Mcclellan-Palomar Airport
Aircraft Accident/Incident Report

Julian, California 92036
Monday, May 10, 2004 21:00 PDT

NTSB Narrative Summary Released at Completion of Accident

The twin engine airplane collided with rising mountainous terrain while in cruise flight on an IFR clearance. The airplane, N304PA, was on a night IFR flight and was number four in a trail of five company airplanes flying the same route. The time separation between each airplane was about 5 to 10 minutes. The airplane directly ahead of N304PA was N434PA. After being handed off from Los Angeles Center, the flight crew of N304PA contacted the TRACON sector controller at 2043:48 PDT, reporting level at 8,000. The TRACON sector controller instructed the pilot to fly heading 260 after the Julian VOR and intercept the localizer. At 2045:47, the TRACON sector controller told the pilot of N434PA to descend to 6,000 feet. The pilot of N434PA acknowledged the clearance. At 2047:55, the sector controller transmitted, "Seminole four papa alpha descend and maintain five thousand two hundred." The pilot of N304PA responded, "Down to five thousand two hundred for three zero four papa alpha." According to information provided by the TRACON sector controller, this clearance was intended for N434PA. The controller did not recognize that the clearance had been acknowledged by N304PA rather than N434PA. At 2049:55, the pilot of N304PA reported that he had ATIS information Zulu and the sector controller responded, "Seminole three zero four papa alpha thank you very much." At that time the data block on the TRACON controller's display was showing N304PA descending through about 6,600 feet. The Minimum Enroute Altitude for the airway segment being flown was 7,700 feet. At 2050:27, the sector controller again cleared N434PA to descend and maintain 5,200 feet. A Minimum Safe Altitude Warning (MSAW) alert on N304PA was presented to the Center controller at 2049:03. The aircraft's data block remained on the Center controllers display until the radar controller forced it off at 2050:07. The Center controller did not notify the TRACON sector controller that he was receiving a MSAW alert as required by FAA directives. The TRACON's MSAW system generated two predicted altitude alerts on the accident airplane at 2050:46 and 2050:51. According to FAA MSAW documentation, two consecutive predicted alerts will initiate an MSAW warning to the controller working the affected aircraft. Collectively, these alerts would have caused a 5 second aural alert to the sector controller beginning at 2050:51, along with a flashing red "LA" in N304PA's data block from 2050:51 until about 2051:06. The aircraft then descended below radar coverage, the track went into coast status, and the alert terminated. The wreckage of N304PA was located on a ridgeline 200 yards south of the Julian VOR at 5,537 feet msl. No preimpact airplane mechanical anomalies were identified.

NTSB Probable Cause Narrative

The incorrect use of an abbreviated callsign by the TRACON sector radar controller to issue a descent clearance to N434PA and the sector controllers failure to detect that the clearance had been read back with the full callsign by the pilot of N304PA. Also causal was the pilots failure to question a clearance that descended them below the published Minimum En route Altitude (MEA). Contributing to the accident was the failure of both the Center and TRACON controllers to properly respond to the aural and visual Minimum Safe Altitude Warning System (MSAW) alert.

Event Information

Type of Event Accident
Event Date 5/10/2004
Event Day of the Week Monday
Time of Event 2100
Event Time Zone Pacific Daylight Time
Event City Julian
Event State CALIFORNIA
Event Country --
Zipcode of the event site 92036
Event Date Year 2004
Event Date Month 5
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 330820N
Event Location Longitude 1163504W
Event Location Airport McClellan-Palomar
Event Location Nearest Airport ID KCRQ
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 35
Degrees magnetic from airport 80
Airport Elevation 331
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 2053 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 258
Weather Observation Facility ID KRMN
Elevation of weather observation facility 1390
Distance of event from weather observation facility (units?) 18
Time Zone of the weather observation PDT
Lighting Conditions Night/Dark
Lowest Ceiling Height 2000
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) 10
Air Temperature at event time (in degrees celsius) 15
Dew Point at event time (in degress fahrenheit) 10
Wind Direction (degrees magnetic) 180
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) 29.87
Density Altitude (feet) 1764
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 2
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 16985
NTSB Notification Source FAA
NTSB Notification Date May 10 2004 12:00AM
NTSB Notification Time 2130
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 Visual Meteorological Cond
FAA District Office WP-FSDO-San Diego, CA

Aircraft Involved

Aircraft #1

Aircraft Registration Number N304PA
NTSB Number LAX04FA205
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 Piper
Aircraft Model PA-44-180
Aircraft Series Identifier --
Aircraft Serial Number 4496123
Certified Max Gross Weight 3800
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 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection May 4 2004 12:00AM
Airframe hours since last inspection 17
Airframe Hours 2468
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Yes
ELT Type --
Aircraft Owner Name Merrill Lynch Business Financail Services
Aircraft Owner Street Address 222 N. La Salle St Fl 17
Aircraft Owner City Chicago
Aircraft Owner State IL
Aircraft Owner Country USA
Aircraft Owner Zipcode 60601
Operator is an individual? No
Operator Name PAN AM INTERNATIONAL FLIGHT ACADEMY
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 530 W Deer Valley Rd, Suite200
Operator City Phoenix
Operator State CA
Operator Country USA
Operator Zip code 85027
Operator Code PN7S
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 Yes
Departure Point Same as Event No
Departure Airport Code KDVT
Departure City Phoenix
Departure State AZ
Departure Country USA
Departure Time 1830
Departure Time Zone MST
Destination Same as Local Flt --
Destination Airport Code KCRQ
Destination City Palomar
Destination State CA
Destination Country USA
Specific Phase of Flight Cruise
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Nov 8 2004 2:58PM
User who most recently changed record RICJ
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 --