# NTSB LAX88FA082: Piper PA-28-181, N2938X, Napa, CA, January 8, 1988 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 7, 1988, 18:19 local (Jan 8, 1988, 02:19 UTC) - Place: Napa, CA - Coordinates: 38.550506, -122.150085 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.5505&lon=-122.1501&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report July 9, 1990 - Report: Approved by Office Director - NTSB case key (mKey): 25801 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX88FA082 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/25801/pdf - Page: https://openairdocs.org/ntsb/LAX88FA082 ## Probable cause PILOT'S INFLIGHT LOSS OF CONTROL OF THE AIRCRAFT WHILE MANEUVERING IN IFR CONDITIONS AFTER BECOMING DISORIENTED WHILE EXECUTING AN INSTRUMENT APPROACH PROCEDURE. FACTORS IN THE ACCIDENT WERE THE PILOTS LACK OF RECENT INSTRUMENT FLIGHT EXPERIENCE AND THE AIRCRAFT FUEL STATE WHICH WAS NEAR EXHAUSTION. CONTRIBUTING TO THE ACCIDENT WAS THE PILOTS DECISION TO CONTINUE THE FLIGHT IN THE FACE OF A WEATHER BRIEIFING WHICH ADVISED AGAINST VFR FLIGHT, AND HIS DECISION NOT TO PROCEED TO AN ALTERNATE DESTINATION WITH BETTER WEATHER CONDITIONS AT A EARLIER STAGE IN THE FLIGHT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - weather condition - clouds (contributing factor) - weather condition - low ceiling (contributing factor) - weather condition - fog (contributing factor) - weather condition - rain (contributing factor) - light condition - dark night (contributing factor) - preflight planning/preparation - improper, pilot in command (cause) - weather forecast - disregarded, pilot in command (cause) - in-flight planning/decision - poor, pilot in command (cause) - Miscellaneous/other, maneuvering - holding(ifr) - fluid,fuel - low level (contributing factor) - not performed, pilot in command (contributing factor) - Miscellaneous/other, approach - faf/outer marker to threshold (ifr) - ifr procedure - misjudged, pilot in command (contributing factor) - became lost/disoriented - inadvertent, pilot in command (cause) - lack of recent instrument time, pilot in command (contributing factor) - Loss of control - in flight, maneuvering - aircraft control - not maintained, pilot in command (cause) - anxiety/apprehension, pilot in command (contributing factor) - spatial disorientation, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE PLT WAS RETURNING AFTER A 2 WEEK VACATION TRIP TO ARIZONA. AT AN ENROUTE STOP THE PLT ORDERED THE ACFT FUELED TO PARTIAL TANK CAPACITY ON 1 SIDE & FULL ON THE OTHER. HE ALSO GOT A WX BRIEFING WHICH ADVISED AGAINST VFR FLT DUE TO CLOUDS, FOG & RAIN. THE PLT HAD AN INST RATING BUT WAS NOT CURRENT. THE PLT CONT ON TO THE DEST & FOUND WORSE WX CONDS THAN FORECAST. HE ASKED OAKLAND CENTER FOR AN APPROACH & WAS GIVEN HOLDING INSTRUCTIONS & TOLD TO EXPECT DELAYS DUE TO HEAVY IFR TRAFFIC. AT THAT TIME THE ACFT HAD ABOUT 1 HR & 30 MINS OF FUEL LEFT. THE PLT HELD FOR 47 MINS BEFORE AN APPROACH CLEARANCE WAS ISSUED. ON THE APPROACH THE PLT REPORTED THE VOR INBOUND BUT RADAR DATA SHOWED HE WAS OVER THE ARPT INSTEAD. THE PLT WAS 3 MILES PAST ARPT WHEN CONTROLLERS TOLD HIM HIS POSITION. PLT CLAIMED HE HAD A FIRE & HAD LOST HIS GYROS & ASKED FOR VECTORS TO ARPT. ACFT CRASHED WHILE MANEUVERING IN IFR COND. NO EVIDENCE OF FIRE OR GYRO FAILURE WAS FOUND. ## Aircraft - Registration: [N2938X](https://openairdocs.org/deregistered/N2938X-1989-02-21), registration cancelled 1989-02-21, S/N 287990575 (OpenAirDocs) - Reported make and model: PIPER PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Category: Airplane - Serial number: 28-7990575 - Airframe hours: 1346 - Engines: LYCOMING O-360-A4M 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Petersen, John C. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 2, 1987, 76 hours before - Departed: WJF, LANCASTER, CA - Destination: APC, NAPA, CA - Airport: APC, Napa County, runway 18, 5,931 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, expired; seat: left; toxicology performed; flight hours: 1,123 total, 758 in this make and model, 990 as pilot in command, 36 in the last 90 days, 15 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 180° at 7 knots - Visibility: 2 statute miles - Lowest ceiling: 800 ft overcast - Altimeter: 30.00 inHg - Observed at: APC, 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 19880107000209A](https://openairdocs.org/incident/19880107000209A), Jan 7, 1988: Piper PA28181, Napa, CA, Destroyed, 2 fatal. Weather brief VFR not advised. Not current IFR.flew into IMC.filed. Had to hold. Became confused lost control crashed. 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.