NTSB Factual Report

HISTORY OF FLIGHT

On April 17, 2016, about 1629 Pacific daylight time, a Cessna 172K, N7133G, was destroyed when it impacted terrain during a landing attempt at Airport in the Sky (AVX), Santa Catalina Island/Avalon, California. The private pilot and his passenger received serious injuries. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed.

AVX is situated in rugged terrain, atop a mountain that was leveled off to construct the airport. Under the approach path to runway 22, the terrain rises steeply to the airport elevation and runway threshold. According to a pilot and his friend who were standing at the airport watching the airplane arrive, when on final approach to runway 22, it appeared low, and possibly slow as well. The pilot-witness waited for the engine sound to increase to indicate a climb attempt, but he did not hear that. As the airplane began descending below the local horizon, the witnesses observed it enter a very steep right-wing down bank, and disappear from view. They listened and watched for indication of either impact or a successful escape, but heard and saw nothing to indicate either. They then notified the airport operations staff that they believed the airplane had crashed.

The two witnesses departed soon thereafter in another Cessna 172 (N365ES), and conducted a brief and unsuccessful visual scan for the airplane. About 2 minutes later, they heard a radio call on the AVX common traffic advisory frequency (CTAF) to another airplane, indicating that the US Coast Guard had detected an ELT signal about 0.7 miles southeast of the airport. The pilot-witness announced that he was returning to the area to conduct a visual aerial search, and that he suspected that the accident site was north of the airport. Shortly thereafter, the pilot-witness and his passenger located the wreckage, and guided ground personnel to it. They were also successful in establishing radio communications with the accident pilot, who was using his handheld aviation transceiver.

According to the accident pilot, he was approaching runway 22 for a landing when he determined that the airplane was too low. He attempted to climb and turn to avoid terrain. The airplane banked sharply to the right, and struck terrain shortly thereafter. The airplane came to rest nearly inverted, and the pilot was able to exit the airplane. His passenger remained trapped in the wreckage, but there was no fire.

First responders extracted the passenger, and both she and the pilot were airlifted to a mainland hospital. The wreckage was recovered to a secure facility for investigative examination.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with an instrument rating. He was one of five co-owners of the airplane, and had purchased his share about 2 months before the accident, in late February 2016. The pilot reported that as of the date of the accident, he had about 174 hours total flight experience, including about 84 hours in the accident airplane make and model. His most recent flight review was completed in November 2015, and his most recent Federal Aviation Administration (FAA) third-class medical certificate was issued in April 2013.

AIRCRAFT INFORMATION

FAA information indicated that the airplane was manufactured in 1969, and was equipped with a Lycoming O-320 series engine. A review of airplane maintenance records revealed that the most recent annual inspection was completed in January 2016. At that time, the airplane had a total time in service of about 4,952 hours. The maintenance records did not reveal any unusual or repetitive entries, or any recent engine power-related entries.

In November 2014, a 406 MHz emergency locator transmitter (ELT) was installed in the airplane.

METEOROLOGICAL INFORMATION

The 1551 AVX automated weather observation included winds from 260º at 11 knots, visibility 10 miles, clear skies, temperature 24º C, dew point 0º C, and an altimeter setting of 30.02 inches of mercury.

The 1651 AVX automated observation was very similar, but included winds from 250º at 14 knots.

COMMUNICATIONS

After departing LGB, the pilot utilized FAA air traffic control (ATC) flight-following services for his channel crossing to the island. He cancelled that service when he neared AVX, and then communicated his arrival on the designated common traffic advisory frequency (CTAF).

AIRPORT INFORMATION

General Information

Santa Catalina Island is located about 20 miles offshore from the southern California mainland. The island terrain is extremely rugged. AVX was situated on a small mesa, at an elevation of about 1,600 feet above mean sea level (msl). According to the Catalina Conservancy, which is the steward agency for AVX, the airport mesa was man-made by removing the tops of two adjacent mountains, and using that material to fill in the lower-elevation region between the two.

The airport and runway topography are somewhat unusual. It is very common practice for flight schools and fixed base operators in that region to require airport-specific checkouts prior to allowing any pilot to fly there on his/her own.

Runway Information

The single paved runway, designated 4/22, measured 3,000 by 75 feet. The threshold of runway 22 was situated at an elevation of 1,553 feet. Over the first 2,000 feet, the runway sloped evenly upward to an elevation of about 1,597 feet msl. This yielded a runway gradient of about 2.2 percent, or about 1.26º. Beyond that point, the runway rose more gradually, to a maximum elevation of about 1,605 feet at the runway 4 threshold. The gradient profile made the runway appear "humped," and rendered aircraft positioned at opposite thresholds invisible to one another.

Catalina Conservancy Web Site Information for Pilots

The Catalina Conservancy published the following information for pilots on its web site:

"The approach end of Catalina's runway 22 begins at the edge of a 1500' cliff. This gives the airport some characteristics similar to landing on an aircraft carrier that is 1,602' in the air.

Be Aware:

1) There are no familiar visual cues for altitude reference. You MUST [emphasis original] rely on your Altimeter. [capitalization original]

2) There is usually a strong downdraft at the approach end of the runway caused by the prevailing winds falling over the 1500' cliff. Be prepared for this downdraft and possible loss of altitude during your short final.

3) The uphill slope of Runway 22 can cause approach and flare problems for inexperienced pilots."

Approach Path Indication System

Runway 22 was equipped with a Pulsating Visual Approach Slope Indicator (PVASI), which was installed in 1993. The PVASI approach path was set to a 3 degree glide path relative to local horizontal. Thus, when on the 3 degree glide path, the actual approach path (and pilot's sight picture) was aligned about 4.3º relative to the runway plane. The PVASI was positioned about 450 feet down runway 22, about 80 feet to the left of the runway 22 centerline. The published PVASI threshold crossing height was 39 feet.

According to the PVASI manufacturer's data, the nominal approach path was 0.35º "thick," and indicated to the pilot by a steady white light. The next lower profile, "below course," indicated by a steady red light, was 0.175º thick. The lowest indicated profile, "well below course," indicated by a pulsating red light, was 2.5º thick. Above-nominal glide path was 2.5º thick, and indicated by a pulsating white light.

Based on these values, a pilot would observe a steady white light when on an approach path slope between 3.175º and 2.825º. A steady red "below course" indication would appear on approach path slopes between 2.825º and 2.65º, and a flashing red "well below course" indication would appear on approach path slopes between 2.65º and 0.15º

AVX Runway 22 Approach Accidents

Review of NTSB accident data revealed that between 1985 and 1993, there were five AVX runway 22 approach/landing accidents. Subsequent to 1993, and including this subject accident, there were ten additional AVX runway 22 approach/landing accidents. None of the 15 accidents were fatal. All were personal flights operating certificated, single-engine airplanes in day visual meteorological conditions.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in a ravine, approximately 400 feet north-northwest of, and 150 feet below, the runway 22 threshold. The impact location and wreckage area were situated on steeply sloping terrain; ground scars and the final resting point indicated that the airplane slid and/or tumbled downhill from the impact point.

The wreckage came to rest inverted, against an outcrop of small trees. The right wing was fracture-separated from the fuselage, and the fuselage was significantly torn, crumpled, and otherwise deformed.

Detailed examination of the airframe and engine did not reveal any pre-impact mechanical deficiencies or failures that would have precluded continued normal operation and flight. Damage signatures were consistent with the airplane striking terrain in a right wing down, nose-first attitude. The cabin structure retained most of its original occupiable volume, with the exception of the two cockpit footwells. The primary cabin impact damage and deformation was consistent with impact loads applied from the lower forward right side. Additional damage, particularly to the aft fuselage and empennage, was consistent with the airplane tumbling and/or sliding down the steeply-sloped terrain at the accident site.

The fuel selector was found set to the left tank, the flaps were set to about 20º, and the elevator trim was approximately neutral: all of these settings are consistent with those of a normal final approach. Propeller damage was consistent with the engine developing power at the time of impact. Refer to the public docket for this accident for detailed information.

An Appareo brand Stratus 2S GPS device was recovered from the wreckage. The pilot reported that he used the device during the accident flight, so it was sent to the NTSB Recorders Laboratory in Washington DC for data download.

ADDITIONAL INFORMATION

Pilot's Flight Preparations and Recollections

In a telephone interview with the NTSB investigator, the pilot reported that he had never flown into AVX before. Neither the co-owners nor the insurer of the airplane required or suggested any AVX-specific checkout or dual flight prior to solo flights there.

In preparation for the flight, the pilot conducted some research about AVX by speaking with some fellow pilots, and reading on the internet. From that research he learned/recalled that the runway was "bowed," meaning it crested and, after touchdown, appeared shorter than it actually was. The pilot also stated that he learned that there were some "optical illusions" associated with the runway, but other than the "bowed" effect, he was unable to be more specific about what those illusions were.

When the pilot was asked whether, as part of his approach path alignment, he saw or used the PVASI, and what its indications were, he responded that he was unaware of its existence, and did not recall seeing or using any light-based approach slope indicators.

In his discussion shortly after the accident with a sheriff who was a first responder, the pilot reported that when on the final approach, he realized that he was too low and added power to climb. He stated that the right wing went down, and that he "added rudder" but that rudder application was ineffective.

The pilot was able to extract himself from the wreckage, and used his handheld aviation-frequency transceiver to attempt to call for help. Those communications attempts were unsuccessful until N365ES returned and visually located the wreckage.

Accident Notification and Location Activities

The two witnesses from N365ES who believed that N7133G had crashed could not be certain of the accident due their lack of any definitive aural or visual evidence. Their notification to the airport operations staff prompted that individual to conduct a brief visual search, but that search was unsuccessful.

At 1629, which was less than a minute after the accident, the first signal from the airplane's ELT was received by one of the satellites in the detection network. The signal provided the airplane identification, but was insufficient to enable a position solution. Due to the lack of any position information, personnel at the Air Force Rescue Coordination Center (AFRCC) in Florida had to wait for a second detection before they could notify the geographically appropriate search and rescue agency. According to AFRCC personnel, they then began attempting to contact the airplane owners listed on the ELT registration by telephone, but were unsuccessful.

Although the airplane was co-owned by five persons, the ELT registration/contact list only contained three names and phone numbers. One of those persons had sold his share to the accident pilot about 6 weeks prior, and the phone number listed for another co-owner was incorrect. At 1647, the third co-owner (initials "FQ") on the list was telephoned by the AFRCC, but FQ was unable to take the call because he was working.

The next satellite detection of the ELT occurred at 1649, and enabled the first position solution. That solution indicated that the accident site was situated about 4,300 feet southeast of AVX, which was about 5,300 feet from the actual accident location. Based on that position solution, AFRCC notified the United States Coast Guard (USCG) District 11 Rescue Coordination Center (RCC), whose personnel made contact with the AVX operations staff, who in turn used CTAF to contact an inbound airplane, and request search assistance. That radio call also prompted the pilot of N365ES to turn back towards AVX, and execute an aerial visual search.

At 1658, the USCG RCC made telephone contact with co-owner FQ, and notified him that the airplane's ELT signal had been detected. FQ placed telephone calls to the other four co-owners, but did not reach any of them. Shortly thereafter FQ determined that the accident pilot had departed LGB, with an intended destination of Catalina/AVX.

About 1710, the local Los Angeles County Sheriff office was notified of a possible aircraft accident, and that office began a coordinated search and rescue response.

A third satellite detection occurred at 1723, and the data from that and the previous detection enabled a second position solution. The revised position was just north of AVX, and was situated about 1,100 feet from the actual accident location. That revised position information was communicated to the USCG, and then to persons directly involved in the search.

At an unknown time, the pilot and passenger of N365ES visually located the wreckage, and guided first responders to the scene.

Airplane Weight and Balance Information

Review of available information indicated that the airplane was within its weight and balance limits for the departure, flight, and accident. The airplane gross weight was estimated to be about 1,890 lbs at the time of the accident, which was about 410 lbs below the maximum allowable value of 2,300 lbs.

Airplane Performance Information

The airplane manufacturer's Owners' Manual (OM) provided various guidance elements in several sections throughout the document. In the checklist-style "Normal Procedures section, the OM specified approach speeds of "70 to 80 MPH (flaps up), 65 to 75 MPH (flaps down)." The only landing performance data was for 40º flaps, and an approach speed of 69 "IAS [indicated air speed] MPH.," A "Performance Data" sheet provided by an airplane co-owner, and which was reportedly in the airplane, cited an approach speed of "70 to 80 MPH," but did not specify a flap setting. In his written communications with the NTSB, the pilot stated that he used "20 degrees - 65kts." The units on the outer/primary ring of the airspeed indicator were presented in mph, but were not explicitly labeled as such. The inner ring units were presented in knots, and explicitly labeled as such.

The "Balked Landi

NTSB Probable Cause

The pilot's failure to maintain a proper approach path on landing because he failed to familiarize himself with the airport's unique approach hazards and recommended procedures before the flight. Also causal was the pilot's failure to recognize the airplane's improper approach and to execute a go-around in a timely manner.