NTSB Factual Report

HISTORY OF FLIGHT

On March 1, 2009, about 2300 Pacific Standard Time, a Diamond DA-40, N521DS, impacted the waters of the Pacific Ocean while its pilot was executing an RNAV/GPS approach to Runway 14 at Arcata Airport, Arcata/Eureka, California. The commercial pilot and his passenger were killed in the accident sequence, and the airplane, which was owned by Mitchell Enterprises Inc., was destroyed by the impact. The Title 14 Code of Federal Regulations Part 91 personal pleasure cross-country flight, which was operating in night visual meteorological conditions (VMC), departed Bakersfield, California, at 1936. The pilot was on an instrument flight rules (IFR) flight plan, and had been issued a clearance for the approach into Arcata, Airport. There was no report of an emergency locator transmitter (ELT) signal. Debris from the wreckage was first discovered on a nearby beach four days after the accident.

According to family members, the pilot spent a number of hours on Friday, February 28, 2009, looking on the internet and calling around his local area in an effort to locate an airplane to use on a cross-country flight from Florida to Les Vegas. Although his first choice was a twin engine airplane, he was not able to find one available. He first contacted the owner of N521DS about 1100, on that Friday. He inquired about renting the airplane for a multi-day cross-country flight, and arranged for a checkout by the owner's check pilot the next morning, and for rental of the airplane beginning on that same day (Saturday). On Saturday morning the pilot and his passenger arrived at Plant City Airport about 0800. The passenger stayed in the office area of the airplane's owner while the pilot went through the pre-rental process. That process included having his log books reviewed by the check pilot, undergoing 30 minutes of ground checkout, and an in-flight checkout lasting one hour. The pilot then completed the rental agreement, put $1,000.00 cash on deposit, and gave the owner his credit card number for billing the flight time beyond the $1,000.00 deposit.

According to the owner, during the rental/checkout process, the pilot said that he was building time, and that he and his passenger were going to fly to Las Vegas, and would return on Tuesday, Wednesday, or Thursday, depending on the weather. According to the check pilot, the checkout went well, with the pilot displaying good knowledge of the airplane, as well as good piloting skills.

The pilot and his passenger departed Plant City Airport about 1100 Eastern Standard Time, and arrived at Mobile Regional Airport, Mobile, Alabama, about 1340 Central Standard Time (CST), for a leg flight time of about three hours and forty minutes. They stayed on the ground at Mobile for about one hour and fifty minutes, and then departed there about 1530 CST. They arrived at Huntsville Municipal Airport, Huntsville, Texas, about 1920 CST, for a leg flight time of about three hours and fifty minutes.

After landing at Huntsville, the pilot had 39 gallons of 100 low-lead aviation fuel added to the fuel tanks. According to the Huntsville Aviation employee who pumped the fuel, the pilot initially stated that after refueling they were going to continue on. But, according to that employee, during the refueling process the pilot and his passenger started discussing how tired each one of them was, and they eventually made the decision to stay in Huntsville overnight.

The owner of Huntsville Aviation then drove them to a local hotel, arriving there about 2000 CST. As he was leaving them at the hotel, they mentioned that after they checked in, they were going to walk to one of the adjacent restaurants for dinner before returning to the hotel.

On the second morning of the trip, about 0700 CST, when the first Huntsville Aviation employee arrived at the airport, the pilot and his passenger where already at the airplane. The pilot was observed performing his preflight inspection, after which he and his passenger came into the Huntsville aviation office, reportedly to get warm. They then went back out to the airplane, and the pilot began to taxi out for takeoff about 0715.

The next known location of the airplane was in Sedona, Arizona, where later that day it took on 31.6 gallons of fuel, before departing that location about 1730 Mountain Standard Time (MST). Although the airplane's arrival time at Sedona (an airport without a control tower) could not be determined, the investigation did reveal that while at Sedona the pilot made a phone call to his mother, ate a meal, and filed two flight plans through the CSC DUATS system. The first flight plan, which was for a leg from Sedona, Arizona to Palmdale, California, was filed at 1607 MST. The second flight plan, which was filed at 1700 MST, was for a leg from Palmdale, California, to Arcata, California.

Although the pilot had filed from Sedona to Palmdale, upon reaching Palmdale he continued on to Meadows Field, Bakersfield, California, which is located about 65 nautical miles northwest of Palmdale. He arrived there at 1841 Pacific Standard Time (PST), for a leg flight time of about two hours and fifteen minutes. Then, at 1900, the pilot took on 29.0 gallons of 100LL aviation fuel from an Atlantic Aviation fueling truck, and departed for Arcata at 1936 PST. An annotation at the top of the refueling slip indicated that the Bakersfield refueling was a "top off."

After departing Bakersfield, the pilot picked up his instrument flight rules (IFR) clearance, whereupon he was cleared to his filed altitude of 8,000 feet, with a route clearance of direct to Arcata. At 2002 PST, while in the vicinity of Visalia, California, he contacted Oakland Flight Watch to inquire about some reports of turbulence that he overhead while airborne. Although the pilot only asked for the turbulence information, the Flight Watch briefer responded with a more expanded weather update. He informed the pilot that there were AIRMET's (Airmen's Meteorological Information) in effect for low level wind shears and moderate turbulence below 18,000 feet, with icing from the freezing level to 20,000 feet. The briefer further advised him that he was moving into an area of moderate precipitation, but that he would move into an area of isolated widely scattered precipitation once he passed Stockton, California. He also indicated that pilot reports were indicating icing in the central California area at an altitude range of about 15,000 to 18,000 feet. He also told the pilot that there was a pilot report of moderate turbulence at 4,000 feet about five miles southeast of Tracy, California. The briefer informed him that there was light rain north of Stockton, with clouds scattered to broken about 4,100 to 5,000 feet. He also informed the pilot that the current conditions in Arcata were light rain, winds from 150 degrees at 10 knots, gusting to 20 knots, visibility 9 miles, scattered clouds at 5,000 feet, a broken ceiling at 6,000 feet, and an overcast ceiling at 9,500 feet. At the end of the update the controller asked, "Is that what you needed, or can I help you with anything else?" The pilot then indicated that that was all he needed, and thanked the briefer for his help. The pilot then continued on direct to his destination.

As the pilot proceeded into the northwest corner of California, he was advised to switch from Oakland Center to Seattle Center. When he first made contact with the Seattle Center, the pilot advised the controller that his transmissions were "broken up." In response the controller said that the Center transmissions should get better as the pilot continued on toward Arcata. About four minutes after the pilot's first contact with Seattle Center, the controller gave him the altimeter setting (29.67) and asked him what his altitude was. The pilot responded that he was indicating 9,300 feet, and the controller then reminded him that his last assigned altitude was 10,000 feet, and then asked if he was "…having difficulty." The pilot then explained that he was climbing back to his assigned altitude, that it was very turbulent, with a lot of ups and downs and moderate to severe turbulence.

About two minutes later, the controller advised the pilot that crews of other aircraft had reported light to moderate turbulence while on the ILS (Instrument Landing system) approach to Arcata. He then cleared him to descend to 9,000 feet, and then about 30 seconds after that, he asked the pilot if he knew what approach he wanted into Arcata. The pilot replied with "negative," and then asked what approach others were doing at the time. The controller advised him that most pilots coming from the south (as he was) were doing the ILS and circling to runway 14. The pilot started to respond with, "I guess I can," but then appeared to terminate his statement mid-sentence, and then said the he would get back to the controller with the approach he wanted. The controller then advised him that there had been a couple of pilots that had chosen to shoot the RNAV/GPS approach from the north to Runway 14. The pilot responded with, "Yeh, we can do an RNAV/GPS for 14."

The controller then cleared the pilot direct to CULDU (the initial approach fix for the RNAV/GPS 14 approach), spelling out CULDU phonetically for the benefit of the pilot. The pilot responded by asking the controller to say the letters again (for CULDU), and the controller responded by spelling out CULDU phonetically again, and explaining to the pilot that CULDU was the initial approach fix for the RNAV/GPS approach to runway 14. The pilot then stated that it was "… really turbulent right now," and then asked if he could get back to the controller for "…that information." The controller approved that request, and then about fifteen seconds later the pilot transmitted, "Alright, can you repeat that fix again?" The controller again stated that the fix was CULDU, that it was the initial approach fix, and then again spelled it out phonetically.

There was no response from the pilot for the next one minute and twenty seconds, and then he asked the controller to verify that the fix was CUDLU (note misspelling). The controller advised the pilot that that was "very close" and that the fix was named CULDU (the controller again spelling it phonetically). The pilot responded with, "Okay, I got it this time. Thank you."

The controller then advised the pilot that the radar depiction of area weather showed moderate to heavy precipitation over the Arcata area, and advised him that those conditions would be along his route of flight the whole time he was inbound. The controller then repeated the fact the rain intensity was showing as moderate to heavy.

About three minutes later, the controller cleared the pilot to descend and maintain 8,000 feet, and the pilot read back the clearance. The controller then told the pilot that the 8,000 feet was the IFR minimum altitude, and that he needed to try to hold that altitude the best he could. He further stated that the pilot could go above it, but that to go below it, "…would be bad." The pilot then acknowledged that transmission.

About six minutes later the pilot was cleared to 7,000 feet, and about two minutes after that he was cleared to 6,000 feet. About 90 seconds after being cleared to 6,000 feet, the controller reminded the pilot that weather radar was showing moderate to heavy precipitation between his present location and CULDU. The pilot acknowledged that transmission, and then stated that he saw the area of precipitation with his onboard equipment. The controller then advised him that turns to both the left and the right was approved if the pilot needed to go around some of the weather. The pilot then advised the controller that he was going to turn toward the west, to a heading of 250 degrees, and then he would come back to CULDU. The controller acknowledged that transmission, and advised the pilot that on that heading he (the controller) would be able to get the pilot to a lower altitude sooner. The controller then told the pilot to continue on his heading of 250 degrees, and then cleared him to descend to 5,000 feet. About two minutes after clearing the pilot to 5,000 feet, the controller advised the pilot that the Arcata altimeter was 29.67, and requested that the pilot, "…maintain at or above 5,000 feet, please." The pilot responded to that call by saying that he was indicating 4,900 feet, and that he was climbing back up. The controller then advised the pilot that he would be able to clear him direct to CULDU in about a minute and a-half.

About one minute and thirty seconds after being cleared down to 5,000 feet, the pilot was cleared to descend to 4,000 feet, and to proceed direct to CULDU. About 90 seconds later, the controller told the pilot to cross CULDU at or above 4,000 feet, and that he was cleared for the RNAV/GPS 14 approach to Arcata airport. The pilot read back the clearance, but read back the altitude limit as, "at or below 4,000 feet," instead of, "at or above 4,000 feet." The controller repeated the altitude clearance limit, and the pilot then correctly acknowledged it.

Recorded radar data shows that the pilot then proceeded to CULDU, executed a course reversal outbound (northwest) of CULDU in order to intercept the inbound course. Then about seven minutes after being cleared for the approach, while back inbound to CULDU at 3,600 feet, the controller advised the pilot that radar service was terminated, that he should report his IFR cancellation or down time to the controller on the controller frequency, and that he was then cleared to switch to the Arcata CTAF (Common Traffic Advisory Frequency). The pilot acknowledged that clearance, and then apparently switched his radio to the CTAF frequency.

Although the controller cleared the pilot to switch frequencies, he (the controller) continued to monitor the progress of the approach. About three minutes after he had cleared the pilot off of his frequency, the controller noticed that the airplane had descended to an altitude of 1,400 feet, but that it had not yet reached UYFOR (the final approach fix, with a published minimum crossing altitude of 2,100 feet). About a minute and a-half later, after seeing the airplane continue to descend while still not yet at UYFOR, the controller attempted to contact the pilot over the Seattle Center frequency. Over the next twelve minutes, the controller attempted contact with the pilot ten separate times. The first five times he transmitted the call sign "November 521 Delta Sierra," and the next five time he used the call sign, "Diamond 521 Delta Sierra." After being unsuccessful at making contact with the pilot during that twelve minute period, the controller contacted Oakland Radio over the land line telephone, and requested that the Oakland Radio operator attempt to contact the pilot at Arcata via Oakland Radio's radio frequency there. That attempt was unsuccessful, and no further contact was made with the pilot. The last radar mode C radar target from the airplane was recorded at 4 degrees, 04.66 minutes North, 124 degrees, 10.63 minutes West (about one-tenth mile from UYFOR), at 300 feet above the ocean surface.

PERSONNEL INFORMATION

The 30 year old pilot held a commercial pilot certificate, with ratings of Airplane Single Engine Land (ASEL), Airplane Multiengine Land (AMEL), and Instrument Airplane (INSTA). He held a C/CL-65 Type Rating, with limitations of Second-In-Command (SIC) privileges only, and circling approaches in visual meteorological conditions (VMC) only. He also held a certified flight instructor (CFI) certificate, with a rating for flight instruction in single engine land airplanes. His last aviation medical certificate, a First Class, was issued on March 20, 2008, with no restrictions or limitations. A resume he completed in October of 2008, indicated that he had accumulated 104 hours of night time, 513 hours of cross-country time, and a total instrument time (both actual and simulated) of 88 hours. The resume also indicated that he had 336 hours of experience with the Garmin G1000 integrated flight instrument system (the system present in the accident airplane).

AIRPLANE INFORMATION

The airplane was a Diamond DA-40, serial number 40.621, manufactured in

NTSB Probable Cause

The pilot's failure to maintain proper altitude and glidepath while executing a night instrument approach. Contributing to the accident was the pilot's fatigue.