N9703C

HISTORY OF FLIGHT

On June 8, 1998, at 0804 hours Pacific daylight time, a Piper PA-28-181, N9703C, impacted hilly terrain near Bangor, California. The airplane, owned and operated by the pilot, cruised into instrument meteorological conditions during the personal flight conducted under the provisions of 14 CFR Part 91. Instrument meteorological conditions existed in the vicinity of the accident site, and no flight plan was filed. The airplane was destroyed, and the private pilot was fatally injured. The passenger, who also held a private pilot certificate, and the family dog were also fatally injured. Neither pilot was instrument rated. The planned nonstop flight to Bend, Oregon, originated from Lincoln, California, about 0740.

A review of the recorded radar data, and the pilot and controller statements, indicated that after takeoff the pilot requested and received radar flight following service. At 0759, while proceeding north-northwest bound between 2,000 and 2,100 feet mean sea level (msl) as indicated by the airplane's Mode C transponder, the pilot established contact with the Federal Aviation Administration (FAA) Oakland Air Route Traffic Control Center (ARTCC) Sector D42 radar controller.

At 0759:28, the pilot advised the controller that he was not flying in visual meteorological conditions (VMC), was in the clouds, and was on autopilot. The controller acknowledged the transmission and asked the pilot "what will be the route of flight?" The pilot responded "three four zero." The controller stated "use caution and maintain VFR" (visual flight rules).

At 0800:06, the pilot again informed the controller that he was in the clouds and could not maintain flight under VFR. The controller responded at 0800:51 by stating "maintain VFR."

The controller then provided the pilot with heading instructions to the Oroville Airport, located 10 nautical miles (nmi) north-northwest of his position, and the following exchange of communications occurred:

At 0801:06, the pilot asked "what's the conditions at Oroville?" The controller replied at 0801:11 by stating "Cherokee zero three Oroville does not have weather reporting."

At 0801:17, the pilot said "How about Chico?" (The Chico Airport is located about 22 nmi northwest of Oroville.) The controller replied "Cherokee zero three charlie the Chico ah one three five three observation visibility four and mist fifteen hundred overcast."

The controller next informed the northwest bound pilot, at 0801:52, of the weather conditions at an airport located approximately 20 nmi south of his position by stating "Cherokee zero three charlie the Marysville ah airport is reporting visibility ten miles scattered clouds at two thousand broken clouds at three thousand and six thousand overcast."

The pilot responded with "Can you ah give me a bearing to ah Marysville please?" The controller replied "Cherokee zero three charlie suggest heading of one niner five vectors Marysville." The pilot's last recorded transmission was at 0802:15 when he replied "one niner five thank you."

The airplane's last recorded position by the radar facility at the Beale Air Force Base was at 0803:34, and by the Oakland ARTCC at 0803:38. At this time, the airplane was about 39 degrees 24 minutes 52 seconds north latitude, by 121 degrees 24 minutes 50 seconds west longitude. The airplane descended from 2,500 to 2,100 feet during the last 1/4 minute of recorded flight.

About 0803 a witness, who was located within about 2 miles of the crash site, telephoned the Butte County Sheriff to inform them that he had heard the sound of an airplane's engine rev up and then suddenly stop with the sound of a "thump." The witness indicated it sounded as though an airplane had crashed.

Another witness, who resides in Bangor, similarly reported hearing the sound of a rapidly descending airplane with its engine running at a very high speed. The witness said the sound terminated with a "thud," and he assumed the airplane had crashed.

PERSONNEL INFORMATION

Pilot.

No flights were observed recorded in the pilot's personal flight record logbook since December 1, 1997, and this last entry listed a local flight from Palm Springs, California. The pilot's total logged flight time was indicated as approximately 1,589 hours.

The flight times shown in the "Flight Time Matrix" portion of the National Transportation Safety Board's factual report core form are estimates. The times are based upon a combination of the pilot's logbook data, FAA files, and an application for insurance dated January 20, 1997. On that date, the pilot reported his flight experience consisted of 1,325 hours, of which 1,050 hours were in the Piper PA-28-181 airplane.

The pilot's logbook indicated that he had flown over 1,167 hours on cross-country trips, which included several flights between California and Oregon. During the past 13 years, the only airplane listed as having been flown was the accident airplane. In December 1997, the pilot reported to his insurance company that he never flies without his wife (the passenger onboard). A comparison between the pilot and passenger's logbooks revealed that most of their flights were performed together in the accident airplane.

The pilot did not possess an instrument rating. His total logged instrument flight experience was 6 hours.

Passenger.

A review of the passenger's personal flight record logbook revealed she acquired all of her flight training in the accident airplane. She was issued a private pilot certificate in September 1994, after obtaining about 96 hours of dual flight instruction, and had a total flight time of 216 hours.

Since certification, all of her logged flights were flown in the accident airplane. The last flight listed in her logbook was dated November 16, 1997, and was flown from Palm Springs. On that date, her total recorded flight time was about 313 hours.

The passenger did not possess an instrument rating. Her total logged instrument flight time was 4 hours.

Air Traffic Controller.

During the on-scene phase of the accident investigation the FAA's Oakland ARTCC controller, who had been communicating with the pilot during the last few minutes of the airplane's recorded flight, visited the crash site on his own initiative. The controller reported to the Safety Board that all communications with the pilot had been "clear," and the pilot had sounded responsive to his instructions. Nothing unusual was noted in the manner by which the pilot spoke. All communications with the airplane were from the same pilot, who had a male-sounding voice.

The controller stated that he recalled the pilot advising him that he was not flying in VFR conditions, was in a cloud, and had the autopilot turned on. The controller further indicated that he last observed the airplane on radar in a descent after the pilot commenced a course reversal turn from 340 degrees to 195 degrees, seconds after he had informed the pilot of the weather at an airport which was located south of his position.

The Safety Board's air traffic control group chairman conducted an interview of the controller on June 15, 1998, at the Oakland ARTCC facility, and reviewed the controller's training and personnel records. The air traffic controller was hired by the FAA in 1993, and he was promoted to full performance level in 1996. The controller holds a private pilot certificate (issued in 1990), and he stated that he has flown light airplanes over California's Central Valley. He was aware that terrain elevation increased over the mountainous region east of the valley floor.

The controller stated that when the accident pilot told him that he was flying on autopilot in the clouds he was "shocked," but he did not consider the airplane to be an emergency. He recalled that the airplane's altitude fluctuated between 1,700 and 2,400 feet. The controller believed that the pilot was flying in a minimum instrument altitude area of 5,800 feet, and explained that he understood minimum instrument altitudes are established at 2,000 feet above the highest terrain in the boxes drawn on the chart.

The controller reported that he did not know how to activate the minimum safe altitude warning (MSAW) feature for VFR airplanes. (Oakland ARTCC management reported that MSAW was available for use with Mode C transponder equipped tracked VFR airplanes.)

The records indicated, in summary, that between 1995 and 1998, the controller had received training regarding the handling of lost/disoriented aircraft, radar assistance to VFR aircraft in weather difficulty, minimum IFR altitudes, MSAW and safety alert procedures.

The controller had been found responsible for two previous operational errors, in March 1997, and in January 1998. The primary factor related to the first error involved coordination between controllers. The primary factor related to the second error involved the controller's failure to correlate the aircraft's position with the minimum instrument altitude chart. This action resulted in the pilot's operation below the minimum instrument altitude. (See the Safety Board's Group Chairman's Factual Report for additional details.)

AIRCRAFT INFORMATION

The airplane was equipped with dual flight controls, and was controllable from either front seat location. The rear seats were not located; they had been removed from the airplane.

A review of the airframe and engine logbooks indicated that the airplane was maintained on an annual inspection basis. No evidence of outstanding squawks or open maintenance items was located in the recovered and impact damaged records.

The airplane was equipped with a Century II autopilot which provided heading, course tracking, and turn functions. No altitude hold capability existed.

METEOROLOGICAL INFORMATION

Pilot Briefing.

At 0618, when the pilot telephoned the FAA's Rancho Murieta, California, Automated Flight Service Station, he informed t...