NTSB Factual Report

HISTORY OF FLIGHT

On December 24, 1996, at 1133 hours Pacific standard time, a Piper PA-28-140, N943R, collided in flight with a Cessna 150M, N63137, about 1.5 miles east of the Montgomery Field Airport, San Diego, California while both aircraft were on final approach to parallel runways. The commercial pilot and one passenger in the Piper were fatally injured and the aircraft was destroyed. The commercial pilot and one passenger in the Cessna received minor injuries and that aircraft was substantially damaged. Visual meteorological conditions prevailed and both aircraft were on instructional flights. The Piper departed Montgomery Field for a local flight, and the Cessna departed from Ramona Airport at approximately 1030.

Simultaneous VFR and IFR operations were in progress at Montgomery Field to parallel runways 28R and 28L. The Cessna aircraft was executing a straight-in instrument approach to runway 28R and was following another high wing Cessna to that runway. The Piper aircraft was approaching the airport VFR from the northeast and was sequenced to cross the final approach to runway 28R and make a straight-in approach to runway 28L. The Piper was sequenced number two to land on that runway behind another aircraft in closed traffic.

Aboard the Piper was a flight instructor and an unlicensed primary student pilot. The pilot contacted Montgomery tower at 1128 and reported his position east of Lake Murray (a VFR reporting point 5 miles east of the airport) and requested landing instructions. At 1129, he revised his position "over Cowles." The tower instructed the aircraft to proceed southbound and issued traffic at 11o'clock and 2 miles, a Cessna aircraft descending through 2,100 feet, and further instructed the Piper pilot to report the Cessna in sight. There was no acknowledgment of the clearance from the Piper. Recorded CDR radar data shows the Piper at approximately 3,000 feet altitude during this time.

The Cessna was returning to Montgomery Field on an IFR flight plan and clearance. Aboard the aircraft was a flight instructor in the left seat giving instruction to another flight instructor in the right seat, who was training to upgrade to instrument flight instructor. The Cessna had been cleared for the NDB runway 28 right approach by SOCAL TRACON, and at 1129, contacted Montgomery tower "with you on the NDB for the miss." The tower requested a transponder ident and issued traffic at "1:00 moving to 12:00 o'clock, 1 mile, altitude indicates two thousand three hundred." At 1130, the Cessna reported another Cessna aircraft in sight at one o'clock and "we'll continue on the NDB." In a later interview, the flight instructor stated that at this time they were past the DEORO outer compass locator and were descending from 2,100 feet to the step down fix altitude of 1,340 feet at PALOS intersection.

At 1131, the tower transmitted "Cherokee one three seven, traffic behind to your left, inbound for the parallel runway is a Cherokee." The pilot of the Cessna replied "Okay, this is Cessna six three one three seven, we're looking for the Cherokee." The tower then acknowledged "Cessna six three one three seven , roger." In his personnel statement, the air traffic controller stated that he "observed N63137 and N943R approximately 3 miles to the east on final" prior to this transmission.

The Piper pilot reported "approximately three miles out for landing" at 1131. The tower replied "in sight, number two, follow traffic left base to one mile final for runway two eight left, cleared to land." The Piper acknowledged, "follow traffic, two eight left, cleared to land."

At 1132, the Cessna pilot radioed "Cessna six three one three seven, midair." In two subsequent transmissions, the pilot of the Cessna confirmed the midair and stated his intent to land first on a freeway and then in an open area. Several attempts by the tower to contact the Piper were unsuccessful.

Review of the recorded radar data disclosed that the two aircraft's radar targets merged together at approximately latitude 32 degrees 48.0 minutes north, and longitude 117 degrees 05.3 minutes west at 1,400 feet msl while tracking approximately 280 degrees magnetic.

According to ground based witnesses, after the collision the Piper entered a descending left turn, which continued until impact with the ground. The witnesses reported that the aircraft turned approximately 180 degrees before impact and the bank angle and rate of descent increased as the turn progressed. The aircraft impacted in a large tree adjacent to a parking lot at the south end of the Navy Golf Course at GPS latitude 32 degrees 47.51 minutes north, and longitude 117 degrees 06.23 minutes west.

The left seated pilot of the Cessna reported that his recollection was of a "pretty hard" impact, during which the aircraft veered left and he hit his head. When he looked out the windshield his aircraft was in a left descending turn and the engine and propeller were stopped. The Piper was at his 11 o'clock position in the same attitude and he was viewing it from its 5:30 (o'clock) perspective. He took control of the aircraft from the second pilot, leveled his aircraft's wings and radioed the tower that there had been a midair collision. He turned right with the intention of landing in the northbound lanes of Interstate 15; however, because of heavy automobile traffic on the highway, he turned back to the left and located a site that had been leveled for construction (on West Canyon Avenue south of Aero Drive) and landed there (approximate latitude 32 degrees 48.0 minutes north, and longitude 117 degrees 07.3 minutes west). The aircraft rolled about 400 feet before impacting a dirt embankment and stopping.

The left seated pilot of the Cessna also reported that SOCAL approach had cleared them for the NDB 28R approach from outside the DEORO outer compass locator. They had crossed the compass locator at 2,100 feet and descended to the step-down fix altitude of 1,340 feet at PALOS intersection. He recalled that the tower sequenced them behind a high wing at their one o'clock position and he also recalled that a Cherokee checked in with the tower over Cowles mountain which was in his three o'clock position. The tower communications were very congested (busy) and transmissions were being blocked (stepped on) by other aircraft. The pilot said that approaching PALOS intersection at about 1,375 feet, he complimented his student on what a good job he was doing; he was exactly on centerline of 28R. About the same time, the tower called traffic at 6 - 7 o'clock. He looked back as well as he could but did not see any traffic. His student called "PALOS intersection descending to 880 feet." About 15 to 30 seconds later they collided with the Piper, having never seen it. It had approached from behind and struck them from above. The pilot estimated that they were at 1,000 to 1,100 feet msl when the collision occurred. After the collision he realized that he had lost a substantial amount of altitude, and that there was no way that he could reach the airport without engine power and so made an off-airport landing.

The tower supervisor certified that there were four people in the tower cab at the time of the accident. All four were FAA Air Traffic Control Specialists; two were full performance level controllers and two were developmental level controllers. The working local controller was a full performance level controller.

PERSONNEL INFORMATION

The pilot logbook of the pilot/flight instructor of the N943R was not located after the accident. His experience as of July 25, 1996, was available from the application form for his flight instructor rating, which was issued on that date. As of that date, the pilot had accumulated a total flying time of 279 hours. The operator of the aircraft was able to provide records covering the period from October 26, 1996, to December 20, 1996, which showed that the pilot had flown 43.3 hours during that period. His second class airman's medical certificate, dated July 1, 1996, reflected a total flying time of 260 hours, and uncorrected distant visual acuity of 20/20.

The logbook of the second (student) pilot aboard N943R showed that he had accumulated 10.9 flying hours, all dual instruction in the accident aircraft between November 17, 1996, and the date of the accident. A check of FAA records revealed that he had not been issued a student pilot medical certificate.

The pilot/flight instructor of the Cessna reported total flying time of 9,400 hours. His second class airman's medical certificate was issued May 1, 1995. Distant vision in his left eye was recorded as 20/100 corrected to 20/20 and in his right eye was 20/70 corrected to 20/15.

The second pilot in the Cessna reported 677 hours total flying time. He was flying the aircraft by reference to the instruments at the time of the accident using "foggles" to restrict external vision.

METEOROLOGICAL CONDITIONS

A special weather observation taken by Montgomery tower at 1148 reported scattered clouds at 2,500 feet agl and visibility of 40 miles. The temperature was 63 degrees Fahrenheit and the dew point 46 degrees, with surface winds from 360 degrees at 9 knots.

WRECKAGE AND IMPACT INFORMATION

The Cessna landed in a hilly area approximately 1/2 mile southeast of the Montgomery Field airport on a plateau that had been machine leveled in preparation for construction. The aircraft came to rest upright on a southwesterly heading with the nose against an embankment and the nose wheel collapsed. There were three parallel tread marks in the dirt extending northeast about 400 feet from the resting position of the landing gear.

According to the pilot of the Cessna, the landing was in a normal attitude, without any engine power, on all three landing gear; however, there was insufficient distance to stop the aircraft and the aircraft impacted the dirt embankment which caused the nose of the aircraft to go up, the nose wheel to collapse, and the right elevator to be damaged when the aircraft rolled backward down off the embankment. Minor injuries to the pilot and his passenger were incurred during the impact with the embankment.

Both propeller blades of the Cessna were bent smoothly forward about 30 degrees from the midspan to the tip. The outboard portion of the blades was twisted to a high pitch angle. Approximately 8 inches of one blade tip was missing. Approximately 10 inches of the other blade tip exhibited leading edge damage and chordwise scratches across the face of the blade.

The missing blade tip was located by a citizen the day after the accident on the roof of his residence. The tip exhibited damage to all surfaces and damage to the leading edge. In the face of the blade, near the extreme tip, there was an indentation of the head of an AN4 size bolt.

There was a slash (cut) approximately 2.5 feet long on the upper surface of the Cessna's left wing over the fuel tank. The slash, principally in the fuel tank cover, extended from about 1 foot aft and 6 inches inboard of the left wing fuel cap, to 1.5 feet forward and 1 foot outboard of the same cap. The slash was interrupted in the center where it passed over the outboard side of the flange of the fuel tank filler adapter. Small pieces of metal on the sides of the cut were bent forward and paint debris adjacent to the slash exhibited a chevron pattern pointing from rear to front. A radio communication antenna attached to the wing root fairing 6 inches inboard of the aft end of the slash was broken about 6 inches above its base, and the upper portion of the antenna was bent 90 degrees to the left and was parallel with the upper surface of the wing. A long wire antenna extending from behind the windshield to the top of the vertical fin was undamaged.

There was also an area of scraping and paint transfer (approximately 2 square feet) on the upper surface of the Cessna's left wing leading edge skin in front of the fuel tank. The sheet metal fairing between the windshield and the root of the left wing was bent forward at one corner

The Piper aircraft impacted in a large tree on level terrain adjacent to a parking lot at the south end of the Navy Golf Course. The entire aircraft was present at the accident site. A postimpact fire was extinguished using hand held fire extinguishers by two emergency medical technicians, who observed and responded to the accident from a nearby hospital.

The fuselage aft of the rear cabin bulkhead was lodged in the large branches of the tree about 6 feet off the ground, and oriented pointing toward the south. The fuselage forward of the aft cabin bulkhead was damaged by impact and fire. The instruments, avionics, and structure from the nose section of the aircraft were widely scattered over an area approximately 50 feet south of the aft fuselage. The engine, propeller, and forward fuselage, including the instrument panel, were located approximately 20 feet south of the tree.

Both wings of the Piper exhibited leading edge crushing. The integral fuel tanks were separated from their respective wings and were found at the southern extremity of the wreckage field.

The Piper wreckage was examined at Ramona Aircraft Salvage on December 27, 1996. Red paint, approximately the same color as that of the Cessna's fuel cap, was found on the leading edge of the Piper's tail skid. A thin line of similar red paint was on the belly of the Piper's aft fuselage starting about 6 inches in front of the tail skid and extended forward approximately 24 inches, and angling to the left approximately 20 degrees with respect to the Piper's fuselage centerline.

Three transverse slashes were found extending across the belly skin panels of the Piper's fuselage, left to right, approximately on centerline, at fuselage stations 105, 111, and 116. The main wing spar extends through the fuselage at station 108, and there was a slash in front of the spar, another aft of the spar and forward of the battery box, and a third which ended with a 8-inch-deep indentation in the left-hand side of the battery box and battery. The slashes extended approximately the width of the fuselage, and bent metal edges indicated that the cutting was from left to right. A damaged electrical contactor was attached to the battery box with two AN4 bolts.

Control cables which operate the Piper's horizontal stabilator and rudder pass under the floor of the cabin, near centerline, approximately 1 inch above the lower fuselage skin. The aft segments of these four cables, still attached to their respective actuators in the aft fuselage, were pulled taut. Three were found evenly severed at fuselage station 111, and the fourth at station 105. Control cables which operate the aileron controls pass through the center of the fuselage above the four stabilator and rudder cables. The aileron cables pass aft through the spar, around pulleys, and then extend laterally outboard to the ailerons. A turnbuckle in the right-hand cable, located between the aft side of the wing spar and the forward face of the battery box, was found severed in the body of the turnbuckle.

MEDICAL INFORMATION

An autopsy was performed on the occupants of the Piper by the County of San Diego, Office of the Medical Examiner, and toxicological tests were performed by the FAA Civil Aeromedical Institute in Oklahoma City, Oklahoma. The results of the toxicological tests were negative for alcohol and all screened drugs.

ADDITIONAL INFORMATION

Air Traffic Control procedures relevant to the separation of VFR aircraft approaching to land at an airport with an air traffic control tower are addressed in FAA Order 7110.65(J). In Chapter 2, General Control, Section 2-1-21, Traffic Separation, states: ". . . issue traffic advisories to all aircraft (IFR or VFR) on your frequency when in your judgment their proximity may diminish to less than the applicable separation minima. Where no separation minima applies, such as for VFR aircraft outside of Class B and Class C airspace, or a TRSA, issue traffic advisories to those aircraft on your frequency when in your judgment their proximity warrants it."

In Section 4 of the same order und

NTSB Probable Cause

The failure of the pilot-in-command of the Piper PA-28, N943R, to maintain an adequate visual lookout to see and avoid the Cessna 150, N63137. A factor in the accident was the failure of the air traffic controller to issue a traffic advisory to the pilot concerning the Cessna 150.