# NTSB LAX96FA067: Cessna 340A, N37324, San Dimas, CA, December 7, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 7, 1995, 06:24 local (14:24 UTC) - Place: San Dimas, CA - Coordinates: 34.099864, -117.810157 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.0999&lon=-117.8102&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report January 8, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 29243 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX96FA067 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29243/pdf - Page: https://openairdocs.org/ntsb/LAX96FA067 ## Probable cause the pilot's impairment of judgment and performance due to drugs, his resultant improper planning/decision, his failure to follow proper IFR procedures, and his failure to maintain proper altitude during a missed approach. Factors relating to the accident were: the pilot's inadequate weather evaluation, and the adverse weather condition (below landing minimums). ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, missed approach (ifr) - planning/decision - improper, pilot in command (cause) - impairment(drugs), pilot in command (cause) - light condition - dawn - weather condition - below approach/landing minimums - weather evaluation - inadequate, pilot in command (contributing factor) - missed approach - initiated, pilot in command - ifr procedure - not followed, pilot in command (cause) - object - tree(s) - object - building(nonresidential) - proper altitude - not maintained, pilot in command (cause) ## Analysis The pilot departed his home base in VFR conditions without filing a flight plan and did not request or receive a preflight or en route weather briefing from the FAA. While en route, he contacted Southern California TRACON (SOCAL) and requested an ILS runway 26 approach to the destination airport. SOCAL cleared the pilot for the approach and to change to an advisory frequency. There was no current weather report available at the airport because the tower was closed, but another pilot who was on the same frequency stated that the airport weather was 'zero zero.' (An automated weather observation system at the airport recorded 'zero zero' conditions near the time of the accident.) Ground witnesses heard the airplane as the pilot began a missed approach. However, the airplane collided with trees and a snack bar building about 1/4 mile northwest of the departure end of the runway. Impact occurred as the airplane was in a right turn through a heading of 345 degrees, which was the opposite direction of turn for the missed approach procedure. Toxicology test of the pilot's blood showed 1.518 mcg/ml Fenfluramine and 0.678 mcg/ml Phentermine; these are appetite suppressant drugs that are chemically related to amphetamines and have a high incidence of abuse. Neither of these drugs was approved by the FAA for use while flying aircraft. The amount of Fenfluramine in the pilot's blood was above a normal level for control of appetite. ## Factual narrative HISTORY OF FLIGHT On December 7, 1995, about 0624 hours Pacific standard time, a Cessna 340A, N37324, was destroyed during a missed approach to the Brackett Airport, La Verne, California. The pilot, the sole occupant, received fatal injuries. Instrument meteorological conditions prevailed for the State of California business flight which originated at Big Bear Lake, California, on the morning of the accident. No flight plan had been filed. There was no record of a preflight weather briefing given by an Federal Aviation Administration (FAA) facility prior to the flight. According to an FAA voice transcript, the pilot contacted Southern California Tracon (SOCAL) after departure from Big Bear. He stated that he had the Ontario weather and was requesting an ILS into Brackett Field. The pilot was assigned a transponder code of 0202. The pilot of a Beech Baron that had just departed from Brackett stated on the frequency that "It's zero zero right now". The accident pilot responded "have you been in there?" The Baron pilot responded "just took off from there." SOCAL questioned the Baron pilot regarding the Cable Airport weather. He stated that Cable may be VFR and there was no fog there. At 0614, SOCAL cleared the pilot for the ILS runway 26L approach when the aircraft was 9 miles east of the final approach fix. The pilot was cleared to change to the Brackett tower frequency 118.2 for traffic advisories and 125.5 in case of a missed approach. The Brackett air traffic control tower (ATCT) was not open at the time of the accident. At 0646, the ATCT Limited Aviation Weather Reporting Station (LAWRS) recorded the weather as sky obscured, indefinite ceiling zero, and zero visibility in fog. Local area witnesses confirmed the weather condition. The aircraft subsequently collided with trees and a building about 1/4 mile northwest of the departure end of runway 26L in a recreational park area of San Dimas, California. An on-scene FAA inspector interviewed two witnesses who were cleaning aircraft at the southeast corner of the airport near the time of the accident. They reported that a twin engine aircraft had made two attempts at landing on runway 26L. They also stated that the aircraft sounded quite low or near the runway surface, but due to the fog they could not see the aircraft. They said that each time the aircraft passed abeam of them they would then hear the power being applied for a missed approach. The pilot of the Beech Baron that departed about 30 minutes prior to the accident stated that the tops of the fog at the time of his departure were ragged. He estimated them to be 1,600 feet msl. A witness/pilot located south of the runway in the East Shore RV Park reported hearing an aircraft fly low over his location about the time of the accident. Another witness/pilot located at his residence about 2,000 feet from the west end of the runway stated that he heard the aircraft do a missed approach or a late go-around about midfield. PERSONNEL INFORMATION According to the pilot logbooks that were reviewed, the pilot had documented about 5,282 total flight hours. Examination of logbooks No. 3 and 4 indicated that the pilot had flown the accident airplane about 653 hours. At the pilot's last flight physical he reported a total flight time of 5,200 hours. AIRCRAFT INFORMATION The aircraft records were not recovered. Partially burned remnants of a propeller logbook, serviceable parts tags, and FAA form 337 were found at the accident site. Also found were an outdated registration certificate and operating limitations for an experimental category that the aircraft had been put into during an application process for a supplemental type certificate in 1991. Subsequently, the airplane was put back into a normal category. During the course of the investigation, the FAA aircraft records archived in Oklahoma City, Oklahoma, indicated the aircraft was still in the experimental category. WRECKAGE AND IMPACT INFORMATION The accident site was located in the Frank G. Bonelli Regional County Park, about 2,000 feet northwest of the departure end of runway 26L. The wreckage path was oriented at 345 degrees magnetic over a distance of about 633 feet. The farthest airplane component of the wreckage was found about 1,100 feet north from the runway extended centerline. The accident site elevation is about 1,060 feet msl. The entire airframe and it's components were accounted for at the accident site. At the beginning of the wreckage path the first point of contact was a 40-foot-tall pine tree. Broken branches and paint chips with fiberglass were found on the ground beneath the tree. About 196 feet further along the wreckage path, an oak tree was located with numerous aircraft parts commingled in the branches. The parts were from the right wing and wing tip fuel tank. In the tree and on the ground were located several 3- and 4-inch cut logs about 26 inches long. In the tree branches was the beginning of a picnic patio roof structure where the right aileron and other right wing parts were found. A portion of the right wing tip fuel tank tail cone and a right wing flap section were located on the patio ground slab. The next major component of the aircraft was the right engine and its propeller which were found inside the snack bar building. A postcrash fire consumed the interior of the building with resultant fire damage to the engine and propeller. The propeller blades were melted. A portion of the right outboard wing leading edge was located at the west corner of the building. Just north of the snack bar building was a mobile building with minor damage to the east end where the right engine vacuum pump was located. The spline portion of the drive coupling was missing, however, the remaining part of the coupling at the pump body was intact. The pump chamber cover was missing and the interior of the pump was without vanes or vane body. The major portion of the fuselage, empennage, and the left wing structure were located near an embankment where a postcrash fire had burnt in the area of the left nacelle fuel tank and the wing aft spar area. The left engine with it's propeller was located 633 feet from the initial impact area. The propeller was missing two blade tips. The landing gear actuator was examined and was found to be in the up position, as was the landing gear selector switch. The right main landing gear was found in the up position. The airplane was equipped with an after market "Fowler Flap" system. The right flap actuator was extended 4.8 inches. The left actuator was broken in the mid-screw position. The flap switch was found in the up position. The instrument indications were documented on-scene. The radar altimeter decision height "bug" or indicator was found set at 210 feet agl. The pilot's electric altimeter was indicating 1,060 feet msl; 29.98 inHg; and with the power off flag displayed. The horizontal situation indicator (HIS) heading bug was found at 251 degrees. The compass card was indicating 002 degrees. The omni bearing selector (OBS) was indicating 258 degrees. All HIS warning flags were displayed. The No. 2 radio OBS was indicating 300 degrees. (For more instrument indications and switch positions refer to supplement B of this report.) Due to the fragmentation of the airframe, complete control continuity was not established. AIRPORT INFORMATION On December 8, 1995, the ILS runway 26L approach was flight checked by the FAA. The results of the check were satisfactory for all systems including lighting. FAA forms 8240-7 and 17 are attached. During a personal interview of the airport manager, he stated that the runway end identifier lights (REIL) may have been out of service on the morning of the accident. He stated that there had been a problem with them and an electrician had been called. The light prob ## Aircraft - Registration: [N37324](https://openairdocs.org/deregistered/N37324-1997-01-24), registration cancelled 1997-01-24, S/N 340A0348 (OpenAirDocs) - Reported make and model: Cessna 340A - Registry model: [Cessna 340A](https://openairdocs.org/model/cessna-340a) (registry code 2076405) (OpenAirDocs) - Category: Airplane - Serial number: 340A0348 - Engines: Continental TSIO-520-N 310 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Hugh J. Gallagher - Airworthiness certificate: Standard, Normal - Departed: L35, BIG BEAR LAKE, CA - Destination: POC, LA VERNE, CA - Airport: POC, Brackett Airport, runway 26L, 4,833 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 5,282 total, 653 in this make and model ## Weather - Conditions: Instrument (IMC), Dawn - Altimeter: 30.00 inHg - Observed at: POC, 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 19951207040109A](https://openairdocs.org/incident/19951207040109A), Dec 7, 1995: Cessna 340A, La Verne, CA, Destroyed, 1 fatal. Public use 340 collided with trees and building on missed approach. Weather below minimums known by pilot. 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.