Catalina Airport
Aircraft Accident/Incident Report

Avalon, California 90704
Wednesday, December 24, 2003 10:20 PST

NTSB Narrative Summary Released at Completion of Accident

The twin-engine airplane impacted mountainous terrain during a VOR-B approach in actual instrument weather conditions. The commercial pilot (first pilot) and airline transport pilot (owner/second pilot), were conducting an aircraft checkout flight. The VOR is located on top of a mountain at an elevation of 2,090 feet. The VOR/DME-B approach consists of tracking the 352-degree radial inbound to the VOR from the north descending from 3,200 feet down to the minimum descent altitude of 2,100 feet prior to the Initial Approach Fix (IAF). The IAF is 2.2 nm from the Missed Approach Point (MAP). The MAP is 1.0 nm north of the airport runway and 2.8 nm from the VOR. The published missed approach procedure consists of a climb from 2,100 feet to 3,200 feet direct to the VOR on the 352 radial, then hold at the VOR. Review of the recorded radar data disclosed that while executing the VOR-B approach, the airplane appeared to fly the published approach procedure normally with the exception of paralleling the final approach course (352-degree radial) about 1 mile to the east. The pilots had told the controllers that they were flying the approach with the intentions of executing the missed approach procedure. Once the airplane passed the missed approach point (MAP), the pilots failed to execute the climb portion of the missed approach procedures. The airplane continued to track towards the VOR at the minimum descent altitude until impacting the mountain just below the VOR.

NTSB Probable Cause Narrative

The failure of both pilots to properly execute the published missed approach procedure.

Event Information

Type of Event Accident
Event Date 12/24/2003
Event Day of the Week Wednesday
Time of Event 1020
Event Time Zone Pacific Standard Time
Event City Avalon
Event State CALIFORNIA
Event Country --
Zipcode of the event site 90704
Event Date Year 2003
Event Date Month 12
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 332235N
Event Location Longitude 1182509W
Event Location Airport CATALINA
Event Location Nearest Airport ID AVX
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 1.8
Degrees magnetic from airport 172
Airport Elevation 1602
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 1022 Pacific Standard Time
Direction of event from weather observation facility (degrees) 172
Weather Observation Facility ID AVX
Elevation of weather observation facility 1602
Distance of event from weather observation facility (units?) 2
Time Zone of the weather observation PST
Lighting Conditions Day
Lowest Ceiling Height 100
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 1.25
Air Temperature at event time (in degrees celsius) 11
Dew Point at event time (in degress fahrenheit) 10
Wind Direction (degrees magnetic) 120
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 4
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.07
Density Altitude (feet) --
Intensity of Precipitation Light
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 5
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 5
Investigating Agency NTSB
NTSB Docket Number (internal use) 18621
NTSB Notification Source FAA
NTSB Notification Date Dec 24 2003 12:00AM
NTSB Notification Time 1040
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Oct 27 2005 6:51AM
User who most recently changed record NTSB\JOHB
Basic weather conditions Instrument Meteorological Cond
FAA District Office WP FSDO LONG BEACH, CA

Aircraft Involved

Aircraft #1

Aircraft Registration Number N3747U
NTSB Number LAX04FA077
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 Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name Piper
Aircraft Model PA-34-200T
Aircraft Series Identifier --
Aircraft Serial Number 34-7570287
Certified Max Gross Weight 4773
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 Aug 7 2003 12:00AM
Airframe hours since last inspection --
Airframe Hours 3320.1
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Golf Air Inc
Aircraft Owner Street Address 1000 E William Street, Suite 204
Aircraft Owner City Carson City
Aircraft Owner State NV
Aircraft Owner Country USA
Aircraft Owner Zipcode 89701
Operator is an individual? No
Operator Name Long Beach Flying Club
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 2631 Spring Street
Operator City Long Beach
Operator State CA
Operator Country USA
Operator Zip code 90806
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 LGB
Departure City LONG BEACH
Departure State CA
Departure Country USA
Departure Time 954
Departure Time Zone PST
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code LGB
Destination City LONG BEACH
Destination State CA
Destination Country USA
Specific Phase of Flight Missed approach (IFR)
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Aug 29 2005 4:00PM
User who most recently changed record COOS
Since inspection or accident Last Inspection
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --