NTSB Factual Report

HISTORY OF FLIGHT

On December 7, 1995, about 0624 hours Pacific standard time, a Cessna 340A, N37324, was destroyed during a missed approach to the Brackett Airport, La Verne, California. The pilot, the sole occupant, received fatal injuries. Instrument meteorological conditions prevailed for the State of California business flight which originated at Big Bear Lake, California, on the morning of the accident. No flight plan had been filed. There was no record of a preflight weather briefing given by an Federal Aviation Administration (FAA) facility prior to the flight.

According to an FAA voice transcript, the pilot contacted Southern California Tracon (SOCAL) after departure from Big Bear. He stated that he had the Ontario weather and was requesting an ILS into Brackett Field. The pilot was assigned a transponder code of 0202. The pilot of a Beech Baron that had just departed from Brackett stated on the frequency that "It's zero zero right now". The accident pilot responded "have you been in there?" The Baron pilot responded "just took off from there." SOCAL questioned the Baron pilot regarding the Cable Airport weather. He stated that Cable may be VFR and there was no fog there.

At 0614, SOCAL cleared the pilot for the ILS runway 26L approach when the aircraft was 9 miles east of the final approach fix. The pilot was cleared to change to the Brackett tower frequency 118.2 for traffic advisories and 125.5 in case of a missed approach.

The Brackett air traffic control tower (ATCT) was not open at the time of the accident. At 0646, the ATCT Limited Aviation Weather Reporting Station (LAWRS) recorded the weather as sky obscured, indefinite ceiling zero, and zero visibility in fog. Local area witnesses confirmed the weather condition.

The aircraft subsequently collided with trees and a building about 1/4 mile northwest of the departure end of runway 26L in a recreational park area of San Dimas, California.

An on-scene FAA inspector interviewed two witnesses who were cleaning aircraft at the southeast corner of the airport near the time of the accident. They reported that a twin engine aircraft had made two attempts at landing on runway 26L. They also stated that the aircraft sounded quite low or near the runway surface, but due to the fog they could not see the aircraft. They said that each time the aircraft passed abeam of them they would then hear the power being applied for a missed approach.

The pilot of the Beech Baron that departed about 30 minutes prior to the accident stated that the tops of the fog at the time of his departure were ragged. He estimated them to be 1,600 feet msl.

A witness/pilot located south of the runway in the East Shore RV Park reported hearing an aircraft fly low over his location about the time of the accident.

Another witness/pilot located at his residence about 2,000 feet from the west end of the runway stated that he heard the aircraft do a missed approach or a late go-around about midfield.

PILOT INFORMATION

According to the pilot logbooks that were reviewed, the pilot had documented about 5,282 total flight hours. Examination of logbooks No. 3 and 4 indicated that the pilot had flown the accident airplane about 653 hours. At the pilot's last flight physical he reported a total flight time of 5,200 hours.

AIRPLANE INFORMATION

The aircraft records were not recovered. Partially burned remnants of a propeller logbook, serviceable parts tags, and FAA form 337 were found at the accident site. Also found were an outdated registration certificate and operating limitations for an experimental category that the aircraft had been put into during an application process for a supplemental type certificate in 1991. Subsequently, the airplane was put back into a normal category. During the course of the investigation, the FAA aircraft records archived in Oklahoma City, Oklahoma, indicated the aircraft was still in the experimental category.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in the Frank G. Bonelli Regional County Park, about 2,000 feet northwest of the departure end of runway 26L. The wreckage path was oriented at 345 degrees magnetic over a distance of about 633 feet. The farthest airplane component of the wreckage was found about 1,100 feet north from the runway extended centerline. The accident site elevation is about 1,060 feet msl. The entire airframe and it's components were accounted for at the accident site.

At the beginning of the wreckage path the first point of contact was a 40-foot-tall pine tree. Broken branches and paint chips with fiberglass were found on the ground beneath the tree.

About 196 feet further along the wreckage path, an oak tree was located with numerous aircraft parts commingled in the branches. The parts were from the right wing and wing tip fuel tank. In the tree and on the ground were located several 3- and 4-inch cut logs about 26 inches long. In the tree branches was the beginning of a picnic patio roof structure where the right aileron and other right wing parts were found. A portion of the right wing tip fuel tank tail cone and a right wing flap section were located on the patio ground slab.

The next major component of the aircraft was the right engine and its propeller which were found inside the snack bar building. A postcrash fire consumed the interior of the building with resultant fire damage to the engine and propeller. The propeller blades were melted. A portion of the right outboard wing leading edge was located at the west corner of the building.

Just north of the snack bar building was a mobile building with minor damage to the east end where the right engine vacuum pump was located. The spline portion of the drive coupling was missing, however, the remaining part of the coupling at the pump body was intact. The pump chamber cover was missing and the interior of the pump was without vanes or vane body.

The major portion of the fuselage, empennage, and the left wing structure were located near an embankment where a postcrash fire had burnt in the area of the left nacelle fuel tank and the wing aft spar area.

The left engine with it's propeller was located 633 feet from the initial impact area. The propeller was missing two blade tips.

The landing gear actuator was examined and was found to be in the up position, as was the landing gear selector switch. The right main landing gear was found in the up position.

The airplane was equipped with an after market "Fowler Flap" system. The right flap actuator was extended 4.8 inches. The left actuator was broken in the mid-screw position. The flap switch was found in the up position.

The instrument indications were documented on-scene. The radar altimeter decision height "bug" or indicator was found set at 210 feet agl. The pilot's electric altimeter was indicating 1,060 feet msl; 29.98 inHg; and with the power off flag displayed. The horizontal situation indicator (HIS) heading bug was found at 251 degrees. The compass card was indicating 002 degrees. The omni bearing selector (OBS) was indicating 258 degrees. All HIS warning flags were displayed. The No. 2 radio OBS was indicating 300 degrees. (For more instrument indications and switch positions refer to supplement B of this report.)

Due to the fragmentation of the airframe, complete control continuity was not established.

AIRPORT INFORMATION

On December 8, 1995, the ILS runway 26L approach was flight checked by the FAA. The results of the check were satisfactory for all systems including lighting. FAA forms 8240-7 and 17 are attached.

During a personal interview of the airport manager, he stated that the runway end identifier lights (REIL) may have been out of service on the morning of the accident. He stated that there had been a problem with them and an electrician had been called. The light problem had not been NOTAMED (Notice To Airmen). He stated that a pilot indicated to him that on the morning of the accident had they been on, they would have blinded him from the strobe flash in the fog.

MISSED APPROACH PROCEDURES

The missed approach procedure at Brackett is to climb on the runway heading (260 degrees) to 1,600 feet, then a left climbing turn to intercept the Pomona 164-degree radial to Prado intersection at 4,000 feet.

METEOROLOGICAL INFORMATION

The Brackett Field FAA ATCT weather observations are performed by the FAA under the LAWRS program. The 0646 weather observation was the first scheduled observation for December 7, 1995. It was reporting: sky condition indefinite ceiling vertical visibility zero feet obscured; visibility zero mile; weather fog; wind calm; altimeter 30.00 inHg.

MEDICAL AND PATHOLOGICAL INFORMATION

On December 12, 1995, an autopsy was performed on the pilot by the Los Angeles County Coroner/Medical Examiner. During the course of the autopsy samples were obtained for toxicological analysis by the FAA Civil Aeromedical Institute (CAMI) located in Oklahoma City, Oklahoma. The results of the analysis were negative for carbon monoxide, cyanide, and ethanol. According to CAMI, the analysis was positive for Fenfluramine in the blood and liver, and Phentermine was also detected in the blood and liver, both at toxic levels.

TESTS AND RESEARCH

Both engines were shipped to the Continental Motors factory in Mobile, Alabama, where on February 5, 1996, they were disassembled and examined under the supervision of a Safety Board representative. A copy of the report is attached.

On December 11, 1995, the two navigation/communication radios were taken to an FAA approved avionics facility for examination. The following frequencies were observed;

NAV/COM NO. 1) Communication 124.5 MHz, Navigation 110.5 MHz. The sector frequency for SOCAL is 125.5 MHz. The Brackett ILS frequency is 110.5 MHz.

NAV/COM NO. 2) Communication 118.2 (or 9) MHz, Navigation 112.2 MHz. The gas discharge multisegment display lamp for the No. 2 Communication's third digit from the left was partially damaged. The lamp was either an 8 or a 9. The Brackett ATCT primary frequency is 118.2 MHz. The Paradise VOR frequency is 112.2 MHz.

According to the accident pilot's maintenance technician, he had not performed an annual inspection on the aircraft for 1 1/2 years or so. The only work that he recalled was the replacement of a tire and an exhaust stack. The technician stated that he had no records for work that he had done in the past. Their maintenance arrangement was that he would not charge the pilot for labor; instead, they would swap labor for legal services. The pilot, however, would pay for parts.

On January 30, 1996, the propellers were taken to an FAA approved propeller repair station for examination under the supervision of the Safety Board. Examination revealed that the propellers had not been in the feathered position at impact. Impact signatures indicate that they were several degrees above the low pitch setting and with power.

On December 20, 1995, the flight and navigation instruments were taken to an FAA approved repair station for functional testing. The testing was in accordance with the manufacturer's specifications. Minor impact damage was noted on the pilot's turn coordinator.

ADDITIONAL INFORMATION

The wreckage was released to the insurance company representative on April 28, 1996.

NTSB Probable Cause

the pilot's impairment of judgment and performance due to drugs, his resultant improper planning/decision, his failure to follow proper IFR procedures, and his failure to maintain proper altitude during a missed approach. Factors relating to the accident were: the pilot's inadequate weather evaluation, and the adverse weather condition (below landing minimums).