# NTSB LAX91FA138: Piper PA-28R-201T, N2776M, Vacaville, CA, March 20, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: March 19, 1991, 22:20 local (Mar 20, 1991, 06:20 UTC)
- Place: Vacaville, CA
- Coordinates: 38.410739, -122.009315 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.4107&lon=-122.0093&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report May 28, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 26989
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX91FA138
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26989/pdf
- Page: https://openairdocs.org/ntsb/LAX91FA138

## Probable cause

THE PILOT'S CONTINUED VFR FLIGHT AT NIGHT UNDER LOW CLOUDS, AND HIS FAILURE TO MAINTAIN SUFFICIENT ALTITUDE OVER RISING TERRAIN.  FACTORS RELATED TO THE ACCIDENT WERE: DARKNESS, THE ADVERSE WEATHER AND TERRAIN CONDITIONS, AND THE CONTROLLER'S INACCURATE RESPONSE TO THE PILOT'S COMMENT ABOUT FLYING OVER FLAT TERRAIN.

## Sequence of events

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

- In flight encounter with weather, cruise - normal
  - light condition - dark night (contributing factor)
  - terrain condition - rising (contributing factor)
  - weather condition - clouds (contributing factor)
  - weather condition - low ceiling (contributing factor)
  - flight into known adverse weather - continued, pilot in command (cause)
- In flight collision with terrain/water, cruise
  - terrain condition - mountainous/hilly (contributing factor)
  - proper altitude - not maintained, pilot in command (cause)
  - information unclear, atc personnel(dep/apch) (contributing factor)

## Analysis

BFR FLT AT NGT, PLT RCVD 2 WX BRIEFINGS & FILED VFR FLT PLN. LOW CIGS PREVAILED ALONG RTE. ABT 7 MIN AFTER TKOF, PLT OPENED FLT PLN & RCVD VFR ADZY FM OAKLAND CTR WITH HANDOFF TO TRAVIS RAPCON. AFTER DISCUSSION ABT RTE, RADAR CTLR PROVIDED VECTOR OF 050 DEG. AT 2216:15, CTLR TOLD PLT RADAR CTC WAS LOST DUE TO ACFT'S LOW ALT & SUGGESTED A CLIMB 'AT LEAST ABOVE 3000 FT.'  AT ABT 2216:55, RADAR CTC WAS REACQUIRED & CTLR TOLD PLT HE WAS 8 MI NORTH OF NAPA; TO THIS, THE PLT TRANSMITTED, 'OK, (PAUSE) ITS ALL FLAT COUNTRY OUT HERE I THINK ISN'T IT' & THE CTLR REPLIED 'YEA.'  AT 2218:19, CTLR ISSUED HDG OF 080 DEG & ASKED ABT ACFT'S ALT. WHEN PLT SAID 2500', CTLR ADZD 2900' MTN WAS ABT 1 MI RGT OF COURSE. AT 2219:45, CTLR ADZD MTN PEAK WAS LESS THAN 1 MI NE OF ACFT. PLT INDCD HE WOULD TURN LEFT, BUT SOON THEREAFTER, ACFT CRASHED NR TOP OF A RIDGE AT 2450 FT MSL. APRX 12 MI ESE AT TRAVIS AFB (ELEV 62 FT), 2155 PST WX WAS IN PART: 1200' SCT, 2500' SCT, 5000' OVC, & VIS 7 MI WITH LGT RAIN.

## Aircraft

- Registration: [N2776M](https://openairdocs.org/deregistered/N2776M-1991-07-08), registration cancelled 1991-07-08, S/N 28R7803144 (OpenAirDocs)
- Reported make and model: PIPER PA-28R-201T (PA-28R-201)
- Registry model: [Piper PA-28R-201T](https://openairdocs.org/model/piper-pa-28r-201t) (registry code 7102813) (OpenAirDocs)
- Category: Airplane
- Serial number: 7803144
- Engines: CONTINENTAL TSIO-360-F 200 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Business, Part 91
- Operator: Physical Therapy & Wellness Ct
- Registered owner: Physical Therapy & Wellness Ct
- Last inspection: Unknown, January 2, 2000
- Departed: HWD, HAYWARD, CA
- Destination: DAVIS, CA
- Flight plan: VFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 76; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; toxicology performed; flight hours: 21,000 total, 25 in the last 90 days

## Weather

- Conditions: Instrument (IMC), Night/dark
- Wind: 180° at 10 knots
- Temperature: 48 °F, dew point 46 °F
- Observed at: SUU, 12 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 19910319006559A](https://openairdocs.org/incident/19910319006559A), Mar 19, 1991: Piper PA28R201T, Vacaville, CA, Destroyed, 2 fatal. Impacted a cloud obscured mountain just below a ridge. Appeared uncertain of terrain in area.

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.