# NTSB LAX95FA062: Piper PA-28-140, N4647R, Holtville, CA, December 28, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 27, 1994, 18:23 local (Dec 28, 1994, 02:23 UTC) - Place: Holtville, CA - Coordinates: 32.830089, -115.190742 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.8301&lon=-115.1907&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report October 27, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28903 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95FA062 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28903/pdf - Page: https://openairdocs.org/ntsb/LAX95FA062 ## Probable cause the pilot's becoming lost/disoriented during a night cross- country flight at a time the flight was in a critical low fuel state, and his failure to maintain aircraft control during a go-around from an aborted precautionary landing. Factors in the accident were: 1) the pilot's inadequate inflight fuel consumption calculations; 2) his failure to refuel the aircraft; 3) his failure to use all available FAA resources once the critical flight state became apparent; 4) spatial disorientation; and 5) darkness. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, go-around (vfr) - fluid,fuel - low level - fuel consumption calculations - inadequate, pilot in command (contributing factor) - refueling - not performed, pilot in command (contributing factor) - communications/information/atc - not used, pilot in command (contributing factor) - became lost/disoriented - inadvertent, pilot in command (cause) - precautionary landing - attempted, pilot in command - terrain condition - open field - light condition - dark night (contributing factor) - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled ## Analysis WITNESSES HEARD THE ACCIDENT PILOT CALLING ON THE UNICOM FREQUENCY. HE SOUNDED AS THOUGH HE WAS HAVING DIFFICULTY LOCATING THE AIRPORT, SO ANOTHER PILOT IN HIS VICINITY SUGGESTED THAT THE ACCIDENT PILOT FOLLOW HIS AIRCRAFT TO THE AIRPORT. THE ACCIDENT PILOT AGREED, BUT AFTER THE OTHER PILOT ARRIVED AT THE AIRPORT THE ACCIDENT PILOT STILL FAILED TO LAND. WITNESSES HEARD HIM SAY THAT HE WAS LOW ON FUEL AND THAT HE WOULD HAVE TO DO SOMETHING. THE PILOT SAID HE COULD NOT FIND THE AIRPORT, BUT WOULD LAND ON THE HIGHWAY IF NECESSARY. THE PILOT REPORTED THAT HE WAS SWITCHING TANKS FOLLOWED BY 'WE'RE GOING TO CRASH, WE'RE GOING TO CRASH, WE'RE CRASHING.' A WITNESS REPORTED THAT THE AIRCRAFT ATTEMPTED A LANDING ON THE INTERSTATE, BUT THEN BEGAN A CLIMBING RIGHT TURN UNTIL IT BEGAN A DESCENT AND CRASHED. THE WITNESS SPOTTED FLAMES AND IMMEDIATELY RAN TO THE LOCATION. HE DESCRIBED THE WEATHER AT THE ACCIDENT SITE AS CLEAR BUT VERY DARK. ## Factual narrative HISTORY OF FLIGHT On December 27, 1994, at 1823 Pacific standard time, a Piper PA-28-140, N4647R, collided with desert terrain during a precautionary landing attempt on an interstate highway near Holtville, California. Based on weather reports from a local airport and a ground witness, marginal visual flight rules (VFR) conditions with visibility restricted by ground fog existed at the intended destination. The aircraft was destroyed in the crash sequence and postcrash fire. The pilot and passenger sustained fatal injuries. The flight originated at Palo Alto, California, at approximately 1400 on the day of the accident and was reportedly destined for Yuma, Arizona. At approximately 1735 a witness pilot (No. 1), who was also inbound to Imperial from the north, contacted UNICOM on 122.7. He advised Imperial traffic that he was at 8,000 feet over Salton City and requested landing information. Imperial UNICOM reported "visibility 1 1/2 miles, winds calm, runway 32 in use." About this time, he heard the accident pilot also calling Imperial UNICOM. He reported his position as 38 miles north of the Imperial VOR at 7,000 feet. During his radio transmission, he asked "what visibility 1 1/2 miles meant." The witness pilot (No. 1) of the first aircraft thought the accident pilot sounded inexperienced, so by radio he offered to try to help direct him to the Imperial airport. He asked the accident pilot to turn on his landing light so that he could verify his position. The accident pilot complied, and his location was identified by the witness pilot (No. 1) as being approximately 5 miles behind his aircraft on approximately the same inbound heading. He asked the accident pilot if he could see the white strobe on his tail and he replied that he could. The witness pilot (No. 1) then advised him to follow the strobe and he would lead him to the airport. As they proceeded inbound, the witness pilot (No. 1) continued to describe prominent landmarks to the accident pilot in order to help him identify Imperial airport. He described the accident pilot's responses as confused, disoriented, and generally unresponsive. As the accident pilot continued inbound towards the Imperial airport, he reported his altitude as 4,000 feet, and that he could only see fog. The witness pilot (No. 1) encouraged him to descend so that he would be able to see the airport. Believing the accident pilot was still behind him, the witness pilot (No. 1) continued on to his destination, landing at Imperial airport at 1750. After landing he became more concerned, because although the airport had been VFR when he landed, he could see a fog bank about 1 1/2 miles to the northeast which was moving toward the airport. Although the accident pilot had been communicating in what was described as a "normal" tone and did not sounded overly concerned about his situation, the witness pilot (No. 1) now realized that the situation could actually be more serious than he had originally judged. After waiting approximately 25 minutes for the arrival of the accident pilot, he concluded that he had possibly mistaken his suggestion and had flown toward the white strobe at the Brawley airport instead following the strobe on his aircraft. At this time, he began having trouble maintaining air-ground communications between himself and the accident pilot. About 1815 witness pilot (No. 1) heard an Ameriflite pilot taking off from Imperial. He told the pilot that there was an aircraft in the area that was having difficulty in finding the airport and asked that he help by relaying radio transmissions. The Ameriflite pilot (witness pilot No. 2) advised the accident pilot that the Calexico/Mexicali area looked clear and suggested either of those airports as alternate destinations. The accident pilot had not been responding directly to any proposed suggestions, but instead kept asking: "Do you see me?" He was then heard saying that he had only "10 minutes of fuel left," followed by the statement that he had "5 minutes of fuel" remaining and that he would have to do something. A few moments later, he was heard saying "I can't find the place, I'm going to Yuma". At that time he reported his altitude as 4,000 feet and asked "How far is Yuma?" Witness pilot (No. 1) advised him that Yuma was about 60 miles away and to land on the interstate highway if he could not find the airport. The accident pilot next reported that he was eastbound at 500 feet over the interstate and that he was going to land on the freeway. Witness pilot (No. 1) cautioned him not to land on the dirt, and the pilot replied that he would land on the freeway. The last transmissions from the accident pilot were "I'm switching tanks," followed by "we're going to crash, we're going to crash, we're crashing." Witness pilot (No. 1) reported that he heard a woman's voice in the background. There were no further transmissions from the accident pilot. A witness who was living in a motor home approximately 1/4-mile north of the accident site, reported that while looking out his window he observed an aircraft with its landing lights illuminated attempt, what he believed was, an eastbound landing on the interstate. As the aircraft neared touchdown, it suddenly began a climbing right turn south of the freeway. The aircraft continued in the turn and then began a descent until it was lost from view. A few seconds later, the witness reported that he observed flames south of the interstate. He immediately ran to the location, which was approximately 500 feet south of the freeway. When he arrived, he found an aircraft had crashed and was on fire. He returned to the interstate and flagged down a motorist, who subsequently notified authorities. The witness described the weather at the accident site as clear but very dark. A review of radar data revealed an aircraft with an altitude encoding transponder squawking 1200. At 1807 the aircraft was observed on a southeasterly descent from 6,200 feet msl. After passing to the east of the Imperial airport, the aircraft proceeded to maneuver in that area before turning eastbound. As the descent continued, radar contact with the aircraft was eventually lost at 1821. At that time, the aircraft had descended to an altitude of 100 feet msl, approaching to within approximately 3.5 miles of the accident site. The accident site is approximately 100 feet below sea level. PERSONNEL INFORMATION The pilot's log books could not be located, however, the certified flight instructor (CFI) who gave him his last biannual flight review (BFR) was interviewed. He described the pilot as knowledgeable of flight procedures, but somewhat "bull-headed" in his approach to flying. It was his opinion that the pilot had attempted to make his flight from Palo Alto to Yuma non-stop which, according to the CFI, he had done successfully in the past. On this occasion he believed that he might have encountered unfavorable winds, but elected to continue until the last moment when remaining fuel became a critical factor. The CFI stated that, although the pilot had flown this route many times, he had not logged a significant amount of night flight time and it was questionable whether or not he had flown the route at night. He also reported that the pilot had been working on an instrument rating on and off for the past 5 years. AIRCRAFT INFORMATION The aircraft and engine log books could not be located, however, the Federal Aviation Administration (FAA) reported that their records showed that the aircraft engine, a Lycoming 150 hp O-320-E2A, had been replaced with a 180 hp O-360-A1A, in accordance with supplemental type certificate (STC) 739CE. METEOROLOGICAL INFORMATION According to witnesses, a localized fog bank moved over the intermediate destination during the time the pilot was attempting to locate the airport, which reduced ground visibility. Witness pilot ## Aircraft - Registration: [N4647R](https://openairdocs.org/deregistered/N4647R-1995-03-21), registration cancelled 1995-03-21, S/N 2821401 (OpenAirDocs) - Reported make and model: PIPER PA-28-140 - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Category: Airplane - Serial number: 28-21401 - Engines: LYCOMING O-360-A1A 160 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Business, Part 91 - Registered owner: Robert Alan Harris - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 2, 1994 - Departed: PAO, PALO ALTO, CA - Destination: YUM, YUMA, AZ - Airport: IPL, Imperial County Airport, runway 32, 5,304 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 5,000 total ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 350° at 5 knots - Visibility: 0.06 statute miles - Lowest ceiling: 100 ft - Temperature: 52 °F, dew point 52 °F - Altimeter: 30.00 inHg - Observed at: IPL, 22 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 19941227042329A](https://openairdocs.org/incident/19941227042329A), Dec 27, 1994: Piper PA28140, Imperial, CA, Destroyed, 2 fatal. Missed airport. Low on fuel. Tried land on highway. Unable began climbing turn. Lost reference lights. Crashed. ## Other investigations on N4647R (2) 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. - [NTSB OAK72DVA45](https://openairdocs.org/ntsb/OAK72DVA45), Feb 21, 1972: Piper PA-28 (N4647R), Caruthers, CA, substantial damage - [NTSB OAK68D0302](https://openairdocs.org/ntsb/OAK68D0302), Feb 29, 1968: Piper PA-28 (N4647R), Redding, CA, substantial damage 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.