# NTSB LAX96FA226: Piper PA-32R-300, N4303X, Goleta, CA, June 7, 1996 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 7, 1996, 10:43 local (17:43 UTC) - Place: Goleta, CA - Coordinates: 34.499935, -120.119186 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.4999&lon=-120.1192&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 23, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 29279 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX96FA226 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29279/pdf - Page: https://openairdocs.org/ntsb/LAX96FA226 ## Probable cause failure of the flying pilot to maintain control of the airplane, due to spatial disorientation, which resulted in an uncontrolled descent and collision with the water. Factors relating to the accident were: the lack of recent instrument experience by the flying pilot and the lack of monitoring (and/or remedial action) by the other pilot. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - iaf to faf/outer marker (ifr) - weather condition - fog - weather condition - low ceiling - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (cause) - lack of recent instrument time, pilot in command (contributing factor) - monitoring - inadequate, copilot/second pilot (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis Two instrument-rated pilots departed for a planned 24-mile instrument flight. About 5 minutes after takeoff, one of the pilots contacted the radar controller and requested an instrument landing clearance. The controller cleared the pilot for an ILS runway 7 approach to Santa Barbara. When the airplane was about 1 mile west of the final approach fix, it had descended to 1,500 feet. The published glide slope altitude for the fix was 1,774 feet. At 1042, as the airplane was still inbound toward the final approach fix, it reversed course, then it proceeded in a westerly and then a northerly direction. Radar data showed that the airplane then descend through 1,100 feet on a northeasterly heading. A low altitude alert alarm sounded in the ATC control room, and radar contact was lost. (Note: the pilots had not reported any abnormal condition with the airplane or equipment, nor was a safety advisory (alert) transmitted to the airplane.) A witness observed that the airplane came out of clouds in a steep descent and impacted the water at a high rate of speed. He estimated the visibility was 2 miles in fog. Wreckage was recovered, and no mechanical malfunction was found. A review of the pilots' logbooks and airplane utilization records revealed that neither pilot met the FAA instrument flight currency requirements. ## Factual narrative HISTORY OF FLIGHT On June 7, 1996, at 1043 hours Pacific daylight time, a Piper PA-32R-300, N4303X, registered to Condor Air Limited, Wilmington, Delaware, crashed into the Pacific Ocean and sank about 8.9 statute miles west of the Santa Barbara Municipal Airport, Santa Barbara, California. The accident occurred in instrument meteorological weather conditions during an instrument landing system (ILS) approach to runway 07 at Santa Barbara. The airplane was destroyed, and the two instrument rated private pilots were fatally injured. The personal flight originated from Santa Ynez, California, at an estimated time of 1030. The distance between the Santa Ynez and the Santa Barbara airports via the Gaviota Vortac (navigation aid) and the Habit intersection (approach fix) is approximately 24 nautical miles (nm). At 1034:43, the pilot of N4303X contacted the Santa Barbara radar controller, indicated that he had just departed from Santa Ynez, and requested an approach (clearance) to Santa Barbara. The controller identified the airplane located 1 mile southeast of Gaviota, issued the pilot an instrument clearance to Santa Barbara, and instructed the pilot to descend to 3,000 feet mean sea level (msl). Recorded radar data from the Los Angeles Air Route Traffic Control Center (ARTCC) indicated that at 1036:00 the airplane was at 3,700 feet. The controller cleared the pilot for an ILS approach at 1037:16. No acknowledgment was heard by the controller, and at 1037:30, the controller said ". . . zero three xray did you copy." Three seconds later the pilot responded and said "uh zero three xray say again." At 1037:37, the controller informed the pilot that he was 6 miles from Napps (the final approach fix). Also, the controller instructed the pilot to turn left to a heading of 105 degrees, to maintain 2,000 feet until established on the localizer, and informed the pilot that he was cleared for the ILS approach. The pilot responded at 1037:44 and said "left one zero five maintain two." No further transmissions were recorded from the pilot. A review of recorded radar track data from ARTCC revealed that the airplane continued descending while flying in an easterly direction toward Santa Barbara. The airplane was at 1,800 feet approximately 5.5 miles west of the Napps intersection. At 1042:09, the airplane was at 1,500 feet when it was approximately 1 mile west of Napps. (According to the runway 07 instrument approach procedures chart, when established on the ILS glide slope, airplanes should cross Napps at 1,774 feet msl.) Seconds later, the airplane reversed its direction of flight. During the next 1/2 minute it proceeded in westerly and then northerly directions away from the airport. Controllers observed the course deviation. At 1042:49, an audible low altitude alert (alarm) sounded in the control room. The radar controller subsequently reported to the National Transportation Safety Board that he observed the airplane proceeding away from the airport and rapidly losing altitude. No safety advisory was issued. Radar contact was lost as the airplane descended through 1,100 feet on a northeasterly heading. The airplane crashed into the Pacific Ocean within an estimated 1 to 2 miles from where an eyewitness was located. The witness reported that he observed the airplane in a steep bank (over 60 degrees) rapidly descending in a westerly direction, and also heard a loud engine noise. The witness further stated that the airplane's right wing and nose appeared to contact the water at the same time. A U.S. Coast Guard vessel responded to the crash site area as pointed out by the witness. The Coast Guard reported observing evidence of an oil and fuel slick and a steady stream of bubbles southeast of the El Capitan State Beach. On June 12, 1996, the main wreckage from the accident airplane was found near the area. PERSONNEL INFORMATION Two instrument rated private pilots were found in the airplane wreckage. Their respective seat positions could not be ascertained nor determined which of the pilots was flying at the time of the accident. In this report, the pilots are referred to as the first pilot and the second pilot without inference to their respective piloting duties. The deceased pilots owned and operated the airplane along with another partner. The partner reported that he was familiar with the sound of the pilots' voices, and he listened to the recorded radio transmissions made during the accident flight. The partner stated that the second pilot had made the radio transmissions, and he opined that the first pilot was therefore likely handling the flight controls from the left seat position. First Pilot, Flight Experience and Currency Between May 26 and 27, 1996, the first pilot was observed flying the airplane with his wife. The line service manager at the Modesto airport reported that the pilot purchased 31.9 gallons of 100LL fuel which completely filled the airplane's tanks. The pilot then flew the airplane for 1.5 hours and terminated the flight with a landing at Santa Barbara. These flights were the last ones recorded in the pilot's personal flight record logbook. According to his logbook, he successfully completed a biennial flight review in January, 1994. The pilot's last instrument competency check was completed in May, 1995. Within 6 months of the accident date, the pilot's logbook recorded 2.5 hours of instrument flight time which included 1 instrument approach. No hood time or synthetic trainer time was recorded. Second Pilot, Flight Experience and Currency On June 6, 1996, the second pilot was observed flying the airplane during a local area daytime sightseeing flight under VFR conditions. The pilot flew from Santa Barbara to Santa Ynez. The partner estimated that the flight duration was between 1 and 2 hours. The pilot had planned to fly the airplane back to its Santa Barbara home base, but an overcast sky condition existed so he left the airplane at Santa Ynez for the night. The pilot's personal flight record logbook was also reviewed. It covered the time period starting in August, 1993. The pilot listed three flights in the logbook. The last flight was listed as a biennial flight review, and that occurred in the accident airplane in August, 1994. The pilot listed his total flight time as 2,651.2 hours. Airplane utilization records were reviewed for the period between November, 1995, and May, 1996. No evidence was found indicating the second pilot had flown the airplane during this period. The partner reported that during the past 2 years, the pilot had not flown any other airplane. No evidence was found of the pilot having completed an instrument competency flight check within 2 years of the accident. In a May, 1995, insurance application form, the pilot reported that he had flown PA-32 airplanes for 607 hours. Also, he had flown 22 hours during the preceding year. AIRCRAFT INFORMATION The airplane was equipped with dual flight controls which allowed for piloting from either of the front seats. One attitude gyro (artificial horizon) was installed on the left side of the instrument panel. The maintenance record review indicated that on December 17, 1992, an overhauled attitude gyro was installed to replace the airplane's defective gyro. Neither it nor the navigation radios were recovered. The impact damaged instrument panel was found partially fragmented. According to the partner, the airplane was equipped with an automatic direction finder (ADF) which did not work, a loran, a radio altimeter, and a 3-axis (Century III) autopilot, which worked "OK." Based upon a review of the airplane's log books, the last transponder, altimeter, and pitot-static system checks were accomplished on May 15, 1994. (The FAA requires that these aircraft equipment and systems are functioning properly before flight into instr ## Aircraft - Registration: [N4303X](https://openairdocs.org/deregistered/N4303X-1997-11-19), registration cancelled 1997-11-19, S/N 32R7680008 (OpenAirDocs) - Reported make and model: Piper PA-32R-300 - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7680008 - Airframe hours: 4809 - Engines: Lycoming IO-540-K1A5D 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: E.Madson, L.Colvin, C.Voorhis - Registered owner: Condor Air, Ltd. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 16, 1995, 63 hours before - Departed: IZA, SANTA YNEZ, CA - Destination: SBA - Flight plan: IFR - Airport: SBA, Santa Barbara Municipal, runway 7, 6,052 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; toxicology performed; flight hours: 559 total, 168 in this make and model, 493 as pilot in command, 11 in the last 90 days, 3 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 130° at 7 knots - Lowest ceiling: 700 ft overcast - Temperature: 63 °F, dew point 59 °F - Altimeter: 30.00 inHg - Observed at: SBA, 8 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 19960607013019A](https://openairdocs.org/incident/19960607013019A), Jun 7, 1996: Piper PA32R300, Santa Barbara, CA, Destroyed, 2 fatal. Lost control and crashed into ocean on ILS approach. No biennial and not IFR current. Aircraft not IFR current also ## Other investigations on N4303X (1) 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. - [NTSB MIA89LA089](https://openairdocs.org/ntsb/MIA89LA089), Feb 18, 1989: Piper PA-32R-300 (N4303X), Fort Lauderdale, FL, substantial damage. Probable cause: FAULTY INSTALLATION OF AVIONICS EQUIPMENT WHICH CAUSED WIRING IN THE LANDING GEAR SYSTEM TO BE IMPROPERLY REINSTALLED. 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.