LAX96FA050

NTSB accident investigation · Piper PA-32-300 · Fullerton, CA · November 20, 1995

Accident · FatalField investigationFinal report
Date
November 20, 1995, 06:34 local (14:34 UTC)
Place
Fullerton, CA
Injuries
3 fatal; on the ground: 1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N888JKPiper PA-32-300
Weather
Instrument (IMC) · Day
Status
Completed · report August 20, 1996
Report
Approved by Office Director
FAA report
19951120037809A
Case key
29241

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the pilot-in-command's failure to follow IFR procedures in that he descended below the minimum descent altitude and failed to execute a missed approach. Contributing to the accident was the pilot-in-command's self-induced pressure to get to work.

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.

In flight collision with objectApproach - faf/outer marker to threshold (ifr)
Operation with known deficiencies in equipment - attemptedPilot in command(cfi)
Overconfidence in personal abilityPilot in command(cfi)
Weather condition - below approach/landing minimumsFactor
Minimum descent altitude - belowPilot in command(cfi)Cause
Ifr procedure - not followedPilot in command(cfi)Cause
Missed approach - not performedPilot in command(cfi)Cause
Self-induced pressurePilot in command(cfi)Factor

Analysis

The noninstrument-rated pilot and CFII were on a localizer instrument approach. The airplane did not have a DME, and the pilots had requested and were advised by approach control when they were over the final approach fix. The airplane descended below the minimum descent altitude and collided with a telephone pole and an apartment building about 1 mile short of the runway. The weather was indefinite 100 feet, with visibility 1/4 mile in fog. The paraplegic CFII required special rudder controls to fly the airplane; the airplane was not equipped with the controls. The CFII was due at his normal workplace near the airport about 25 minutes after the accident time. One person on the ground was fatally injured.

Factual narrative

History of flight

On November 20, 1995, at 0634 hours Pacific standard time, a Piper PA-32-300, N888JK, was destroyed during an instrument approach to the Fullerton, California, airport. Both pilots and one person on the ground were fatally injured. Instrument meteorological conditions prevailed at the time. The flight had originated at Big Bear, California, on the morning of the accident. No flight plan had been filed for the personal flight.

After departure from Big Bear, the airplane was radar identified by Southern California Approach Control (SOCAL) when it was 4 miles northwest of the Redlands airport. The aircraft was assigned an initial transponder code of 0232. The controller requested to verify that the airplane was descending out of 7,000 feet. A pilot from the accident airplane responded with a pause, and then a request to standby. The pilot responded to SOCAL stating that they were out of 7,200 feet. The SOCAL controller responded their radar return indicated 7,000 feet, even with the Ontario altimeter of 30.07 inHg.

A request for an instrument approach into Fullerton had been made while en route. SOCAL had cleared the aircraft for the localizer runway 24 approach. The Fullerton air traffic control tower was not open at the time of the accident. FAA personnel in the tower made a weather observation at 0655 hours. They reported the weather as indefinite ceiling 100 foot, with a 1/4 mile visibility in fog. An on-scene witness reported the visibility at 0630 was about 75 to 100 feet.

About 0626:35, the pilot contacted SOCAL and reported "juliet kilo is level 3,000, 14 DME out from on the localizer at Fullerton we would like that inbound please." The aircraft was then assigned a second transponder code of 0105. The controller advised the pilot that the Fullerton weather was not available and proceeded to give the pilot the John Wayne altimeter setting of 30.08 inHg. The controller further stated "at John Wayne and Long Beach its pretty bad Long Beach is worse than Orange County." The pilot advised approach that if they missed the approach they would go to John Wayne.

About 0628:07, the pilot was cleared for the approach into the Fullerton airport when 7 miles east of the final approach fix "Qewti". The pilot requested that the controller advise him when he was over "Qewti". Subsequently, the pilot was advised that he was over "Qewti" at 0631:40. About 2 minutes later, the aircraft collided with trees, poles, and an apartment building about 1 mile east of runway 24.

Personnel information

Left Seat Pilot

According to the pilot's logbook, he started taking flight instruction on December 24, 1993. He received his private pilot's license on December 22, 1994. The last logbook entry was dated November 2, 1995. At that time, the logbook documented about 295 total flight hours.

The private pilot, a co-owner of the aircraft, had been working towards an instrument rating in the accident airplane with the right seat flight instructor (CFII). According to the pilot's logbook, he had accumulated about 14 hours of simulated instrument time and about 15 hours actual time. They occasionally flew together to their respective job locations in the Los Angeles area from Big Bear Lake. On the morning of the accident the pilot had told his wife that he was going to drive to work because of the weather.

Right Seat Pilot

The right seat pilot was an FAA certified flight instructor with airplane ratings for single engine land and instruments. He was a full-time employee for the city of Anaheim, California. The flight instructor's logbook was not recovered. At the pilot's last second-class flight physical dated April 6, 1995, he reported 1,200 total flight hours with 30 hours in the last 6 months. According to his supervisor, he was due at work at 0700 on the morning of the accident. His office location is about 6 miles southeast of the Fullerton airport.

The CFII pilot was a paraplegic and held a Statement of Demonstrated Ability (waiver). He was required to have special controls adapted to the rudder pedals to maintain full control of the airplane.

Aircraft information

A postaccident examination of the aircraft structure, systems, and powerplant was conducted with representatives of Piper Aircraft and Lycoming Aircraft Engines. The examination of the aircraft structure did not find a hand control (a major alteration/modification) to the rudder system. The installation requires an FAA form 337 and a pilot operating handbook supplement.

According to the aircraft equipment list, the distance measuring equipment (DME) had been removed 11/18/92. At that time, a Magellan SkyNav 5000 global positioning system (GPS) was installed. The installation is required to be placarded "GPS FOR VFR USE ONLY" in full view of the pilot. The instrument panel and it's markings were destroyed by postcrash fire damage.

Wreckage and impact information

The wreckage was examined on the morning of the accident. The airplane collided with a two-story apartment building about 1 mile from the approach end of runway 24 at approximatly 120 feet msl. There were initial tree and telephone impact signatures noted 20 to 30 feet higher. The engine, propeller, and cabin area were located on the second floor in a bedroom area. The wreckage and the building were partially consumed in a postcrash fire.

Between the east property line/fence and the apartment building were located wing sections from both right and left wings. A right aileron was located near the top of a telephone pole tangled in wires. Several utility wires were found laying on the ground. There were palm trees located near the property line with impact scars.

There were various airplane parts found on the roof that had not been fire damaged.

The manual flap extension handle was found latched in the full flap 40-degree position. The flaps and the actuating system were destroyed.

According to the airplane equipment list, there was an AutoControl III autopilot installed. On-scene examination of the panel area revealed a control box/navigation approach coupler switch. The switch was found in the localizer normal position. It could not be determined whether the autopilot was engaged or not.

A neighbor reported finding a propeller blade tip laying next to a curb. The tip was curled back and unburnt with some brown chordwise staining/transfer. A measurement from the tip inboard was about 1.50 inches.

The wreckage was removed the day of the accident to a storage area for further examination.

Meteorological information

The Fullerton 0655 weather observation conducted on the morning of the accident was: sky condition, indefinite ceiling vertical visibility 100 feet obscured; visibility 1/4 mile; weather, fog; temperature and dew point 54 degrees Fahrenheit; wind, calm; altimeter 30.07 inHg.

According to pilot reports, the tops of the fog deck appeared to be uniform throughout the area. At 0650, from Santa Ana, a pilot reported the tops as 700 feet msl. An air carrier out of Los Angeles reported the tops at 800 msl.

A voice tape obtained from SOCAL revealed that during a controller position change near the accident time, a recorded comment from one controller to another stated "500 foot tops at Santa Ana."

Airport information

The Fullerton Municipal Airport has one runway, 06/24. According to the Airport/Facilities Directory, the runway is 3,121 feet in length with a 253-foot displaced threshold for runway 24.

There is a localizer runway 24 instrument approach which requires either a DME or radar service to identify the three intersections of the approach and to reach the minimum descent altitude. They are: ZAROW at 10.0 miles; QEWTI (the final approach fix) at 5.6 miles; and CONGA at 2.6 miles. The DME antenna is located about .6 miles from the approach end of runway 24.

According to the inst

Aircraft

Registration
N888JK
Reported as
Piper PA-32-300
Category
Airplane
Serial number
32-7240093
Airframe hours
3,640
Engine
Lycoming IO-540-KIG5D, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Michael L. Benson
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 14, 1995 · 52 hours before
Departed
L35 · Big Bear, CA
Destination
FUL · CA
Airport
FUL · Fullerton Municipal, runway 24, 3,120 × 75 ft, asphalt

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
46
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
1,200 total · 30 in the last 90 days

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
0.25 statute miles
Lowest ceiling
100 ft
Temperature
54 °F, dew point 54 °F
Altimeter
30.00 inHg
Observed at
FUL, 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.