Brackett Field Airport
Aircraft Accident/Incident Report

San Dimas, California 91773
Friday, October 6, 2000 19:38 PDT

NTSB Narrative Summary Released at Completion of Accident

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 TRACON. Review of the recorded air/ground communications tapes disclosed that at no time did either controller issue an alert advisory for terrain avoidance to the flight.

NTSB Probable Cause Narrative

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.

Event Information

Type of Event Accident
Event Date 10/6/2000
Event Day of the Week Friday
Time of Event 1938
Event Time Zone Pacific Daylight Time
Event City San Dimas
Event State CALIFORNIA
Event Country --
Zipcode of the event site 91773
Event Date Year 2000
Event Date Month 10
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 340857N
Event Location Longitude 1174700W
Event Location Airport Brackett Field
Event Location Nearest Airport ID POC
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 3.6
Degrees magnetic from airport 332
Airport Elevation 1011
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1947 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 332
Weather Observation Facility ID POC
Elevation of weather observation facility 1011
Distance of event from weather observation facility (units?) 3
Time Zone of the weather observation PDT
Lighting Conditions Night
Lowest Ceiling Height 1000
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Partial Obscuration
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 2
Air Temperature at event time (in degrees celsius) --
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) 260
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 8
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.92
Density Altitude (feet) --
Intensity of Precipitation --
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 2
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 16868
NTSB Notification Source FAA
NTSB Notification Date Oct 6 2000 12:00AM
NTSB Notification Time 2048
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Dec 28 2004 12:45PM
User who most recently changed record NTSB\JOHB
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N222ES
NTSB Number LAX01FA004
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Destroyed
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Piper
Aircraft Model PA-34-200
Aircraft Series Identifier PA-34-200
Aircraft Serial Number 34-7250331
Certified Max Gross Weight 4200
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 100 Hour
Date of Last Inspection Sep 26 2000 12:00AM
Airframe hours since last inspection 54
Airframe Hours 7039.6
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Air Desert Pacific
Aircraft Owner Street Address 1889 McKinley Way
Aircraft Owner City La Verne
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 91750
Operator is an individual? No
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? --
Certified for Part 133 or 137 Operation --
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) Instructional
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code CNO
Departure City CHINO
Departure State CA
Departure Country USA
Departure Time 1830
Departure Time Zone PDT
Destination Same as Local Flt --
Destination Airport Code POC
Destination City Brackett Field
Destination State CA
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred No
Date of most recent change to record Oct 29 2004 7:51PM
User who most recently changed record RICJ
Since inspection or accident Time of Accident
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --