Brackett Field Airport
Aircraft Accident/Incident Report

Pomona, California 91750
Saturday, March 14, 2009 11:15 PDT

NTSB Narrative Summary Released at Completion of Accident

The airplane departed the airport on an instrument-flight-rules clearance. The weather at the airport was 500-foot overcast, with a visibility of 1 mile. The overcast layer was solid up through 3,100 feet mean sea level (msl). The departure instructions were to climb on heading 150 to 1,400 feet msl, then initiate a climbing turn to heading 130, intersect the VOR 164 radial outbound until 9 miles south of the airport, and climb to 4,000 feet. Just after takeoff, at approximately 1,400 feet, the airplane made a climbing turn to 146 degrees and continued to climb on that course for about 1.5 minutes. At 2,500 feet, the airplane started a right-hand turn. The deviation of the airplane’s course prompted the terminal radar approach controller (TRACON) to ask if the pilot had canceled his clearance. The pilot responded in a steady even tone, “Negative, nine alpha bravo still climbing.” Five seconds later the airplane was no longer in radar contact. The radar track depicted the airplane in a climbing right-hand turn in a tightening spiral directly over the accident location. The aircraft wreckage was located on a hillside about 2 miles south of the departure airport and in the vicinity of the last radar return. A review of the pilot’s flight records revealed that he held an instrument rating issued in August 2006, and had logged just two instrument approaches since January 2007, neither within the last 90 days. Additionally, he had accumulated 0.8 hours of simulated instrument time and 0.8 hours of actual instrument time since January 2007. There is no record of the pilot obtaining an instrument proficiency check within the 12 months prior to the accident. The tone of the pilot’s response to TRACON’s radio query implied that he was not aware that the airplane had deviated from the departure clearance and was in a steadily tightening right-hand turn. This lack of awareness could be attributed to spatial disorientation or a distraction away from the primary flight instruments.

NTSB Probable Cause Narrative

The pilot's spatial disorientation while flying in instrument meteorological conditions that resulted in a loss of control of the airplane. Contributing to the accident was the pilot's lack of recent instrument flying experience.

Event Information

Type of Event Accident
Event Date 3/14/2009
Event Day of the Week Saturday
Time of Event 1115
Event Time Zone Pacific Daylight Time
Event City Pomona
Event State CALIFORNIA
Event Country --
Zipcode of the event site 91750
Event Date Year 2009
Event Date Month 3
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 340309N
Event Location Longitude 1174750W
Event Location Airport Brackett Field Airport
Event Location Nearest Airport ID KPOC
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 2
Degrees magnetic from airport --
Airport Elevation 1011
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1147 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 360
Weather Observation Facility ID KPOC
Elevation of weather observation facility 1011
Distance of event from weather observation facility (units?) 2
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height 500
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 1
Air Temperature at event time (in degrees celsius) 11
Dew Point at event time (in degress fahrenheit) 8
Wind Direction (degrees magnetic) --
Variable Wind Indicator Variable
Wind Speed (knots) 5
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 --
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) 26596
NTSB Notification Source FAA Operations Center
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Feb 10 2010 5:17PM
User who most recently changed record coos
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N129AB
NTSB Number WPR09FA150
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 PA28-236
Aircraft Series Identifier --
Aircraft Serial Number 28-7911303
Certified Max Gross Weight 3000
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 1
Cabin Crew Seats --
Passenger Seats 3
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 Mar 6 2009 12:00AM
Airframe hours since last inspection --
Airframe Hours 4298
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Netsense Inc
Aircraft Owner Street Address 437 S Cataract Ave Ste 4B
Aircraft Owner City San Dimas
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 91773
Operator is an individual? No
Operator Name Charles W Shaffer
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City La Verne
Operator State CA
Operator Country USA
Operator Zip code 91750
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
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 KPOC
Departure City La Verne
Departure State CA
Departure Country USA
Departure Time 1113
Departure Time Zone PDT
Destination Same as Local Flt --
Destination Airport Code KMHV
Destination City Mojave
Destination State CA
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Feb 10 2010 4:37PM
User who most recently changed record coos
Since inspection or accident Last Inspection
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight Yes
Air Medical Flight No
Medical Flight --