NTSB Factual Report

HISTORY OF FLIGHT

On March 3, 1995, about 0938 hours Pacific standard time, a Piper PA-23-150, N1260P, was destroyed during an in-flight collision with mountainous terrain in the coastal hills on the U.S. Marine Corps Base at Camp Pendleton, near Oceanside, California. The aircraft was owned and operated by the pilot, and was engaged in transporting two doctors into Mexico for volunteer medical help for the poor. Both pilots and the two passengers received fatal injuries. Marginal visual meteorological conditions prevailed along the coastal route and no flight plan was filed.

The personal flight had originated at Sacramento, California, on the morning of the accident about 0530 hours, with the passenger pickup at Santa Ana, California. The flight departed John Wayne Airport, Santa Ana, California, about 0921 hours with an intermediate destination of Brown Field (SDM), San Diego, California. Observations made by Marine Corps personnel at Camp Pendleton indicated that the coastal hills, to include the accident site, were shrouded in clouds.

The airplane had been cleared for takeoff at 0920 on runway 19L from intersection KILO. The departure clearance was to turn left to 150 degrees, maintain visual flight rules (VFR) at or below 2,500 feet mean sea level (msl). Once airborne the airplane was issued traffic, a CH46 helicopter, then switched to SOCAL Approach on frequency 132.7.

At 0923 SOCAL Approach verifies radar contact and asks the destination and cruising altitude. The pilot replies VFR to SDM, climbing to 3,500 feet to stay below the cloud deck. At 0926 the pilot contacts approach and says "SOCAL Approach 60P, i'm going to level off here." Radar information had the airplane at 1,300 feet msl at that time.

At 0931:20, approach advises 60P that radar contact was lost and the pilot acknowledges. Six seconds later, approach transmitted "Apache 60P, radar service terminated squawk VFR, for further advisories attempt contact Long Rifle (Camp Pendleton) on 132.2". Once again, the pilot acknowledged. The controller inadvertently gave the pilot 132.2, instead of the Long Rifle Range Control frequency of 123.2, which is not listed on the sectional charts. The SOCAL TRACON pulled the tapes on 132.2 for review. The pilot attempted to contact Long Rifle twice, but had been covered by other transmissions. Those were the last recorded transmissions from the airplane.

During the departure from John Wayne, a transponder code of 5206 was assigned to the airplane by SOCAL TRACON. Initial review of recorded radar data observed the airplane paralleling the coastline about 3/4-mile offshore to an area near Dana Point, California. According to SOCAL TRACON, in the area of Dana Point radar service was terminated and the pilot was requested to change the transponder to 1200, which he never did. The accident site is about 16 miles south of Dana Point and about 8 miles north of the Oceanside VOR.

The accident site is in an area of coastal hills dominated by steep, rugged terrain, which rises to about 3,000 above sea level within 5 to 10 miles of the shoreline. The aircraft contacted the top of one ridge line in a canyon area, then impacted the near-vertical opposite canyon wall.

The airplane was made available on a voluntary basis by the pilot for expenses to the medical relief organization, LIGA International. During the weekend of the accident, about 21 aircraft from the southwestern United States participated in an airlift of medical doctors and other personnel into four locations within the state of Sinaloa, Mexico, for voluntary medical assistance to the poor. Three other airplanes participating in the airlift departed from John Wayne Airport on the morning of the accident and all filed IFR flight plans to Brown Field.

PILOT INFORMATION

The pilot reported a total flight time of 700 hours, with 70 hours in the last 6 months, at his last second class flight physical dated September 2, 1994. He held a medical waiver of demonstrated ability for no useful vision in the left eye.

A review of the pilot's logbook revealed about nine untotaled pages of flight log. The pages are estimated to represent about 59.5 additional hours through the last entry dated January 29, 1995, for an estimated total flight time of 829 hours.

The pilot was issued a private pilot's certificate on July 5, 1990, and since that time, he acquired a commercial pilot's certificate. He was rated for airplane single and multiengine land and instrument airplane. On November 10, 1992, the pilot was issued a flight instructors rating for airplane single engine and instrument airplane.

PILOT RATED PASSENGER INFORMATION

According to the pilot-rated passenger's wife, he paid the owner/pilot $200.00 towards expenses to go along as a passenger after another pilot/friend had canceled. She stated that the owner/pilot had called at 0300 hours on the morning of the accident and said that they were going, as weather was improving.

At the pilot/passenger's last second class flight physical dated August 23, 1994, he reported a total flight time of 1160 hours, with 225 hours in the last 6 months. He held a commercial pilot's certificate, and was rated for airplane single and multiengine land airplanes and instruments. He was also a flight instructor for single and multiengine land airplanes and instruments. At the time of the last rating, November 11, 1994, he reported a total flight time of 1330 hours.

AIRPLANE INFORMATION

The airplane was manufactured as a 1955 model. According to limited record information, the airplane had accrued about 3,738 hours of total operation.

The last annual inspection was conducted on March 18, 1994. At that time, the logbook entry documented a total flight time of 3,598 hours, with 1,700 hours on the right recording tachometer. Postcrash examination of the recording tachometers revealed recorded hours of 1840.15 for the right and 1045.47 for the left. The Hobbs meter was found indicating 1767.3/2 hours.

The airplane was equipped with a King KX-170-B VHF communication/navigation radio with a King KI-209 VOR/GS indicator, and a Narco AT-6-A transponder with an encoder. A handheld Magellan global positioning system (GPS) had been borrowed from a fixed-base operator at Sacramento for the trip.

The airplane had an FAA supplemental type certificate (STC) for the use of automobile gasoline. According to a fuel receipt, at 0509 hours on the morning of the accident, the airplane was fueled at Yolo County Airport, Davis, California, with 33.85 gallons of no-lead gas (UN1203) from a self-serve dispenser.

WRECKAGE AND IMPACT INFORMATION

The wreckage site was located on the U.S. Marine Corps military reservation at Camp Pendleton, California. The airplane had collided with a ridgeline about 1,475 feet msl. Postcrash examination of the wreckage was conducted at National Aircraft in Long Beach, California.

Examination of the left wing revealed that it had been severed outboard of the left engine nacelle. The aileron and the aileron counterweight were still attached to the outer wing panel. The pitot tube was noted to still be in position on the bottom of the wing panel. The panel exhibited wing tip and leading edge damage. The remainder of the wing structure, outboard of the left engine nacelle, inboard to the wing root, was separated at the fuselage with the landing gear still attached by hydraulic hoses, but separated from the trunnion hinge points. Both fuel tanks were still attached to wing structure and covered by their respective wing skins.

Postcrash examination of the right wing revealed that it had also separated outboard of the engine nacelle. The aileron and the aileron counterweight were still attached to the wing section. The auxiliary (outboard) fuel tank was still in position inside the wing structure. The right main fuel tank was found missing along with the top and bottom wing skins. Wing tip and leading edge damage was noted on the panel. The right inboard section of the wing from the outboard edge of the engine nacelle inboard was severed at the wing root, with the landing gear still attached to the wing structure. The landing gear doors were still attached.

Examination of the propeller blades from both propellers revealed leading edge damage trailing edge "S" bending and chordwise striations. A right propeller blade lost several inches of it's tip.

METEOROLOGICAL INFORMATION

The nearest official weather reporting facility was at the U.S. Marine Corps weather service at Camp Pendleton, California. At 1000 hours on the morning of the accident, they were reporting: 800 feet scattered clouds; estimated 1,000 feet broken clouds; 1,500 feet overcast; visibility 3 miles with light rain and fog; temperature 62 degrees Fahrenheit; dewpoint 57 degrees Fahrenheit; wind 200 degrees at 10 knots; and the altimeter was 30.07 inches of mercury.

An AIRMET (in-flight weather advisory message) for IFR conditions and mountain obscuration was valid for the accident area and time.

At 0309 hours on the morning of the accident, the pilot obtained a preflight weather briefing from the FAA Rancho Murieta Flight Service Station. The request was for weather from Sacramento to southern California's Orange County. The pilot did not ask for specific information regarding the San Diego area. There was no record of contact with the pilot for an update of weather for the route south towards San Diego from Santa Ana (Orange County).

Surface weather observations from Santa Ana (John Wayne Airport) and Camp Pendleton around the accident flight time showed marginal visual flight rules (MVFR) ceilings at Santa Ana and Camp Pendleton, and an instrument flight rules (IFR) visibility condition at Camp Pendleton.

MEDICAL AND PATHOLOGICAL INFORMATION

On March 7, 1995, the San Diego County Medical Examiner performed an autopsy on the pilot. The cause of death was attributed to multiple trauma. There were no conditions identified that would have affected the pilot's ability to pilot an aircraft.

During the course of the autopsy, samples were obtained for toxicological analysis by the Federal Aviation Administration Civil Aeromedical Institute in Oklahoma City, Oklahoma. The results of the analysis was negative for drugs and alcohol.

TESTS AND RESEARCH

On June 22, 1995, the engines were examined with a representative of Lycoming Engines from Williamsport, Pennsylvania. No preexisting conditions or failures were found that would have contributed to or caused the accident.

An examination of the airframe identified all major components of the airframe as being present. Control continuity was not possible due to the extent of fragmentation.

Postcrash examination of the damaged radios and their frequencies revealed the following:

KING KX-170-B Navigation 115.30 (Oceanside VOR)

KING KX-170-B Communication 131.20

KING KI-209 VOR/GS 000 degrees (OBS)

NARCO AT-6-A Transponder 5306

Magellan GPS Destroyed

ADDITIONAL INFORMATION

On June 22, 1995, the National Transportation Safety Board released the wreckage to the insurance company representative.

NTSB Probable Cause

THE PILOT'S INTENTIONAL VFR FLIGHT INTO KNOWN ADVERSE WEATHER. THE LOW CEILING WAS A FACTOR.