# NTSB LAX90FA031: Piper PA-28R-200, N2723R, Camarillo, CA, November 13, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: November 12, 1989, 21:40 local (Nov 13, 1989, 05:40 UTC)
- Place: Camarillo, CA
- Coordinates: 34.230091, -119.069274 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.2301&lon=-119.0693&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed, report July 29, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 26602
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX90FA031
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26602/pdf
- Page: https://openairdocs.org/ntsb/LAX90FA031

## Probable cause

IMPROPER IFR PROCEDURE BY THE PILOT, AND HIS FAILURE TO MAINTAIN THE MINIMUM DESCENT ALTITUDE (MDA) FOR THAT SEGMENT OF THE VOR APPROACH.  FACTORS RELATED TO THE ACCIDENT WERE:  DARKNESS, LOW CEILING, FOG, HAZE, THE PILOT'S LACK OF RECENT INSTRUMENT EXPERIENCE, AND HIS PROBABLE SPATIAL DISORIENTATION.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- In flight collision with terrain/water, approach - iaf to faf/outer marker (ifr)
  - light condition - dark night (contributing factor)
  - weather condition - low ceiling (contributing factor)
  - weather condition - fog (contributing factor)
  - weather condition - haze/smoke (contributing factor)
  - ifr procedure - improper, pilot in command (cause)
  - minimum descent altitude - not maintained, pilot in command (cause)
  - lack of recent instrument time, pilot in command (contributing factor)
  - spatial disorientation, pilot in command (contributing factor)

## Analysis

DRG A NIGHT ARRIVAL, THE PLT CONTACTED NAS POINT MUGU APCH CTL & WAS CLRD FOR A VOR RWY 26 APCH.  AS THE PLT CONTD THE APCH, THE ACFT VEERED RADICALLY OFF COURSE TO THE RIGHT & DSCNDD PREMATURELY.  THE CTLR ISSUED A SAFETY ALERT & TOLD THE PLT TO TURN LEFT TO A HEADING OF 210 DEG & TO CLIMB & MAINT 2100 FT.  THE PLT ACKNOWLEDGED, BUT FAILED TO TAKE ADEQUATE CORRECTIVE ACTION.  SUBSEQUENTLY, THE ACFT COLLIDED WITH MOUNTAINOUS TERRAIN AT AN ELEVATION OF ABOUT 1100 FT, AS IT WAS APCHG THE FINAL APCH FIX (FAF).  MIN DSCNT ALT (MDA) ON THAT SEGMENT OF THE APCH WAS 2100 FT MSL.  APRX 10 MI SW AT POINT MUGU (ELEV 12 FT), THE 2155 PST WX WAS IN PART:  1000 FT OVC, 6 MI VIS WITH FOG & HAZE.  THE PLT HAD BEEN ISSUED AN INSTRUMENT RATING ON 4/28/89.  SINCE THAT DATE, HE HAD LOGGED ONLY 5.5 HRS OF INSTRUMENT TIME & 4 INSTRUMENT APCHS.

## Aircraft

- Registration: [N2723R](https://openairdocs.org/deregistered/N2723R-1992-05-01), registration cancelled 1992-05-01, S/N 28R35269 (OpenAirDocs)
- Reported make and model: PIPER PA-28R-200
- Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs)
- Category: Airplane
- Serial number: PA-28R-35269
- Airframe hours: 3792
- Engines: LYCOMING IO-360-C1C 200 horsepower reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Registered owner: Frederick Steuer
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, April 1, 1989, 57 hours before
- Departed: VNY, VAN NUYS, CA
- Destination: CMA, CAMARILLO, CA
- Flight plan: IFR
- Airport: CMA, Camarillo, runway 26, 6,010 × 150 ft, concrete

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 53; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 380 total, 320 in this make and model

## Weather

- Conditions: Instrument (IMC), Night/dark
- Wind: 20° at 6 knots
- Temperature: 61 °F, dew point 54 °F
- Altimeter: 30.00 inHg
- Observed at: NTD, 10 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 19891112046519A](https://openairdocs.org/incident/19891112046519A), Nov 12, 1989: Piper PA28R200, Camarillo, CA, Destroyed, 1 fatal. Off course and below msa on a VOR approach collided with mountain.

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.

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