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ASN Wikibase Occurrence # 30008
Last updated: 3 September 2019
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Date:06-OCT-2000
Time:19:38
Type:Silhouette image of generic PA34 model; specific model in this crash may look slightly different
Piper PA-34-200
Owner/operator:Air Desert Pacific
Registration: N222ES
C/n / msn: 34-7250331
Fatalities:Fatalities: 2 / Occupants: 2
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:near Brackett Field, 1 miles SW of La Verne, California -   United States of America
Phase: Approach
Nature:Training
Departure airport:Chino, CA (CNO)
Destination airport:Brackett Field, CA (POC)
Investigating agency: NTSB
Narrative:
The airplane collided with rising mountainous terrain while executing a missed approach procedure in instrument conditions during an instructional flight. At 1929 the TRACON controller (POMR) cleared the airplane for the VOR-A approach, and advised the pilot to contact the tower. The pilot acknowledged, then contacted the ATCT local controller (LC) and stated they were on the VOR-A approach outside of the final approach fix (FAF). Two minutes later the POMR controller, after observing the aircraft's target off course, contacted the LC to ask why the airplane was circling the airport. The LC stated he would find out and get back to the POMR controller. The LC asked the pilot if he wished to cancel IFR or continue the approach. The pilot replied that he wanted to continue and the LC told him to report the runway in sight. The LC, who was monitoring the flight's target track on the tower's DBRITE radar display, also informed the pilot that they appeared to be west of course. At 1932:20 the LC asked if they had the airport in sight. The pilot replied they had the airport in sight. The LC then contacted POMR and advised that the pilot was canceling IFR and had the airport in sight. The POMR controller then dropped the accident airplane's data block from his radar display. 47 seconds later, the LC asked the pilot to confirm he had the runway in sight. The pilot replied in the negative. The controller then asked if the pilot wanted the missed approach. The pilot replied that he had the ground and a freeway in sight. The pilot was instructed to continue and report the airport in sight. A few seconds later the pilot again reported the airport in sight, and was cleared to land runway 26L. At 1934:25 the LC asked the pilot what he was doing and if he had the airport in sight. The pilot asked if anything was wrong. The controller advised the pilot he was now three miles west of the airport and suggested he turn to a heading of 080-degrees. The controller also told the pilot to maintain visual flight conditions, and to report the runway in sight. At 1936:02 the controller advised the pilot the airport was 1.5 miles at the pilot's 12:00 o'clock position. He also asked if the pilot had the airport in sight. The pilot replied negatively. The controller instructed the pilot to make a 10-degree right turn to enter the downwind. The controller again informed the pilot that the airport was a little over a mile at their 12:00 position. The pilot replied he had the airport in sight. The controller instructed the pilot not to lose sight of the airport again, and cleared him to land. After observing the flight deviate from a track to the airport, at 1939:29 the controller asked the pilot for their current heading. The pilot then requested a missed approach. The controller instructed the pilot to execute the missed approach and to standby for a frequency change. The LC then called the TRACON sector controller and a discussion ensued between the two about the flight's VFR versus IFR status, with the TRACON controller saying that he thought the pilot had cancelled IFR and went VFR. The LC controller stated that "he had cancelled, he had the airport in sight, he lost sight of the airport, and he is asking me now if he can go missed approach so I don't know what to do with him." The Local Controller said he could work the pilot and try and get him back to the airport unless POMR wanted to take him. POMR stated that if the pilot was IMC and did not have the airport in sight that "I would have him turn southbound immediately." The LC then told the pilot to turn south and climb immediately to 5,000 feet. There was no response by the flight. Review of the recorded radar data disclosed that beginning at 1933:10 (about 5 minutes before the accident), the Minimum Safe Altitude Warning (MSAW) system was flashing an alert on both the TRACON controllers display and the DBRITE display in the tower; however, after the TRACON controller dropped the airplane's data tag the MSAW alert was automatically suppressed at the T
Probable Cause: The pilots becoming lost and disoriented during an improperly conducted IFR approach, and subsequent missed approach, that led to a collision with rising mountainous terrain. Also causal was the local controller canceling the IFR approach when the pilot specifically stated he wanted to continue the IFR approach, and the local controller, as well as sector controllers failure to issue a unsafe proximity to terrain safety alert to the pilots (MSAW alert) as required by the Air Traffic Control Handbook.

Sources:

NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20001212X22177&key=1
FAA register: 2. http://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=222ES

Safety recommendations:

Safety recommendation A-01-35 issued 24 September 2001 by NTSB to FAA
Safety recommendation A-01-36 issued 24 September 2001 by NTSB to FAA
Safety recommendation A-01-37 issued 24 September 2001 by NTSB to FAA
Safety recommendation A-01-38 issued 24 September 2001 by NTSB to FAA
Safety recommendation A-01-39 issued 24 September 2001 by NTSB to FAA
Safety recommendation A-01-40 issued 24 September 2001 by NTSB to FAA


Revision history:

Date/timeContributorUpdates
27-Sep-2008 01:00 ASN archive Added
09-Dec-2014 02:11 Dr. John Smith Updated [Time, Cn, Operator, Total fatalities, Total occupants, Other fatalities, Location, Country, Phase, Nature, Departure airport, Destination airport, Source, Damage, Narrative]
09-Dec-2014 02:12 Dr. John Smith Updated [Narrative]
21-Dec-2016 19:16 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
21-Dec-2016 19:20 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
12-Dec-2017 19:16 ASN Update Bot Updated [Operator, Departure airport, Destination airport, Source, Narrative]

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