# NTSB LAX97FA075: Piper PA-28-140, N943R, San Diego, CA, December 24, 1996 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 24, 1996, 11:33 local (19:33 UTC) - Place: San Diego, CA - Coordinates: 32.800575, -117.129211 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.8006&lon=-117.1292&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 2 minor - Status: Completed, report April 10, 1998 - Report: Approved by Office Director - NTSB case key (mKey): 29600 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX97FA075 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29600/pdf - Page: https://openairdocs.org/ntsb/LAX97FA075 ## Probable cause (aircraft 2) The failure of the pilot-in-command of the Piper PA-28, N943R, to maintain an adequate visual lookout to see and avoid the Cessna 150, N63137. A factor in the accident was the failure of the air traffic controller to issue a traffic advisory to the pilot concerning the Cessna 150. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Midair collision, approach - vfr pattern - final approach - traffic advisory - not issued, atc personnel(lcl/gnd/clnc) (contributing factor) - visual separation - not maintained, atc personnel(lcl/gnd/clnc) (contributing factor) - visual lookout - inadequate, pilot in command (cause) - Midair collision, approach - faf/outer marker to threshold (ifr) - traffic advisory - not issued, atc personnel(lcl/gnd/clnc) (contributing factor) - visual separation - not maintained, atc personnel(lcl/gnd/clnc) (contributing factor) - visual lookout - inadequate, pilot of other aircraft (cause) ## Analysis (aircraft 2) When the low wing Piper PA-28, N943R, contacted the tower 5 miles east of the airport, the tower controller pointed out the Cessna 150, N63137, at 11 o'clock, 2 miles, and instructed the pilot to fly southbound and report that aircraft in sight. The transmission was not acknowledged, and the Piper pilot flew southwest bound and never reported the Cessna in sight. When both aircraft were on a 3-mile final approach to parallel runways, the controller, with both aircraft in sight, issued a traffic advisory to the Cessna regarding the Piper behind them, but did not issue a traffic advisory to the Piper regarding the Cessna in front of them. The two aircraft collided in flight, 1.5 miles east of the airport. The Piper, with a student pilot in the left seat and a flight instructor in the right seat, overtook the high wing aircraft from above, behind and to the right. The lower fuselage of the Piper contacted the upper fuselage and propeller of the high wing aircraft. The Cessna's propeller severed the primary control cables of the Piper and it descended out of control and crashed. The Cessna made a off-airport forced landing and collided with a berm during the ground roll. ## Factual narrative (aircraft 2) HISTORY OF FLIGHT On December 24, 1996, at 1133 hours Pacific standard time, a Piper PA-28-140, N943R, collided in flight with a Cessna 150M, N63137, about 1.5 miles east of the Montgomery Field Airport, San Diego, California while both aircraft were on final approach to parallel runways. The commercial pilot and one passenger in the Piper were fatally injured and the aircraft was destroyed. The commercial pilot and one passenger in the Cessna received minor injuries and that aircraft was substantially damaged. Visual meteorological conditions prevailed and both aircraft were on instructional flights. The Piper departed Montgomery Field for a local flight, and the Cessna departed from Ramona Airport at approximately 1030. Simultaneous VFR and IFR operations were in progress at Montgomery Field to parallel runways 28R and 28L. The Cessna aircraft was executing a straight-in instrument approach to runway 28R and was following another high wing Cessna to that runway. The Piper aircraft was approaching the airport VFR from the northeast and was sequenced to cross the final approach to runway 28R and make a straight-in approach to runway 28L. The Piper was sequenced number two to land on that runway behind another aircraft in closed traffic. Aboard the Piper was a flight instructor and an unlicensed primary student pilot. The pilot contacted Montgomery tower at 1128 and reported his position east of Lake Murray (a VFR reporting point 5 miles east of the airport) and requested landing instructions. At 1129, he revised his position "over Cowles." The tower instructed the aircraft to proceed southbound and issued traffic at 11o'clock and 2 miles, a Cessna aircraft descending through 2,100 feet, and further instructed the Piper pilot to report the Cessna in sight. There was no acknowledgment of the clearance from the Piper. Recorded CDR radar data shows the Piper at approximately 3,000 feet altitude during this time. The Cessna was returning to Montgomery Field on an IFR flight plan and clearance. Aboard the aircraft was a flight instructor in the left seat giving instruction to another flight instructor in the right seat, who was training to upgrade to instrument flight instructor. The Cessna had been cleared for the NDB runway 28 right approach by SOCAL TRACON, and at 1129, contacted Montgomery tower "with you on the NDB for the miss." The tower requested a transponder ident and issued traffic at "1:00 moving to 12:00 o'clock, 1 mile, altitude indicates two thousand three hundred." At 1130, the Cessna reported another Cessna aircraft in sight at one o'clock and "we'll continue on the NDB." In a later interview, the flight instructor stated that at this time they were past the DEORO outer compass locator and were descending from 2,100 feet to the step down fix altitude of 1,340 feet at PALOS intersection. At 1131, the tower transmitted "Cherokee one three seven, traffic behind to your left, inbound for the parallel runway is a Cherokee." The pilot of the Cessna replied "Okay, this is Cessna six three one three seven, we're looking for the Cherokee." The tower then acknowledged "Cessna six three one three seven , roger." In his personnel statement, the air traffic controller stated that he "observed N63137 and N943R approximately 3 miles to the east on final" prior to this transmission. The Piper pilot reported "approximately three miles out for landing" at 1131. The tower replied "in sight, number two, follow traffic left base to one mile final for runway two eight left, cleared to land." The Piper acknowledged, "follow traffic, two eight left, cleared to land." At 1132, the Cessna pilot radioed "Cessna six three one three seven, midair." In two subsequent transmissions, the pilot of the Cessna confirmed the midair and stated his intent to land first on a freeway and then in an open area. Several attempts by the tower to contact the Piper were unsuccessful. Review of the recorded radar data disclosed that the two aircraft's radar targets merged together at approximately latitude 32 degrees 48.0 minutes north, and longitude 117 degrees 05.3 minutes west at 1,400 feet msl while tracking approximately 280 degrees magnetic. According to ground based witnesses, after the collision the Piper entered a descending left turn, which continued until impact with the ground. The witnesses reported that the aircraft turned approximately 180 degrees before impact and the bank angle and rate of descent increased as the turn progressed. The aircraft impacted in a large tree adjacent to a parking lot at the south end of the Navy Golf Course at GPS latitude 32 degrees 47.51 minutes north, and longitude 117 degrees 06.23 minutes west. The left seated pilot of the Cessna reported that his recollection was of a "pretty hard" impact, during which the aircraft veered left and he hit his head. When he looked out the windshield his aircraft was in a left descending turn and the engine and propeller were stopped. The Piper was at his 11 o'clock position in the same attitude and he was viewing it from its 5:30 (o'clock) perspective. He took control of the aircraft from the second pilot, leveled his aircraft's wings and radioed the tower that there had been a midair collision. He turned right with the intention of landing in the northbound lanes of Interstate 15; however, because of heavy automobile traffic on the highway, he turned back to the left and located a site that had been leveled for construction (on West Canyon Avenue south of Aero Drive) and landed there (approximate latitude 32 degrees 48.0 minutes north, and longitude 117 degrees 07.3 minutes west). The aircraft rolled about 400 feet before impacting a dirt embankment and stopping. The left seated pilot of the Cessna also reported that SOCAL approach had cleared them for the NDB 28R approach from outside the DEORO outer compass locator. They had crossed the compass locator at 2,100 feet and descended to the step-down fix altitude of 1,340 feet at PALOS intersection. He recalled that the tower sequenced them behind a high wing at their one o'clock position and he also recalled that a Cherokee checked in with the tower over Cowles mountain which was in his three o'clock position. The tower communications were very congested (busy) and transmissions were being blocked (stepped on) by other aircraft. The pilot said that approaching PALOS intersection at about 1,375 feet, he complimented his student on what a good job he was doing; he was exactly on centerline of 28R. About the same time, the tower called traffic at 6 - 7 o'clock. He looked back as well as he could but did not see any traffic. His student called "PALOS intersection descending to 880 feet." About 15 to 30 seconds later they collided with the Piper, having never seen it. It had approached from behind and struck them from above. The pilot estimated that they were at 1,000 to 1,100 feet msl when the collision occurred. After the collision he realized that he had lost a substantial amount of altitude, and that there was no way that he could reach the airport without engine power and so made an off-airport landing. The tower supervisor certified that there were four people in the tower cab at the time of the accident. All four were FAA Air Traffic Control Specialists; two were full performance level controllers and two were developmental level controllers. The working local controller was a full performance level controller. PERSONNEL INFORMATION The pilot logbook of the pilot/flight instructor of the N943R was not located after the accident. His experience as of July 25, 1996, was available from the application form for his flight instructor rating, which was issued on that date. As of that date, the pilot had accumulated a total flying time of 279 hours. The operator of the aircraft was able to provide records covering the period from October 26, 1996, to December 20, 19 ## Aircraft 1 - Registration: [N943R](https://openairdocs.org/deregistered/N943R-1998-08-27), registration cancelled 1998-08-27, S/N 2824855 (OpenAirDocs) - Reported make and model: Piper PA-28-140 - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Category: Airplane - Serial number: 28-24855 - Airframe hours: 3153 - Engines: Lycoming O-320-E3D 150 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Registered owner: Briar N. Segal - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, October 10, 1996, 82 hours before - Departed: MYF, CA - Airport: MYF, Montgomery Field, runway 28L, 3,399 × 60 ft, asphalt ## Aircraft 2 - Registration: [N63137](https://openairdocs.org/deregistered/N63137-2012-10-04), registration cancelled 2012-10-04, S/N 15077129, built 1975 (OpenAirDocs) - Reported make and model: Cessna 150M - Registry model: [Cessna 150M](https://openairdocs.org/model/cessna-150m) (registry code 2071830) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 15077129 - Airframe hours: 8688 - Engines: Continental O-200A 100 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Antone Texeira - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: 100 hour, December 12, 1996, 18 hours before - Departed: L39, RAMONA, CA - Destination: MYF - Flight plan: IFR - Airport: MYF, Montgomery Field, runway 28R, 4,600 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N943R; age 35; commercial, flight instructor; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: right; toxicology performed; flight hours: 360 total, 24 in the last 30 days, 1 in the last 24 hours - Pilot, aircraft N63137; age 62; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 9,400 total, 3,000 in this make and model, 9,300 as pilot in command, 80 in the last 90 days, 20 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 9 knots - Visibility: 40 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 46 °F - Altimeter: 30.00 inHg - Observed at: MYF, 2 nm away ## 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 19961224040151A](https://openairdocs.org/incident/19961224040151A), Dec 24, 1996: Piper PA28140, San Diego, CA, Destroyed, 2 fatal. On final overtook and collided with N68137 a 150 both on fianl for parallel rwys. 943R crashed. 68137 landed safely - [Accident 19961224040179A](https://openairdocs.org/incident/19961224040179A), Dec 24, 1996: Cessna 150M, San Diego, CA, Substantial damage. On approach to airport crashed with N943R. 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.