# NTSB LAX96FA108: Piper PA-28-181, N791CR, Ramona, CA, February 8, 1996 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Field investigation · Final report - Date: February 8, 1996, 10:52 local (18:52 UTC) - Place: Ramona, CA - Coordinates: 33.069541, -116.82936 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.0695&lon=-116.8294&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report February 26, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 29258 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX96FA108 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29258/pdf - Page: https://openairdocs.org/ntsb/LAX96FA108 ## Probable cause (aircraft 2) inadequate visual lookout by the pilots of both airplanes, which resulted in their failure to see and avoid each other. ## Probable cause (aircraft 1) inadequate visual lookout by the pilots of both airplanes, which resulted in their failure to see and avoid each other. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Midair collision, descent - visual lookout - inadequate, pilot in command (cause) - visual lookout - inadequate, pilot of other aircraft (cause) - Forced landing, emergency descent/landing - Midair collision, descent - visual lookout - inadequate, pilot in command (cause) - visual lookout - inadequate, pilot of other aircraft (cause) - Forced landing, emergency descent/landing - In flight collision with terrain/water, emergency landing - terrain condition - rough/uneven ## Analysis (aircraft 2) The pilots of Piper PA-28, N791CR, and Avions Pierre Robin R.2160, N216JM, were approaching an uncontrolled airport to enter the traffic pattern and land. Before reaching the traffic pattern, both pilots heard other traffic on the common traffic advisory frequency (CTAF). As they were positioning themselves to enter a left traffic pattern at a 45-degree angle, a midair collision occurred. The PA-28 pilot said that before the collision, he made a radio transmission announcing his position and intentions to land on runway 27. Moments later, he saw a 'blue and white flash' to his right and below his right wing, then he felt an impact as the two airplanes collided. After the collision, the PA-28 pilot declared an emergency and continued to a landing on runway 27; he did not realize that the PA-28's right main gear had separated until the airplane touched down. The R.2160 pilot said that before the collision, he looked for another airplane that he heard on the CTAF, but did not see it. Moments later, his canopy 'blew off' as the airplanes collided, and the engine began to vibrate severely. The R.2160 pilot landed in an open field, but the airplane erupted in flames after touchdown and was destroyed. There was evidence that the PA-28's right main landing gear tire struck the R.2160's upper canopy, and that the R.2160's propeller struck the PA-28's nosegear tire, nosegear strut, and the underside of the cowling. ## Analysis (aircraft 1) The pilots of Piper PA-28, N791CR, and Avions Pierre Robin R.2160, N216JM, were approaching an uncontrolled airport to enter the traffic pattern and land. Before reaching the traffic pattern, both pilots heard other traffic on the common traffic advisory frequency (CTAF). As they were positioning themselves to enter a left traffic pattern at a 45-degree angle, a midair collision occurred. The PA-28 pilot said that before the collision, he made a radio transmission announcing his position and intentions to land on runway 27. Moments later, he saw a 'blue and white flash' to his right and below his right wing, then he felt an impact as the two airplanes collided. After the collision, the PA-28 pilot declared an emergency and continued to a landing on runway 27; he did not realize that the PA-28's right main gear had separated until the airplane touched down. The R.2160 pilot said that before the collision, he looked for another airplane that he heard on the CTAF, but did not see it. Moments later, his canopy 'blew off' as the airplanes collided, and the engine began to vibrate severely. The R.2160 pilot landed in an open field, but the airplane erupted in flames after touchdown and was destroyed. There was evidence that the PA-28's right main landing gear tire struck the R.2160's upper canopy, and that the R.2160's propeller struck the PA-28's nosegear tire, nosegear strut, and the underside of the cowling. ## Factual narrative (aircraft 2) History of Flight On February 8, 1996, at 1052 hours Pacific standard time, a Piper PA28-181, N791CR, and an Avions Pierre Robin R2160, N216JM, collided about 3 miles southwest of Ramona Airport, Ramona, California. The pilot in each airplane was conducting a visual flight rules (VFR) personal flight to Ramona Airport. N791CR landed on runway 27 at Ramona Airport and N216JM crashed and burned in an open field about 1 1/2 miles southwest of Ramona Airport. N791CR, registered to a private individual and operated by Airtime Aviation, Carlsbad, California, sustained substantial damage; N216JM, registered to and operated by the pilot, was destroyed by impact and the postimpact fire. The certificated private pilot aboard N791CR and the certificated commercial pilot aboard N216JM both sustained minor injuries. Visual meteorological conditions prevailed. N791CR departed Palomar Airport, Carlsbad, at 1035 hours; N216JM departed Montgomery Airport, San Diego, California, at 1033 hours. N791CR: National Transportation Safety Board investigators interviewed the pilot at Ramona Airport on February 8, 1996. The pilot said that he was flying to Ramona Airport to practice some touch-and-go landings and takeoffs. The pilot flew to the practice area after departing Palomar Airport. The pilot executed a few "S" turns after he arrived at the practice area and proceeded toward Ramona Airport. When the flight was about 2 miles east of Mt. Woodson he heard some airplanes on Ramona Airport's common traffic advisory frequency (CTAF - 122.7 MHz). He said that runway 27 was in use and he continued toward Mt. Woodson to enter the left traffic pattern at a 45-degree angle. The airplane's altitude was 2,700 feet mean sea level (all altitudes in this report, unless otherwise noted, are mean sea level altitudes). When the airplane was abeam Mt. Woodson he began a descent and announced his position and landing intentions on runway 27 on the CTAF. Moments after leaving 2,000 feet, he saw a blue and white flash off and below his right wing and then felt the impact. Other than the blue and white flash, he never saw N216JM. After the collision, the pilot declared an emergency and landed on runway 27. He said that he did not realize that the airplane's right main landing gear separated at the collision. On touchdown, the airplane began to skid to the right and then stopped. The pilot exited the airplane without any assistance. N216JM Safety Board investigators interviewed the pilot at Palomar hospital, Escondido, California, on February 8, 1996. The pilot said that he was going to Ramona Airport to drop off some keys to his mechanic. He said that he received a weather briefing from the FAA, San Diego Flight Service Station, before departing on the accident flight. He said that he received VFR radar advisories from the FAA, South Coast TRACON (Terminal Radar Approach Control). When the flight was a few miles southwest of Mt. Woodson, the sector controller terminated the radar advisory service. When the airplane was abeam Mt. Woodson, descending through 2,600 feet, he heard another airplane report in the vicinity of Mt. Woodson. He looked for the airplane, but did not see it. Moments later, the canopy blew off and the engine began to vibrate severely. He elected to land in an open field. The airplane bounced when it touched down and almost immediately erupted into flames. The pilot exited the airplane when it came to rest. In a follow-up telephone interview conducted on February 9, 1996, the pilot said that the airplane was level at the time of the collision. He said that the airplane's altitude was 3,500 feet when the sector controller terminated the radar services and he descended the airplane to 2,400 feet. While level at 2,400 feet, he heard the other airplane announce his position moments before the collision. Safety Board investigators interviewed several ground witnesses. All but one of the witnesses saw the airplanes after the collision. This ground witness that saw the airplanes before and during the collision reported that he was in front of his residence when he saw the airplanes. He said that both airplanes appeared to be flying in a formation with one airplane above the other. He became distracted momentarily and then returned his attention to the airplanes. The lower airplane [N216JM] then appeared to climb into the other airplane. The upper airplane [N791CR] continued its flight to the airport. The lower airplane [N216JM] crashed in an open field. Crew Information: N791CR: The pilot holds a private pilot certificate with an airplane single engine land rating that he received on August 7, 1995. He also holds an unrestricted third-class medical certificate dated March 31, 1995. Safety Board investigators examined the pilot's flight hour's logbook. The flight hours reflected on page 3 of this report were derived from the logbook examination. The examination disclosed that the pilot satisfied the general recency and biennial flight review requirements of current federal air regulations. N216JM: The pilot holds a commercial pilot certificate with airplane single engine land and instrument ratings. He also holds a third-class medical certificate; the certificate contains a "must wear glasses" limitation endorsement. Safety Board investigators did not examine the pilot's flight hours' logbook. The flight hours reflected on page 3 of this report were provided by the pilot. The pilot also provided the Safety Board with a copy of the pilot's logbook entry depicting his last biennial flight review. The data received from the pilot shows that he satisfied the general recency and biennial flight review requirements of current federal air regulations. Aircraft Information Safety Board investigators examined both airplanes' maintenance logbooks. The examination disclosed that the airplanes were maintained according to current federal air regulations. Both airplanes are a low wing construction. N216JM had a glass canopy with a 360-degree view and an unrestricted upward view. The pilot said that before accident, he placed a sun restrictor device on the upper part of the canopy. Airport Information Ramona Airport is operated by the County of San Diego, and is located 2 miles east of Ramona. It has one 4,000-foot-long by 150-foot-wide asphalt surfaced runway. The runway is oriented in an east/west direction (9/27). The field elevation is 1,393 feet and the posted traffic pattern altitude is 2,400 feet. The airport does not have an FAA Air Traffic Control Tower. Pilots can obtain airport information by using the CTAF. According to the airport manager, the CTAF is operated by Pacific Executive Aviation, a fixed-based operator on the field. The CTAF operator told Safety Board investigators that there were several airplanes in the traffic pattern at the time of the accident. He said that he does not specifically recall talking to either airplane. He said that he did give airport and traffic pattern information to some airplanes approaching the airport. Meteorological Information Ramona Airport does not have an official weather observation facility. The weather data reflected on page 4 of this report was obtained from the accident pilots and ground witnesses. According to the witnesses, visual meteorological conditions existed at the time of the accident and the surface and airborne visibility exceeded 20 miles. Safety Board investigators used a Sun and Moon Information computer program and determined that at the time and approximate location of the collision at 2,500 feet elevation, the magnetic bearing to the sun was 143 degrees. The sun was about 40.1 degrees above the horizon. Wreckage and Impact Information N791CR The airplane came to rest, right-side-up, about 2,006 feet from runway 27 threshold, and about 10 feet north of the ## Factual narrative (aircraft 1) History of Flight On February 8, 1996, at 1052 hours Pacific standard time, a Piper PA28-181, N791CR, and an Avions Pierre Robin R2160, N216JM, collided about 3 miles southwest of Ramona Airport, Ramona, California. The pilot in each airplane was conducting a visual flight rules (VFR) personal flight to Ramona Airport. N791CR landed on runway 27 at Ramona Airport and N216JM crashed and burned in an open field about 1 1/2 miles southwest of Ramona Airport. N791CR, registered to a private individual and operated by Airtime Aviation, Carlsbad, California, sustained substantial damage; N216JM, registered to and operated by the pilot, was destroyed by impact and the postimpact fire. The certificated private pilot aboard N791CR and the certificated commercial pilot aboard N216JM both sustained minor injuries. Visual meteorological conditions prevailed. N791CR departed Palomar Airport, Carlsbad, at 1035 hours; N216JM departed Montgomery Airport, San Diego, California, at 1033 hours. N791CR: National Transportation Safety Board investigators interviewed the pilot at Ramona Airport, on February 8, 1996. The pilot said that he was flying to Ramona Airport to practice some touch-and-go landings and takeoffs. The pilot flew to the practice area after departing Palomar Airport. The pilot executed a few "S" turns after he arrived at the practice area and proceeded toward Ramona Airport. When the flight was about 2 miles east of Mt. Woodson he heard some airplanes on Ramona Airport's common traffic advisory frequency (CTAF - 122.7 MHz). He said that runway 27 was in use and he continued toward Mt. Woodson to enter the left traffic pattern at a 45-degree angle. The airplane's altitude was 2,700 feet mean sea level (all altitudes in this report, unless otherwise noted, are mean sea level altitudes). When the airplane was abeam Mt. Woodson he began a descent and announced his position and landing intentions on runway 27 on the CTAF. Moments after leaving 2,000 feet, he saw a blue and white flash off and below his right wing and then felt the impact. Other than the blue and white flash, he never saw N216JM. After the collision, the pilot declared an emergency and landed on runway 27. He said that he did not realize that the airplane's right main landing gear separated at the collision. On touchdown, the airplane began to skid to the right and then stopped. The pilot exited the airplane without any assistance. N216JM Safety Board investigators interviewed the pilot at Palomar hospital, Escondido, California, on February 8, 1996. The pilot said that he was going to Ramona Airport to drop off some keys to his mechanic. He said that he received a weather briefing from the FAA, San Diego Flight Service Station, before departing on the accident flight. He said that he received VFR radar advisories from the FAA, South Coast TRACON (Terminal Radar Approach Control). When the flight was a few miles southwest of Mt. Woodson, the sector controller terminated the radar advisory service. When the airplane was abeam Mt. Woodson, descending through 2,600 feet, he heard another airplane report in the vicinity of Mt. Woodson. He looked for the airplane, but did not see it. Moments later, the canopy blew off and the engine began to vibrate severely. He elected to land in an open field. The airplane bounced when it touched down and almost immediately erupted into flames. The pilot exited the airplane when it came to rest. In a follow-up telephone interview conducted on February 9, 1996, the pilot said that the airplane was level at the time of the collision. He said that the airplane's altitude was 3,500 feet when the sector controller terminated the radar services and he descended the airplane to 2,400 feet. While level at 2,400 feet, he heard the other airplane announce his position moments before the collision. Safety Board investigators interviewed several ground witnesses. All but one of the witnesses saw the airplanes after the collision. This ground witness that saw the airplanes before and during the collision reported that he was in front of his residence when he saw the airplanes. He said that both airplanes appeared to be flying in a formation with one airplane above the other. He became distracted momentarily and then returned his attention to the airplanes. The lower airplane [N216JM] then appeared to climb into the other airplane. The upper airplane [N791CR] continued its flight to the airport. The lower airplane [N216JM] crashed in an open field. Crew Information: N791CR: The pilot holds a private pilot certificate with an airplane single engine land rating that he received on August 7, 1995. He also holds an unrestricted third-class medical certificate dated March 31, 1995. Safety Board investigators examined the pilot's flight hour's logbook. The flight hours reflected on page 3 of this report were derived from the logbook examination. The examination disclosed that the pilot satisfied the general recency and biennial flight review requirements of current federal air regulations. N216JM: The pilot holds a commercial pilot certificate with airplane single engine land and instrument ratings. He also holds a third-class medical certificate; the certificate contains a "must wear glasses" limitation endorsement. Safety Board investigators did not examine the pilot's flight hours' logbook. The flight hours reflected on page 3 of this report were provided by the pilot. The pilot also provided the Safety Board with a copy of the pilot's logbook entry depicting his last biennial flight review. The data received from the pilot shows that he satisfied the general recency and biennial flight review requirements of current federal air regulations. Aircraft Information Safety Board investigators examined both airplanes' maintenance logbooks. The examination disclosed that the airplanes were maintained according to current federal air regulations. Both airplanes are a low wing construction. N216JM had a glass canopy with a 360-degree view and an unrestricted upward view. The pilot said that before accident, he placed a sun restrictor device on the upper part of the canopy. Airport Information Ramona Airport is operated by the County of San Diego, and is located 2 miles east of Ramona. It has one 4,000-foot-long by 150-foot-wide asphalt surfaced runway. The runway is oriented in an east/west direction (9/27). The field elevation is 1,393 feet and the posted traffic pattern altitude is 2,400 feet. The airport does not have an FAA Air Traffic Control Tower. Pilots can obtain airport information by using the CTAF. According to the airport manager, the CTAF is operated by Pacific Executive Aviation, a fixed-based operator on the field. The CTAF operator told Safety Board investigators that there were several airplanes in the traffic pattern at the time of the accident. He said that he does not specifically recall talking to either airplane. He said that he did give airport and traffic pattern information to some airplanes approaching the airport. Meteorological Information Ramona Airport does not have an official weather observation facility. The weather data reflected on page 4 of this report was obtained from the accident pilots and ground witnesses. According to the witnesses, visual meteorological conditions existed at the time of the accident and the surface and airborne visibility exceeded 20 miles. Safety Board investigators used a Sun and Moon Information computer program and determined that at the time and approximate location of the collision at 2,500 feet elevation, the magnetic bearing to the sun was 143 degrees. The sun was about 40.1 degrees above the horizon. Wreckage and Impact Information N791CR The airplane came to rest, right-side-up, about 2,006 feet from runway 27 threshold, and about 10 feet north of the ## Aircraft 1 - Registration: [N791CR](https://openairdocs.org/aircraft/N791CR), registered now, S/N 28-8090259, built 1980 (OpenAirDocs) - Reported make and model: Piper PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8090259 - Airframe hours: 5769 - Engines: Lycoming O-360-A4M 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Airtime Aviation - Registered owner: Claude E. & Ruth E. Fenner - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: 100 hour, December 4, 1995, 59 hours before - Departed: CRQ, CARLSBAD, CA - Destination: L39 - Airport: L-39, Ramona, runway 27, 4,000 × 150 ft, asphalt ## Aircraft 2 - Registration: [N216JM](https://openairdocs.org/deregistered/N216JM-1996-05-09), registration cancelled 1996-05-09, S/N 202 (OpenAirDocs) - Reported make and model: Robin, Avions Pierre R.2160 - Registry model: [Avions Pierre Robin PIERRE ROBIN R2160](https://openairdocs.org/model/avions-pierre-robin-pierre-robin-r2160) (registry code 0960101) (OpenAirDocs) - Category: Airplane - Serial number: 202 - Airframe hours: 600 - Engines: Lycoming O-320-D2A 160 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Robert C. Doban - Airworthiness certificate: Standard, Normal; Standard, Aerobatic; Standard, Utility - Last inspection: Annual, April 19, 1995, 29 hours before - Departed: MYF, SAN DIEGO, CA - Destination: L39 - Airport: L-39, Ramona ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N791CR; age 23; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 69 total, 7 in this make and model, 32 as pilot in command, 17 in the last 90 days, 2 in the last 30 days, 1 in the last 24 hours - Pilot, aircraft N216JM; age 71; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 1,320 total, 482 in this make and model, 1,241 as pilot in command, 15 in the last 90 days, 5 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Visibility: 100 statute miles - Lowest ceiling: none ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19960208001481A](https://openairdocs.org/incident/19960208001481A), Feb 8, 1996: Piper PA28181, Ramona, CA, Substantial damage. On downwind leg from runway, collided with 216JM, landed. - [Accident 19960208001482A](https://openairdocs.org/incident/19960208001482A), Feb 8, 1996: Avions R2160, Ramona, CA, Destroyed. On downwind leg for runway, collided with N791CR. Crashed and burned. 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.