 29, .PDF, 813 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295855&FileExtension=.PDF&FileName=Excerpt%20from%20Engine%20Log%20(Aircraft%20Flight%20Log)-Redacted.PDF - Excerpt from Engine Logbook (item 30, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295856&FileExtension=.PDF&FileName=Excerpt%20from%20Engine%20Logbook-Redacted.PDF - LDA 19R Approach (item 31, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295857&FileExtension=.PDF&FileName=LDA%2019R%20Approach-Master.PDF - LDA APP from Aircraft (pilot) (item 32, .PDF, 514 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295858&FileExtension=.PDF&FileName=LDA%20APP%20from%20Aircraft%20(pilot)-Master.PDF - Prop Log (item 33, .PDF, 383 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295859&FileExtension=.PDF&FileName=Prop%20Log-Redacted.PDF - Weight and Balance (item 34, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295862&FileExtension=.PDF&FileName=Weight%20and%20Balance-Master.PDF - Toxicological Report (item 35, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295863&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 36, .PDF, 525 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295864&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 37, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295865&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Audio Tape (item 38, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40296205&FileExtension=.PDF&FileName=Audio%20Tape-Master.PDF - Video Tape (item 39, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40296206&FileExtension=.PDF&FileName=Video%20Tape-Master.PDF From the NTSB's public API. 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