NTSB Factual Report

HISTORY OF FLIGHT

On November 20, 1995, at 0634 hours Pacific standard time, a Piper PA-32-300, N888JK, was destroyed during an instrument approach to the Fullerton, California, airport. Both pilots and one person on the ground were fatally injured. Instrument meteorological conditions prevailed at the time. The flight had originated at Big Bear, California, on the morning of the accident. No flight plan had been filed for the personal flight.

After departure from Big Bear, the airplane was radar identified by Southern California Approach Control (SOCAL) when it was 4 miles northwest of the Redlands airport. The aircraft was assigned an initial transponder code of 0232. The controller requested to verify that the airplane was descending out of 7,000 feet. A pilot from the accident airplane responded with a pause, and then a request to standby. The pilot responded to SOCAL stating that they were out of 7,200 feet. The SOCAL controller responded their radar return indicated 7,000 feet, even with the Ontario altimeter of 30.07 inHg.

A request for an instrument approach into Fullerton had been made while en route. SOCAL had cleared the aircraft for the localizer runway 24 approach. The Fullerton air traffic control tower was not open at the time of the accident. FAA personnel in the tower made a weather observation at 0655 hours. They reported the weather as indefinite ceiling 100 foot, with a 1/4 mile visibility in fog. An on-scene witness reported the visibility at 0630 was about 75 to 100 feet.

About 0626:35, the pilot contacted SOCAL and reported "juliet kilo is level 3,000, 14 DME out from on the localizer at Fullerton we would like that inbound please." The aircraft was then assigned a second transponder code of 0105. The controller advised the pilot that the Fullerton weather was not available and proceeded to give the pilot the John Wayne altimeter setting of 30.08 inHg. The controller further stated "at John Wayne and Long Beach its pretty bad Long Beach is worse than Orange County." The pilot advised approach that if they missed the approach they would go to John Wayne.

About 0628:07, the pilot was cleared for the approach into the Fullerton airport when 7 miles east of the final approach fix "Qewti". The pilot requested that the controller advise him when he was over "Qewti". Subsequently, the pilot was advised that he was over "Qewti" at 0631:40. About 2 minutes later, the aircraft collided with trees, poles, and an apartment building about 1 mile east of runway 24.

PILOT INFORMATION

Left Seat Pilot

According to the pilot's logbook, he started taking flight instruction on December 24, 1993. He received his private pilot's license on December 22, 1994. The last logbook entry was dated November 2, 1995. At that time, the logbook documented about 295 total flight hours.

The private pilot, a co-owner of the aircraft, had been working towards an instrument rating in the accident airplane with the right seat flight instructor (CFII). According to the pilot's logbook, he had accumulated about 14 hours of simulated instrument time and about 15 hours actual time. They occasionally flew together to their respective job locations in the Los Angeles area from Big Bear Lake. On the morning of the accident the pilot had told his wife that he was going to drive to work because of the weather.

Right Seat Pilot

The right seat pilot was an FAA certified flight instructor with airplane ratings for single engine land and instruments. He was a full-time employee for the city of Anaheim, California. The flight instructor's logbook was not recovered. At the pilot's last second-class flight physical dated April 6, 1995, he reported 1,200 total flight hours with 30 hours in the last 6 months. According to his supervisor, he was due at work at 0700 on the morning of the accident. His office location is about 6 miles southeast of the Fullerton airport.

The CFII pilot was a paraplegic and held a Statement of Demonstrated Ability (waiver). He was required to have special controls adapted to the rudder pedals to maintain full control of the airplane.

AIRPLANE INFORMATION

A postaccident examination of the aircraft structure, systems, and powerplant was conducted with representatives of Piper Aircraft and Lycoming Aircraft Engines. The examination of the aircraft structure did not find a hand control (a major alteration/modification) to the rudder system. The installation requires an FAA form 337 and a pilot operating handbook supplement.

According to the aircraft equipment list, the distance measuring equipment (DME) had been removed 11/18/92. At that time, a Magellan SkyNav 5000 global positioning system (GPS) was installed. The installation is required to be placarded "GPS FOR VFR USE ONLY" in full view of the pilot. The instrument panel and it's markings were destroyed by postcrash fire damage.

WRECKAGE AND IMPACT INFORMATION

The wreckage was examined on the morning of the accident. The airplane collided with a two-story apartment building about 1 mile from the approach end of runway 24 at approximatly 120 feet msl. There were initial tree and telephone impact signatures noted 20 to 30 feet higher. The engine, propeller, and cabin area were located on the second floor in a bedroom area. The wreckage and the building were partially consumed in a postcrash fire.

Between the east property line/fence and the apartment building were located wing sections from both right and left wings. A right aileron was located near the top of a telephone pole tangled in wires. Several utility wires were found laying on the ground. There were palm trees located near the property line with impact scars.

There were various airplane parts found on the roof that had not been fire damaged.

The manual flap extension handle was found latched in the full flap 40-degree position. The flaps and the actuating system were destroyed.

According to the airplane equipment list, there was an AutoControl III autopilot installed. On-scene examination of the panel area revealed a control box/navigation approach coupler switch. The switch was found in the localizer normal position. It could not be determined whether the autopilot was engaged or not.

A neighbor reported finding a propeller blade tip laying next to a curb. The tip was curled back and unburnt with some brown chordwise staining/transfer. A measurement from the tip inboard was about 1.50 inches.

The wreckage was removed the day of the accident to a storage area for further examination.

METEOROLOGICAL INFORMATION

The Fullerton 0655 weather observation conducted on the morning of the accident was: sky condition, indefinite ceiling vertical visibility 100 feet obscured; visibility 1/4 mile; weather, fog; temperature and dew point 54 degrees Fahrenheit; wind, calm; altimeter 30.07 inHg.

According to pilot reports, the tops of the fog deck appeared to be uniform throughout the area. At 0650, from Santa Ana, a pilot reported the tops as 700 feet msl. An air carrier out of Los Angeles reported the tops at 800 msl.

A voice tape obtained from SOCAL revealed that during a controller position change near the accident time, a recorded comment from one controller to another stated "500 foot tops at Santa Ana."

AIRPORT INFORMATION

The Fullerton Municipal Airport has one runway, 06/24. According to the Airport/Facilities Directory, the runway is 3,121 feet in length with a 253-foot displaced threshold for runway 24.

There is a localizer runway 24 instrument approach which requires either a DME or radar service to identify the three intersections of the approach and to reach the minimum descent altitude. They are: ZAROW at 10.0 miles; QEWTI (the final approach fix) at 5.6 miles; and CONGA at 2.6 miles. The DME antenna is located about .6 miles from the approach end of runway 24.

According to the instrument approach chart, the intersection crossing altitudes in sequence are: 3,000 feet at ZAROW; 2,000 feet at QEWTI; and 880 feet at CONGA. The minimum decision altitude for the localizer/DME approach with the Santa Ana altimeter setting is 580 feet and 1 statute mile visibility.

When the aircraft reported 14 DME out from Fullerton level at 3,000 feet msl, the radar data indicated 2,900 feet msl. The initial approach fix ZAROW was crossed at 2,700 feet msl. The crossing altitude at the final approach fix Qewti is at 2,000 feet msl, which the radar data indicated was crossed about 1,700 feet msl. At Conga, 2.6 DME from runway 24, the radar data indicated the aircraft crossed at an altitude of 500 feet msl.

MEDICAL AND PATHOLOGICAL INFORMATION

On November 21, 1995, the Orange County Coroners office performed an autopsy on both pilots. During the course of the autopsy, samples were obtained from both pilots for toxicological analysis by the FAA Aeromedical Institute of Pathology at Oklahoma City, Oklahoma. The results of the analysis were negative for drugs and alcohol.

TESTING AND RESEARCH INFORMATION

Attempts were made to recover the non-volatile memory from the Magellan SkyNav 5000 GPS. That was not accomplished due to the postcrash fire damage.

The altimeter was recovered and examined at an FAA approved instrument repair shop. The indications observed at the accident site were: altitude 51,340 feet; and the barometric pressure window indicated 30.06 inHg. Internal and external examination conducted at the instrument shop revealed that the altimeter sustained fire and impact damage. According to the instrument technician, the internal mechanism was unseated from the jewel pivots allowing the hairspring to run the indicated altitude up, most likely from impact.

According to the airplane records, the last documented altimeter overhaul was conducted on February 2, 1992. On March 8, 1993, the Apollo encoder was adjusted to 20,000 feet as per FAR 43, appendix E (c). At the same time, the transponder decoder was ramp tested as per FAR 43, appendix F.

Additionally, the last documented compliance with FAR's 91.411 (altimeter system and altitude reporting equipment tests and inspections), and FAR 91.413 (ATC transponder tests and inspections) were conducted on March 9, 1995.

ADDITIONAL INFORMATION

A notepad type paper was recovered from the accident site. The paper had handwritten notations regarding the approach into Fullerton. They were 5.3 QEWTI 880 and 2.3 CONGA 580. Also, on the notepad was the first transponder code (0232) assigned to the airplane upon the initial call to SOCAL while over Snow Valley at 8,500 feet msl inbound to Fullerton.

NTSB Probable Cause

the pilot-in-command's failure to follow IFR procedures in that he descended below the minimum descent altitude and failed to execute a missed approach. Contributing to the accident was the pilot-in-command's self-induced pressure to get to work.