# NTSB LAX95FA105: Piper PA-32R-301T, N560LM, Ceres, CA, February 11, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 10, 1995, 19:54 local (Feb 11, 1995, 03:54 UTC) - Place: Ceres, CA - Coordinates: 37.650684, -121.13002 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.6507&lon=-121.1300&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report August 23, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28914 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95FA105 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28914/pdf - Page: https://openairdocs.org/ntsb/LAX95FA105 ## Probable cause the pilot inadvertently becoming lost/disoriented during a missed approach, his failure to follow the proper missed approach procedure, and his failure to maintain control of the aircraft due to spatial disorientation. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, missed approach (ifr) - missed approach - not followed, pilot in command (cause) - became lost/disoriented - inadvertent, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - crop ## Analysis THE PILOT EXECUTED A MISSED APPROACH IN INSTRUMENT METEOROLOGICAL CONDITIONS. A GROUND WITNESS BRIEFLY OBSERVED THE AIRPLANE PROCEEDING IN AN OPPOSITE DIRECTION OF THE FINAL APPROACH COURSE ON A FLIGHT PATH NOT IN ACCORDANCE WITH THE MISSED APPROACH. THE AIRPLANE ABRUPTLY ENTERED INTO A 90-DEGREE BANKING TURN AND DISAPPEARED INTO THE CLOUDS. THE AIRPLANE CRASHED IN A NEAR-VERTICAL DESCENT ATTITUDE MOMENTS LATER. THE PILOT'S LAST COMMUNICATIONS TO THE LOCAL CONTROLLER WERE UNINTELLIGIBLE. THE WRECKAGE EXAMINATION SHOWED THAT THE MAIN LANDING GEARS WERE IN TRANSIT. THERE WAS NO EVIDENCE OF ANY AIRPLANE OR ENGINE PREEXISTING MALFUNCTIONS OR FAILURES. ## Factual narrative HISTORY OF FLIGHT On February 10, 1995, at 1954 hours Pst (all times in this report are Pacific standard time based on the 24-hour clock), a Piper PA-32R-301T, N560LM, crashed in an almond grove in Ceres, California. The crash site is about 3 miles southeast of Harry Sham Field, Modesto, California. The pilot obtained an instrument flight rules (IFR) clearance and was executing an instrument landing system (ILS) approach to Harry Sham Field, runway 28R. The airplane, registered to and operated by the pilot, was destroyed by impact forces and the resulting postcrash fire; several almond trees were destroyed. The certificated private pilot and his passenger sustained fatal injuries. Instrument meteorological conditions prevailed. The flight departed Phoenix, Arizona, metropolitan area from an undetermined airport at an undetermined time. The pilot's family told National Transportation Safety Board investigators that he and his wife departed Modesto for Phoenix on February 6, 1995. On February 10, 1995, the pilot called his secretary and told her that he would be returning to Modesto that day, but he was intending to stop in the Los Angeles, California, area and conduct some business. The Federal Aviation Administration (FAA) air traffic division records show that the pilot obtained a weather briefing from Prescott (Arizona) Flight Service Station at 0614 hours. At 1607 hours, the pilot contacted the Luke Air Force Base (AFB) radar approach control. The sector controller had received an automated handoff from the Phoenix Terminal Radar Approach Control (TRACON) at 1604 hours. Later, the pilot requested and received VFR flight following to Modesto, California. The pilot received subsequent radar flight following services from Albuquerque (New Mexico) Air Route Traffic Control Center (ARTCC), Los Angeles ARTCC, Joshua Approach Control (formally Edwards AFB Approach Control), High Desert TRACON, Bakersfield (California) Approach Control and the Lemoore Naval Air Station Approach Control. At 1847 hours, the pilot requested and received an IFR clearance to Modesto from the Lemoore sector controller. At 1904 hours, the Lemoore sector controller handed off the flight to the Oakland ARTCC sector 22 controller. At 1911 hours, the pilot informed the sector 22 controller that he was beginning a descent to 6,000 feet (all altitudes, unless otherwise noted, are mean sea level altitudes). At 1911 hours, the sector 22 controller advised the pilot to contact Castle AFB approach control. The pilot acknowledged and complied with the instructions. At 1924 hours, the controller instructed the pilot to maintain 3,000 feet. The controller then provided the pilot with multiple radar vectors to the Modesto (Harry Sham Field) runway 28 ILS final approach course. At 1947 hours, the controller cleared the flight for an approach and instructed the pilot to contact Modesto tower. At 1950:46 hours, the pilot initially contacted the Modesto tower local controller and said that he was over the ILS outer marker. The controller responded, in part, " . . . saratoga zero lima mike (0LM), runway 28R, cleared to land." The pilot did not respond. At 1953:30 hours, the local controller instructed the pilot to report the field in sight. The pilot response (at 1953:34 hours) was unintelligible. There were no other communications between the pilot and the local controller. The local controller told investigators that he did not observe the postcrash fireball. A ground witness told Stanislaus County Sheriff's deputies that he heard an airplane, looked up, and saw the beacon light of a small airplane flying in an easterly direction. The airplane suddenly made a 90-degree left banking turn and that the engine sounds diminished during the turn. The airplane disappeared in the fog and he could no longer see the airplane's rotating beacon or navigation lights. About 10 seconds after the airplane made the sudden left turn, the witness said he felt the ground shake followed by a " . . . ball of flames . . . ." PERSONNEL INFORMATION The pilot held a private pilot certificate with airplane single- engine land and instrument airplane ratings. He also held an unrestricted third-class medical certificate issued by an FAA designated airman medical examiner on November 1, 1993. Safety Board investigators recovered remnants of the pilot's flight hours logbook(s). The logbook(s) condition prevented investigators from determining the pilot's total flight hours or his recency of instrument flight experience. Current federal air regulations require that a pilot accrues 6 instrument flight hours within the preceding 6 months of any instrument flight. Three hours of the required instrument flight experience can be flown in a simulator. The Modesto Flight Center provided flight training for the pilot. The pilot's initial instrument flight instructor said that she provided flight instruction between 6 and 7 years before the accident. She had not flown with the pilot for about 3 years. Another flight instructor gave the pilot a biennial flight review about 18 months before the accident. This was the last instruction that the pilot received from Modesto Flight Center. AIRCRAFT INFORMATION The FAA records show that the airplane was initially registered to the pilot on May 24, 1989. According to the pilot's family, Jolliff Aviation, Modesto Airport, maintained the airplane. The family said that Jolliff Aviation accomplished an annual inspection on the airplane before the pilot departed on the accident flight. The owner of Jolliff Aviation told investigators that the pilot retained him to pick up the airplane from his hangar for an annual inspection on February 3, 1995. On February 6, 1995, the pilot called the owner and told him he was going on a trip and that he would need the airplane. The owner told the pilot that he was just beginning the inspection, but he would end the inspection and return the airplane to service. The owner also said that he accomplished the airplane/engine last annual inspection " . . . sometime in February 1994." Jolliff Aviation records, however, show the airplane's initial annual inspection was initiated on January 20, 1994. The owner could not provide any records showing the date the annual inspection was done. The annual inspection work order does not show that the inspection was delayed due to parts back order or any other reason. At the time of the last recorded inspection, the airplane accrued 1,302 hours. AIDS TO NAVIGATION On February 11, 1995, the FAA Airways Facilities Division conducted an operational check on the Modesto Airport instrument landing system. The instrument landing system was found within the specified operational limitations. The pilot of Sundance flight 874, which preceded the accident airplane on the ILS, reported that his ILS approach " . . . was made with no abnormal deviations in electronic guidance, or adverse weather . . . ." The FAA, Western-Pacific Region Air Traffic Division, AWP-505, provided the Safety Board with radar data (National Track Analysis Program (NTAP)) from the Oakland (California) Air Route Traffic Control Center (ARTCC). Review of the data showed that the last radar hit on the airplane was at 1916:46 hours and about 51 nautical miles southeast of the accident site. The FAA quality assurance specialist said that the Oakland radar specialist provided the radar information for the airplane's specific discrete transponder code while being provided radar flight following services by Oakland ARTCC. The Castle AFB radar controller changed the transponder code on the airplane, but this code was not entered into the computer during the data retrieval. Unfortunately, the radar tape was returned to service and further radar data on the accident airplane is no longer available. WRECKAGE AND I ## Aircraft - Registration: [N560LM](https://openairdocs.org/deregistered/N560LM-1995-07-27), registration cancelled 1995-07-27, S/N 32R8229002 (OpenAirDocs) - Reported make and model: PIPER PA-32R-301T (PA-32R-301) - Registry model: [Piper PA-32R-301T](https://openairdocs.org/model/piper-pa-32r-301t) (registry code 7103220) (OpenAirDocs) - Category: Airplane - Serial number: 32R-8229002 - Engines: LYCOMING TIO-540-S1AD 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Davis, Larry Ray And Mary - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 20, 1994 - Departed: PHOENIX, AZ - Destination: MOD - Airport: MOD, Harry Sham Field, runway 28R, 5,911 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 1,300 total ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 170° at 4 knots - Visibility: 2 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 50 °F, dew point 48 °F - Observed at: MOD, 3 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 19950211001499A](https://openairdocs.org/incident/19950211001499A), Feb 11, 1995: Piper PA32R301T, Modesto, CA, Destroyed, 2 fatal. Struck almond trees on ILS approach. Appears lost control during banking and gear extension. Burned on impact. 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.