Livermore Muni Airport
Aircraft Accident/Incident Report

Livermore, California 94551
Friday, December 23, 2005 15:20 PST

NTSB Narrative Summary Released at Completion of Accident

The airplane collided with terrain 9 miles from the destination airport. The pilot was cleared for the instrument landing system approach into the airport. During the descent, the airplane was below the glideslope but tracking the localizer. The pilot contacted the air traffic control tower controller and was cleared to land. The last recorded radar target for the airplane was at 1,600 feet mean sea level (msl) and the initial impact occurred at 1,400 feet msl. The radar data indicated that the target maintained a descent rate of about 1,100 feet per minute during the last minute of flight and was flying at a radar derived ground speed of approximately 112 knots. Though the en route controller received a minimum safe altitude alert (MSAW), he had transferred control of the airplane 1 minute prior to the receipt of the initial MSAW alert. However, the airplane crossed a named intersection at 3,300 feet msl after it was cleared to cross the intersection at 4,000 feet msl while under the en route controller's control. The en route controller did not advise the pilot of the altitude deviation. The air traffic control tower controller did not issue an MSAW to the pilot, even though the equipment was configured to receive MSAW alerts. The tower controller said that he did not recall receiving the alerts and no recording was available to indicate whether or not an aural MSAW alert was received. An evaluation of the operation of the MSAW alerting system following the accident showed that it was functional. Examination of the airframe and engine did not reveal any mechanical anomalies to preclude normal operation. Metallurgical examination of the altimeter showed that the 10,000-foot pointer was not at its correct position at the time of impact and at an undetermined time prior to the accident, moved aft on its shaft and became loose. The effect of the 10,000-foot pointer on the pilot's flight performance could not be ascertained with the available evidence.

NTSB Probable Cause Narrative

The pilot's failure to maintain the appropriate glidepath alignment during an instrument landing system approach, resulting in collision with terrain. A contributing factor to the accident was the failure of the air traffic controllers to issue a minimum safe altitude warning (MSAW) alert.

Event Information

Type of Event Accident
Event Date 12/23/2005
Event Day of the Week Friday
Time of Event 1520
Event Time Zone Pacific Standard Time
Event City Livermore
Event State CALIFORNIA
Event Country --
Zipcode of the event site 94551
Event Date Year 2005
Event Date Month 12
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 374137N
Event Location Longitude 1213825W
Event Location Airport Livermore Muni
Event Location Nearest Airport ID LVK
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 10.4
Degrees magnetic from airport --
Airport Elevation 400
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1521 Pacific Standard Time
Direction of event from weather observation facility (degrees) 250
Weather Observation Facility ID KLVK
Elevation of weather observation facility 400
Distance of event from weather observation facility (units?) 9
Time Zone of the weather observation PST
Lighting Conditions Day
Lowest Ceiling Height 600
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Partial Obscuration
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 3
Air Temperature at event time (in degrees celsius) 16
Dew Point at event time (in degress fahrenheit) 14
Wind Direction (degrees magnetic) 130
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 3
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.22
Density Altitude (feet) --
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) 21550
NTSB Notification Source FAA
NTSB Notification Date Dec 23 2005 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record May 29 2007 12:24PM
User who most recently changed record NTSB\lema
Basic weather conditions Instrument Meteorological Cond
FAA District Office WP-OAK- FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N5942S
NTSB Number LAX06FA066
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Beech
Aircraft Model 36
Aircraft Series Identifier --
Aircraft Serial Number E-17
Certified Max Gross Weight 3600
Aircraft Category Airplane
Aircraft Registration Class --
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 Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Aug 1 2005 12:00AM
Airframe hours since last inspection 37
Airframe Hours 8358
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Yes
ELT Type --
Aircraft Owner Name Medic Air
Aircraft Owner Street Address 4730 Sierra Madre Road
Aircraft Owner City Santa Barbara
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 93110
Operator is an individual? No
Operator Name Edwin Mack
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City Santa Barbara
Operator State CA
Operator Country USA
Operator Zip code 93110
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 SBA
Departure City Santa Barbara
Departure State CA
Departure Country USA
Departure Time 1342
Departure Time Zone PST
Destination Same as Local Flt --
Destination Airport Code LVK
Destination City Livermore
Destination State CA
Destination Country USA
Specific Phase of Flight Approach
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record May 1 2007 6:30PM
User who most recently changed record STAM
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 --