Accident Details
Probable Cause and Findings
The pilot's loss of situational awareness and his failure to adhere to the prescribed instrument approach procedures, including the track and altitudes flown. The underlying reasons for the pilot's loss of situational awareness are unknown.
Aircraft Information
Registered Owner (Current)
Analysis
HISTORY OF FLIGHT
On December 14, 2001, about 1528 Pacific standard time, a Cessna T210L, N210RE, collided with rising mountainous terrain during an instrument approach to the Hemet-Ryan (uncontrolled) Airport, about 4 nautical miles (nm) northeast of San Jacinto, California. The airplane was destroyed by impact forces and a postimpact ground fire. The instrument rated private pilot was fatally injured. Instrument meteorological conditions prevailed in the vicinity, and an instrument flight rules (IFR) flight plan was filed. At the time of the accident, the airplane was between the initial and final approach fixes and was approximately 5.9 nm east of the specified southerly approach course. The airplane was being operated as a personal flight under 14 CFR Part 91. Reportedly, the pilot had planned to fly to Hemet-Ryan to pickup relatives and transport them to Santa Monica, California, for a family gathering. The pilot departed from the Santa Monica Municipal Airport about 1446.
At 1515, as the airplane was en route to the Hemet-Ryan Airport, a March Air Reserve Base (ARB) air traffic controller (March GCA) established radar contact with the accident airplane's pilot. The following minute the pilot advised the controller that he was descending from 7,000 to 6,000 feet mean sea level (msl). The controller informed the pilot that the altimeter was 29.68 inches of mercury.
The pilot indicated that he desired to start the instrument approach to the Hemet-Ryan Airport at Seter. (Seter is the name of an initial approach fix depicted on the GPS-A initial approach procedure (IAP) chart for the airport.) At 1516:39, the controller stated to the pilot "cross Seter at ah five-thousand cleared GPS into Hemet."
The pilot responded by asking "...cleared direct Seter right now?" The controller replied "affirmative, you can go direct at this time." The pilot then stated "ok, direct Seter and did you say descend to five-thousand?"
The controller replied at 1516:59, and stated "stand by sir, I'm trying to see where the approach starts at, fifty-five or five, stand by." The pilot responded and said "I show it fifty-five on my ah on my chart here." The controller replied "yeah, I believe you're right, yeah you can cross Seter at five-thousand-five hundred cleared GPS into Hemet."
Recorded radar data from the Los Angeles Air Route Traffic Control Center (LAX ARTCC) and the Southern California Terminal Radar Approach Control (SOCAL TRACON) indicate that between 1523:27 and 1523:49, the northeast bound accident airplane passed Seter, descended from 5,600 to 5,500 feet (as indicated by the airplane's Mode C-equipped transponder), and began tracking in an easterly direction toward the Kende intersection.
For several minutes thereafter, there were no additional recorded communications to or from the accident pilot. Then, at 1525:15, the controller attempted to communicate with the pilot. The controller advised the pilot to report canceling his IFR flight on the current radio frequency, or after landing via telephone. The controller heard no response from the pilot.
About this time, the accident airplane was approximately 0.6 nm south of the Kende intersection and was crossing the 153-degree prescribed direct course to the San Jacinto final approach fix. About 12 seconds later, the airplane's 077-degree track had become 092 degrees.
At 1525:33, 1525:40, and 1525:47, the controller again attempted to contact the pilot. During the latter effort, the controller stated, "If you hear me ident." At 1526:02, the controller stated, "I copy the ident."
The last recorded radar hit occurred 23 seconds earlier, at 1525:39, at which time the airplane had descended to 5,100 feet. The airplane's location at 1526:02 was subsequently recalled by the controller as being southeast of Kende.
The pilot's last recorded radio transmission occurred at 1526:05, when he said "ah March, do you read me, zero romeo echo." The controller replied at 1526:08, and stated "OK, I hear you now its, ah when you get behind those mountain ranges over there its ah we usually lose radar and radio back there."
At 1526:16 and 1526:26, the controller again transmitted IFR cancellation instructions to the pilot, but no reply was recorded. The controller transmitted "zero romeo echo, radar contact lost" at 1526:51.
No witness reported observing the accident. The pilot's route of flight between the location where radar contact was last recorded and the 6.6 nm distance to the crash site is unknown. During the last minute of radar recorded flight, the airplane's average track and ground speed were about 092 degrees and 160 knots. Based on this ground speed, and the 107-degree direct course between the last recorded radar return (hit) and the crash site, the accident occurred about 1528.
PERSONNEL INFORMATION
The pilot held a private pilot certificate with the following ratings: airplane single and multiengine land, instrument airplane, and rotorcraft helicopter. On February 20, 2001, when the pilot was issued a second-class aviation medical certificate, with the restriction that he must wear corrective lenses, his reported total flight time was 1,150 hours.
A relative of the pilot, who completed the National Transportation Safety Board's "Pilot/Operator Aircraft Accident Report" form, indicated that the pilot's experience flying the accident model of airplane was 425 hours. Data extracted from the pilot's flight record logbook indicates that the pilot's total flight time was in excess of 1,215 hours. Also, the pilot's total actual and simulated instrument flying experience was in excess of 39 and 83 hours, respectively.
On October 10, 2001, the pilot successfully completed an instrument proficiency check (IPC) in his (accident) airplane. According to the certified flight instructor (CFI) who administered the IPC, during the flight the pilot demonstrated steep turns, unusual attitudes, holding, compass turns, ILS and VOR instrument approaches. The CFI did not report that the pilot demonstrated any proficiency performing GPS approaches.
AIRCRAFT INFORMATION
GPS Installation and Revision Service Data.
According to Able Avionics, Van Nuys, California, about April 23, 2001, its repair station personnel installed a Garmin International Inc. GPS receiver model GNS 530 into the pilot's airplane. The airplane was not equipped with a separate automatic direction finder (ADF receiver) or a secondary GPS receiver. The GNS 530 unit was certificated for instrument en route, terminal, and nonprecision instrument procedures.
The GNS 530's serial number was 78401266. The software version in the unit was unchanged since Able's acquisition of the unit from the manufacturer. The pilot was advised to keep the receiver's aviation database current using Jeppesen's revision service.
Personnel at Jeppesen verbally reported to the Safety Board investigator that in order to maintain a current database in the GNS 530, the pilot had subscribed to its Skybound Datawriter revision service. This service provides for revisions on a 28-day cycle via internet downloads. Jeppesen reported that the pilot had subscribed to this revision service. However, they were unable to ascertain whether, in fact, the pilot had downloaded the current data. Jeppesen's personnel also noted, however, that there had not been any changes to the Hemet GPS-A approach procedure between the receiver's April installation and the December accident date.
Flight Limitation, Equipment Certification, and Maintenance.
The Federal Aviation Administration (FAA) certified the airplane for flight into instrument meteorological conditions (IMC). The airplane was not certified for flight into icing conditions. The airplane was equipped with a heated pitot tube and an alternate source for obtaining static atmospheric pressure for emergency use if the primary static port became blocked. The primary static port was not heated.
The FAA authorized IFR operation of the GNS 530 under a field approval process following a functional evaluation on May 2, 2001. Also, an (S-TEC-60-2) autopilot having pitch, roll, and altitude hold capability was installed in the airplane. Its installation was accomplished under the provisions of a supplemental type certificate.
An FAA avionics inspector reviewed the installation documentation for the GPS and the autopilot, in addition to data associated with the pitot-static system and transponder checks. In summary, the FAA inspector reported that the reviewed documentation included several FAA Form 337s and airplane logbooks. The documents were found satisfactory, and no discrepancies were reported.
METEOROLOGICAL INFORMATION
About 1530, a person located about 5 miles west of the accident site reported hearing a low flying airplane pass by his location. The person indicated that he did not observe the airplane because there were low clouds in the area. The person's elevation was about 1,500 feet msl, and he estimated the cloud base was about 500 feet above the ground.
Weather Briefings.
At 1035, the pilot telephoned the Hawthorne, California, Flight Service Station (FSS) and requested a weather briefing for an IFR flight from Santa Monica to Hemet. The FSS briefer informed the pilot, in pertinent part, of the issuance of airmen's meteorological information (AIRMET) for moderate icing and stated that the freezing level was "just under six thousand feet." The forecast condition for 1400 in the vicinity of the March ARB (15 nm west-northwest of the Hemet-Ryan Airport) was for a broken sky condition with clouds based between 2,000 and 3,000 feet above ground level (agl), visibility 3 to 5 miles, light rain showers and mist. After 1600, the March ARB forecast was for scattered to broken clouds based at 4,000 feet agl, with isolated light rain showers, and surface wind from 280 degrees at 25 knots.
The FSS briefer ...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX02FA049