LAX85IA175

NTSB incident investigation · Piper PA-44-180 · San Jose, CA · March 16, 1985

Incident · No injuriesIncident investigationFinal report
Date
March 15, 1985, 17:13 local (Mar 16, 1985, 01:13 UTC)
Place
San Jose, CA
Injuries
158 uninjured
Phase of flight
Approach
Aircraft
N2138GPiper PA-44-180N476ACMcdonnell Douglas DC-9
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Case key
24558

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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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.

Near collision between aircraftApproach - iaf to faf/outer marker (ifr)
Radar,brite - inadequateFactor
Ifr separation standards - not maintainedAtc personnel(dep/apch)
Improper decisionAtc personnel(dep/apch)Cause
Terrain condition - risingFactor
Near collision between aircraftApproach - iaf to faf/outer marker (ifr)
Radar,conflict alert - inadequateFactor
Ifr separation standards - not maintainedAtc personnel(dep/apch)
Improper decisionAtc personnel(dep/apch)Cause
Terrain condition - risingFactor

Analysis

A Piper seminule was vectored to the final apch course & cleared for an ILS apch at 3000FT MSL. A DC-9, in trail at 5000FT MSL, was overtaking the seminule. The controller elected to change their sequence & cleared the seminule to climb to 4000FT MSL due to rising terrain & make a right 360.the DC-9WAS subsequently issued an approach clearance & descent FROM5000FT, which compromised separation requirements. The conflict alert was missed, in part because it was identical with the terrain proximity alert, which sounded frequently.

A Piper seminule was vectored to the final apch course & cleared for an ILS apch at 3000FT MSL. A DC-9, in trail at 5000 ft MSL, was overtaking the seminule. The controller elected to change their sequence & cleared the seminule to climb to 4000FT MSL due to rising terrain & make a right 360. The DC-9 was subsequently issued an approach clearance & descent from 5000FT, which compromised SEPA4RATION requirements. The conflict alert was missed, in part because it was identical with the terrain proximity alert, which sounded frequently.

Aircraft · 2

Registration
N2138G
Reported as
Piper PA-44-180
Category
Airplane
Serial number
7995191
Engine
Lycoming O-360-EIAD, 180 horsepower, reciprocating
Damage
No damage
Flight
Business · Part 91
Operator
Bud Walen Aviation
Airworthiness certificate
Standard, Normal
Departed
VNY · Van Nuys, CA
Flight plan
IFR
Airport
SJC · San Jose Intl, runway 30, 4,419 × 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.

Registration
N476AC
Reported as
Mcdonnell Douglas DC-9
Category
Airplane
Serial number
48028
Engine
P&W JT8D-9, 14,500 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Air California
Airworthiness certificate
Standard, Transport
Departed
SNA · Santa Ana, CA
Flight plan
IFR
Airport
SJC · San Jose Intl, runway 30, 8,899 × 150 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N2138G
Age
62
Certificates
Private, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
839 total · 15 in this make and model · 716 as pilot in command · 30 in the last 90 days · 5 in the last 24 hours
Role
Pilot, aircraft N476AC
Age
42
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
17,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 10 knots
Visibility
5 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 52 °F
Altimeter
30.00 inHg
Observed at
SJC, 10 nm away