NTSB Factual Report

HISTORY OF FLIGHT

On December 27, 1994, at 1823 Pacific standard time, a Piper PA-28-140, N4647R, collided with desert terrain during a precautionary landing attempt on an interstate highway near Holtville, California. Based on weather reports from a local airport and a ground witness, marginal visual flight rules (VFR) conditions with visibility restricted by ground fog existed at the intended destination. The aircraft was destroyed in the crash sequence and postcrash fire. The pilot and passenger sustained fatal injuries. The flight originated at Palo Alto, California, at approximately 1400 on the day of the accident and was reportedly destined for Yuma, Arizona.

At approximately 1735 a witness pilot (No. 1), who was also inbound to Imperial from the north, contacted UNICOM on 122.7. He advised Imperial traffic that he was at 8,000 feet over Salton City and requested landing information. Imperial UNICOM reported "visibility 1 1/2 miles, winds calm, runway 32 in use." About this time, he heard the accident pilot also calling Imperial UNICOM. He reported his position as 38 miles north of the Imperial VOR at 7,000 feet. During his radio transmission, he asked "what visibility 1 1/2 miles meant."

The witness pilot (No. 1) of the first aircraft thought the accident pilot sounded inexperienced, so by radio he offered to try to help direct him to the Imperial airport. He asked the accident pilot to turn on his landing light so that he could verify his position. The accident pilot complied, and his location was identified by the witness pilot (No. 1) as being approximately 5 miles behind his aircraft on approximately the same inbound heading. He asked the accident pilot if he could see the white strobe on his tail and he replied that he could. The witness pilot (No. 1) then advised him to follow the strobe and he would lead him to the airport.

As they proceeded inbound, the witness pilot (No. 1) continued to describe prominent landmarks to the accident pilot in order to help him identify Imperial airport. He described the accident pilot's responses as confused, disoriented, and generally unresponsive. As the accident pilot continued inbound towards the Imperial airport, he reported his altitude as 4,000 feet, and that he could only see fog. The witness pilot (No. 1) encouraged him to descend so that he would be able to see the airport.

Believing the accident pilot was still behind him, the witness pilot (No. 1) continued on to his destination, landing at Imperial airport at 1750. After landing he became more concerned, because although the airport had been VFR when he landed, he could see a fog bank about 1 1/2 miles to the northeast which was moving toward the airport. Although the accident pilot had been communicating in what was described as a "normal" tone and did not sounded overly concerned about his situation, the witness pilot (No. 1) now realized that the situation could actually be more serious than he had originally judged.

After waiting approximately 25 minutes for the arrival of the accident pilot, he concluded that he had possibly mistaken his suggestion and had flown toward the white strobe at the Brawley airport instead following the strobe on his aircraft. At this time, he began having trouble maintaining air-ground communications between himself and the accident pilot.

About 1815 witness pilot (No. 1) heard an Ameriflite pilot taking off from Imperial. He told the pilot that there was an aircraft in the area that was having difficulty in finding the airport and asked that he help by relaying radio transmissions. The Ameriflite pilot (witness pilot No. 2) advised the accident pilot that the Calexico/Mexicali area looked clear and suggested either of those airports as alternate destinations.

The accident pilot had not been responding directly to any proposed suggestions, but instead kept asking: "Do you see me?" He was then heard saying that he had only "10 minutes of fuel left," followed by the statement that he had "5 minutes of fuel" remaining and that he would have to do something. A few moments later, he was heard saying "I can't find the place, I'm going to Yuma". At that time he reported his altitude as 4,000 feet and asked "How far is Yuma?" Witness pilot (No. 1) advised him that Yuma was about 60 miles away and to land on the interstate highway if he could not find the airport.

The accident pilot next reported that he was eastbound at 500 feet over the interstate and that he was going to land on the freeway. Witness pilot (No. 1) cautioned him not to land on the dirt, and the pilot replied that he would land on the freeway. The last transmissions from the accident pilot were "I'm switching tanks," followed by "we're going to crash, we're going to crash, we're crashing." Witness pilot (No. 1) reported that he heard a woman's voice in the background. There were no further transmissions from the accident pilot.

A witness who was living in a motor home approximately 1/4-mile north of the accident site, reported that while looking out his window he observed an aircraft with its landing lights illuminated attempt, what he believed was, an eastbound landing on the interstate. As the aircraft neared touchdown, it suddenly began a climbing right turn south of the freeway. The aircraft continued in the turn and then began a descent until it was lost from view. A few seconds later, the witness reported that he observed flames south of the interstate. He immediately ran to the location, which was approximately 500 feet south of the freeway. When he arrived, he found an aircraft had crashed and was on fire. He returned to the interstate and flagged down a motorist, who subsequently notified authorities. The witness described the weather at the accident site as clear but very dark.

A review of radar data revealed an aircraft with an altitude encoding transponder squawking 1200. At 1807 the aircraft was observed on a southeasterly descent from 6,200 feet msl. After passing to the east of the Imperial airport, the aircraft proceeded to maneuver in that area before turning eastbound. As the descent continued, radar contact with the aircraft was eventually lost at 1821. At that time, the aircraft had descended to an altitude of 100 feet msl, approaching to within approximately 3.5 miles of the accident site. The accident site is approximately 100 feet below sea level.

PERSONNEL INFORMATION

The pilot's log books could not be located, however, the certified flight instructor (CFI) who gave him his last biannual flight review (BFR) was interviewed. He described the pilot as knowledgeable of flight procedures, but somewhat "bull-headed" in his approach to flying. It was his opinion that the pilot had attempted to make his flight from Palo Alto to Yuma non-stop which, according to the CFI, he had done successfully in the past. On this occasion he believed that he might have encountered unfavorable winds, but elected to continue until the last moment when remaining fuel became a critical factor.

The CFI stated that, although the pilot had flown this route many times, he had not logged a significant amount of night flight time and it was questionable whether or not he had flown the route at night. He also reported that the pilot had been working on an instrument rating on and off for the past 5 years.

AIRCRAFT INFORMATION

The aircraft and engine log books could not be located, however, the Federal Aviation Administration (FAA) reported that their records showed that the aircraft engine, a Lycoming 150 hp O-320-E2A, had been replaced with a 180 hp O-360-A1A, in accordance with supplemental type certificate (STC) 739CE.

METEOROLOGICAL CONDITIONS

According to witnesses, a localized fog bank moved over the intermediate destination during the time the pilot was attempting to locate the airport, which reduced ground visibility. Witness pilot (No. 1) said the weather condition was expected, and had been occurring on regular basis as a result of nightly temperature changes and the large body of water located northeast of the airport. The weather condition at the Imperial airport was localized and did not effect all the airports in the local area.

A review of the sun and moon illumination tables at the time revealed that the accident occurred near the end of astronomical twilight.

AIDS TO NAVIGATION

Imperial VORTAC, 115.9 VHF, is located 5.7 miles southeast of the airport. Los Angeles Center, which has radar capability, can be contacted on 128.6 VHF. San Diego Flight Service can be contacted on 122.2, 122.4, 122.5, and also transmits on 117.8 VHF. The frequencies for these facilities are regularly published on charts and facility directories. All facilities were operational at the time of the accident. The aircraft was reportedly equipped with LORAN.

COMMUNICATIONS

The accident pilot contacted the Imperial airport UNICOM. He communicated with both UNICOM personnel and two other pilots over the UNICOM frequency. There was no evidence that he used any other communication frequency after he made initial contact with Imperial UNICOM until the time of the accident.

AIRPORT INFORMATION

Imperial airport is an uncontrolled airport located on the northern edge of the city of El Centro, and on the southern edge of the city of Imperial. The airport has a rotating beacon and medium intensity runway lights (MIRL) on both runways, 14-32 and 08-26. In addition, runway 32 has a visual approach slope indicating (VASI) system. There is a published VOR approach for runway 32. Aircraft refueling with 100LL is available. All lighting systems were operational at the time of the accident.

WRECKAGE AND IMPACT INFORMATION

A path of ground scars and debris was found on the accident site's level desert terrain on a magnetic bearing of 285 degrees. The initial ground scar contained red navigation light lense fragments. At the end of the initial 7-foot-long scar was a skip of 22 feet before the next impact scar. The second impact scar was 27 feet long and along the 285-degree axis. The aircraft came to rest 45 feet beyond the second scar on a final heading of 240 degrees.

The aircraft came to rest in an inverted attitude. The right wing was separated, but was lying in the same general area relative to the fuselage as it would if it were still attached. The wing tip exhibited crush on the forward portion of the tip. The right wing flap was partially separated from the wing at its outboard attachment point. There was a section of the leading edge that was burned away which corresponded to the location of the right main fuel tank. There was fuel remaining in the right tank.

The left wing was still attached, however, its attachment point to the fuselage had been engulfed and consumed by the postcrash fire. The left wing flap was found in the retracted position. The fuselage from the spinner aft to the empennage had also been engulfed and consumed by the postcrash fire. There was fuel remaining in the left tank. The right elevator was partially detached from the horizontal stabilizer.

The flap handle was not in a detent position, although it was near the first notch which, according to the manufacturer corresponds to 10 degrees of flaps. The fuel selector was not located. Control continuity was established for all flight control surfaces.

The communication radio channel selector was found on 119.50 with the volume control turned to the low end stop. The navigation radio channel selector was found on 122.55. The omni bearing selector (OBS) was found set on 065 degrees. The altitude encoding transponder was found with a "1200" code and with the selector switch in the "altitude" position.

The landing gear light filament was stretched and broken, however, the bulb itself was still intact.

The propeller exhibited chordwise scoring, along with leading and trailing edge nicks and gouges. One blade tip was bent forward and exhibited a torsional twist. The second blade was bent aft at a point approximately midspan.

The engine remained attached to the firewall, although it showed evidence of impact and fire damage. The magnetos were destroyed by fire and could not be examined. All spark plugs except for the bottom No. 1 plug were removed and visually examined. The top plugs were dry and their electrodes appeared worn. The bottom No. 2 and 4 plugs were dry, while the No. 3 plug was wet with oil. The bottom No. 3 and 4 plug electrodes appeared normal, while the No. 2 plug electrode appeared worn.

A fuel sample was taken from the right wing tank. Approximately 1 quart of blue colored fuel consistent with 100 octane LL AVGAS was collected and visually examined. The sample was free of visible contamination. No other fuel analysis was conducted.

Visible lubricant was present under valve covers. The color and viscosity of the oil was consistent with engine oil. No visible contamination was noted.

Valve and gear continuity was established during a partial hand rotation of the crankshaft.

Compression was established in the No. 2 cylinder during a partial hand rotation of the crankshaft.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was conducted on December 31, 1994, by the Imperial County Coroner's Office, with specimens retained for toxicological examination. The toxicological test results were positive for Naproxen and Acetaldehyde.

FIRE

A postcrash fire had consumed the forward fuselage and cabin area by the time the fire department units arrived on the scene.

SURVIVAL ASPECTS

The passenger was ejected from the aircraft. The pilot was located in the left front seat. Two seat belt buckles were found in a latched position.

ADDITIONAL INFORMATION

The aircraft was recovered by aircraft retrieval personnel and secured in an aircraft storage facility in Ramona, California. The wreckage was released to a representative of the registered owner on April 4, 1995.

There were no reported emergency locator transmitter (ELT) signals reported in the vicinity at the time of the accident. No ELT was found in the aircraft wreckage.

NTSB Probable Cause

the pilot's becoming lost/disoriented during a night cross- country flight at a time the flight was in a critical low fuel state, and his failure to maintain aircraft control during a go-around from an aborted precautionary landing. Factors in the accident were: 1) the pilot's inadequate inflight fuel consumption calculations; 2) his failure to refuel the aircraft; 3) his failure to use all available FAA resources once the critical flight state became apparent; 4) spatial disorientation; and 5) darkness.