WPR19FA095

NTSB accident investigation · North American T28 · Compton, CA · March 14, 2019

Accident · FatalClass 3 · FieldFinal report
Date
March 13, 2019, 18:50 local (Mar 14, 2019, 01:50 UTC)
Place
Compton, CA
Injuries
1 fatal, 1 serious, 1 uninjured
Phase of flight
Landing
Aircraft
N5440FNorth American T28N48962Cessna 152
Defining events
Landing-landing roll: Runway incursion veh/AC/personLanding-landing roll: Runway incursion veh/AC/person
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviaiton Administration
Case key
99107

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The failure of the T-28 pilot to see and avoid the Cessna while landing with reduced visibility due to sun glare, which resulted in a collision on the runway. Contributing to the accident was his failure to use the airport's common traffic advisory frequency during the approach and landing.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

N5440F · North American T28

Light condition: bright lightEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeNorth American T-28B: 1 caseAll aircraft: 28 casesProbable cause
Light condition: glareEnvironmental issues › Conditions/weather/phenomena · Effect on personnelNorth American T-28B: 1 caseAll aircraft: 109 casesProbable cause

N48962 · Cessna 152

Attention/monitoring: attentionPersonnel issues › Psychological · Pilot of other aircraftCessna 152: 4 casesAll aircraft: 226 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

N5440F · North American T28

N48962 · Cessna 152

Analysis

The student pilot and flight instructor in the Cessna were landing at the non-tower-controlled airport when a North American T-28 collided with the Cessna from behind, fatally injuring the student. Radar data indicated that the T-28 overflew the airport before joining the downwind leg of the traffic pattern for the landing runway; about this time, the Cessna was on final approach. The pilot of the T-28 reported that the bright sun and the haze created a glare on the windscreen that obscured his forward vision, making it difficult for him to see directly ahead, and the glare became worse as he descended toward the runway on final approach. The T-28 pilot saw the Cessna ahead of him on the runway just before the collision occurred. The instructor onboard the Cessna could not recall the details of the flight but reported that his student would have made radio calls on the airport's common traffic advisory frequency (CTAF) as they approached the airport for landing. The CTAF was not recorded, and the radio frequency settings of the Cessna could not be determined due to thermal damage. Examination of the T-28 revealed that its radio was not tuned to the airport's CTAF; therefore, the T-28 pilot was neither receiving position reports from other aircraft in the traffic pattern, nor was he broadcasting his position. The circumstances of the accident are consistent with the T-28 pilot's failure to see and avoid the Cessna while landing with reduced visibility due to sun glare, and it is likely that his failure to monitor and use the CTAF contributed to the accident.

Factual narrative

FAA Advisory Circular (AC) 90-66B, Non-Towered Airport Flight Operations, recommends that: All traffic within a 10-mile radius of a non-towered airport or a part-time-towered airport when the control tower is not operating should continuously monitor and communicate, as appropriate, on the designated CTAF until leaving the area or until clear of the movement area. After first monitoring the frequency for other traffic present passing within 10 miles from the airport, self-announcing of your position and intentions should occur between 8 and 10 miles from the airport upon arrival. Departing aircraft should continuously monitor/communicate on the appropriate frequency from startup, during taxi, and until 10 miles from the airport, unless 14 CFR or local procedures require otherwise. Neither pilot was in contact with an air traffic control facility, nor were they required to be. CPM's common traffic advisory frequency (CTAF) was not recorded. The Cessna's radio settings could not be determined due to thermal damage. The T-28 was equipped with a Garmin GTR SL40 communications radio, located immediately below a Garmin 327 transponder mounted to the bottom of the panel. When the electrical system was powered on following the accident, the active radio frequency was 125.00 and the standby frequency was 121.50. The CPM CTAF was 123.05. Commonly referred to as "GUARD," 121.5 MHz is reserved for emergency communications for aircraft in distress, as well as the frequency utilized by earlier generation emergency locator transmitters as a means of locating downed aircraft. When positioned in the pilot's seat in the T-28, investigators noted that the radio frequencies were partially obscured from the pilot’s field of vision. While in a normal flying position, an investigator of similar height of the T-28 pilot could only see the bottom half of the displayed frequencies. On March 13, 2019, about 1850 Pacific daylight time, a Cessna 152 airplane, N48962, and a North American T-28 Trojan (T-28), N5440F, were involved in an accident near Compton, California. The T-28 sustained substantial damage and the airline transport pilot onboard was not injured. The student pilot onboard the Cessna was fatally injured, and the flight instructor sustained serious injuries; the airplane was destroyed. The T-28 was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight; the Cessna was operated as a Title 14 CFR Part 91 instructional flight. Review of radar data revealed two discrete secondary beacon code targets that were correlated to the two airplanes as they approached Compton/Woodley Airport (CPM); the Cessna from the south-southwest and the T-28 from the north/east. (See figure 1.) The instructor onboard the Cessna stated that he and the student were simulating a diversion to CPM. He was seriously injured during the accident and could not recall the details of the flight but stated that the student would have made all radio calls over theairport's common radio frequency. Radar indicated that the Cessna entered the airport traffic pattern on the downwind leg at an altitude about 950 ft above ground level (agl), then proceeded to fly the base and final legs of the traffic pattern for runway 25 left (25L). Figure 1. Recorded radar data of both airplanes The T-28 pilot stated that he was returning the airplane to CPM following maintenance. As he approached the area at an altitude about 1,000 ft above ground level (agl), he began to become concerned, because the haze was extreme and the sun was low and bright, obscuring his forward vision. He was initially unable to find CPM but located an open area without buildings and thought that was likely the airport, which he confirmed as he got closer. In an effort to announce his presence at the airport, he overflew the runway from the southeast, crossing midfield then making left descending turns into the left traffic pattern for runway 25. Radar data indicated that the T-28 approached CPM from the east, overflew the airport about 700 to 750 ft agl, then entered the left downwind leg of the traffic pattern for runway 25L. (See figure 2.) Figure 2. Radar data The T-28 pilot stated that as he turned from the base to final legs, the bright sun and the haze created a glare on the windscreen that obscured his forward vision, making it difficult for him to see directly ahead. As he descended toward the runway, the glare became worse and he realized he was between runways 25L and 25R. He side-stepped to runway 25L and the airplane touched down on the runway surface. Several seconds later, the pilot saw the Cessna on the runway ahead of him. He applied hard braking and felt the impact with the other plane and resulting explosion immediately thereafter. The T-28 continued about 1,000 ft before coming to rest off the right side of runway 25L. (See figure 3.) Figure 3. Compton Airport accident diagram Multiple video recordings captured the accident (see figure 4); review of the footage revealed that the Cessna touched down on runway 25L and continued its landing roll. The T-28 crossed the runway threshold about 10 seconds after the Cessna and subsequently touched down about 1850:36. On the landing roll, adjacent to the runway halfway point sign, the T-28 impacted the Cessna. Figure 4. Video frames of the airplanes before impact The time of sunset was 1859:24. The sun’s azimuth at the time of the accident was 267° (see figure 5) and the elevation was slightly above the horizon at 0.50°. Figure 5. Sun information T-28 Pilot (A-1) The 84-year-old pilot was issued a third-class special issuance Federal Aviation Administration (FAA) airman medical certificate with a limitation for glasses for near vision. On his most recent medical exam, his color vision and field of vision were normal, and his uncorrected distant vision was 20/30. At his November 2017 ophthalmology examination, the pilot was diagnosed with age-related cataracts that had both a nuclear andcortical component. He was noted to wear eyeglasses with prism correction, and his uncorrected distant vision was 20/30 in each eye. An ophthalmology exam on October 2019 found a worsening of his cataracts and distant vision. Review of the pilot’s uncorrected vision results from exams spanning over thirty years for first or second-class medical certification showed some gradual decrement of distant vision with aging, which required him to wear corrective lenses when flying. The T-28 pilot stated that he used his “Flight Guide” book for determining airport frequencies. Examination of the actual guide found at the airplane revealed that the page for CPM was missing; a paper note in place of the page read, “Pg 34, Aug 2017 Compton a/d removed.” The Cessna came to rest on the north side of runway 25L, about 150 ft west of the left outboard wing. The T-28 was 450 ft further west of the Cessna. The marks on runway revealed no indications of braking by the T-28 before the collision.

Aircraft · 2

Registration
N5440F
Reported as
North American T28 (B)
Category
Airplane
Serial number
138294
Built
1956
Engine
Wright R-1820-86B, 1,475 horsepower, reciprocating
Damage
Minor damage
Flight
Personal · Part 91
Operator
Tomorrows Aeronautical Museum
Registered owner
Tomorrows Aeronautical Museum
Airworthiness certificate
Special, Experimental (Special)
Departed
WHP · Los Angeles, CA
Destination
CPM · Compton, CA
Airport
CPM · Compton/Woodley, runway 25L, 3,322 × 60 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.

Registration
N48962
Reported as
Cessna 152 (No Series)
Category
Airplane
Serial number
15281075
Built
1977
Airframe hours
20,105
Engine
Lycoming O-235-L2C, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Long Beach Flying CLub
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · February 20, 2019 · 68 hours before
Departed
LGB · Long Beach, CA
Destination
LGB · Long Beach, CA
Airport
CPM · Compton/Woodley, runway 25L, 3,322 × 60 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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N5440F
Age
84
Injuries
None
Certificates
Flight instructor, Airline transport, Flight engineer, Military, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
March 15, 2017
Seat
Front
Restraint
4-point
Flight hours
24,000 total · 400 in this make and model · 18,000 as pilot in command · 3 in the last 90 days · 1 in the last 30 days · 1 in the last 24 hours
Role
Flight instructor, aircraft N48962
Age
34
Injuries
Serious
Certificates
Commercial, Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Flight hours
9,542 total · 1,674 in this make and model · 9,402 as pilot in command · 107 in the last 90 days · 55 in the last 30 days · 1 in the last 24 hours
Role
Student pilot, aircraft N48962
Age
40
Injuries
Fatal
Certificate
Student
Medical
Class 1, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
22 total · 22 in this make and model · 1 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
Wind
270° at 11 knots, gusting 16
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 32 °F
Altimeter
30.02 inHg
Observed at
KHHR, 5 nm away

Docket · 12

The files NTSB released with the investigation on April 13, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 124 MB in all.

FAA reports on this event · 2

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