NTSB Factual Report

HISTORY OF FLIGHT

On November 14, 1996, at 0119 hours Pacific standard time, a Cessna 310I, N8046M, operated by AEX Air, Mesa, Arizona, collided with five unoccupied parked airplanes during initiation of a missed approach at the Van Nuys Airport, Van Nuys, California. The airplane was destroyed, and the airline transport pilot was fatally injured. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The on-demand air taxi flight was operating under 14 CFR 135. The flight originated from North Las Vegas, Nevada, on November 13, 1996, at 2347.

The operator dispatched the pilot to fly under visual flight rules (VFR) to the Burbank, California, municipal airport where he was scheduled to deliver 224 pounds of bank check cargo. While en route, the pilot received weather information which indicated that Burbank's weather was below landing minimums, and the pilot diverted to the Van Nuys Airport.

As the pilot approached Van Nuys, at 0108:35, a Southern California Terminal Radar Approach Control Facility (SCT) controller informed the pilot that two other airplane pilots had recently reported the weather condition at Van Nuys was VFR. About 4 minutes later, the SCT controller issued the pilot an IFR clearance to perform an instrument landing system (ILS) approach to runway 16R at the Van Nuys Airport. The pilot acknowledged the clearance and commenced the approach.

At 0113:20, while the pilot was proceeding inbound on the ILS approach, the SCT controller instructed the pilot to change to the airport's advisory radio frequency. (The FAA control tower at the Van Nuys Airport had closed the previous evening around 2245.) The SCT controller also stated " . . . report canceling (IFR) I'll be monitoring."

The last recorded radio transmission from the pilot was at 0116:47 when the pilot informed the SCT controller that he had the "airport in sight." The pilot did not request closure of his flight plan. About this time the radar data indicated that the airplane's altitude was at 2,000 feet.

The radar data indicated that the airplane continued descending as it approached the airport, and by 0117:52 the airplane was approximately 0.4 nautical miles (nm) north of the field and at 1,100 feet. (The airport's middle marker is located about 0.4 nm north of the airport, and the decision height for the ILS approach is 1,050 feet.)

The radar data further indicated that the airplane crossed over the north end of the 799-foot mean sea level airport about 0118:10, at an altitude of 900 feet. Thereafter, the airplane began gaining altitude.

At 0118:15 the radar data indicated the airplane had climbed to 1,000 feet, and at 0118:24 the airplane was at 1,200 feet. This was the last recorded altitude for the southbound flying airplane. The airplane was subsequently found to have impacted the tarmac an estimated 1/3-mile south-southeast of the last radar recorded position.

Two witnesses reported observing what they believed were the last few seconds of the airplane's flight. The first witness, who was located near the approach end of runway 16R, reported that he observed an aircraft approximately 0.5 mile north of the airport. The witness indicated that the airplane appeared to be lined up with the runway and was attempting to land. The airplane disappeared into the fog when it had descended to about 75 feet above ground level.

The second witness, an on-duty airport police officer who was monitoring arriving inbound airplanes, reported that he heard the pilot of N8046M announce his position as approaching the airport. Thereafter, he observed an airplane cross over, or nearly over, the threshold of runway 16R and then disappear in the fog while descending in a southerly direction. The officer recorded the airplane's arrival time at 0120. No witnesses reported observing the airplane crash at the airport.

DAMAGE TO AIRPLANES

The accident airplane was destroyed upon impacting the ground. As it slid to a stop it collided with and substantially damaged the following five parked airplanes: N2607Y, N8148Q, N8700W, N8811J, and N177TP.

PERSONNEL INFORMATION

Instrument Flying Accident History.

In November, 1987, the pilot was seriously injured in an airplane accident when he descended into terrain during initiation of a flight conducted under instrument meteorological conditions. The accident occurred during a nighttime departure in fog. (See National Transportation Safety Board report number SEA88FA023 for additional details.)

Recent Employment History.

In mid-1996 the pilot had acquired conditional employment with Air Nevada Airlines. Air Nevada operated under 14 CFR 135 as a scheduled air carrier engaged in passenger carrying flights from its base in Las Vegas. On May 4, 1996, the pilot satisfactorily completed an initial airplane IFR competency flight check. The check ride was performed in a Cessna 402, and it met the FAA's requirements for the pilot to act as a second-in-command under 14 CFR 135.

According to Air Nevada's director of operations, in order for the pilot to acquire permanent employment he was required to complete its training course, possess an airline transport pilot certificate, and pass an instrument competency flight check as a pilot-in-command (PIC).

The pilot underwent additional flight training, and in July he obtained an airline transport pilot certificate. At that time, he had about 2,400 total hours of flight time which included 325 hours in multiengine airplanes, 145 hours of night flying, and 36 hours of actual instrument flight time.

Following the training, Air Nevada reevaluated the pilot's flying abilities and provided him with an opportunity to demonstrate whether he could now meet Air Nevada's standards for becoming a PIC. On August 8, 1996, the pilot underwent an initial instrument PIC competency check ride. Air Nevada indicated that the pilot did not conform to its standards. In particular, during execution of an ILS approach the pilot's judgment and instrument procedures were graded as unsatisfactory. The pilot's employment was terminated on August 8 following the flight.

Upon the pilot's departure from Air Nevada, he did not surrender the airline's employee identification badge. Imprinted on the badge was its expiration date of May, 1998. The badge was subsequently located in the wreckage of N8046M along with carbon copies of completed cockpit jump seat authorization forms from two 14 CFR 121 air carriers. The forms were dated October 31 and November 1, 1996, and each bore the pilot's name.

Flight and Ground Training History Information.

For employment consideration, on September 26, 1996, the pilot submitted his resume to AEX Air, Inc. On October 4, the pilot accepted AEX's job offer, and he was informed to report to Phoenix, Arizona, for initial indoctrination on October 10. According to AEX, the pilot completed all required company and FAA ground and flight training by October 11, and passed the company's check ride to perform as PIC the following day. Thereafter, the pilot commenced air carrier operations flying cargo principally between Burbank and Las Vegas, Nevada.

During the 30-day period preceding the accident, the pilot flew approximately 62 hours, all of which were in multiengine airplanes. No record of instrument flight time was reported.

Regarding the pilot's authority to land at the Van Nuys Airport, AEX company management verbally reported to the Safety Board that the pilot was authorized to land at Van Nuys Airport if the weather at Burbank was below minimums. The management subsequently verbally retracted the statement and indicated that the pilot should have diverted to the Fox Airfield in Lancaster, California.

Personnel from the FAA's Scottsdale, Arizona, Flight Standards District Office (FSDO), which oversees the Arizona-based operator, reviewed AEX's flight and ground training program. The FAA reported that the operator's "Operations Manual" along with its training program and records were current and adequate.

Under the Safety Board's direction, personnel from the FAA's Van Nuys, California, FSDO subsequently reviewed records covering the flight and ground training which AEX indicated it had provided to the pilot. The FAA reported finding evidence that AEX failed to provide the pilot with all the flight and ground training required by its certificate.

AIRPLANE INFORMATION

The FAA reported finding no evidence of outstanding airworthiness directives or current discrepancies listed in the on-board squawk sheets. To the extent that records were located, compliance was found with required inspections.

METEOROLOGICAL INFORMATION

At the time of the accident, no FAA facility reported the weather conditions at the Van Nuys Airport. The National Weather Service (NWS) had installed an automated surface observing system (ASOS) at the airport. However, it had not been commissioned for use. Accordingly, its recorded weather information was not being relayed to the FAA..

Weather data subsequently recovered from the ASOS indicated that about 23 minutes before the accident the airport's visibility was 2.5 statue miles. Ten minutes before the accident the visibility was 1.75 miles. Three minutes before the accident it was 0.75 miles, and there was an easterly wind (from 080 degrees) at 3 knots. All reports following the accident indicated the visibility was 0.25 miles, and that condition remained until 0556. (According to the NWS, the lowest value capable of being recorded by this ASOS was 0.25 miles.)

Several persons noted the local airport weather conditions near the time of the accident. One witness, who was located near the approach end of runway 16R, reported seeing a fog bank located at the east side of the airport. The fog bank was drifting in a westerly direction over the airport. At 0119, an airport officer located near the approach end of runway 16R, estimated that the visibility was not over 0.25 miles.

Another witness, who was an instrument-rated air taxi pilot, described the Van Nuys Airport weather conditions at 0115. He reported that the ceiling was 20 feet and the visibility was 20 feet. This witness subsequently estimated that at the time of his observations he was located about 0.5 miles west of the crash site.

At 0120 the Burbank Airport reported its official weather, in pertinent part as follows: wind calm, runway 08 visual range 2,000 feet variable 3,000 feet, fog, indefinite ceiling 200 feet, temperature and dew point 52 degrees Fahrenheit, altimeter 30.02 inHg.

AIDS TO NAVIGATION

According to FAA records of facility operation, all electronic aids to navigation necessary to accomplish an ILS approach to the Van Nuys Airport were functional during the airplane's approach.

COMMUNICATION

The FAA did not report that any anomalies occurred during its air-ground radio communications with the pilot.

AIRPORT AND GROUND FACILITIES

The Van Nuys Airport is located approximately 7 miles west of the Burbank Airport. The FAA control tower at the Burbank Airport operates 24 hours per day.

The control tower at the Van Nuys Airport operates daily between 0600 and 2245. During this period the airport is surrounded by Class D (controlled) airspace. According to the FAA's "Airport Facility Directory," when the control tower is not in operation the airport becomes uncontrolled, and the airspace changes to Class G (uncontrolled). Airport security including patrol service is accomplished, in part, by Los Angeles Department of Airport personnel, 24 hours per day.

WRECKAGE AND IMPACT INFORMATION

From an examination of the airplane and the accident site, the airplane was found to have initially impacted the ground on taxiway E-12, about 2,500 feet south-southeast of runway 16R's landing threshold. The initial ground track was observed along a 144 magnetic course starting approximately 525 feet east of the runway's centerline. Main landing gear tire tread marks, and nose cone skid marks which corresponded with the airplane's structure, were evident along an approximate 675-foot-long path between the initial point of impact (IPI) and the accident airplane's point of rest.

The entire airplane structure was found at the crash site. The airplane was found in an upright, wings level, nose down attitude. The outboard 8-foot-long portion of the right wing was found severed. The cabin roof was found peeled in an aft direction between the front windshield's centerpost and the baggage compartment area. The cockpit was located partially beneath the wing of an adjacent airplane (see photographs).

All propeller blades were observed torsionally bent, gouged, and scratched. The continuity of the flight control system was confirmed between all flight control surfaces and the left side control yoke.

The airplane's nose gear assembly was found collapsed in an upward direction into the wheel well. The main gear were found extended. The landing gear drive tube attached to the gear bellcrank was found approximately 1/4-inch away from the down position microswitch which is consistent with an in-transit gear position. The cockpit landing gear control knob was found in the up (retracted) position. The Cessna participant opined that it may take 2 or 3 seconds for the landing gear to begin retracting after the gear control knob is moved to the up position.

Regarding airframe structure and the engines, over 80 loose rivets were found. Evidence of oil and exhaust leaks were noted, and engine air induction hoses were found deteriorated. Chaffing of the left fuel selector push/pull rod against the mixture control cable was evident, the left engine's exhaust stacks had a severely eroded slip joint, bolts were missing from the right engine induction air box, and the air filter housing was cracked. There was no evidence of fire.

MEDICAL AND PATHOLOGICAL INFORMATION

On November 15, 1996, the Los Angeles County Coroner conducted an autopsy on the pilot. The autopsy report indicated that the pilot's death was due to multiple blunt force injuries. The coroner verbally reported to the Safety Board that the pilot did not instantly die from his injuries.

According to the manager of the FAA's Toxicology and Accident Research Laboratory, the results of toxicology tests on the pilot were negative for carbon monoxide, ethanol, and all screened drugs.

SURVIVAL (SEARCH & RESCUE) FACTORS

Chapter 10 of the "Air Traffic Control" (ATC) manual No. 7110.65J, addresses emergencies. In pertinent part, the manual indicates that the FAA's air route traffic control centers "shall be responsible for receiving and relaying all pertinent ELT signal information to the appropriate authorities." Information regarding an ELT signal heard or reported in a terminal environment will be relayed by the ARTCC to the U.S. Air Force's Rescue Coordination Center (AFRCC).

According to the AFRCC, emergency locator transmitter (ELT) signals were initially heard (first alert) during a satellite pass at 0230. At 0345 a satellite again heard the ELT, and the transmission was determined to be originating from the Van Nuys area.

When the airplane failed to land at Burbank, the operator initiated a search via telephone, and the FAA's Hawthorne Flight Service Station (FSS) was contacted. At 0332, personnel at Hawthorne FSS who were queried contacted personnel at SCT. SCT, in turn, contacted the Van Nuys Airport police who indicated that at 0120 the airplane had arrived at the airport.

At 0409, AFRCC personnel notified FAA personnel at the Hawthorne FSS and at the Los Angeles Air Route Traffic Control Center of the ELT's transmission. The FAA reported to the AFRCC that no ELT signal was being received by any of its ground-based receivers.

The AFRCC subsequently reported detecting multiple ELT transmissions emanating from the Van Nuys area. According to the FAA's air traffic quality assurance staff at its Western-Pacific Regional Headquarters (AWP-505), no FAA facility reported hearing any ELT signal on its receiving equipment in the vicinity of the San Fernando Valley between 0119 and 0530.

Between 0521

NTSB Probable Cause

The pilot's failure to maintain a climb following initiation of a missed approach in fog due to spatial disorientation, and his inadequate training by company personnel. Potential rescue was delayed due to the FAA radar controller's failure to follow established communication procedures for overdue aircraft.