LAX98FA210

NTSB accident investigation · Cessna 152 · Santa Ana, CA · June 24, 1998

Accident · FatalField investigationFinal report
Date
June 23, 1998, 17:07 local (Jun 24, 1998, 00:07 UTC)
Place
Santa Ana, CA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N67421Cessna 152
Weather
Visual (VMC) · Day
Status
Completed · report February 16, 2001
Report
Approved by Office Director
FAA report
19980624014789A
Case key
29957

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 failure of the pilot-in-command to identify a proper touchdown point on the runway and maintain an appropriate glidepath so as to remain clear of vortex turbulence from the preceding large aircraft. A factor in the accident was the pilot's failure to initiate a go-around in the known presence of vortex turbulence.

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.

Vortex turbulence encounteredApproach - vfr pattern - final approach
Proper glidepath - not maintainedPilot in commandCause
Proper touchdown point - not identifiedPilot in commandCause
Go-around - not performedPilot in commandFactor
Loss of control - in flightApproach - vfr pattern - final approach
In flight collision with terrain/waterDescent - uncontrolled

Analysis

While the solo student pilot of the Cessna 152 was on downwind leg for landing, the air traffic controller directed the student's attention to a Boeing 757 aircraft that was preceding the student's aircraft for landing on the parallel runway. The threshold of the parallel runway is abeam and 500 feet to the right of the runway the student was to land on. The controller then advised of a 10-knot quartering headwind from the right, issued a wake turbulence precaution, and cleared the student pilot for the landing option. Witnesses reported that as the student pilot was on final approach, descending through approximately 100-foot altitude (agl), the aircraft abruptly rolled inverted and crashed short of the runway threshold. The Safety Board prepared a Study of Wake Turbulence Encounter using data from the Boeing 757's flight data recorder, tower communication tapes, and tower reported surface winds. The report concluded that the Cessna 152 descended into the Boeing 757's wake when the wake was 37 to 41 seconds old. The student's flight instructor told the Safety Board that the student, who had 136 hours of dual instruction and 20 hours of solo flight time, had received instruction in wake turbulence avoidance at three points in ground instruction. Furthermore, the instructor said that training as they had at the air carrier airport, most flights involved wake turbulence avoidance.

Factual narrative

History of flight

On June 23, 1998, at 1707 hours Pacific daylight time, a Cessna 152, N67421, rolled abruptly, pitched down, and impacted terrain while on final landing approach at the John Wayne Airport, Santa Ana, California. The aircraft was destroyed and the student pilot was fatally injured. Visual meteorological conditions prevailed for the instructional flight that was operating in the airport traffic pattern performing takeoffs and full-stop landings.

Witnesses reported that the aircraft was on a stabilized short final approach to runway 19L, approximately 100 feet agl, when the wings of the aircraft abruptly rolled approximately 90 degrees and the nose dropped. There is disagreement among witnesses whether the aircraft rolled to the right or to the left. In 2 or 3 seconds, the aircraft achieved a near vertical, nose-down attitude, which continued to impact. The witnesses reported that a Boeing 757 (later identified as American Airlines flight 2154) aircraft had landed on parallel runway 19R, upwind of runway 19L, approximately 30 seconds prior to the accident, and that surface winds were from the southwest at approximately 10 knots. A witness also reported that a departing Boeing 737 aircraft had been holding short of runway 19R (between 19R and 19L) at the departure end, and was moving into position on runway 19R at the time of the accident.

A private pilot witnessed the accident while working on the terminal ramp about 300 feet east of the accident site. He reported that the aircraft's descent and attitude looked normal on final approach. He estimated that the aircraft was at 50 to 100 feet agl and airspeed of approximately 50 knots, when the nose pitched up mildly and wings of the aircraft "snap" rolled to the right approximately 90 degrees and the nose dropped. In 2 or 3 seconds, the aircraft achieved a near-vertical, nose-down attitude, which continued to impact. In a followup interview, this witness reported that he knew the aircraft rolled to the right because he recalled seeing the landing gear from his perspective. He also added that the accident did not appear to him to have been a stall event, the airspeed appeared normal.

A nonpilot witness who observed the accident from the 405 (San Diego) Freeway reported the approach was smooth and "perfectly normal" until the airplane "dipped" slightly left and then abruptly right until the wings were straight up and down and the aircraft dove to the ground.

A flight instructor and (instrument) student who observed the accident while holding for takeoff on runway 19L at intersection kilo believed that they saw the aircraft roll to its left.

Another flight instructor observed the accident from another aircraft on final approach behind the accident aircraft and said that, as he watched, the accident aircraft pitched up briefly, the right wing came up, and it rolled violently to the left until the wings were past vertical. It then dove to the ground. He said that it was extremely fast and violent and that both he and his student remember it rolling to the left. He said that the Boeing 757 had passed them up and landed a little long on runway 19R and that wake turbulence avoidance was definitely a factor. He and his student planned to remain high and land long on runway 19L using full flaps. He said that the accident aircraft was on or a bit below the VASI glidepath. He also said that traffic was quite heavy with 5 or 6 aircraft in the runway 19L pattern, plus departing and arriving jets on runway 19R.

Personnel information

The student pilot was enrolled in a FAR Part 61 course of instruction. His logbook recorded his first instructional flight in May, 1996, and his total flying time at the date of the accident was 156.4 hours, of which 136.4 were dual instruction hours and 20.0 were solo hours.

His flight instructor, who had instructed him for the entire duration, characterized him as a cautious student who showed good judgement. The flight instructor said that the student's high number of flight hours was in part due to interruptions in his training due to business and personal issues, and in part due to the students own conservatism.

According to the instructor, the student received instruction in wake turbulence avoidance at several points in his instruction. In the school's private pilot ground school, which he attended, wake turbulence was discussed twice, once in aerodynamics and a second time in weather, where the effect of wind on wake turbulence was discussed. At lesson number 10 in the syllabus, the student was required to watch a video instruction tape on wake turbulence. Finally, the instructor said, flying from John Wayne Airport, almost every flight involved wake turbulence avoidance. They had discussed wake turbulence on nearly every dual flight and the student had demonstrated positive wake turbulence avoidance "hundreds of times" while flying dual. He had also performed many landings on runway 19L while large aircraft were holding between runways 19R and 19L, by coming in high over their exhaust wake and landing long.

Aircraft information

According to the operator's records, the aircraft was dispatched with no deferred maintenance items (squawks) open. According to the two flight instructors who flew the two previous flights in the aircraft, one earlier on the day of the accident and the other the previous night, there were no mechanical discrepancies noted during their flights.

According to the operator, it is their usual practice to always dispatch their aircraft with the fuel tanks full. The fueling vendor provided refueling records showing that the accident aircraft was fueled with 5.8 gallons some time after 1600 on the day of the accident.

Meteorological information

At 1717, the weather at John Wayne Airport was clear sky, visibility 20 miles, and wind from 210 degrees at 10 knots. According to the operator's "Aviation Weather Check form" (attached), the pilot obtained preflight weather information from the John Wayne Automatic Terminal Information Service (ATIS) at 1350. On the form the pilot noted a 3 - 4 knot crosswind component.

Communications

John Wayne Tower was operating two local control frequencies at the time of the accident. Local control one (1) controlled runway 1L/19R and airspace west of the airport. Local control two (2) controlled runway 1R/19L and airspace east of the airport. The accident aircraft was in radio contact with local control two and the Boeing 757 (American 2154) was in contact with local control one. Runways 19L and 19R were in use.

Prior to 1700, the pilot received a clearance for flight in the airport traffic pattern, taxied to runway 19L, and performed one flight in the runway 19L airport traffic pattern terminating in a full-stop landing and taxi-back for another takeoff. The accident occurred on the pilot's second flight of the day. According to the local control 2 tape transcript provided by the Federal Aviation Administration (FAA), the pilot was cleared for his second takeoff on runway 19L at 1701:54. At 1703:00, the tower controller advised the pilot to turn left 15 degrees and extend his upwind leg and that the tower would call his crosswind turn. At 1703:36, the tower instructed the pilot to turn crosswind leg and sequenced him number 3 for landing. The pilot acknowledged that he was turning downwind. Two other aircraft entered downwind behind the accident aircraft and the second aircraft was advised that he was number 5 for landing. At 1705:13, the controller asked the pilot of the accident aircraft if he had his traffic, a Cessna, in sight on base leg, ahead. The pilot replied affirmatively. At 1705:43, the controller asked the pilot if he had the Boeing 757 in sight on 3-mile final for runway 19R. The pilot replied affirmatively. The controller then transmitted: "cessna four two one maintain visual separation from the arri

Aircraft

Registration
N67421
Reported as
Cessna 152
Category
Airplane
Serial number
15281828
Airframe hours
5,388
Engine
Lycoming O-235-L2C, 110 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Registered owner
Sunrise Aviation, Inc.
Airworthiness certificate
Standard, Utility
Last inspection
100 hour · January 26, 1998 · 67 hours before
Airport
SNA · John Wayne Apt/Orange Co., runway 19L, 2,887 × 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
49
Certificate
Student
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
157 total · 150 in this make and model · 21 as pilot in command · 16 in the last 90 days · 8 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 10 knots
Visibility
20 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 57 °F
Altimeter
29.00 inHg
Observed at
SNA

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.