NTSB Factual Report

HISTORY OF FLIGHT

On November 12, 2015, at 1930 Pacific standard time, a Beech A36 airplane, N78CR, impacted mountainous terrain while on a practice instrument approach to General William J. Fox Airfield (WJF), Lancaster, California. The private pilot and certified flight instructor (CFI) were seriously injured and the airplane was substantially damaged. The airplane was registered to TA Services LLC, and operated under the provisions of Title 14 Code of Federal Regulations Part 91. Night visual meteorological conditions prevailed and an instrument flight plan was filed. The flight originated from Bakersfield, California at 1900.

The pilot stated that he was receiving instrument flight instruction from a certified flight instructor, and they were conducting a three-leg cross country flight. The flight originated from Camarillo, California, on the first leg at 1805 and landed in Bakersfield at 1845, and departed on the second leg at 1900 en route to WJF. The pilot reported that the flight was cleared for the RNAV RWY 6 approach. They crossed HONUL, a waypoint fix 3.5 miles west of the final approach fix, about 1,900 feet below the minimum crossing altitude, and impacted trees in the mountainous area 10 miles southwest of the airport. .

A Los Angeles County Fire Department helicopter located the aircraft accident location and a sheriff deputy arrived on-scene about 45 minutes after the accident. In a statement to the Los Angeles Country Sheriff at the accident scene, the pilot said that he thought he was flying too high and instead was flying too low, at which time he collided with terrain. He also stated there were no mechanical malfunctions, only pilot error.

Certified voice recordings provided by the Federal Aviation Administration (FAA), and OpsVue radar track data was reviewed and a synopsis was created. Altitudes are in feet above mean sea level (msl). There were no certified transcripts produced by the FAA on this event, which was not required, therefore a partial transcript was produced by the National Transportation Safety Board Air Traffic Control (ATC) investigator, and is located in the official docket of this investigation.

OpsVue track data indicated that the pilot first checked in with the Joshua Control Facility (JCF) about 34 miles northwest WJF, southeast bound on a heading direct to the airport at an altitude of 11,300 ft and a ground speed of about 151 knots. At 1938:15 the pilot requested the RNAV RWY 06 approach to a full stop at WJF and at 1939:31 the controller cleared the flight direct to JILMU (intermediate fix for the RNAV RWY 06 approach). At 1941:32 the controller instructed the pilot to descend and maintain 7,000 ft (the published minimum altitude crossing JILMU on the RNAV RWY 06 approach). The pilot continued flying southeast bound on the heading he checked in on for about 6 miles before turning southbound in the direction of JILMU. The pilot continued flying on about a 190o heading until 1944:38 when the controller instructed the pilot to turn right 15o for a better turn to final. Radar track data indicated that the airplane actually turned to the left about 10o to around a 180o heading, rather than right 15o as instructed.

The flight tracking continued on the 180o for about 3.5 miles when at 1946:52 the controller cleared the pilot direct to HONUL with an altitude restriction of at or above 7,000 ft until reaching HONUL. The pilot read back what sounded like "JOEL" and moments after the clearance the radar track data indicated the airplane turning right toward JILMU again.

At 1949:24, the pilot reported JILMU inbound and at that time was at an altitude of 7,250 ft and a ground speed of about 96 knots. The controller was on a landline with Fox Field tower affecting arrival coordination at the time of the radio report. Radar track data indicated that the airpane continued on a southerly heading through JILMU and the final approach course and the pilot re-called the controller for approach clearance at 1950:20. At 1950:27 the controller cleared the pilot for the approach, with no supplemental information. Upon being cleared however, radar track data indicated that the airplane turned right back to the north/northwest and then turned onto the final approach course approximately 1.5 miles out from HONUL, and well below the published minimum altitude for that segment of the approach. During the same time, a position relief briefing was taking place at Joshua Control, and it was mentioned that the pilot was struggling with his approach. At 1953:05 the controller asked the pilot if he had the terrain in sight, at which time the airplane was about 900-1,000 ft below the published approach altitude, and the pilot first responded with the airport in sight when he was asked again if he had terrain in sight, and the pilot responded that he did. At 1953:18 the controller instructed the pilot to contact Fox Field tower, at that time the airplane was at an altitude of 5,325 ft and a ground speed of about 88 knots.

At 1953:54, the pilot checked in with Fox Field tower about 3/4 miles outside of HONUL on the RNAV RWY 6 for a full stop. The airplane was at an altitude of 4,775 ft and descending at a ground speed of about 72 knots. The tower controller instructed the pilot to report 3 miles out, and at 1954:17 the pilot acknowledged appropriately. This was the last recorded transmission from the pilot. At 1954:33 the airplane crossed HONUL at about 4,225 ft and at a ground speed of about 69 knots. At 1954:35 and 1954:37, two "clicks" were heard on the voice recordings, and at 1954:38 the last recorded track data of the airplane indicated an altitude of 4,150 ft and a ground speed of about 71 knots and was approximately coincident with the accident location.

METEOROLOGICAL INFORMATION

At 1956 the Fox Field the Automated Surface Observation System (ASOS) recorded the weather conditions as wind from 300o at 3 knots, 10 statute miles visibility, sky was clear, temperature was 4°C, dew point was -11°C, and altimeter setting was 30.14 inHg.

The U.S. Naval Observatory database for November 12, 2015, shows that for the Lancaster, CA, area the sun set was at 1650, moon rise at 0708, moon set at 1755, and moon illumination was 0%.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located towards the top of a shallow ridge, on the up-slope side. The terrain was populated with brush and a wide distribution of dead pine trees. The wreckage debris path contained broken tree branches, and ground gouges leading up to the airplane. The airplane's engine had been separated from the firewall and displaced under the airplane nose. The landing gear was extended. The cockpit and fuselage was intact. The leading edge of both wings had leading edge damage consistent with multiple tree impacts. The tail was intact, however, displaced to the right about 20-degrees. The propeller had separated from the engine, exhibited leading edge blade damage, and blade tip curling on all three blades.

ADDITIONAL INFORMATION

FAA Order JO 7110.65, Air Traffic Control, stated in part:

2-1-6. SAFETY ALERT

"Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude that, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft. Once the pilot informs you action is being taken to resolve the situation, you may discontinue the issuance of further alerts. Do not assume that because someone else has responsibility for the aircraft that the unsafe situation has been observed and the safety alert issued; inform the appropriate controller.

a. Terrain/Obstruction Alert. Immediately issue/initiate an alert to an aircraft if you are aware the aircraft is at an altitude that, in your judgment, places it in unsafe proximity to terrain and/or obstructions. Issue the alert as follows:

PHRASEOLOGY-LOW ALTITUDE ALERT (call sign), CHECK YOUR ALTITUDE IMMEDIATELY.

and, if the aircraft is not yet on final approach,

THE (as appropriate) MEA/MVA/MOCA/MIA IN YOUR AREA IS (altitude)."

2-4-3. PILOT ACKNOWLEDGMENT/READ BACK

"Ensure pilots acknowledge all Air Traffic Clearances and ATC Instructions. When a pilot reads back an Air Traffic Clearance or ATC Instruction:

a. Ensure that items read back are correct.

NOTE-

1. ATC Clearance/Instruction Read Back guidance for pilots in the AIM states:

a. Although pilots should read back the "numbers," unless otherwise required by procedure or controller request, pilots may acknowledge clearances, control instructions, or other information by using "Wilco," "Roger," "Affirmative," or other words or

remarks with their aircraft identification.

b. Altitudes contained in charted procedures, such as departure procedures, instrument approaches, etc., need not be read back unless they are specifically stated by the controller.

c. Initial read back of a taxi, departure or landing clearance should include the runway assignment, including left, right, center, etc. if applicable.

2. Until a pilot acknowledges a controller's clearance or instruction, a controller cannot know if a pilot will comply with the clearance or remain as previously cleared."

NTSB Probable Cause

The flight instructor's failure to comply with published instrument approach procedures during an instrument approach in dark night, visual meteorological conditions, which resulted in impact with terrain. Contributing to the accident was the controller's failure to issue a safety alert upon noting the airplane's low altitude.