Narratives From The On-line NTSB/FAA General Aviation Crash Data Base Of Accidents At/Near the Palo

Alto Airport
FAA/NTSB keeps records of General Aviation crashes on-line going back to 1964. There have been about 147 crashes at the Palo Alto Airport during that time, a goodly number of them involving fatalities. The online database of these crashes provides the narratives of the NTSBs (National Transportation Safety Board) investigation of each crash/accident/incident. Review of these incidents can be most instructive, since the role of the pilot as a contributor in each of these incidents becomes very clear. Pilot failure to perform correctly can be seen as the primary cause of many of these accidents. Currently, no one at the City Government level is paying attention to the safety issues associated with the Palo Alto Airport. To do so would no doubt require an employee, which would increase the costs of the operation of the airport—which currently generates only so much money from the various fees it collects. If the City fails to do a better job than the County has been doing monitoring, and forcing a higher level of safety in the operations of this airport—then these sorts of accidents will continue to occur, putting everyone living in the five-mile radius of the airport at risk. -----http://www.ntsb.gov/ntsb/brief.asp?ev_id=20050312X00305&key=1

NTSB Identification: LAX05LA109. The docket is stored in the Docket Management System (DMS). Please contact Records Management Division Accident occurred Monday, March 07, 2005 in Half Moon Bay, CA Probable Cause Approval Date: 9/14/2007 Aircraft: Cirrus Design Corp. SR22, registration: N517SW Injuries: 2 Uninjured. The pilot taxied the airplane from the parking area to the end of the runway for takeoff, which was about 1.5 miles, with the right brake on to maintain alignment with the taxiway. He had turned onto the runway, when the passenger saw flames coming from the right main landing gear brake area. The airplane sustained structural damage to the right wing from the fire. The pilot said that for the past several months, the airplane had been "pulling left," and he had to drag the right brake in order to taxi straight. Two weeks prior to the accident, the pilot informed maintenance of the issue. Maintenance personnel found that the left brake cylinder and assembly had been leaking fluid. They

repaired the left brake assembly, and returned the airplane to service. Three days prior to the accident, there was a report to maintenance that the left brake was pulling excessively. Section 4 of the airplane's operating manual, contained a caution note, which directed pilots to taxi with the minimum power needed for forward movement. It stated that excessive braking could result in overheated or damaged brakes, which could result in brake system malfunction or failure. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's excessive braking during taxi that resulted in the right brake overheating and a fire. A factor in the accident was the pilot's continued operation with known deficiencies.
http://www.ntsb.gov/ntsb/brief.asp?ev_id=20050106X00023&key=1

NTSB Identification: LAX05FA058. The docket is stored in the Docket Management System (DMS). Please contact Records Management Division Accident occurred Sunday, January 02, 2005 in Palo Alto, CA Probable Cause Approval Date: 4/25/2006 Aircraft: Piper PA-46-350P, registration: N4165P Injuries: 1 Minor, 3 Uninjured. The airplane landed long and overran the runway, colliding with a berm and marshy terrain about 300 yards beyond the runway end. The first leg of the flight originated at Mammoth Lakes, California, destined for Palo Alto. En route at 18,000 feet over the Sierra Nevada Mountains, the pilot observed erratic high oil temperature and low oil pressure readings and diverted to Modesto to have the engine checked. No mechanics were available at the airport and the pilot subsequently departed for Palo Alto, after adding oil to the engine for the 65-mile remaining trip, heading west. En route to Palo Alto, and in actual IFR conditions, the pilot experienced erratic operation of both GPS navigation systems (one failed after losing a lock on the satellites), which troubled the pilot since she had had a very bad prior experience with losing the navigation systems in actual IFR and icing conditions in a non-radar environment. Shortly after that, the oil pressure and oil temperature indications became erratic again, with the oil temperature flickering near the upper limit and the oil pressure flickering near the lower limit. The pilot said she pushed the reset buttons and cycled the circuit breakers and the audible alarms for the oil temperature and pressure sounded. In addition, the ice warning system

activated, alerting the pilot to select the deice functions, and after turning them on, the pilot observed clear ice breaking off the wings. Then the fuel gages started to give erratic indications, cycling to near empty and back again. The pilot told the TRACON controller she needed to land as soon as possible and the controller suggested two nearby airports, one with an 11,000-foot-long runway; however, since the original destination was only 8 minutes further on, the pilot elected to continue to Palo Alto. As she approached the airport, the oil temperature continued to fluctuate and the associated warning horn sounded. She continued to reset (silence) the horn as she approached the airport. The pilot was given the winds at Palo Alto (120 degrees at 8 knots) and since she was concerned with losing the engine over a populated city area, she requested runway 31 in order to make a straight-in approach. The pilot was cleared to land on the 2,500-foot-long runway 31. The pilot said she realized she was high on the approach but did not think about a go-around because of the concern with the potential for an engine failure. The airplane landed about halfway down the runway and could not stop before overrunning the runway and colliding with a berm and marshy terrain about 300 yards beyond the runway end. The aircraft is equipped with an integrated engine parameter instrument and warning system (EMIS), which is a precision measurement and display system containing both analog and digital displays of engine related parameters with alarms for parameter exceedances. In normal operation mode, the Enhanced Digital Indicator (EDI) posts a digital enhancement of the selected analog indicators. The automatic exceedance warning mode has the highest priority. When an exceedance is detected, the EDI will automatically select that indicator and display the readings on the LCD. The peak exceedance value of the indicator will flash in the display and be recorded in non volatile memory for future extraction. The EDI was powered up and placed into exceedance review mode. While in exceedance review mode, the EDI reported the following exceedances: 1) Oil Temperature (OT) recorded three events with a peak exceedance of 278 with an average exceedance of 278 for 11 seconds; 2) Oil Pressure (OP) recorded one event with a peak exceedance of 0 (zero) with an average exceedance of 0 for 81 seconds; 3) Manifold Pressure (MP) recorded nine events with a peak exceedance of 42.0 with an average exceedance of 42.0 for 2 seconds; 4) Turbine Inlet Temperature (T.I.T.) recorded one event of 43 seconds at an average exceedance of 1750. The Cylinder Head Temperature (CHT), Fuel Flow (FF), and Propeller rpm (rpm) indicators did not report any exceedances. A functional test of the EMIS system, to include all probes, analog gages, and associated wiring, was conducted, with no anomalies found. The electrical connection of the temperature probe was forcibly manipulated in an attempt to make the indicator fluctuate. All attempts to duplicate a fluctuating oil temperature indication

failed. A detailed examination of the engine found no evidence of a malfunction with the lubricating system or evidence of lubrication related damage to the core engine. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: the pilot's misjudged distance and speed on final approach, which led to a long landing and a runway overrun. Also causal was the pilot's inadequate in-flight decision to continue flight with indications of apparent serious system anomalies, failure to divert to a more suitable destination alternate, and failure to perform a go-around when an overshoot became obvious. Factors in the accident were the short runway at Palo Alto and the pressure placed on the pilot by the apparent indications of multiple system failures and the potential for a catastrophic engine failure. The cause of the erratic engine instrument indications was not resolved.
http://www.ntsb.gov/ntsb/brief.asp?ev_id=20050525X00667&key=1

NTSB Identification: LAX05CA148. The docket is stored in the Docket Management System (DMS). Please contact Records Management Division Accident occurred Tuesday, April 26, 2005 in Palo Alto, CA Probable Cause Approval Date: 9/13/2005 Aircraft: Cessna 172N, registration: N737WF Injuries: 3 Uninjured. The airplane veered off the runway and impacted a taxiway following a loss of control during takeoff. The student reported that while on the takeoff roll the airplane was on the centerline of the runway. The airplane started to drift to the right of the centerline. The student said he either released some of the pressure on the right rudder pedal and/or applied some left pedal to correct the drift of the airplane. The certified flight instructor (CFI) reported that during the takeoff roll, with the student at the controls, it "sharply and abruptly" yawed to the left and then "very abruptly rotated." The CFI attempted to regain control of the airplane; however, the airplane impacted "sideways on the parallel taxiway." The student and the CFI both stated that the airplane and engine had no mechanical failures or malfunctions during the flight. The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

The student's failure to maintain directional control and the CFI's failure to adequately supervise the flight.
http://www.ntsb.gov/ntsb/brief.asp?ev_id=20070418X00435&key=1

NTSB Identification: LAX07LA122. The docket is stored in the Docket Management System (DMS). Please contact Records Management Division Accident occurred Sunday, April 08, 2007 in So Lake Tahoe, CA Probable Cause Approval Date: 7/30/2008 Aircraft: Scottish Aviation Bulldog 120, registration: N706X Injuries: 1 Fatal, 1 Serious. The pilot and his passenger departed for a flight across the Sierra Nevada mountain range to a destination on the California coast. According to the surviving passenger, the pilot intended to follow a highway through the mountains; however, he experienced difficulty in climbing high enough to clear the terrain. He elected to circle, to gain sufficient altitude to pass over a mountain summit. During the circling climb, the pilot flew south into even higher mountainous terrain. The airplane was unable to climb or maintain altitude, and struck a tree with the right wing. The airplane came to rest inverted in a pasture. No evidence was found of a preimpact mechanical malfunction or failure during examination of the airframe and engine. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's failure to maintain clearance from objects and the mountainous terrain
http://www.ntsb.gov/ntsb/brief.asp?ev_id=20080211X00174&key=1

NTSB Identification: LAX08LA055 14 CFR Part 91: General Aviation Accident occurred Friday, February 01, 2008 in Palo Alto, CA Probable Cause Approval Date: 12/24/2008 Aircraft: CESSNA 152, registration: N49811 Injuries: 1 Uninjured. Prior to the accident flight, a maintenance inspection was performed. A piece of the baffling was found in the throat of the carburetor venturi. The carburetor was inspected and reinstalled on the airplane. On the accident flight, the pilot/mechanic performed a post maintenance run-up with no mechanical

problems noted. She taxied the airplane to the runway for takeoff and performed another run-up. Again there were no mechanical problems noted, and all the gages showed normal indications. On the takeoff roll the engine developed 2,300 rpm’s. About 500 feet mean sea level (msl), she noticed a hesitation in the engine and decided to make a 180-degree turn back to the runway. The airplane was still high on the approach, so the pilot reduced the airspeed, performed S-turns, and then slipped the airplane to lose altitude. She was still high, and about halfway down the runway, she further reduced the airspeed, which increased the sink rate. She lowered the nose to slow the sink rate, and was in the process of raising the nose again to flare for landing when the nose struck the runway. An inspection of the engine revealed zero compression of the number 1 cylinder with blow-by past the piston rings and exhaust valve. Maintenance personnel also noted that the bottom number 1 cylinder spark plug was "excessively" fouled with carbon deposits. There were no problems noted with the carburetor. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: Loss of engine power during the takeoff initial climb due to lack of compression to a cylinder.
http://www.ntsb.gov/ntsb/brief.asp?ev_id=20090622X51947&key=1

NTSB Identification: WPR09LA302 14 CFR Part 91: General Aviation Accident occurred Saturday, June 20, 2009 in San Jose, CA Aircraft: MOONEY M20TN, registration: N411JL Injuries: 2 Uninjured. On June 20, 2009, about 1318 Pacific daylight time, a Mooney M20TN, N411JL, experienced a landing gear collapse after touchdown at the Norman Y. Mineta San Jose International Airport (SJC), San Jose, California. The pilot/owner operated the airplane under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. The pilot and passenger were not injured. The airplane sustained substantial damage to the fuselage and both wings, as well as the horizontal stabilizer. Visual meteorological conditions prevailed for the cross-country flight that departed the Lake Tahoe Airport (TVL), South Lake Tahoe, California, about 1100. No flight plan had been filed. The flight had been destined for the Palo Alto Airport of Santa Clara County (PAO), Palo Alto, California.

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20100217X24906&key=1

NTSB Identification: WPR10FA136 14 CFR Part 91: General Aviation Accident occurred Wednesday, February 17, 2010 in Palo Alto, CA Aircraft: CESSNA 310R, registration: N5225J Injuries: 3 Fatal. This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. On February 17, 2010, about 0754 Pacific standard time, a Cessna 310R airplane, N5225J, was destroyed when it impacted multiple residential structures and terrain following an in-flight collision with power lines and a power line tower. The collision occurred shortly after takeoff from the Palo Alto Airport (PAO), East Palo Alto, California. The commercial pilot and his two passengers were killed. There were no reported ground injuries. The airplane was registered to Air Unique Inc., Santa Clara, California, and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Instrument meteorological conditions prevailed and an instrument flight plan was filed for the cross-country flight. The flight was originating at the time of the accident with an intended destination of Hawthorne, California. Multiple witnesses located adjacent to the accident site reported observing portions of the accident sequence. One witness, who was walking on a levee near the accident site reported that she observed an airplane “suddenly appear from the fog” left of her position. The witness stated that she continued to watch the airplane fly in a level or slightly nose up attitude from her left to her right at a low altitude until it impacted power lines shortly after. Examination of the accident site revealed that the airplane struck power lines and a power line tower about 50 feet above ground level. Various portions of wreckage debris, power lines, and power line tower structure were scattered throughout the wreckage debris path. The wreckage debris path was measured on a southwesterly heading for approximately 900 feet from the first identified point of contact (FIPC) to the main wreckage. All major structural components of the airplane were located within the wreckage debris path. A post-crash fire and wreckage debris damaged multiple residential structures and vehicles along the debris path. The airplane was recovered to a secure location for further examination.

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20001214X41813&key=1

NTSB Identification: LAX85FA088 . The docket is stored on NTSB microfiche number 27414. Accident occurred Thursday, December 27, 1984 in UPLAND, CA Aircraft: CESSNA 182Q, registration: N735MJ Injuries: 4 Fatal. THE INSTRUMENT RATED PLT & 3 PAX DEPARTED PALO ALTO FOR AN INTENDED 3-HOUR LONG DAY VFR FLT TO SANTA ANA, CA. THE FINAL DESTINATION WAS TO BE MX. THE PLT HAD NOT FLOWN AT NIGHT OR ON INSTRUMENTS IN OVER 6 YRS. HE ELECTED TO DELAY DEPARTING PAO UNTIL 1611 PST DUE TO FORECAST MARGINAL WEATHER. THE PLT DID NOT COMMUNICATE WITH ATC OR FSS WHILE EN ROUTE & UPON ARRIVAL IN SOUTHERN CA, AT NIGHT, MARGINAL VFR WX WAS ENCOUNTERED. A LOCALIZED AREA OF MODERATE TO HEAVY RAIN EXISTED OVER UPLAND, APRX 28 MILES NORTH OF SNA. THE ACFT WAS OBSERVED TO CIRCLE CABLE ARPT. WHEN SOUTH OF THE ARPT AND FLYING ON A NORTHERLY HEADING AT CRUISE SPEED, IT DESCENDED AND CRASHED INTO AN UNPOPULATES AND DARK AREA OF LEVEL TERRAIN. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: VISUAL LOOKOUT..NOT MAINTAINED..PILOT IN COMMAND ALTITUDE..NOT MAINTAINED..PILOT IN COMMAND Contributing Factors WEATHER CONDITION..RAIN LIGHT CONDITION..DARK NIGHT LACK OF RECENT EXPERIENCE IN TYPE OPERATION..PILOT IN COMMAND IN-FLIGHT BRIEFING SERVICE..NOT USED..PILOT IN COMMAND IN FLIGHT WEATHER AVOIDANCE ASSISTANCE..NOT OBTAINED..PILOT IN COMMAND

IN-FLIGHT PLANNING/DECISION..IMPROPER..PILOT IN COMMAND PRESSURE INDUCED BY OTHERS..PILOT IN COMMAND
http://www.ntsb.gov/ntsb/brief.asp?ev_id=20001213X31832&key=1

NTSB Identification: LAX87FA296A. The docket is stored on NTSB microfiche number 37730. Accident occurred Friday, August 07, 1987 in PALO ALTO, CA Probable Cause Approval Date: 9/1/1989 Aircraft: CESSNA 152, registration: N152SC Injuries: 5 Uninjured. A MIDAIR COLLISION OCCURRED ABT 2.8 MI WEST OF PALO ALTO ARPT (PAO) AS CESSNA 152, N152SC, WAS ON A LEFT X-WND DEP FM RWY 30 & MOONEY M20J, N5201Y WAS TRANSITTING THE ARPT TRAFFIC AREA (ATA) FM SE TO NW & DSCNDG FM 2400' TO 1500'. N152SC WAS ON TWR FREQ. N5201Y (ON A TRAFFIC WATCH FLT FOR A LCL RDO STN) HAD JUST BEEN GIVEN A FREQ CHG TO SAN CARLOS (SQL) TWR TO TRANSIT ITS ATA, WHICH WAS NEXT TO THE PAO ATA. THE LCL CTL PSN AT PAO WAS BEING WORKED BY A DEVELOPMENTAL CTLR (D/C) UNDER SUPVN OF THE TWR SUPVR. HE DIDN'T IDENT N5201Y ON HIS BRITE RADAR. THE SUPVR SAW A PSBL CONFLICT DEVELOPING & WAITED A FEW SEC BFR ISSUING AN ADZY TO SEE IF THE D/C WOULD SEE & RESOLVE IT. THE SUPVR THEN TRANSMITTED A TRAFFIC ADZY TO N152SC, BUT THERE WAS NO REPLY. ABT 9 SEC LTR, THE 2 ACFT CONVERGED & COLLIDED. NEITHER AIRCREW SAW THE OTR ACFTIN TIME TO AVOID A COLLISION, BUT BOTH WERE ABLE TO LND SAFELY. THE D/C HAD 8 HRS OF OJT IN THAT PSN. THE AIRSPACE WAS COMPLEX WHERE 5 ATA'S ADJOINED EACH OTHER; THE VARIABLE TCA FLOOR SEGMENTS RANGED FM 4000' OVER PAO TO 1500' OVER SQL. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: TRAFFIC ADVISORY..DELAYED..ATC PERSONNEL(LCL/GND/CLNC) SUPERVISION..INADEQUATE..ATC PERSONNEL(SUPERVISOR) VISUAL LOOKOUT..INADEQUATE..PILOT IN COMMAND VISUAL LOOKOUT..INADEQUATE..PILOT OF OTHER AIRCRAFT
http://www.ntsb.gov/ntsb/brief.asp?ev_id=20001213X26266&key=1

NTSB Identification: LAX88FA264 . The docket is stored on NTSB microfiche number 36152. Accident occurred Tuesday, July 19, 1988 in PORTOLA VALLEY, CA Probable Cause Approval Date: 6/7/1989 Aircraft: BEECH 76, registration: N2074M Injuries: 1 Fatal. WHILE DINING WITH FRIENDS WITH WHOM HE RESIDED, THE PILOT TOLD THEM THAT HE WAS 'GOING FLYING'. AT THE COMPLETION OF THE FLIGHT HE WOULD FLY OVER THE HOUSE BEFORE HE RETURNED TO PALO ALTO AIRPORT (PAO). THE PILOT TWICE CIRCLED THE RESIDENCE WHICH IS ABT 7 MILES SOUTHWEST OF PAO AT A LOW ALTITUDE AND THEN PROCEEDED WEST. GROUND WITNESSES REPORTED THAT WHEN THE AIRPLANE WAS ABT 1/2 MILE WEST OF THE RESIDENCE IT ENTERED A 70 DEG NOSE HIGH ATTITUDE. THE MANEUVER RESEMBLED A LEFT HAMMERHEAD STALL EXCEPT BEFORE IT REACHED THE NOSE DOWN ATTITUDE IN ENTERED A LEFT SPIN. ONE WITNESS CLOSE TO THE ACCIDENT SITE RPTD THAT THE AIRPLANE HAD STOPPED ITS SPIN ROTATION AND WAS IN ABT A 45 DEG NOSE DOWN ATTITUDE AT IMPACT. THE WITNESSES NEAR THE ACCIDENT SITE REPTD THAT 1 OF THE ENGS SOUNDED IRREGULAR. THE POST CRASH INVESTIGATION DISCLOSED NO EVIDENCE OF ANY AIRPLANE OR ENGINE PREEXISTING MALFUNCTIONS OR FAILURES. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: JUDGMENT..POOR..PILOT IN COMMAND PROPER ALTITUDE..NOT MAINTAINED..PILOT IN COMMAND FLIGHT CONTROLS..IMPROPER USE OF..PILOT IN COMMAND STALL/SPIN..INADVERTENT..PILOT IN COMMAND Contributing Factors LIGHT CONDITION..NIGHT AEROBATICS..ATTEMPTED..PILOT IN COMMAND

http://www.ntsb.gov/ntsb/brief2.asp? ev_id=20011113X02226&ntsbno=LAX02FA019&akey=1

LAX02FA019 HISTORY OF FLIGHT On October 31, 2001, about 1800 Pacific standard time, a Cessna 182S, N7270E, impacted trees and terrain 1.5 miles from Little River Airport (048), Little River, California. The pilot operated the rental airplane under the provisions of 14 CFR Part 91. The airplane was destroyed in the post-impact fire. The commercial pilot, the sole occupant, sustained fatal injuries. The personal cross-country flight departed Palo Alto Airport of Santa Clara County (PAO), Palo Alto, California, about 1700, en route to Little River. A combination of night visual and instrument meteorological conditions prevailed, and no instrument flight rules (IFR) or visual flight rules (VFR) flight plan had been filed for the cross-country flight. The wreckage was at 39 degrees 16.31 minutes north latitude and 123 degrees 42.87 minutes west longitude. According to the Federal Aviation Administration (FAA) records, there is no record that the pilot requested or received a weather briefing for the flight. A witness at the airport said that just before 1800 he heard an aircraft circling in the vicinity of the airport; however, he could not see it because of the low clouds and fog over the field. Using his hand-held radio on the common traffic advisory frequency (CTAF) 122.7, the witness established contact with the pilot. The pilot said he was trying to land at the airport, and at one point could see the runway lights through the fog, but had lost sight of the runway. The witness then heard the aircraft continue to the east at what sounded like a reduced power setting. There was no further communications from the pilot. A resident living near the crash site heard the sounds of an impact and reported the event to the sheriffs department. Search efforts were hampered by fog and low visibility conditions and the wreckage was not located until about 1000 on November 1st. The accident site is 1.5 miles north east of the airport at an elevation about 200 feet higher than the runway. PERSONNEL INFORMATION A review of FAA airman records revealed the pilot held a commercial certificate with airplane single engine land and instrument ratings. The pilot

held a second-class medical certificate issued on August 30, 2001. It had the limitations that the pilot must wear corrective lenses and possess glasses for near and intermediate vision. According to the pilot's last medical certificate application on August 20, 2001; he had accrued 3,200 hours of total flight time, with 150 flight hours in the last 6 months. The pilot's logbook was not available for review. Coast Flyers in Little River employed the pilot as a 14 CFR Part 135 day VFR operations pilot. The owner estimated the accident pilot's total flight time as: 3,000 total hours, 150 hours - night, and 150 hours - instrument. AIRCRAFT INFORMATION The National Transportation Safety Board investigator-in-charge (IIC) reviewed the airframe and engine logbooks. The airplane was a Cessna 182S, serial number 18280480. An annual inspection was completed on October 10, 2001, and no open discrepancies were noted. The tachometer read 399 at the last inspection. A Textron Lycoming IO-540-AB1A5 engine, serial number L-26757-48A, powered the airplane. Total time on the engine at the last annual inspection was 399 hours. METEOROLOGICAL CONDITIONS The closest official weather observation station was the Ukiah Municipal Airport (UKI), Ukiah, California, located 26 nautical miles southeast of the accident site. The elevation of the weather observation station was 625 feet mean sea level (msl). A routine aviation weather report (METAR) for UKI was issued at 1756. It stated: skies 5,000 feet overcast; visibility 10 miles; winds calm; temperature 50 degrees Fahrenheit; dew point 43 degrees Fahrenheit; altimeter 29.99 InHg. The airport manager at Little River estimated the weather conditions at the time of the accident: visibility about a 1-mile and a 300-foot ceiling. WRECKAGE AND IMPACT INFORMATION Investigators from the Safety Board, the FAA, Cessna, and Textron Lycoming examined the airframe and engine on scene. The airplane came to rest in a grove of trees in a nose-down attitude. Portions of tree tops, measuring 3- to 5-

inches in diameter, displayed angled smooth cuts and were located near the main wreckage. An energy path through the trees was on a easterly bearing. All three of the propeller blades showed evidence of S-bending and leading edge gouging. A post-impact fire consumed the airplane. The engine was buried about 3 feet in the ground. The on scene examination of the airframe revealed that all of the flight control cables were present. Control continuity was established except for the right wing section. The flight cables were separated. The separations were broom strawed in appearance. The flaps were in the retracted position. The postimpact fire consumed the fuel system, and a fuel selector valve was not located in the debris. No discrepancies were noted with the airframe. The engine was also examined on scene. The crankshaft would not rotate due to impact damage. The cylinders were examined with a borescope and no damage or foreign object ingestion was noted. They magnetos had been damaged and could not be functionally tested. The magnetos remained secure at their respective mounting pads. The spark plug electrodes were gray in color, which corresponded to normal operation according to the Champion Aviation CheckA-Plug AV-27 Chart. An unsuccessful attempt was made to manually rotate the vacuum pump. The vacuum pump was disassembled. The vanes were broken, which was attributed to impact damage. The fuel flow divider remained secure at the mounting bracket, and the fuel lines remained secure at each flow divider fitting. The fuel injection servo was displaced from the engine and remained partially attached to the mounting pad. The fuel injection servo and induction system components were free of obstruction. The servo fuel inlet screen was free of contaminants. The engine driven fuel pump was destroyed. There were no mechanical anomalies that would have precluded the engine from producing power prior to impact. MEDICAL AND PATHOLOGICAL INFORMATION The Mendocino County Coroner completed an autopsy; however, no specimens were gathered for a toxicological test. ADDITIONAL INFORMATION The IIC released the wreckage to the owner's representative.
http://www.ntsb.gov/ntsb/brief2.asp? ev_id=20001211X12165&ntsbno=LAX93LA168&akey=1

LAX93LA168 On April 8, 1993, at about 1618 hours Pacific daylight time, a Cessna 152, N89022, experienced a loss of control during the landing roll on runway 30 at San Carlos Airport, San Carlos, California. The pilots were conducting a visual flight rules instructional flight. The airplane, operated by Palo Alto Flying Club, Palo Alto, California, sustained substantial damage. Neither the certificated airline transport pilot/flight instructor (CFI) nor the noncertificated student pilot was injured. Visual meteorological conditions prevailed. The flight originated at Palo Alto Airport (PAO), Palo Alto, California, at 1611 hours. Ms. Cynthia Jesch, aviation safety inspector, Federal Aviation Administration (FAA), San Jose [California] Flight Standards District Office, reported that the flight was landing on runway 30 at PAO, during gusting wind conditions. During the landing roll the aircraft exited the left side of the runway and its horizontal stabilizer struck a sign. The CFI reported in the Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2, that the student pilot made a normal landing. On the landing roll-out, the local controller asked the flight where it was going to park. The CFI requested to taxi back for takeoff and was going to remain in the traffic pattern. Moments later, the airplane veered to the left and the CFI admonished the student to "watch your braking." The CFI indicated that the airplane "felt like he [the student] applied uneven braking application with excessive braking of the left brake." The CFI then stated that "...when it was clear that the student lost control [of the airplane] I took over and three (3) seconds later we were at a standstill on the taxiway. Unfortunately, in the interim, we had struck a runway sign with the right stabilizer..."
http://www.ntsb.gov/ntsb/brief2.asp? ev_id=20020614X00886&ntsbno=LAX02LA193&akey=1

LAX02LA193 On June 9, 2002, about 1415 Pacific daylight time, a Cessna 180, N2228C, ground looped and overturned during landing at Columbia Airport (O22), Columbia, California. The pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The private pilot and passenger were not injured; the airplane sustained substantial damage. The personal cross-country flight departed Palo Alto Airport (PAO), Palo Alto, California, at 1330, en route to

Columbia Airport. Day visual meteorological conditions prevailed, and no flight plan had been filed. The pilot stated that he witnessed two other aircraft landing on runway 35, so he also landed on runway 35. The AWOS at Columbia Airport reported the winds to be 290 degrees at 8 knots gusting to 15. He made a three-point landing and was coming to a stop when a sudden burst of wind lifted the left wing and the tail off of the ground, swinging the tail to the right. The tail continued to lift until the propeller struck the ground and the airplane flipped over. He said that the plane was tracking straight on the centerline at 25 miles per hour when the wind disturbance was encountered. The airport has two runways, and are on a magnetic heading of 170-350 and 110-290. Runway 11-29 is 2,600 feet long and 100 feet wide, and is turf.
http://www.ntsb.gov/ntsb/brief2.asp? ev_id=20021213X05606&ntsbno=LAX03FA037&akey=1

LAX03FA037 HISTORY OF FLIGHT On November 24, 2002, about 1800 Pacific standard time, a Beech B36TC, N3242Q, cruised into upsloping mountainous terrain about 3 miles north of Union City, California. At the time of the accident, dark nighttime conditions existed, and the airplane was approaching the Palo Alto Airport of Santa Clara County, located about 12 nautical miles (nm) south of the crash site. Impact forces and a postcrash ground fire destroyed the airplane. The commercial certificated pilot, who was the sole occupant in the airplane, was fatally injured. Instrument meteorological conditions prevailed in the vicinity of the accident site. No flight plan was filed for the personal flight, which was performed under the provisions of 14 CFR Part 91. The Federal Aviation Administration (FAA) had been providing the pilot with en route radar flight-following service, but that service was terminated by the FAA seconds prior to the accident. The pilot's wife reported that the round trip flight originated about 0800 from the Palo Alto Airport, the pilot's home base. Thereafter, the pilot flew to an undetermined airport near Boise, Idaho. The accident occurred during the pilot's return flight home. After departing from near Boise, the pilot flew to the Ontario Municipal Airport, an uncontrolled airport located in Ontario, Oregon. According to a representative from Ontario Aviation, Inc., its records indicated that on

November 24, a purchase transaction was completed with the pilot's credit card for 64.47 gallons of 100 LL aviation fuel. The representative indicated that the self-service fuel pumps were unattended at the time. The airport's Unicom was not in operation. The pilot's departure time from Ontario was not determined, but the pilot's wife estimated it was between 1500 and 1530. Prior to taking off, the pilot telephoned his wife and indicated that he anticipated returning to Palo Alto about 1800. According to the FAA's Western-Pacific Regional quality assurance staff (AWP-505), en route to Palo Alto a radar controller from the Northern California Terminal Radar Approach Control facility (NCT) provided the pilot flying N3242Q with radar flight-following service. The pilot/airplane was assigned a discrete transponder code and was identified on radar. The pilot had not requested minimum safe altitude (terrain proximity) warning (MSAW) advisories, and that additional service was not provided. The FAA reported that, about the time of the accident, the MSAW system was functional at NCT. No outages were reported. Regarding the last few minutes of the airplane's flight, at 1752:55, the southbound pilot contacted NCT. The pilot stated "approach good evening bonanza three two four two quebec's with you five thousand eight hundred descending into palo alto." The controller replied, "three two four two quebec bay approach own navigation to palo alto maintain vfr." ("Maintain vfr" means that the pilot was directed to maintain flight in accordance with visual flight rules.) Three seconds earlier, at 1752:52, recorded radar data indicated that the airplane was descending through 5,800 feet, as indicated by the airplane's Mode C altitude reporting transponder. The airplane's ground speed was about 179 knots, and its magnetic track was about 187 degrees. Three minutes later, the controller contacted the pilot and provided traffic information. The pilot responded by stating "yeah we have both traffic in sight...." The radar data indicates that between 1752:52 and 1758:52, the southbound airplane's altitude decreased to 2,000 feet, and its ground speed decreased to 158 knots. At 1758:56, the NCT controller made his last radio transmission to the pilot.

The controller stated "...no other traffic between you and palo alto remain on your...present beacon code radar service terminated contact tower one one eight point six." Ten seconds thereafter, at 1759:06, the pilot replied with his last recorded transmission by stating "...roger." During this time interval, the airplane's altitude was about 2,100 feet. The airplane was last recorded on radar at 1759:30. At this time, its position was about 37 degrees 38.200 minutes north latitude by 121 degrees 58.833 minutes west longitude. The airplane's altitude had decreased to 1,700 feet, and its ground speed had slowed to 130 knots. The airplane's last recorded ground track was about 167 degrees, magnetic. The distance between the airplane's last recorded radar position and the initial point of ground impact (IPI) is about 1/10-mile. The approximate distance and magnetic bearing between the IPI and the Palo Alto Airport is 12.4 nm and 197 degrees. Two persons reported to the National Transportation Safety Board investigator that about 1800 they observed what they have subsequently learned was the accident airplane flying near their position. The witnesses determined that, at the time of their observations, they were approximately 1/3 mile from the accident site. In summary, the witnesses indicated that their view of the airplane had been restricted due to the presence of fog, and they had only observed the illumination of the airplane's flashing white strobe light as it flew past their location. Minutes later, they observed the glow of a ground fire in the direction the airplane had been flying. PERSONNEL INFORMATION The pilot's wife reported that her husband recorded his flight time in his personal flight record logbook. She provided the Safety Board investigator with her husband's most current logbook for review. A review of the logbook (number two) and FAA records indicates that the pilot was issued a private pilot certificate in 1993, an instrument rating in 1995, and a commercial pilot certificate and multiengine rating in September 1997. Also, the logbook review indicates that the pilot last accomplished an instrument proficiency check and flight review on March 14, 2000, about 2 2/3 years before the accident flight. The logbook indicates that by November 17, 2002, the pilot's total logged flight

time was about 951 hours. The pilot's wife reported that she believes her husband had not flown during the interval between November 18 and 23. During the 12-month period immediately preceding the accident, the pilot flew the accident airplane for approximately 256 hours. AIRPLANE INFORMATION Regarding the airplane's lights, the airplane was equipped with red, green, and white navigation lights, along with an upper fuselage rotating beacon. The airplane also was equipped with wing tip flashing strobe lights. Family members reported that the pilot owned, and was the exclusive pilot, of the accident airplane. The airplane was maintained on an annual inspection basis. The last entry in the airframe logbook was dated June 1, 2002, and it indicated that an annual inspection had been accomplished. On December 11, 2002, the Safety Board investigator interviewed the mechanic who had performed the last annual inspection on the airplane. The mechanic reported that the pilot was not present at the time he had performed the inspection. As best he could recall, at the start of the inspection the airplane appeared in good condition, and there were no outstanding squawks. Following the annual inspection, the mechanic signed the airplane's logbook and returned the airplane to the pilot. The mechanic had no further contact with the airplane or the pilot. The mechanic additionally stated that he recalled the pilot was very particular about his airplane, and anything needing repair was fixed. During the Safety Board investigator's wreckage examination, remnants from the airplane's flight manual were observed in the ashes of the destroyed airplane. During the subsequent inspection of the pilot's hangar, no evidence of a maintenance-related squawk sheet was found. However, a white (chalk) board was observed on which the airplane's tachometer hours, oil change information, etc., had been written. In the pilot's personal flight record logbook, the following two entries were noted regarding airplane anomalies: (1) On October 9, 2002, the log indicated "Electrical Failure and Emergency Landing @ PAO;" and (2) On October 25, 2002, the log indicated "Flap Failure on Final." No logbook record was found of these anomalies having been fixed. The pilot flew the airplane on November 17, 2002. The listed flight time was 1.2 hours. No airplane squawk or notation of difficulty with the airplane was listed in his

logbook for this flight. METEOROLOGICAL INFORMATION The three closest airports to the accident that reported their weather conditions are located at Hayward (elevation 50 feet mean sea level (msl)), Livermore (elevation 397 feet msl), and Palo Alto (elevation 4 feet msl). These airports are, respectively, 7 miles west-southwest, 8 miles northeast, and 12 miles south-southwest from the accident site. Within 15 minutes of the accident, these three airports reported a clear sky, 5to 10-mile visibility, and surface wind between 6 and 7 knots. At 1755, Livermore, which was the closest airport northeast of the accident site, reported 5 miles visibility, mist, and a temperature/dew point of 9 and 8 degrees, respectively. At Palo Alto, the local altimeter setting was 30.17 inches of mercury. The two witnesses were located about 1/3 mile from the crash site. In pertinent part, they reported that at the time "thick" fog existed from 1,450 to 1,725 msl. It was a dark moonless night, and their horizontal visibility was between 30 and 50 feet. When the airplane flew past their location, they only observed its flashing strobe light through the fog. No precipitation was evident. AIDS TO NAVIGATION The FAA reported that all electronic aids to navigation pertinent to the airplane's flight were functional. They were all operating normally in the vicinity of the accident site. COMMUNICATION The FAA reported that no communication difficulties or abnormalities were experienced between NCT and the accident airplane. No communications were recorded with the airplane following NCT's termination of service. Personnel at the Palo Alto Airport control tower indicated that a review of its communication tape did not indicate any record of contact with the pilot of the accident airplane. WRECKAGE AND IMPACT INFORMATION The accident site is located on estimated 28-degree upsloping terrain, 12.4 nm

north-northeast (016 degrees, magnetic) of the Palo Alto Airport. The approximate global positioning satellite (GPS) coordinates of the initial point of impact (IPI) are 37 degrees 38.207 minutes north latitude by 121 degrees 58.692 minutes west longitude. At this location, felled tree limbs and tree trunk abrasions (witness marks) were observed. The estimated elevation of the IPI in the tree trunk is 1,660 feet msl. The main wreckage was found south of the IPI at approximate GPS coordinates of 37 degrees 38.184 minutes north latitude by 121 degrees 58.694 minutes west longitude. The estimated elevation of the main wreckage is 1,690 feet. The measured distance and magnetic bearing between the IPI and the main wreckage is 151 feet and about 163 degrees. The maximum elevation of the hillside south of the main wreckages is about 1,720 feet msl. The entire wreckage was found at the accident site. The airplane's fuselage came to rest in an upright attitude on an approximate heading of 133 degrees. The right wing and navigation light assembly were found separated from the fuselage and located near the IPI, below a tree trunk that had its bark abraded away. A circular 1-foot-long spanwise depression was observed in the wing's leading edge. The size of the depression was consistent with the size of the tree trunk. The outer panel of the left wing was also found separated from the main wreckage. It was located about 90 feet south of the IPI. Remnants of a fire-damaged Jeppesen San Francisco, California, area instrument navigation chart was located in the cockpit. An unburned section was observed that covered the geographic vicinity of the accident site. According to the chart, in the vicinity of the accident site the minimum en route (instrument) altitude was 4,000 feet. MEDICAL AND PATHOLOGICAL INFORMATION The pilot's wife reported that the evening before the accident flight her husband retired at his customary time, between 2100 and 2200. He did not report experiencing any physical problems. The pilot's last aviation medical certificate was issued in the second class in August 2000. Family members reported that the pilot was not taking either over-the-counter or prescription medications. His health was described as being excellent.

On November 25, 2002, an autopsy was performed by the Alameda County Sheriff/Corner's Office, 480 4th Street, Oakland, California, 94607. The FAA's Civil Aeromedical Institute (CAMI), Toxicology and Accident Research Laboratory, performed toxicology tests on specimens from the pilot. CAMI reported that neither ethanol nor evidence of screened drugs was detected in submitted specimens. The Coroner's Bureau of the Alameda County Sheriff's Office also performed toxicology tests on specimens from the pilot. The tests were performed by National Medical Services, Willow Grove, Pennsylvania. With the exception of detecting caffeine in a blood specimen, all other tests were negative. TESTS AND RESEARCH Airframe, Propeller & Accessory Examination. The continuity of the flight control system was confirmed. The landing gear was found in the extended position. The airplane's three propeller blades were observed torsionally deformed and partially twisted into an "S" shape. The drive gear couplings in both of the engine vacuum pumps were found intact, and the drive gears rotated freely. During the manually performed drive gear rotation, suction and air pressure were noted in the pumps' intake and discharge hoses. The magnetic compass was found separated from the instrument panel. It contained fluid and was observed functional. The directional gyroscope and the attitude indicator were not located. The fuselage, cockpit, and the instrument panel were consumed by fire. The navigation lights from the left and right wing tips, and the tail were removed and examined. All filaments appeared stretched. The airplane's fire-damaged barometric altimeter was found set to 30.17 inches of mercury, and the altimeter hands were positioned at 1,700 feet. The fuselage was consumed by a postimpact ground fire. (See the Beech Aircraft participant's report for additional details.) Engine & Accessory Examination.

The engine's crankshaft was rotated and the continuity of the valve and gear train was confirmed. The throttle linkage was found intact at both the engine and cockpit control locations. The flow divider cover was removed, and the fuel screen was observed clear. The bladder was intact. Oil was observed in the engine. The spark plugs were removed and no ovaling of the electrodes was noted. Tree bark was found wedged between compressor vanes inside the turbocharger. (See the Continental Engine participant's report for additional details.) FAA Regulations. In pertinent part, according to regulations published by the FAA at 14 CFR Part 61.56, no person may act as pilot-in-command of an aircraft unless, since the beginning of the 24th calendar month before the month in which that pilot acts as pilot-in-command, that person has (1) accomplished a flight review and (2) has had his logbook endorsed by an instructor who gave the review certifying that the person has satisfactorily completed the review. ADDITIONAL INFORMATION Safety Alerts and Minimum Safe Altitude Warnings. In pertinent part, the "Aeronautical Information Manual" (AIM) contains the following information regarding the issuance of safety alerts to pilots: A safety alert will be issued to pilots of aircraft being controlled by ATC if the controller is aware the aircraft is at an altitude which, in the controller's judgment, places the aircraft in unsafe proximity to terrain. The provision of this service is contingent upon the capability of the controller to have an awareness of a situation involving unsafe proximity to terrain. The issuance of a safety alert cannot be mandated, but it can be expected on a reasonable, though intermittent basis. The primary method for the controller of detecting an airplane's unsafe proximity to terrain is through Mode C automatic altitude reports via the airplane's transponder. The NCT's facility has an automated function, which, if operating, alerts controllers when a tracked Mode C equipped aircraft under their control is below or is predicted to be below a predetermined minimum safe altitude. This MSAW service is designed solely as a controller aid in detecting potentially unsafe aircraft proximity to terrain/obstructions. The radar facility will, when

MSAW is operating, provide MSAW monitoring for all aircraft with an operating Mode C altitude encoding transponder that are tracked by the system and are: (a) Operating on an IFR flight plan, or (B) Operating VFR and have requested MSAW monitoring. Visual Presentation of Descent/Approach Path. The Safety Board investigator noted that the San Francisco Bay area, including the neighboring communities of Fremont and Palo Alto, is visible from the hilltop south of the accident site. No higher elevation exists between the accident site hilltop and the Palo Alto Airport. Wreckage Release. The airplane wreckage was released to the owner's insurance adjuster on December 4, 2002. No parts were retained.
http://www.ntsb.gov/ntsb/brief2.asp? ev_id=20030206X00175&ntsbno=LAX03FA072&akey=1

LAX03FA072 HISTORY OF FLIGHT On January 23, 2002, at 1653, Pacific standard time, a Cirrus SR 20, N893MK, collided with power lines near San Jose, California. The private pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The airplane was destroyed. The pilot, the sole occupant, sustained fatal injuries. The personal cross-country flight departed Napa County Airport (APC), Napa, California, at 1600, en route to Reid-Hillview Airport of Santa Clara County (RHV), San Jose. Day instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The primary wreckage was located at 37 degrees 16 minutes north latitude and 121 degrees 43 minutes west longitude. During the investigation, the recorded voice channels from the Federal Aviation Administration (FAA) Northern California Terminal Radar Approach Control (NCT), Palo Alto ATCT, and Reid-Hillview ATCT were examined. Recorded radar data from the NCT ARTSIIIA system was also reviewed. During the initial portions of the flight after takeoff from Napa, ATC issued

numerous radar vectors and altitude assignments to the pilot for traffic avoidance purposes. Review of the radar data disclosed that the pilot complied with all instructions. At 1627, when the airplane was approximately abeam Oakland International Airport, the NCT Saratoga sector controller instructed the pilot to proceed to navigational fixes near Palo Alto airport (PAO). The pilot questioned the clearance, and in the subsequent exchanges the controller acknowledged his mistaken belief that the pilot was destined to PAO and that the flight was actually destined to RHV. The controller asked the pilot from which fix he would like to initiate the approach, and the pilot requested vectors to the approach "around OZNUM." OZNUM is the Final Approach Fix (FAF) on the RHV GPS 31R procedure. The controller issued a clearance direct to OZNUM. After this exchange, radar indicated the airplane turned almost 90 degrees to the right, and tracked on a course consistent with proceeding direct to PAO. The controller noticed the course deviation, and queried the pilot. The controller provided no specific headings, but told the pilot to make a right turn to avoid traffic associated with San Jose International Airport, and to proceed to OZNUM, which he said was "on the east side of RHV." The pilot acknowledged and made a right turn of approximately 270 degrees, briefly tracking on an approximately southbound course, which did not appear to be aligned with any relevant navigational fix. After approximately 3 miles on that course, the pilot turned left to a track consistent with proceeding direct to OZNUM. The radar data showed that this ground track resulted in the airplane flying overhead RHV, on approximately the reciprocal of the final approach course, i.e., aligned with RHV, and the fixes OZNUM, then ECYON. In his interview, the first NCT LICKE sector controller (L1) said he became aware of N893MK when he overheard the Saratoga sector controller correcting the pilot's course to OZNUM. The L1 controller said he believed the pilot required extra attention and intended to provide what assistance he could. Comparing the voice transcripts to the recorded radar data showed that upon the pilot's initial contact with the LICKE sector, the airplane had passed OZNUM, and begun a slight left turn to the east. At this point the pilot had no further clearance to follow, since the Saratoga controller had cleared him direct to OZNUM with the expectation that L1 would provide vector service. L1's initial instruction was for the pilot to proceed direct to ECYON; the pilot's response was to question the fix. According to L1's statements, he recalled that the airplane was in a position coincident with a downwind leg, and the turn toward ECYON would work out to be the same as a vector to final. Recorded radar data indicates the airplane was flying a course approximately aligned with the Initial Approach Fix (IAF) ZUXOX. Shortly after this exchange, L1 noted

the airplane appeared to begin a left turn towards OZNUM, but he instructed the pilot to turn right toward ECYON in order to remain clear of a higher terrain area. At this time, OZNUM was directly behind the airplane, and ECYON at about the four o'clock position. The pilot completed a right turn, briefly flying a course consistent with tracking towards OZNUM, then made a slight left turn and flew a course consistent with the published segment between ZUXOX and ECYON. L1 said he observed the pilot on this course and issued clearance for the approach. FAA Order 7110.65 specified that Standard Instrument Approach Procedures "shall commence at an Initial Approach Fix or an Intermediate Approach Fix if there is not an Initial Approach Fix. Where adequate radar coverage exists, radar facilities may vector aircraft to the final approach course [by assigning] headings that will permit final approach course interception on a track that does not exceed 30 degrees." The order further states that vectors should be issued if required to intercept the final approach course. ECYON was not an IAF. Review of the radar derived ground track revealed that the intercept angle was about 40 degrees. While the flight was progressing between ECYON and OZNUM, a controller change occurred at LICKE sector. L1 advised the second controller (L2) that N893MK was on the approach and the only remaining task was to issue frequency change to RHV tower. As the airplane passed just northwest of OZNUM, L2 instructed the pilot to contact the tower on frequency "118.6." This frequency is actually assigned to PAO tower. The pilot queried the controller if that was actually correct. The controller insisted, "Yes sir, it is." The pilot complied and contacted PAO tower. The pilot and the PAO controller discussed that he was on the wrong frequency and the pilot said he would switch to the RHV frequency of 119.8. During this conversation, radar indicated the airplane began a turn to the right, with the first target visibly displaced from the final approach course at 1652:33, approximately over JOPAN waypoint. At 1652:50, the pilot reported to RHV tower "descending from JOPAN two thousand feet five point four miles from missed approach point." Radar data agreed with the pilot's report; however, the course had diverged almost 90 degrees from the final approach course. Within 2 seconds of the pilot making initial contact with RHV tower, the ARTS Minimum Safe Altitude Warning System (MSAW, see ATC Group factual report in docket material) provided a visual and audible alert at the RHV tower and NCT. In response to the pilot's call, the RHV tower controller cleared the pilot to land then said "low altitude alert, check your altitude immediately." The

MSAW system activates whenever the targets projected track will encounter higher terrain, or, when the mode C reported altitude is below the minimum safe altitude for the navigational segment being flown. Based on the radar data, the airplane's projected track was diverging away from the centerline of the approach, and toward higher terrain. At the time of the alert the airplane was at about 1,900 feet, and the minimum altitude for the final segment is 1,440 feet. About 30 seconds later, the tower controller notified the pilot that he appeared off course. The pilot made a brief unintelligible transmission and no further radio or transponder signals were received. The radar track of the airplane was lost in the area of high-tension power lines, located 6.7 miles south east of RHV at an altitude of 1,600 feet mean sea level (msl). The last radar data with an altitude return was at 16:53:40, and showed the airplane at a mode C reported altitude of 1,700 feet. PERSONNEL INFORMATION A review of FAA airman records revealed the pilot held a private pilot certificate with an airplane single engine land and instrument airplane rating. The pilot was issued a third-class medical on June 8, 2001, with the limitations the pilot must wear lenses for distant vision, and possess glasses for near vision. An examination of the pilot's logbook indicated a total flight time of 460.7 hours, of those 362.4 hours were dual received. The pilot had logged his total IFR time as 150.3 hours of which 10.7 hours were actual IFR. He had 334 hours in this make and model; 84.8 hours were logged in the last 90 days. The pilot had completed and passed an instrument airplane check ride on January 6, 2003. The designated examiner (DE) was interviewed and related the pilot was very detail orientated, and also very knowledgeable about the Cirrus SR 20. AIRCRAFT INFORMATION The airplane was a Cirrus SR 20, serial number 1038. A review of the airplane's logbooks disclosed the annual inspection was completed on February 20, 2002. Total airframe time was listed as 67.8 hours and a Hobbs time of 67.8 hours. The airplane had a total time of 369.3 hours. The transponder and altimeter/static and altitude reporting systems were

inspected on February 20, 2002. A Teledyne Continental Motors IO-360ES-6B engine, serial number 357190, was installed in the airframe in May 2000. The engine had a total time of 369.3 hours. An aircraft weight and balance report dated February 18, 2002, revised the airplane's weight and balance data sheet. It listed the new empty weight as 2121.23 pounds; total moment of 296507.35-inch pounds, and listed the empty center of gravity as 139.78 inches aft of the datum. The Cirrus SR 20 uses conventional flight controls for ailerons, elevator, and rudder. The control surfaces are pilot controlled through either of two singlehanded side control sticks mounted on each side of the airplane's cockpit. The neutral position of the left side stick is at a 45-degree angle to the right. The neutral position of the right side stick is a 45-degree angle to the left. The accident airplane was being flown from the left pilot seat. A pilot flying from the left seat would rest his left-hand on the side control stick; any inadvertent pressure applied by the pilot could potentially induce an unintentional right turn of the airplane. The accident airplane (SN 1038) was originally equipped with the factory "Avionics Configuration C" package which included dual Garmin GNS 430's. The GNS 430 is a combination global positioning satellite (GPS) receiver, communication, and navigation system. The GNS 430's were mounted in the center console of the airplane below the ARNAV ICDS 2000 display. A major repair and alteration (FAA Form 337) dated February 20, 2002, was filed reporting an upgrade in the avionics, which were installed in the airplane. The transponder was upgraded; a Ryan 9900BX traffic collision avoidance detection (TCAD) system; and a WX-500 stormscope system were installed. AIRPORT, NAVIGATION FACILITIES AND APPROACH INFORMATION The Airport/ Facility Directory, Southwest U. S., indicated RHV runway 31R was 3,101 feet long and 75 feet wide. The runway surface was asphalt. The only IFR approach into RHV is the GPS RWY 31R. According to a review of facility records, all relevant ATC and navigational equipment was operating. There were no NOTAMs or other evidence of any

GPS anomalies in the vicinity of RHV. The GPS 31R approach procedure was a fairly new procedure, prior to the establishment of this approach, RHV did not have any Standard Instrument Approach Procedures. During interviews with the controllers at NCT and RHV they reported that they had been briefed on the approach procedure, and were generally familiar with it, although it did not receive heavy use. The RHV GPS 31R approach course was established in a congested area of high traffic density associated with the airports in the southern San Francisco Bay area. The final approach course closely paralleled the SJC approach course to the southwest, such that airplanes established on these approaches were separated by the minimum allowed lateral distance. To the northeast, terrain rose rapidly, leaving very little room to maneuver for airplanes below 4,000 feet. Review of the radar display terminals at NCT disclosed that video mapping did not directly depict the GPS 31R final approach course. In order to visualize the course, controllers had to visualize a line between the airport symbol, and the OZNUM and ECYON waypoint symbols. The RHV Tower Remote ARTS Color Display (R-ACD) video map did include a depiction of the final approach course as a series of dashed lines. Depictions of JOPAN and OZNUM waypoints also appeared on the map. In their interviews, the controllers noted the waypoint symbols are quite large; the investigators observed that the "points" on the symbols extended approximately 0.75 miles beyond the centerline of the approach course. ARTS radar targets on the controllers display were oriented such that the longer dimension of the return was aligned perpendicular to the azimuth from the radar site, (i.e. "broadside") and a target whose track is diverging from the final approach course would not be readily apparent. This topic is discussed in detail in the ATC Group Factual Report, which is contained in the docket for this accident. METEOROLOGICAL CONDITIONS The closest official weather observation station was Reid-Hillview Airport of Santa Clara County (RHV), San Jose, located 6.7 nautical miles (nm) northwest of the accident site. The elevation of the weather observation station was 133 feet msl. A special aviation weather report (METAR) for RVH was issued at

1653. It stated: skies 1,200 feet broken, 8,000 feet overcast; visibility 4 miles; winds from 280 degrees at 12 knots; temperature 60 degrees Fahrenheit; dew point 59 degrees Fahrenheit; and altimeter 30.24 inHg. WRECKAGE AND IMPACT The terrain at the accident site was mountainous. The airplane came to rest approximately 650 feet on a bearing of 032 degrees from the first identified point of contact (IPC). The accident site was at the bottom of a ravine. The airplane came to rest on a magnetic heading of 056 degrees at an almost level attitude on the upslope side of a 45-degree slope. The first identified point of contact (IPC) was the west side static line approximately 100 feet south of the Pacific Gas and Electric (PG&E) hightension power line tower number 130. The second identified point of contact was the pair of 500 KV power lines located on the east side of the PG&E tower number 130. One of the power lines was lying on the ground adjacent to tower number 130; it had pieces of fiberglass imbedded in a broken bracket, which is used to suspend the power lines from the tower. Approximately 6 feet north of the broken bracket were witness marks on the wire that appeared to be at a 45degree cut into the power line. The power lines are approximately 2 inches across. All of the airplane's flight control surfaces were at the accident site. The rudder, elevators, and horizontal stabilizer assemblies were attached to the empennage. All control surfaces and their associated mass balance weights were in the debris field. The outboard section of the left wing was in a tree approximately 160 feet northeast of the IPC. The left wing section displayed charring. On the left wing section approximately 3 feet inboard from the wing tip, there was a semicircular depression approximately 2 inches across. The airplane was equipped with an emergency ballistic parachute system. The ballistic parachute system had not been deployed. The safety pin, which is used to prevent inadvertent deployment, was still in place. The safety pin had a tag attached to it that is red in color with white lettering and read, "SAFETY PIN REMOVE BEFORE FLIGHT." MEDICAL AND PATHOLOGICAL INFORMATION

The Santa Clara County Coroner completed an autopsy. The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the pilot. The results of analysis of the specimens were negative for carbon monoxide, cyanide, and volatiles. Results for tested drugs were; 0.015(ug/ml, ug/g) Dextromethorphan detected in blood, Dextromethorphan present in urine, Dextrorphan detected in blood, Dextrorphan present in urine, Ephedrin detected in urine, Phenylpropanolamine detected in blood, Phenylpropanolamine present in urine, Pseudoephedrine present in blood, Pseudoephedrine present in urine, and 29.5(ug/ml, ug/g) Acetaminophen detected in urine. TESTS AND RESEARCH Investigators examined the wreckage at Plain Parts, Sacramento, California, on January 26-27, 2003. Investigators removed the engine. The engine was suspended from a hoist; the top spark plugs were removed. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. Investigators attempted to rotate the engine using the accessory side of the engine but were unable to manually rotate the engine. The crankshaft flange was broken off, and bent. Investigators manually rotated the magnetos, and both magnetos produced spark at all posts for cylinders. The vacuum pump was broken from the engine mounting point. The coupler was bent but in tact. The pump could not be rotated by hand. Disassembly of the vacuum pump revealed that the rotor was fractured in three places radialy from the center out, and the vanes were in tact. The oil sump screen was clean and open. The governor screen was clean. The oil screen filter was clean. The fuel pump's rubber diaphragm was unbroken and investigators blew air through the lines. The plunger in the fuel distribution valve moved freely, the rubber diaphragm was unbroken, and investigators did not observe any

contamination. The fuel nozzles were open and the screens were clean. The fuel selector valve was between the left and right positions, slightly towards the right tank. The aircraft uses three cable loops to control the aircraft's three-axis control surfaces: ailerons, rudder, and elevator. All cables start and end their runs from the front of the airplane and are routed to the various controls via a (forward) six and (aft) four gang pulley system. The ailerons use two "kick-out" pulleys to route the aileron cables from the front of the aircraft outboard to the aileron pulleys located in the outboard one third of each wing. The right aileron cable was intact and on the right aileron pulley. The left aileron cable was intact and on the left aileron pulley. The elevator and rudder cables are routed to the 306bulkhead pulley cluster that activates the rudder and elevator control arms attached to their respective pulleys. The aircraft utilizes a rudder / ailerons interconnect system ("RAI") to add rudder input when the pilot deflects the ailerons. The forward (six-gang) and aft (four-gang) control cable pulleys were intact and the control cables were still on their respective pulleys. The cable retainer on the six-gang pulley was bent, but secure. The four-gang pulleys were also intact, although the four control cables were slack since recovery personnel had purposely cut them during the retrieval process. Inspection of the Rudder Aileron Interconnect (RAI) revealed that all RAI components were intact. All cables were intact and on their respective pulleys. The central aileron pulley was bent aft at the 5-7 o'clock position; the cable was attached and intact. The cable was attached and intact on the central pitch pulley sectors. The rudder cables were attached and intact on their rudder bars. Control cable continuity was established throughout the control system. The right-hand side controller linkages to the main control pulley and pulley sectors were intact; the left side controller linkages were destroyed by the impact forces and could not be inspected. The flap actuator was measured at 11 inches. The factory representative reported this corresponded to the fully retracted (Up) position. The elevator pitch trim motor was toward a "nose up" position. The airplane was equipped with an ARNAV ICDS-2000, which is a VFR

moving map, and with the installed EMM-35 (engine monitoring module) also displayed engine data. The displayed data included cylinder head temperature (CHT), engine gas temperature (EGT), engine rpm, and fuel flow. The ICDS stores the data in 1-minute intervals. The ICDS-2000 and the EMM-35 were removed from the airplane and shipped to the manufacturer for further analysis. On March 17, 2003, a National Transportation Safety Board investigator was present at the RNAV Systems Inc., Puyallup, Washington, during the inspection of the ARNAV ICDS-2000 and the EMM-35. The data recovered from the data storage card indicated that the accident airplane, on the date of the accident had departed RHV, flown to APC, shut down the aircraft systems for 43 minutes, and then flown from APC to the area of the accident. The total elapsed time was 3 hours 5 minutes. The engine assembly was removed from the airframe and shipped to the engine manufacturer, Teledyne Continental Motors (TCM) for further examination. On April 23, 2003, investigators from the Safety Board, Cirrus Design, and TCM examined the engine at the TCM factory Mobile, Alabama. The engine was disassembled and examined. No abnormalities were found to preclude engine operation prior the impact. ADDITIONAL INFORMATION The aircraft was released to the owner's representative.