Brown Field Airport
Aircraft Accident/Incident Report

San Diego, California 92173
Thursday, November 21, 1996 16:36 PST

NTSB Narrative Summary Released at Completion of Accident

The pilot (plt) got 2 weather (wx) briefings & was advised of deteriorating IFR wx in the destination area. When he filed an IFR flight plan, he told the briefer that he did not have his charts; the briefer looked up the airway designations & fixes for the plt. Near the destination, TRACON told the plt the airport (arpt) was below minimums, & that 3 aircraft (acft) had made missed approaches without seeing the ground. The controller then suggested nearby arpts that were above approach minimums as alternates. The plt said his car was parked at the arpt, & he wanted to make the approach. Radar data disclosed the acft flew the approach segments at least 1,000 higher than the charted altitudes at speeds between 180 & 155 kts. The acft overflew the missed approach point & arpt, then crossed the adjacent US/Mexico border before ATC could instruct the plt to make an immediate missed approach. The plt responded on the radio 'I guess I don't know where I am.' Radar data showed the acft climbing & descending rapidly as it reversed course, then descend to 300 ft agl as it neared the west arpt boundary. The plt transmitted that he thought he had the arpt in sight. Four seconds later, the acft impacted the departure end of the runway. Ground witnesses observed the acft in cloud bases, & they noted that it narrowly missed a building; it then turned sharply toward the runway before descending steeply to ground impact. The pilot's logbook did not show that he had met instrument currency requirements of 14 CFR 91.

NTSB Probable Cause Narrative

the pilot's lack of situational awareness (becoming lost/disoriented during the approach), his failure to fly the approach as charted, and his failure to maintain aircraft control, while attempting an abrupt turn toward the airport, which led to an inadvertent stall/spin. The pilot's lack of recent instrument experience was a related factor.

Event Information

Type of Event Accident
Event Date 11/21/1996
Event Day of the Week Thursday
Time of Event 1636
Event Time Zone Pacific Standard Time
Event City SAN DIEGO
Event State CALIFORNIA
Event Country --
Zipcode of the event site 92173
Event Date Year 1996
Event Date Month 11
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport BROWN FIELD
Event Location Nearest Airport ID SDM
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation 524
Weather Briefing Completeness Full
Investigator's weather source Weather Observation Facility
Time of the weather observation 1638 Pacific Standard Time
Direction of event from weather observation facility (degrees) 0
Weather Observation Facility ID SDM
Elevation of weather observation facility 524
Distance of event from weather observation facility (units?) 0
Time Zone of the weather observation PST
Lighting Conditions Day
Lowest Ceiling Height 300
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Unknown
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 0.5
Air Temperature at event time (in degrees celsius) 24
Dew Point at event time (in degress fahrenheit) 23
Wind Direction (degrees magnetic) 200
Variable Wind Indicator Unknown
Wind Speed (knots) 4
Wind Velocity Indicator Unknown
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 29
Density Altitude (feet) --
Intensity of Precipitation Moderate
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 1995
NTSB Notification Source --
NTSB Notification Date Nov 21 1996 12:00AM
NTSB Notification Time 1655
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 8 2000 10:27AM
User who most recently changed record dbo
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N3774Q
NTSB Number LAX97FA049
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion Ground
Aircraft Manufacturer's Full Name Beech
Aircraft Model 95-C55
Aircraft Series Identifier 95-C55
Aircraft Serial Number TC-320
Certified Max Gross Weight 5300
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 6
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Feb 1 1996 12:00AM
Airframe hours since last inspection 12
Airframe Hours 1398
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name EARL A. BAUER, MD, INC.
Aircraft Owner Street Address 754 MEDICAL CENTER COURT
Aircraft Owner City CHULA VISTA
Aircraft Owner State CA
Aircraft Owner Country
Aircraft Owner Zipcode 92010
Operator is an individual? --
Operator Name
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address
Operator City
Operator State
Operator Country
Operator Zip code
Operator Code
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code IMP
Departure City IMPERIAL
Departure State CA
Departure Country
Departure Time 1545
Departure Time Zone PST
Destination Same as Local Flt crash at destination city
Destination Airport Code SDM
Destination City
Destination State
Destination Country
Specific Phase of Flight Missed approach (IFR)
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:34AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 26R
Runway Length 7999
Runway Width 200
Sight Seeing flight No
Air Medical Flight No
Medical Flight --