N3747U

1.1 HISTORY OF FLIGHT

On December 24, 2003, about 1020 Pacific standard time, a Piper PA-34-200T, N3747U, impacted mountainous terrain while flying the missed approach portion of the (VOR/DME-B) approach to Catalina Airport (AVX), Avalon, California. Long Beach Flying Club was operating the airplane under the provisions of 14 CFR Part 91. The airline transport pilot/certified flight instructor (CFI), the commercial pilot under instruction (PUI), and three passengers sustained fatal injuries; the airplane was destroyed. The local instructional flight departed Long Beach (LGB), California, about 0954, en route to Avalon. Day instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The primary wreckage was at 33 degrees 22.35 minutes north latitude by 118 degrees 25.09 minutes west longitude.

Southern California Terminal Radar Approach Control (SCT) Approach control cleared the airplane for the very high frequency omni-directional range/ distance measuring equipment-BRAVO (VOR/NDB-B) approach to AVX, and told the pilots to contact AVX UNICOM. The pilots established radio contact with the UNICOM operator, who advised them that the weather was: wind from 120 degrees at 4 knots; ceiling 100 feet overcast; and visibility 1.25 statute miles. AVX UNICOM received no further radio communication from the accident airplane.

The National Transportation Safety Board investigator-in-charge (IIC) reviewed recorded radar data from the Los Angeles Air Route Traffic Control Center (ARTCC) and noted a target identified with the flight's assigned transponder beacon code 4711. Recorded radar data showed that after the radar target departed Long Beach, it gained in altitude on a southerly course until passing the shoreline south of LGB at a mode C reported altitude of 2,900 feet mean sea level (msl). The target continued to gain in altitude to a maximum reported altitude of 4,100 feet msl. The target continued south until passing the Santa Catalina VORTAC (SXC) (very high frequency omni-directional radio range, tactical air navigation). It then started to descend and turned northbound to start the VOR/DME-B approach. The radar track shows the target turning to the south and establishing the approach on a heading of 172 degrees. The airplane continued to descend to the published minimum descent altitude (MDA) of 2,100 feet msl and leveled off.

The target crossed the missed approach point (MAFPI) at the MDA of 2,100 feet msl. The missed approach point is 2.8 nautical miles from the SXC VOR. The SXC VOR is located on top of Mount Orizaba at an altitude of 2,090 feet msl.

The radar track showed that the target maintained an altitude of 2,100 feet msl after the missed approach point before radar contact was lost.

1.2 PERSONNEL INFORMATION

1.2.1 First Pilot

For the purposes of this report the first pilot is identified as the pilot who was occupying the left front seat of the accident airplane.

A review of Federal Aviation Administration (FAA) airman records revealed the first pilot held a commercial pilot certificate with ratings for airplane single and multiengine land. He also held a certified flight instructor certificate with ratings for airplane single and multiengine land, and instrument airplane.

The first pilot held a second-class medical certificate issued on October 15, 2003. It had no limitations or waivers.

No personal flight records were located for the pilot, and the aeronautical experience listed in this report was obtained from a review of the FAA airmen records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated a total time of 730 hours with 200 hours logged in the last 6 months.

1.2.2 Second Pilot

For the purposes of this report the second pilot is identified as the pilot who was occupying the right front seat of the accident airplane.

A review of FAA airman records revealed the second pilot held an airline transport pilot certificate with ratings for airplane multiengine land rating, and a commercial pilot certificate with an airplane single engine land rating. He also held a certified flight instructor certificate with ratings for airplane single and multiengine land, and instrument airplane.

The pilot held a first-class medical certificate issued on January 17, 2003. It had no limitations or waivers.

No personal flight records were located for the pilot, and the aeronautical experience listed in this report was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City. These records indicated a total time of 4,500 hours with 300 hours logged in the last 6 months.

1.3 AIRCRAFT INFORMATION

The airplane was a Piper PA-34-200T, serial number 34-7570287. A review of the airplane's logbooks revealed a total airframe time of 3,320.1 hours at the last annual inspection. The annual inspection was completed on August 7, 2003. The last recorded maintenance indicated the total airframe time of 3,384.0 hours on December 12, 2003.

The airplane had a Teledyne Continental Motors TSIO-360-EB engine, serial number 265612-R, installed on the left side. Engine total time since major overhaul was 1,523.54 hours.

The airplane had a Teledyne Continental Motors TSIO-360-EB engine, serial number 266165-R, installed on the right side. Total time on the engine since major overhaul at the last 100-hour inspection was 1,523.54 hours.

The airplane was equipped with an inoperative Long Range Radio Aid to Navigation (LORAN) system. The airplane was not equipped with a Global Position System (GPS).

Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure.

1.4 METEOROLOGICAL INFORMATION

A staff meteorologist for the Safety Board prepared a factual report, which included the following weather for the departure area and destination.

1.4.1 Catalina Airport (KAVX), Avalon, California

The closest official weather observation station was a nonaugmented Automated Surface Observing System (ASOS) at, Catalina Airport, Avalon, located 3 miles north of the accident site. The elevation of the weather observation station was 1,610 feet msl. Reported weather at 1022, was winds from 120 degrees at 4 knots; visibility 1 1/4 miles; surface weather- light rain/mist; sky condition overcast 100 feet; temperature 52 degrees Fahrenheit; dew point 50 degrees Fahrenheit; altimeter 30.07; Remarks- rain began at 1015.

1.4.2 Long Beach Airport (KLGB), Long Beach, California

The next closest official weather observation station was Long Beach Airport (LGB), Long Beach, located 29 miles northeast of the accident site. The elevation of the weather observation station was 34 feet msl. Reported weather at 0956, was winds from 080-degrees at 4 knots; visibility 10 miles; sky condition overcast at 3,300 feet; temperature 59 degrees Fahrenheit; dew point 52 degrees Fahrenheit; altimeter 30.08 inHg.

1.5 COMMUNICATIONS

1.5.1 Long Beach Airport (Daugherty Field) (LGB)- Airport Traffic Control Tower (ATCT)

The IIC reviewed recorded radio communications and official transcripts between LGB tower controllers and the pilot. All communications were read back correctly or acknowledged unless noted otherwise.

At 0933, the pilot contacted LGB clearance delivery with information UNIFORM and requested an IFR clearance to AVX.

Between the times of 0936 and 0937, the pilot was instructed to contact ground control for taxi instructions, and received taxi instructions to runway 25L at Delta.

Between the times of 0950 and 0954, the pilot was issued his IFR clearance, and then cleared for takeoff.

At 0956, LGB local control instructed the pilot to contact departure (SCT).

1.5.2 Southern California Terminal Radar Approach Control (SCT)

The IIC reviewed recorded radio communications and official transcripts between SCT and the pilot. All communications were read back correctly or acknowledged unless noted otherwise.

At 0957, the pilot contacted Beach Radar Sector (BCHR) and advised he was climbing out of 1,200 feet for 3,000 feet. BCHR cleared N3747U to 4,000 feet, and assigned a heading of 180 degrees.

At 1001, BCHR cleared N3747U to fly direct to Catalina VOR (SXC), and to contact approach on 127.4. The pilot then contacted Catalina Radar Sector (KATR) and reported level at 4,000 feet, which KATR acknowledged.

At 1004, the pilot was asked by KATR if he wanted a vector to the final approach. He replied that he would do the procedure turn. The pilot was cleared to cross SXC at 3,200 feet, and then cleared for the VOR/DME-B approach.

At 1013, KATR advised the pilot that he was left of the approach course approximately 1.5 miles and suggested a correction to the right.

At 1015, KATR asked the pilot if he was making a full stop landing or a missed approach. The pilot advised that he would make a missed approach. KATR advised the pilot that radar service was terminated, and to "return to his frequency on the missed approach." KATR also issued a traffic alert.

At 1016, KATR advised the pilot to stop his descent due to traffic below him at 1,600 feet, which the pilot acknowledged. KATR advised the pilot that the traffic was passing underneath him, and the pilot reported traffic in sight. KATR advised the pilot to continue on the approach and to contact AVX Unicom.

There were no further communications between KATR and the pilot

1.6 AERODROME INFORMATION

1.6.1 Approach Information

The VOR/DME-B approach consists of an approach from the north descending from 3,200 feet down to 2,100 feet prior to the Initial Approach Fix (IAF). The IAF is 2.2 nm from the Missed Approach Point (MAP), the MAFPI intersection. The MAP is 1.0 nm north of the airport runway and 2.8 nm from the SXC VOR. The SXC VOR is located on top of Mount Orizaba at an elevation of...