- Date
- April 23, 1993, 19:32 local (Apr 24, 1993, 02:32 UTC)
- Place
- Twin Peaks, CA
- Injuries
- 2 fatal
- Damage
- Destroyed
- Phase of flight
- Enroute
- Aircraft
- N6884PPiper PA-24-250
- Weather
- Instrument (IMC) · Day
- Status
- Completed · report August 18, 1994
- Report
- Approved by Office Director
- FAA report
- 19930423010509A
- Case key
- 28323
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
The pilot's inadvertent flight into IMC, the radar controller's issuance of incorrect terrain information, the controller's failure to issue a low altitude safety alert, and the controller's failure to provide emergency services.
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.
Analysis
Nearing completion of his flight across the U.S., and about 33 mi from his destination, the pilot descended and encountered an overcast layer. Unable to see the underlying rising mountainous terrain, and uncertain of his exact position, the pilot requested ATC assistance. He advised the controller that he had a 'hole' and was going through it. The airplane was radar identified. The controller approved the descent and advised the pilot to maintain VFR at all times. In response to the pilot's inquiry 'how low is the terrain under me right now?', the controller stated 'the terrain is no factor for you sir.' Shortly thereafter the pilot stated he was '...losing VFR.' The airplane impacted mountainous terrain at 5,550 ft MSL.
Factual narrative
Synopsis:
On April 23, 1993, at about 1932 Pacific daylight time, a Piper PA-24-250, N6884P, operated by the pilot on a personal flight, descended into instrument meteorological weather conditions and collided with mountainous terrain near the community of Twin Peaks, California. The crash site was also about three miles west of Lake Arrowhead. At the time of the accident, the private pilot was receiving radar services from an FAA controller. The airplane was destroyed by impact forces and ground fire, and the pilot and passenger were fatally injured. The flight originated at an unknown time prior to 1708,* and from an undetermined location either in Arizona, or in a state to its north/east. No flight plan was filed.
*All times used in this report are based upon the 24-hour clock and have been converted to Pacific daylight time.
History of flight:
According to the pilot's brother, days earlier the pilot had departed in the accident airplane from his Northern California home. He flew his airplane to Ocala, Florida, to visit a relative. The accident occurred during the pilot's return flight to California.
The brother stated that he resides in Southern California, and during the pilot's return flight he had planned to visit with him. The pilot's intended destination in California was the Brackett Field Airport in La Verne.
The brother reported that the pilot had departed from the Ocala Regional Airport in Florida at about noon on April 22. En route to California, the pilot had probably landed several times and may have landed in Texas. The pilot was due to arrive at the Brackett Field on April 23, between 1700 and 1800.
The airplane's route of flight was not established over the eastern and mid-continental states. Evidence of the airplane's course was found during a search for its radar track and air-to- ground communications throughout the western states within the FAA's Western-Pacific Region. The search revealed that at about 1708, when the airplane was west of Flagstaff, Arizona, the pilot had requested VFR advisories from the Los Angeles Air Route Traffic Control Center (ARTCC). As the airplane proceeded toward Southern California, the pilot made several additional contacts with air traffic controllers.
At 1845, the pilot was informed that he was 31 miles from Daggett, California, and was tracking along a west-southwesterly course. Thereafter, the pilot was directed to change to another radio frequency to continue communicating with controllers at the Los Angeles ARTCC.
During the next twenty minutes, the pilot made several contacts with radar controllers. The pilot requested and received information regarding headings to fly and his distance to Pomona. (Pomona is the name of the VORTAC (navigation aid) adjacent to Brackett Field).
At 1924:28, the pilot inquired "...Could you tell me how low I could go on the present heading I have?" The controller responded with "...Eight Four Papa right now you're in the minimum IFR altitude I could take you down to is ten thousand six hundred, I can't provide you any terrain advisories below that."
Then, at 1924:52, the pilot said "...It's pretty cloudy. I think I can get under em but I'm not sure what the bottoms are." The controller responded with: "Eight Four Papa roger ah I'm not familiar with the terrain out there.... Let me talk to Ontario Approach, we're working on a handoff and they might be able to give you some better help ah getting down. I suggest you maintain your present altitude if you don't have the terrain in sight."
At 1925:16, the pilot responded with "Eight Four Papa thanks. I'd appreciate if you could help me." At 1925:30, the controller instructed the pilot to "...contact Ontario Approach...and they should be able to give you a little better terrain advisory." The pilot acknowledged the controller's transmission and contacted the radar controller at the Ontario Terminal Radar Approach Control (TRACON) facility.
Seconds prior to the handoff, the Los Angeles ARTCC radar controller had briefed the Ontario TRACON radar controller of the pilot's situation. In part, the ARTCC controller told the Ontario controller that: "Eight Four Papa is having a hard time, says it's real smoggy out there and he can't see anything and he's getting real nervous. We're going to ship him over to you right now...." The Ontario controller acknowledged the briefing.
During the remainder of the accident airplane's flight, the pilot only communicated with Ontario TRACON. All communications were provided by the same Ontario TRACON controller. In part, the following communications ensued:
Time* agency excerpt of transmissions**
1927:01 ONTARIO Eight Four Papa Ontario Approach, you're loud and clear sir.
1927:09 PILOT Can you tell me how far I am? It's awful cloudy. I don't know if I can get through the clouds if I go much further.
1927:14 ONTARIO I'll be here to help you sir.
1928:09 PILOT Can you tell how far I am?
1928:12 ONTARIO Eight Four Papa you are exactly three three miles away from Brackett.
1928:20 PILOT Eight Four Papa has a lot of clouds under me. How low can I go where I am right now?
1928:25 ONTARIO Right now you are exactly one two miles north of the Norton Air Force Base.
1928:32 PILOT How low can I go?
1928:35 ONTARIO That depends on you sir, If you can continue a VFR descent, it is at your discretion, advise me if you cannot maintain VFR.
1928:41 PILOT I've got a hole right ahead of me. If I can go on down, I think I can go through it.
1928:46 ONTARIO Maintain VFR at all times sir. Comanche Eight Four Papa proceed as requested.
1929:03 PILOT I've got a hole. I'm going to go through it.
1929:07 ONTARIO That's approved as requested. I will maintain radar contact with you. Maintain VFR at all times. Are you IFR equipped?
1929:16 PILOT Ah yeah, but I can't do it.
1929:18 ONTARIO Okay, understand sir. That's no problem.
1929:23 PILOT How low is the terrain under me right now?
1929:26 ONTARIO The terrain is no factor for you sir. A VFR descent is approved in that area. I will keep an eye on you.
1929:44 ONTARIO If you can continue on a possible heading of one niner zero that will take you to low terrain.
1929:54 PILOT I think I've got my hole.
1929:58 ONTARIO OK. Maintain VFR at all times. Advise me if you do lose VFR. I need to know if you do lose VFR and I'll take you through the terrain.
1930:05 PILOT I think I'm losing VFR. (THIS WAS THE PILOT'S LAST RECORDED VOICE TRANSMISSION.)
1930:07 Ontario ok.
1930:44 ONTARIO Comanche Eight Four Papa off your right and approximately two and a half miles it's going to take you down to terrain features of two thousand one hundred feet.
(The Controller reported to the Safety Board during the post- crash interview that she had erred in informing the pilot that the lower terrain was to his right; she meant left. The Safety Board also noted that a 3,200-foot MSL elevation contour line existed between the airplane's position and the referenced 2,100- foot MSL terrain.)
*The listed transmission times were obtained from Ontario TRACON's transcript.
**Punctuation was added by the Safety Board. The complete FAA certified transcript is included in the Board's "Air Traffic Control Group Chairman's Factual Report."
Radar track data from the Los Angeles ARTCC indicated that from 1930:36 to 1931:00 the airplane flew along a northwesterly course. Radar data from the Ontario TRACON indicated that from about 1930:51 to about 1931:15, the airplane tracked between westerly and northerly courses.
The Los Angeles ARTCC's and the Ontario TRACON's last recorded radar hits on the airplane were at 1931:00, and at about 1931:15, respectively. Both radar facilities indicated that the
Aircraft
- Registration
- N6884P
- Reported as
- Piper PA-24-250
- Category
- Airplane
- Serial number
- 24-2020
- Engine
- Lycoming O-540-A1D5, 250 horsepower, reciprocating
- Damage
- Destroyed
- Fire
- On-Ground
- Flight
- Personal · Part 91
- Operator
- James E. Brown
- Registered owner
- James E. Brown & Ralph E. Ward
- Airworthiness certificate
- Standard, Normal
- Last inspection
- Annual · May 7, 1992
- Destination
- POC · La Verne, CA
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.
Flight crew
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 48
- Certificate
- Private
- Airplane ratings
- Single-engine land
- Medical
- Class 3, Valid Medical--w/ waivers/lim
- Toxicology
- Performed
- Flight hours
- 450 total
Weather
- Conditions
- Instrument (IMC) · Day
- Wind
- Calm
- Temperature
- 45 °F
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.
Other investigations on N6884P · 1
Matched to the same aircraft by N-number and date.