Sunday, September 30, 2018

Beechcraft A36 Bonanza, registered to TA Services LLC, N78CR: Accident occurred November 12, 2015 near General William J. Fox Airfield (KWJF), Lancaster, Los Angeles County, California

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Van Nuys, California 

Aviation Accident Factual Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

https://registry.faa.gov/N78CR

Location: Lancaster, CA
Accident Number: WPR16LA028
Date & Time: 11/12/2015, 1930 PST
Registration: N78CR
Aircraft: BEECH A36
Aircraft Damage: Substantial
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 2 Serious
Flight Conducted Under:  Part 91: General Aviation - Instructional 

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 County 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 airplane 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."

Pilot Information

Certificate: Private
Age: 69, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 02/14/2014
Occupational Pilot: No
Last Flight Review or Equivalent: 01/24/2015
Flight Time:   340 hours (Total, all aircraft), 65 hours (Total, this make and model), 340 hours (Pilot In Command, all aircraft), 17 hours (Last 90 days, all aircraft), 17 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft)

Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 74, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 02/03/2014
Occupational Pilot: Yes
Last Flight Review or Equivalent: 08/08/2015
Flight Time:   6900 hours (Total, all aircraft), 27 hours (Total, this make and model), 6590 hours (Pilot In Command, all aircraft), 100 hours (Last 90 days, all aircraft), 34 hours (Last 30 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N78CR
Model/Series: A36 UNDESIGNATED
Aircraft Category: Airplane
Year of Manufacture: 1975
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: E-739
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 03/16/2015, Annual
Certified Max Gross Wt.: 3651 lbs
Time Since Last Inspection: 27 Hours
Engines: 1 Reciprocating
Airframe Total Time: 6998 Hours at time of accident
Engine Manufacturer: Continental
ELT: Installed, not activated
Engine Model/Series: IO-520-BB
Registered Owner: TA Services LLC
Rated Power: 285 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night
Observation Facility, Elevation: KWJF, 2351 ft msl
Distance from Accident Site: 15 Nautical Miles
Observation Time: 1956 PST
Direction from Accident Site: 72°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 300°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.14 inches Hg
Temperature/Dew Point: 4°C / -11°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Bakersfield, CA (KBFL)
Type of Flight Plan Filed: IFR
Destination: Lancaster, CA (KWJF)
Type of Clearance: IFR
Departure Time: 1900 PST
Type of Airspace: Class E 

Airport Information

Airport: Fox Airfield (KWJF)
Runway Surface Type: Asphalt
Airport Elevation: 2351 ft
Runway Surface Condition: Dry
Runway Used: 6
IFR Approach: RNAV
Runway Length/Width: 7201 ft / 150 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 2 Serious
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Serious
Latitude, Longitude:  34.669444, -118.473611 (est)

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