Reid-Hillview Of Santa Clara C Airport
Aircraft Accident/Incident Report

San Jose, California 95135
Thursday, January 23, 2003 16:53 PST

NTSB Narrative Summary Released at Completion of Accident

The airplane collided with high-tension power lines in a mountainous area after deviating from the GPS approach procedure in instrument conditions. The airplane was equipped with a GPS navigation system incorporating a moving map feature. During the initial portions of the flight after departure, the TRACON sector controller working the flight initially believed the airplane was destined to another airport and issued a clearance accordingly, but corrected the clearance after the pilot questioned the controller. Shortly after this discussion, the pilot significantly deviated from his cleared course for unknown reasons in the general direction of the mistaken airport. The controller noticed the deviation and corrected the pilot's course. A second controller in the next sector the airplane would be worked by overheard the course correction, and inferred the pilot was somewhat confused. After handoff by the first controller, the second sector controller attempted to provide what he believed was a helpful method of handling the airplane in the transition to the GPS approach; however, these methods of clearing the pilot for the GPS approach were not in strict accordance with FAA Order 7110.65, and included an intercept angle with the final approach course that was greater than allowed. The airplane was on a modified downwind and proceeding to the initial approach fix (IAF) when the controller cleared the pilot to turn toward an intermediate fix between the IAF and the final approach fix (FAF) with the idea in mind that this course would be the same as a radar vector to the FAF. The pilot questioned the clearance, and then acknowledged it, and the airplane turned left toward the FAF, which was directly behind the airplane. The controller noticed that the left turn put the airplane heading toward high terrain and advised the pilot to turn right to go to the intermediate fix. After some additional confusion the airplane's track stabilized on the approach course after passing the intermediate fix. As the airplane passed the FAF the controller told the pilot to contact the tower, but gave him the frequency for the wrong airport. The pilot questioned the controller, who insisted the frequency was correct. The pilot then contacted the second airport tower and was told he was on the wrong frequency. Almost 1 minute elapsed between the pilot's acknowledgement of the erroneous frequency, and his initial contact to the correct tower. During this period the airplane's heading diverged approximately 90 degrees from the published final approach course toward rising terrain and the accident site. The Minimum Safe Altitude Warning alarms went off in the TRACON and in the tower, and the tower controller provided a low altitude safety alert based on the alarm by saying "check your altitude immediately;" however, at the time of the low altitude alert, the airplane was about 500 feet above the Minimum Descent Altitude (the accident site elevation was about 200 feet above the MDA.) and the alert was activated not because the airplane's altitude was below the segment minimums but due to the course and altitude being projected to come in contact with terrain in the near future. This may have confused the pilot and decreased the perceived urgency. The limitations of the radar display effectively masked the initial portions of the course deviation and the controller did not see the deviation for some 30 seconds; however, the controller did advise the pilot that he was off course as soon as he was aware of it. The pilot's unintelligible response was about the time the radar target return went into coast mode.

NTSB Probable Cause Narrative

The pilot's failure to maintain the course for the published approach procedure due to his diverted attention. The distraction responsible for the pilot's diverted attention was the erroneous frequency assignment provided by ATC and the resultant task overload induced by this problem and the confusion surrounding the ATC clearances to get established on the final approach course, which likely involved repeated reprogramming of the navigation system. Factors in the accident include the failure of ATC to provide the pilot with a timely and effective safety alert concerning the deviation from the proper course, which was influenced in part by the features of the radar display at both facilities which made the deviation more difficult to detect, and the nature of radar as a secondary tool for a VFR tower controller. An additional factor was the nonstandard method of providing approach clearance, which likely may have exacerbated pilot task overload.

Event Information

Type of Event Accident
Event Date 1/23/2003
Event Day of the Week Thursday
Time of Event 1653
Event Time Zone Pacific Standard Time
Event City San Jose
Event State CALIFORNIA
Event Country --
Zipcode of the event site 95135
Event Date Year 2003
Event Date Month 1
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 371640N
Event Location Longitude 1214301W
Event Location Airport REID-HILLVIEW OF SANTA CLARA C
Event Location Nearest Airport ID RHV
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 6.7
Degrees magnetic from airport 124
Airport Elevation 133
Weather Briefing Completeness Full
Investigator's weather source Weather Observation Facility
Time of the weather observation 1653 Pacific Standard Time
Direction of event from weather observation facility (degrees) 304
Weather Observation Facility ID KRHV
Elevation of weather observation facility 133
Distance of event from weather observation facility (units?) 7
Time Zone of the weather observation PST
Lighting Conditions Day
Lowest Ceiling Height 8000
Lowest Non-Ceiling Height 1200
Sky/Lowest/Cloud Conditions Thin Broken
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 4
Air Temperature at event time (in degrees celsius) 16
Dew Point at event time (in degress fahrenheit) 15
Wind Direction (degrees magnetic) 280
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 12
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.24
Density Altitude (feet) -12
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
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) 16873
NTSB Notification Source FAA
NTSB Notification Date Jan 23 2003 12:00AM
NTSB Notification Time 1712
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 SACRAMENTO, CA FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N893MK
NTSB Number LAX03FA072
Missing Aircraft Indicator --
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 Cirrus Design Corp.
Aircraft Model SR 20
Aircraft Series Identifier --
Aircraft Serial Number 1038
Certified Max Gross Weight 3000
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 Feb 20 2002 12:00AM
Airframe hours since last inspection 301.5
Airframe Hours 369.3
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Yes
ELT Type --
Aircraft Owner Name Aircraft Guaranty Title Corp Trustee
Aircraft Owner Street Address 515 N Sam Houston Parkway E, Suite 305
Aircraft Owner City Houston
Aircraft Owner State TX
Aircraft Owner Country USA
Aircraft Owner Zipcode 77060
Operator is an individual? Yes
Operator Name Grant Scott Kelly
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address On File
Operator City Saratoga
Operator State CA
Operator Country USA
Operator Zip code 95070
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 KAPC
Departure City NAPA
Departure State CA
Departure Country USA
Departure Time 1600
Departure Time Zone PST
Destination Same as Local Flt crash at destination city
Destination Airport Code KRHV
Destination City San Jose
Destination State CA
Destination Country USA
Specific Phase of Flight Approach - final approach fix (FAF)/outer marker to threshold (IFR)
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Oct 30 2004 2:39PM
User who most recently changed record COOS
Since inspection or accident Time of Accident
Event Location Runway Number and Location 31R
Runway Length 3101
Runway Width 75
Sight Seeing flight No
Air Medical Flight No
Medical Flight --