# NTSB LAX95FA338: Swearingen SA-226T, N693PG, Chino, CA, September 18, 1995 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Field investigation · Final report - Date: September 18, 1995, 06:24 local (13:24 UTC) - Place: Chino, CA - Coordinates: 33.999767, -117.680816 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.9998&lon=-117.6808&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report March 25, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 28940 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95FA338 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28940/pdf - Page: https://openairdocs.org/ntsb/LAX95FA338 ## Probable cause The pilot's improper IFR procedure by not initiating a missed approach at the outer marker, by attempting to intercept the glideslope from above after passing the outer marker, and by allowing the airplane to continue descending after reaching the decision height. Factors relating to the accident were: the adverse weather condition, and the approach controller's improper technique in vectoring the airplane onto the ILS localizer. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - faf/outer marker to threshold (ifr) - light condition - dawn - weather condition - fog (contributing factor) - weather condition - below approach/landing minimums - approach/departure control service - improper, atc personnel(dep/apch) (contributing factor) - ifr procedure - improper, pilot in command (cause) - proper glidepath - not followed, pilot in command (cause) - decision height - below, pilot in command (cause) - missed approach - not performed, pilot in command (cause) ## Analysis During arrival at dawn, the pilot contacted Approach Control about 22 miles from the airport at 8,500 feet and requested an ILS runway 26 approach. The ATIS was reporting 1/8 mile visibility with fog; the minimum published visibility for the ILS landing was 3/4 mile. The controller vectored the aircraft so that it intercepted the ILS localizer at the outer marker at an intercept angle that was 5 degrees greater than the maximum allowable intercept of 30 degrees. The intercept point should have been at least 3 miles further away from the airport. The aircraft was 650 feet above the ILS glideslope at the outer marker (which was outside the ILS glideslope parameter). Instead of making a missed approach, the pilot elected to continue the ILS. As he attempted to intercept the glideslope from above, the airplane entered a high rate of descent and passed through the glideslope. The pilot was arresting the descent, when the airplane collided with level terrain about 1,000 feet short of the runway. After the accident, at 0646 edt, the visibility was 1/16 mile with fog. ## Factual narrative On September 18, 1995, at 0624 hours Pacific daylight time, a Swearingen SA-226T, N693PG, collided with level terrain about 1,000 feet short of runway 26 at the Chino, California, airport while executing an ILS approach. The airplane was operated by Great Western Hotels Corporation, La Habra, California, as a positioning flight under 14 CFR Part 91 when the accident occurred. The airplane was destroyed by impact forces and a postimpact fire. The certificated commercial pilot, the sole occupant, received minor injuries. The flight originated from Apple Valley, California, about 0600 hours and was destined for Chino. Night instrument meteorological conditions prevailed at the time. At 0614:23 hours, the pilot contacted Ontario Approach Control (Norton radar sector) and requested an instrument flight rules (IFR) clearance and approach to Chino. The airplane's position was about 22 miles north of Chino at 8,500 feet mean sea level (msl). The Norton radar sector controller radar identified the aircraft at 0615:58 and cleared the pilot direct to the Paradise VOR with instructions to maintain 6,000 feet msl. At 0616:15 hours, the Norton radar sector controller instructed the pilot to contact approach (Pomona Radar Sector) on a different VHF radio frequency. The pilot contacted the Pomona radar sector controller at 0616:39 hours and reported he was descending out of 8,000 feet for 6,000 feet msl. At 0617:20, the Pomona radar sector controller instructed the pilot to descend and maintain 4,000 feet msl. The Pomona radar sector controller transmitted missed approach instructions to the pilot at 0617:43 hours. The instructions transmitted were, "November three papa gulf in the event of missed approach at chino fly heading two six zero climb and maintain three thousand departure frequency will be one two five point five." At 0617:59 hours, the pilot requested that the Pomona radar sector controller repeat the instructions. The Pomona radar sector controller repeated the instructions and the pilot acknowledged with a partial read back as follows; "ok..two six zero three thousand and one two five point five." At 0618:19 hours, the Pomona radar sector controller instructed the pilot to descend and maintain 3,200 feet msl and turn left heading 160 degrees for radar vectors for final. At 0619:14 hours, the Pomona radar sector controller told the pilot to expect vectors across the final approach course for descent. At 0619:51 hours, the Pomona radar sector controller instructed the pilot to descend and maintain 2,500 feet msl. Four seconds later the pilot read back the clearance to the newly assigned altitude of 2,500 feet. At 0620:03 hours, the Pomona radar sector controller cleared the pilot for the instrument landing system (ILS) runway 26 instrument approach procedure. The sector controller stated, " November three papa gulf your six miles from the final approach fix turn right heading two niner zero maintain two thousand five hundred until established on final cleared for the ils runway 26 approach." At 0620:13 hours, the pilot read back his approach clearance. According to the air traffic control transcript of the communications, the pilot stated, "ok do two nine zero and ah maintain two three two thousand five hundred until established and cleared thanks." At 0620:56, the Pomona radar sector controller amended the pilot's clearance and stated, "November three papa golf your var...your uh...I didnt expect such a wide turn fly heading three two zero maintain two thousand for vector to final." At 0621:04 hours, the pilot acknowledged his amended clearance. At 0621:33 hours, the Pomona radar sector controller told the pilot his position was 2 miles (east) from the final approach fix and instructed him to fly 290 degrees and maintain 2,500 feet msl until established on the final approach course and he was cleared for the approach. At 0621:44 hours, the pilot acknowledged the radar heading and the approach clearance. At 0623:16 hours, the Pomona radar sector controller told the pilot his position was 1 mile inside (west) the final approach fix and to switch to the Chino Airport Advisory frequency, but return to Pomona radar frequency to cancel his IFR flight plan. The pilot was vectored through the ILS final approach course about 5 miles east of the outer marker to permit the airplane to descend to a lower altitude. The airplane was then vectored toward the outer marker. Radar data depicted the aircraft intercepting the final approach course at the outer marker about 600 feet above the glide slope. The airplane's descent profile from the radar data indicates a loss of 1,600 feet in less than 3 miles. The airplane collided with the ground about 1,000 feet beyond the missed approach point at the middle marker. The pilot indicated he armed the localizer capture function of the autopilot as the localizer needle began to move. According to the pilot the airplane was slowing to 140 knots. The pilot stated the localizer needle was centered as the airplane crossed the middle marker and the glide slope needle indicator was above glide slope. The pilot then reported pressing the autopilot's track mode and glide slope buttons. The pilot indicated the "airplane seemed to respond normally by intercepting the localizer and pitching down to the glide slope approximately 1,200 feet per minute." Pilot Information The pilot held a commercial pilot certificate with ratings for multiengine aircraft issued on March 17, 1984. The most recent second-class medical certificate was issued to the pilot on February 27, 1995, and contained no limitations. The pilot reported his total aeronautical experience consists of about 3,282 hours, of which 346 hours were accrued in the accident airplane make and model. In the preceding 90 days before the accident, he lists a total of 67 hours flown. He also listed a total of 264 hours of actual instrument experience; 11 hours were accrued in the 90 days before the accident. Airplane Information The airplane was maintained under a manufacturer's continuous airworthiness inspection program. According to the pilot, the most recent inspection was accomplished on September 15, 1995, about 7 flight hours prior to the accident. The aircraft maintenance records were reported to be in the airplane and were destroyed by the postimpact fire. An aircraft sales brochure for the accident airplane indicated a Bendix M4C autopilot was installed. The pilot indicated during two independent interviews, one with the FAA and another with the Safety Board that a Century III autopilot had been installed prior to the accident. The pilot later indicated in his accident report, the Bendix M4C autopilot was installed. According to the manufacturers of both autopilot systems, neither system will intercept the glide slope signal from above without the pilot first making a pitch change command. For the Century III autopilot system, the glide slope deviation indicator must be deflected upward for at least 20 seconds before the logic circuit of the glide slope coupler is armed. According to the manufacturer, this assurance provides that the glide path will be intercepted from below in the normal manner and prevent inadvertent coupling from above. In the Bendix M4C system, the autopilot will only automatically capture the localizer signal. The pilot must manually select the glide slope mode when the glide slope pointer is in the center position to couple the glide slope to the autopilot. This action disengages the altitude mode of the autopilot. Also, any movement of the pitch control knob will automatically release the autopilot system from the glide slope or altitude mode. Meteorological Information The pilot received an automated telephonic weather briefing about 0530 hours. The Chino Air Traffic Control Tower (ATCT) was closed at the time and was not sche ## Aircraft - Registration: [N693PG](https://openairdocs.org/deregistered/N693PG-2013-07-30), registration cancelled 2013-07-30, S/N T207, built 1971 (OpenAirDocs) - Reported make and model: Swearingen SA-226T - Registry model: [Swearingen SA-226T](https://openairdocs.org/model/swearingen-sa-226t) (registry code 8780122) (OpenAirDocs) - Registry engine: [AiResearch TPE331 series](https://openairdocs.org/engine/airesearch-tpe331-series) (registry code 01514, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: T207 - Airframe hours: 5218 - Engines: Garrett TPE 331 840 horsepower turbo prop - Damage: Destroyed - Fire: On-Ground - Flight: Executive/Corporate, Part 91 - Registered owner: Great Western Hotels Corp - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, September 15, 1995, 7 hours before - Departed: APV, APPLE VALLEY, CA - Destination: CNO - Airport: CNO, Chino, runway 26, 4,856 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; commercial; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 3,282 total, 346 in this make and model, 2,852 as pilot in command, 67 in the last 90 days, 27 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Dawn - Wind: calm - Visibility: 0.06 statute miles - Altimeter: 29.00 inHg - Observed at: CNO, 1 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 19950918029139A](https://openairdocs.org/incident/19950918029139A), Sep 18, 1995: Swrngn SA226T, Chino, CA, Destroyed. Struck ground beyond airport during ILS approach. High sink rate. ATC failed give altimeter. Intercept inside faf. 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.