Petaluma Airport
Aircraft Accident/Incident Report

Petaluma, California 95433
Saturday, December 9, 2000 19:27 PST

NTSB Narrative Summary Released at Completion of Accident

After being cleared for a VOR/DME Runway 29 instrument approach in actual instrument meteorological conditions, the pilot failed to align the airplane onto the required 276-degree final approach course and descended beneath the 1,120-foot msl minimum descent altitude. The airplane impacted rising hilly terrain about 3.5 miles northeast of the airport at 1,020 feet msl, while tracking 291 degrees. Although the pilot had been cleared to perform a VOR/DME approach, an operating handheld GPS receiver (not approved for IFR navigation) was found in the airplane, and a GPS Runway 29 approach plate was found on the pilot's kneeboard. The GPS's final approach course was 290 degrees, and the airplane was tracking 291 degrees at the time of impact. Also, during the last 2 minutes of flight, the pilot had performed a stabilized descent from approximately 2,000 to 1,000 feet. The pilot was issued an instrument rating about 6 months before the accident. He had indicated to an acquaintance that he planned to practice instrument flying on the day of the crash. Toxicological tests on blood from the pilot detected a very high level of paroxetine (a prescription antidepressant) and an elevated level of mirtazapine (a prescription antidepressant with substantial sedative effects). The pilot did not indicate the use of these drugs on his last application for the medical certificate.

NTSB Probable Cause Narrative

The pilot's improper IFR procedure, failure to maintain course alignment, and use of a nonapproved handheld GPS receiver for navigation during flight in actual instrument meteorological conditions. Factors contributing to the accident were the low clouds and the pilot's use of prescription drugs not approved for use by the FAA.

Event Information

Type of Event Accident
Event Date 12/9/2000
Event Day of the Week Saturday
Time of Event 1927
Event Time Zone Pacific Standard Time
Event City PETALUMA
Event State CALIFORNIA
Event Country --
Zipcode of the event site 95433
Event Date Year 2000
Event Date Month 12
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 381620N
Event Location Longitude 1223203W
Event Location Airport Petaluma
Event Location Nearest Airport ID O69
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 4
Degrees magnetic from airport 59
Airport Elevation 87
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1933 Pacific Standard Time
Direction of event from weather observation facility (degrees) 301
Weather Observation Facility ID STS
Elevation of weather observation facility 125
Distance of event from weather observation facility (units?) 19
Time Zone of the weather observation PST
Lighting Conditions Night/Dark
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling Obscured
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 0
Air Temperature at event time (in degrees celsius) 11
Dew Point at event time (in degress fahrenheit) 11
Wind Direction (degrees magnetic) 0
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 0
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.04
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 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 14939
NTSB Notification Source FAA
NTSB Notification Date Dec 10 2000 12:00AM
NTSB Notification Time 608
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Mar 2 2004 8:06AM
User who most recently changed record NTSB\MONR
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N739HB
NTSB Number LAX01FA055
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 Cessna
Aircraft Model TR182
Aircraft Series Identifier TR182
Aircraft Serial Number R18200998
Certified Max Gross Weight 3100
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 4
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Nov 17 2000 12:00AM
Airframe hours since last inspection 28
Airframe Hours 1709
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Yes
ELT Type --
Aircraft Owner Name Colin L. and Johnna L. Fox, Trustees
Aircraft Owner Street Address --
Aircraft Owner City San Carlos
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 94070
Operator is an individual? No
Operator Name COLIN L. FOX
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City BURLINGAME
Operator State CA
Operator Country USA
Operator Zip code 94010
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) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code APC
Departure City NAPA
Departure State CA
Departure Country USA
Departure Time 1916
Departure Time Zone PST
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code O69
Destination City Petaluma
Destination State CA
Destination Country USA
Specific Phase of Flight Approach
Report sent to ICAO? --
Evacuation occurred No
Date of most recent change to record Nov 17 2003 3:03PM
User who most recently changed record COOS
Since inspection or accident Time of Accident
Event Location Runway Number and Location --
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --