NTSB Factual Report

HISTORY OF FLIGHT

On August 27, 2000, at 0914 hours Pacific daylight time, a Piper PA-28-140, N428FL, was destroyed when the airplane impacted terrain on Iron Mountain near Poway, California. The commercial certificated pilot, the sole occupant, was fatally injured. The aircraft departed from Gillespie Field, El Cajon, California, about 0905. Visual meteorological conditions prevailed at Gillespie Field; however, witnesses near the accident location said low clouds and fog prevailed there. No flight plan was filed for the personal flight, which was operated by the owner under 14 CFR Part 91. The destination is unknown; however, the prior evening the pilot received an outlook briefing for a flight to Olympia, Washington.

A witness, who held a private pilot certificate, was hiking with friends atop Iron Mountain and heard the aircraft approach and impact the mountain about 200 to 300 yards from his position. The witness reported that there was a solid stratus cloud layer in the valley below with the cloud tops about 100 feet below the peak of Iron Mountain [2,696 feet mean sea level (msl)]. As he listened, the airplane approached from the south and passed nearby to the west of his position. The aircraft was nearby but was not visible; it was either in the clouds or below them. The engine "was running healthy and normally at or near full power". Next he heard a "loud, muffled thud," there was an explosion, and then an orange fireball was visible from near the top of the clouds. The aircraft had impacted on the south face of a ridgeline extending west from the peak of Iron Mountain, about 100 feet below the crest of the ridgeline. The witness reported, "the crash site was just above the top of the fog [stratus] layer".

In conversations with the Safety Board investigator, the same witness elaborated that, from his perspective on the peak of Iron Mountain, tops of the overcast layer were near the elevation of the peak and the stratus deck was solid in all directions, in particular, to the south and southwest. He was accustomed to the sound made by the Piper PA-28 aircraft and was certain that the aircraft passed very near, to the west of his location. He was also certain that, had it been above or in the top of the clouds, he would have seen it. It was either in the clouds or below the clouds. The fireball he observed emanated from the area where the tops of the clouds met the mountainside. When he went to the accident site, the airplane was at an elevation that placed it just at the top of the clouds but still in the fog layer.

PERSONNEL INFORMATION

The pilot's logbook was not located after the accident. On his application for Airman's Medical Certificate, dated August 24, 1999, the pilot listed 2,800 hours total pilot time with 70 hours accumulated in the previous 6 months. On an application for insurance dated February, 2000, he reported having 3120 hours, with 411 hours in Piper PA-28 aircraft.

AIRCRAFT INFORMATION

According to the party representative from The New Piper Aircraft Company, manufacturing records indicate that the aircraft was not equipped with an autopilot during manufacture. Airworthiness records for the aircraft provided by the Federal Aviation Administration (FAA) did not indicate that an autopilot had been installed subsequent to manufacture. No components identifiable with an autopilot system were found in the wreckage.

The aircraft logbooks were not located after the accident, however, an area repair station produced records of an annual inspection performed on the aircraft on March 20, 2000, when the total flying time to date on the aircraft was 3,669 hours.

METEOROLOGICAL CONDITIONS

At 0856, the surface weather observation at MCAS Miramar, 11 miles southwest of the accident site was overcast clouds at 1,300 feet; 7 miles visibility; and surface wind was variable at 4 knots. At 0956, the bases of the overcast clouds were at 1,500 feet, and the visibility remained at 7 miles with calm wind. At 0847, the surface weather observation at Gillespie Field, the point of departure and 9 miles south of the accident site, was overcast clouds at 1,000 feet; visibility 4 miles in fog; and the surface wind was calm. At 0947, the cloud bases and visibility were unchanged.

The Safety Board investigator listened to recordings of two weather briefings provided by telephone at the San Diego Automated Flight Service Station. The recordings were provided by the FAA's Southwest Region Quality Assurance Office and the caller identified himself as the pilot of N428FL.

The first call was at 1540 on August 26th. The caller told the briefer he intended to fly under visual flight rules (VFR) from Gillespie Field to McMinnville, Oregon the next day, via the San Joaquin Valley, and inquired about the weather outlook. He said his first stop would be at Calaveras County. The briefer replied that it was "questionable" whether the morning stratus cloud layer would extend inland as far as Gillespie Field; but that, if it did, the bases of the clouds would be about 1,000 feet and the tops about 2,000 feet. The briefing then continued regarding conditions in the San Joaquin Valley, the destination area, and gave the forecast winds aloft.

The second call was at 2045 on August 26th. The caller requested an "update" of his earlier briefing and told the briefer he intended to fly VFR from Gillespie Field to Olympia, Washington. He was departing the following morning about 0600, and gave the same approximate route of flight, although no intermediate landing points were mentioned. After asking the expected en route time of the trip (8 - 9 hours) the briefer said, "Can you go IFR to start?" The pilot replied "possibly, yeah, probably could, are we gonna be socked in at Gillespie?" The briefer replied that the forecast for the morning was for marginal VFR conditions to exist at Gillespie due to overcast ceilings. The forecast was for the clouds to dissipate about 0900 to 1000. The briefing continued for the remainder of the route where high pressure and VFR conditions were forecast. The briefer, citing the outlook portion of the forecast, said the outlook for the morning was for marginal VFR conditions at San Diego until mid-morning and otherwise conditions were forecast to be VFR throughout the route. He then gave the caller the forecast winds aloft.

There was no record of any further weather briefing.

WRECKAGE AND IMPACT INFORMATION

The accident location was on the south-facing slope of a ridgeline that extended west a short distance from the peak of Iron Mountain. To the north, the mountain slopes upward at a 50- to 60-degree slope to the crest of the ridgeline about 100 feet above. To the east the mountain slopes up to the peak of Iron Mountain at 2,696 feet msl. To the west the terrain slopes steeply downward to a valley orientated north-south with Highway 76 in the bottom. The accident location is at latitude 32 degrees 58.3 minutes north and longitude 116 degrees 57.3 minutes west (GPS). The elevation is approximately 2,375 feet msl. There was a postcrash fire.

The aircraft impacted the mountain in an arid area of large boulders and sparse, dry, shrubbery about 4-feet tall. There was a blackened area about 75 feet up the rock face above the impact location and 50-feet laterally across the rock face. The center of the blackened area was aligned to the north, northeast. At the bottom of the blackened area was the aircraft engine and components identifiable with the cabin area of the aircraft, which were burned. Adjacent below was the partially burned empennage of the aircraft, and adjacent to the left (west) was the partially burned left wing. The right wing, with burn damage at the root, was located down a steep rock face about 100-feet below the empennage.

The aircraft was examined at the facilities of Aircraft Recovery Service, Compton, California, on September 13, 2000.

The engine and cabin area were fire damaged and the instruments and switches were destroyed. The throttle quadrant was identified with the throttle and mixture controls in the full forward position. The propeller exhibited deep leading edge gouges with one blade bent aft 90 degrees at the midspan and the other blade missing about 10 inches of the tip end. The engine exhibited impact damage to the bottom front of the engine. The muffler was separated and the carburetor was broken off at the base. When the carburetor was opened, the left-hand float exhibited inboard compression on the outboard side. The vanes of the vacuum pump were intact although the engine coupling was melted.

Control continuity was established in the wings and the empennage. The stabilator trim actuator was extended to a position corresponding to approximately the 40 percent nose up trim position.

One of the witnesses to the accident revisited the site on September 2, 2000, after the wreckage was recovered. The witness found the aircraft's altimeter and returned it to the Safety Board. The altimeter case exhibited both impact and fire (heat) damage. The instrument's needles were loose and indicated 14,100 feet. The Kollsman setting, read by exposing the unburned portion of the dial, was approximately 29.85.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot's third-class airman's medical certificate was the subject of a special issuance by the FAA due to a history of (aborted) myocardial infarction in 1995. The pilot's most recent (third-class) medical certificate was issued August 24, 1999, and was effective through August 31, 2001. The medical certificate application stated that the pilot's medical program included aspirin (325 mg daily), Zocor (40 mg daily), and Lotrel 5 (10 mg daily).

An autopsy was performed by the San Diego County Medical Examiner, case number 00-01600. The medical examiner reported finding no old or recent infarctions of the heart and was of the opinion, based upon the history and autopsy examination, that the pilot died as a result of multiple traumatic injuries. According to the coroner's report, the pilot's wife reported he was taking Zocor (medication) for elevated cholesterol and an unidentified medication for high blood pressure. Toxicology was performed by the FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma.

TESTS AND RESEARCH

Continuous Data Recording (CDR) recorded radar data was obtained from the FAA Southwest Region Quality Assurance Office (attached). The data, for the last 1 minute 37 seconds of the flight, shows the aircraft, initially, westbound at 1,500 feet climbing to 1,800 feet, about 1 mile south of the accident site. The airplane then made a right turn to a northerly heading and, in the final minute, climbed from 1,800 feet to 2,400 feet. The last radar return was near the accident site at 0914:03 with the aircraft at 2,400 feet.

ADDITIONAL INFORMATION

The aircraft wreckage was released to Gary Wayne and Associates, insurance adjustors, on September 14, 2000.

NTSB Probable Cause

The pilot's intentional flight into known adverse weather.