NTSB Factual Report

HISTORY OF THE FLIGHT

On March 3, 2014, at 1032 Pacific standard time, a Piper PA-46-350P, N9281F, collided with terrain approximately 7 miles east of the Truckee-Tahoe Airport, Truckee, California. The commercial pilot was seriously injured and the single passenger was fatally injured. The airplane was registered to, and operated by, the commercial pilot under the provisions of 14 Code of Federal Regulations, Part 91. The airplane's left wing had separated from the fuselage resulting in substantial damage to the airframe. Marginal visual flight rules (MVFR) conditions prevailed for the flight, which operated on an instrument flight rules (IFR) flight plan. The flight originated at John Wayne-Orange County Airport, Santa Ana, California, about 0800.

Oakland Air Route Traffic Control Center (ARTCC) communications received the pilot's request for an instrument approach into Truckee at 0959. ARTCC cleared the pilot direct to the Truckee Airport via direct LOLLA intersection maintaining 16,000 feet mean sea level (msl). At 1010, the pilot was cleared to cross LOLLA at or above 12,000 feet msl and then was cleared for the GPS-A approach into Truckee. At 1015, ARTCC approved crossing LOLLA at or above 11,300 feet. Radar track data and airplane GPS data showed the airplane approach the initial approach fix (IAF), LOLLA, at 11,200 feet mean sea level (msl), at approximately 200 knots ground speed, and on a 317-degree (magnetic) course. At 1019, the radar track crossed LOLLA and started a right turn to the east. At 1022, ARTCC terminated radar services, which the pilot acknowledged. The radar track depicts the airplane continue in a right turn to align on a course of about 134 degrees, maintaining about 11,200 feet, and 180 knots ground speed. The track depicted about a 30-degree intercept to the final approach course of 104 degrees while maintaining approximately 200 knots, but remained northeast of the final approach course all the way to the missed approach point.

At 1024, the track was northeast of the missed approach point (MARDR), at 10,200 feet (2,000 feet above the minimum descent altitude), and 187 knots ground speed. The published minimum descent altitude (MDA) for the Truckee-Tahoe GPS-A approach is 8,200 feet mean sea level (2,300 feet agl). At 1025, the pilot announced on the ARTCC frequency that he "has a missed approach." The published missed approach procedure is a climbing left turn to 11,500 feet via 312 degrees to TRUCK waypoint and hold. The radar track depicts the airplane making a slight left turn proceeding to the east, making a left 220-degree turn between 11,200 and 11,500 feet, and then continuing in the southeast direction. ARTCC makes radar contact and then asks the pilot if he is heading to TRUCK intersection. The pilot responds in the affirmative, however, a few moments later he requests a higher altitude and a vector to the holding fix (TRUCK). ARTCC cleared the pilot to 15,000 feet and advises that the minimum IFR altitude is 13,000. At 1030, the pilot reported that he was picking up ice and was in instrument meteorological conditions. ARTCC advised him to fly to the west towards lower terrain. ARTCC advised the pilot that they could not give him a vector because he was below the vector altitude, and asks if he flew the missed approach procedure. The pilot responded that he did not "pick it up."

The last minute of GPS data shows a series of progressively lower altitude excursions southeast of the airport starting at 11,800 down to 10,500, then up to 11,200 down to 9,200, and up to 10,800 and then down to 8,500 and finally up to 9,800 followed by a descent down to the terrain at 8,000 feet.

The pilot stated to the NTSB investigator-in-charge (IIC) that he had two GPS receivers onboard the airplane. These included a panel mounted Garmin GNS 430 unit that he used for navigation, and a portable Garmin GPSmap 396 unit that he used primarily for weather information via XM WX satellite weather. He also stated that in the past when flying the GPS-A in to Truckee, he normally approaches the IAF (LOLLA) from the west, makes a right-hand turn on to the final approach course, and configures the airplane with full flaps, gear down, throttle back, maintaining 120 knots. He could not recall the last time he had flown the GPS-A approach in to Truckee.

The Truckee GPS-A approach does depict a westerly initial approach fix (IAF), SIGNA, located 13.4 miles west of LOLLA. From SIGNA direct to LOLLA the required altitude is 11,000 feet on a course of 055 degrees. No procedure turn is required after crossing LOLLA; the pilot can make a right 49-degree turn directly onto the final approach course.

PERSONNEL INFORMATION

The pilot, age 70, held a commercial pilot certificate with ratings for single engine land and instrument airplane issued on May 15, 2004, and a second-class Federal Aviation Administration (FAA) medical certificate issued on March 2, 2012. The pilot's flight logbook showed that the most recent entry was the flight review and instrument proficiency check was completed on June 23, 2011, and he had 3,037.2 hours of flight time. On his March 2, 2012, second-class medical application he reported his total flight experience to be 3,600 hours. The pilot reported during a conversation with the NTSB investigator-in-charge (IIC) that he had about 2,000 hours of flight experience in the PA-46, and that he had not flown instruments regularly, and he had done some instrument training last summer (2013).

The Certified Flight Instructor (CFI) who had performed the pilot's 2011 flight review stated to an FAA inspector that he had performed a flight review and instrument proficiency check with the accident pilot on July 23, 2013, 223 days prior to the accident flight.

AIRCRAFT INFORMATION

The six-seat, low wing, retractable-gear, single engine airplane, serial number 4636095, was manufactured in 1997. It was powered by a Lycoming TIO-540-AE2A, 350-hp engine and equipped with a Hartzell 3 bladed composite constant speed propeller model number HC-I3YR-1E. A review of the airframe and engine maintenance logbooks showed that an annual inspection was performed on March 1, 2014, at a total airframe time of 1,858.5 hours, and engine time of 1,858.5 hours since new. The hobbs meter read 1,861.0 following the accident.

The PA-46-350P pilot operating manual, in section 4, Normal Procedures, Approach and Landing, states the normal technique is airspeed between 80-85 knots indicated airspeed (kias) with flaps down, and 95 kias with flaps up. For an instrument approach the pilot stated that he normally configures the airplane with the gear down, flaps down, and flys at 120 kias.

Section 9 of supplement 4 of the pilot operating manual supplies information necessary for the operation of the ice protection system. The ice protection system was designed and tested for operation in meteorological conditions for Federal Aviation Regulation (FAR) 25, appendix C, for continuous maximum and intermittent maximum icing conditions.

METEOROLOGICAL INFORMATION

The NWS Surface Analysis Chart for 1000 PST on March 3, 2014, chart depicted a high pressure system to the south of the accident site over the California and Nevada border at 1022-hectopascals (hPa) and another off the southern California coast at 1023-hPa. No frontal boundaries were identified over the region influencing California during the period.

The National Center for Atmospheric Research (NCAR) - Research Application Laboratory (RAL) regional radar mosaic image for 1032 PST showed several areas of very light echoes associated with light rain moving from the Pacific across northern California to the west-northwest of the accident site.

Truckee-Tahoe Airport (KTRK) weather at 0950 PST (1750Z), wind from 180° at 7 knots, visibility 9 miles, ceiling overcast at 3,000 feet, temperature 6° Celsius (C), dew point 0° C, altimeter 30.11 inches of mercury (Hg). Remarks: no special reports issued. Truckee-Tahoe Airport (KTRK) weather at 1050 PST (1850Z), wind from 300° at 5 knots, visibility 6 miles in light rain, ceiling overcast at 2,200 feet, temperature 4° C, dew point 1° C, altimeter 30.11 inches of Hg.

The NOAA Earth System Research Laboratory/Global Systems Division (ESRL/GSD) Aircraft Meteorological Data Reports (AMDAR) provided upper air data closer to the time of the accident from aircraft departing from Reno/Tahoe International Airport, Reno, Nevada (–RNO) immediately after the accident. The first ascent sounding from aircraft #10324 at 1149 PST sounding depicted the freezing level at 8,000 feet. Two distinct temperature inversions were also noted, the first between 12,000 and 13,500 feet, and the other between 14,000 and 15,000 feet. The wind profile indicated light southerly winds below 5,000 feet, with wind veering to the west at 7,000 feet with little change in direction with altitude with increasing speeds. A low-level wind maximum was identified at 13,500 feet or the top of the first inversion with wind from 269° at 38 knots. Another AMDAR aircraft #11115 with a moisture sensor departed KRNO at 1239 PST ascent sounding depicted the freezing level at 8,600 feet with an inversion between 13,000 and 14,000 feet. The moisture sensor indicated convergence in the dew point temperature in a layer near 10,000 feet with relative humidity of 80%, which was consistent with the KRNO observations in section 2.2, which reported broken to overcast clouds at 5,500 feet agl or approximately 10,000 feet msl.

The Geostationary Operational Environmental Satellite number 15 (GOES-15) data was obtained from an archive at the Space Science Engineering Center (SSEC) at the University of Wisconsin-Madison (UW) in Madison, Wisconsin, and processed using the Safety Board's Man-computer Interactive Data Access System (McIDAS) software. The GOES-15 visible image depicted a multiple layers of high and low clouds over northern California and over the accident site, with the low clouds becoming oriented in several north-to-south oriented bands in the immediate vicinity of the accident site and east over Nevada. The banded cloud elements oriented perpendicular to the ambient flow and are commonly referred to as transverse bands, and are often associated with mountain wave activity and turbulence. The 1030 PST images shows an overcast layer of clouds over the Truckee area with the transverse banding pattern in the clouds beginning in the vicinity of the accident site and eastward into Nevada and are directly over RNO during this period. A review of the images revealed that the bands of low clouds immediately over and east of the accident site do not move downstream with the wind with time as the high clouds do, but remain relative stationary consistent with orographic clouds associated with mountain wave activity.

The FAA air traffic control display Corridor Integrated Weather System (CIWS) display for 1030 depicted several areas of very light intensity echoes west of the Truckee—Tahoe area and a larger area of echoes associated with rain with tops from 20,000 to 23,000 feet to the northwest. The image was also plotted over a satellite image, which shows the banding structure in the clouds over Nevada immediately east of the accident site.

The FAA Contract Automated Flight Service Station (AFSS) provider Lockheed Martin Flight Services and the Direct Users Access Terminal System (DUATS) providers indicated that there was no request for any weather briefing services on March 2-3, 2014, and no contact en route with Flight Watch during the period.

WRECKAGE & IMPACT INFORMATION

The wreckage was located in mountainous terrain 7 miles east of the Truckee-Tahoe Airport, at an elevation of 7,933 feet mean sea level (msl). The fuselage had come to rest in a snow-covered open area surrounded by mature pine trees. The left wing had sheared off at the wing root and was resting against the empennage. The left horizontal stabilizer had also sheared off at the root. The right wing remained attached to the fuselage, the vertical stabilizer, rudder, right horizontal stabilizer and elevator remained attached to the empennage. The entire fuselage remained intact with no observable reduction of occupiable space. The cabin was accessed through the main cabin door by rescuers. The fuel selector knob was observed in the center (left tank) position. The pitot heat switch was ON. The wreckage was recovered and transported to a facility in Pleasant Grove, California, for further examination.

On April 9, 2014, representatives from the airframe and engine manufacturers examined the airplane under the supervison of the NTSB investigator-in-charge. The main fuselage was strapped down to a trailer where access to the cabin door and full access to the engine was available. The right wing was cut off at the wing root by the recovery personnel. The landing gear damage patterns were consistent with the gear being up during terrain impact. The one-piece elevator separated from the horizontal stabilizer at the hinge points. The fuselage retained most of its structural shape, but did exhibit a vertical crease deformation 14 inches behind the main wing spar and behind the cockpit. Control continuity was established from all control surfaces to the cockpit. The elevator trim drum exhibited 6 exposed threads, corresponding to slight nose down trim. Mechanical continuity was established on the engine by rotating the crankshaft and achieving thumb compression and valve movement on all cylinders. Both magnetos were removed from their mounting pads, and both produced spark when rotated by hand. Engine control continuity was established by tracing the engine throttle, mixture, and propeller control cables from the engine to the control levers in the cockpit.

MEDICAL & PATHOLOGICAL INFORMATION

The FAA's Civil Aerospace Medical Institute performed forensic toxicology on blood samples obtained from the pilot while he was hospitalized. The results were negative for ethanol, and positive for ephedrine, midazolam, ondansetron, and phenylpropanolamine all detected in blood.

ADDITIONAL INFORMATION

FAA-H-8083-15B – Instrument Flying Handbook

The Instrument Flying Handbook describes the pilot's responsibility to execute a procedure turn to align with the final approach course unless either the airplane is being radar vectored to the final approach course, or the annotation "NoPT" (no procedure turn) is shown on the approach procedure for the segment being flown.

"Holding in Lieu of Procedure Turn

A holding pattern in lieu of a procedure turn may be specified for course reversal in some procedures. In such cases, the holding pattern is established over an intermediate fix (IF) or a FAF. The holding pattern distance or time specified in the profile view must be observed. Maximum holding airspeed limitations as set forth for all holding patterns apply. The holding pattern maneuver is completed when the aircraft is established on the inbound course after executing the appropriate entry. If cleared for the approach prior to returning to the holding fix and the aircraft is at the prescribed altitude, additional circuits of the holding pattern are neither necessary nor expected by ATC. If pilots elect to make additional circuits to lose excessive altitude or to become better established on course, it is their responsibility to advise ATC upon receipt of their approach clearance. When holding in lieu of a procedure turn, the holding pattern must be followed, except when RADAR VECTORING to the final approach course is provided or when NoPT is shown on the approach course."

Air Traffic Controllers Handbook (JO 7110.65V), Chapter 4, section 8, paragraph e3.

"For both RNAV and conventional approaches, intercept angles greater than 90 degrees may be used when a procedure turn, a hold-in-lieu of procedure turn pattern, or arrival holding is depicted and the pilot will execute the procedure. If a procedure turn, hold-in-lieu of procedure turn, or arrival holding pattern is depicted and the angle of intercept is 90 degrees or less, the aircraft must be instructed to conduct a straight-in approach if ATC does not want the pilot to execute a procedure turn or hold-in-lieu of procedure turn."

Pilot Ins

NTSB Probable Cause

The pilot’s failure to properly execute the missed approach in instrument conditions. Contributing to the accident were the pilot’s lack of instrument proficiency, as demonstrated by his failure to execute the required procedure turn to align with the final approach course and to configure the airplane for the approach, and his loss of situational awareness and the onset of spatial disorientation during the missed approach.