NTSB Factual Report

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, 5- to 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

NTSB Probable Cause

the pilot's failure to maintain an adequate terrain clearance altitude, which resulted in controlled flight into rising mountainous terrain. Contributing factors were the pilot's loss of situational awareness to his terrain proximity, the dark night, and the localized low clouds that obscured the terrain.