Accident Details
Probable Cause and Findings
The pilot's loss of control due to spatial disorientation while maneuvering during an instrument approach in instrument meteorological conditions.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn December 22, 2015, about 1127 Pacific standard time, a Piper PA-32R-301T, N323PA, was destroyed when it impacted terrain near Castro Valley, California, while conducting an instrument approach to Metropolitan Oakland International Airport (OAK), Oakland, California. The private pilot was fatally injured. Instrument meteorological conditions (IMC) were present in the area, and an instrument flight rules (IFR) flight plan was filed for the flight, which departed Lincoln Municipal Airport (LHM), Lincoln, California, about 1050. The airplane was owned and operated by the pilot, and the personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.
Air traffic control radar and voice communication information from the Federal Aviation Administration (FAA) revealed that the pilot contacted the Northern California Terminal Radar Approach Control facility shortly after takeoff from LHM and requested an IFR clearance to OAK. The pilot was subsequently issued a discrete transponder code and an IFR clearance. About 1122, as the airplane neared the destination, it was established on a heading of 160° at an altitude about 4,000 ft mean sea level (msl). The controller cleared the pilot for the instrument landing system (ILS) approach to runway 28R, instructing him to turn right to a heading of 260° to intercept the localizer course and to descend and maintain an altitude of 3,400 ft msl until established on the approach. The controller told the pilot that the airplane was 1 mile north of the GROVE fix along the approach. According to radar data, at that point, the airplane was 1 mile north of NAGVY, a fix along the approach that was about 3 miles outside of GROVE (see figure 1).
Figure 1 - Approach Overview
The pilot acknowledged the clearance and began descending but did not initiate the right turn. About 30 seconds later, the controller contacted the pilot and provided a heading of 300° to cross and intercept the localizer. The pilot acknowledged, and the airplane began turning right (about 1123; see figure 2). During the turn, the airplane crossed the localizer course, then tracked toward the airport on the south side of the localizer course. About 1124, the controller asked the pilot if he had obtained visual contact with the airport, and the pilot replied, "I'm still in the weather." About 1125, the controller asked the pilot if the airplane was established on the localizer, to which the pilot replied, "I'm re-establishing." When the controller subsequently asked the pilot if he was receiving the glideslope indication, the pilot stated that he was receiving the glideslope but was "off glideslope" and "too high." At this time, the airplane's altitude was 2,600 ft msl; the minimum altitude for that segment of the approach was 3,400 ft msl.
The controller issued a low altitude alert, cancelled the approach clearance, and instructed the pilot to turn right to a heading of 300° and to climb and maintain an altitude of 4,000 ft msl. The pilot acknowledged; however, the airplane began a left turn to the south and did not climb. The controller subsequently instructed the pilot to turn north to a heading of 360° and asked the pilot to verify that the airplane was climbing and turning north. The pilot replied, "360 and climbing." The airplane made a right turn to the north and climbed to 3,700 ft before it began descending. Shortly after, during a partially-blocked transmission, the pilot stated, "I'm losing it." No further transmissions were received from the airplane, and radar contact was subsequently lost.
Figure 2 - Airplane's Flight Path (Localizer Course Depicted in Red) PERSONNEL INFORMATIONThe pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. He held an FAA third-class medical certificate, which was issued in August 2015 with a limitation requiring the use of corrective lenses. Review of the pilot's logbook indicated that he had accumulated about 1,262 total hours of flight experience, of which about 960 hours were in the accident airplane make and model. The pilot had accumulated about 43 total hours of actual instrument flight experience, 3.5 hours of which were in the 6 months before the accident, and about 82 hours of simulated instrument experience. His most recent flight review and instrument proficiency check were conducted on November 21, 2015. AIRCRAFT INFORMATIONThe airplane was manufactured in 2001 and registered to the pilot in July 2007. It was equipped with a Lycoming TIO-540-AH1A, 300-horsepower, turbocharged, reciprocating engine, which drove a Hartzell HK732B constant-speed propeller. Review of maintenance logs indicated that the airplane's most recent annual inspection was completed on November 17, 2015, at a total airframe and engine time of 1,479.8 hours. The airplane was equipped with Garmin 430 and 530 panel-mounted GPS units, an electrically-driven standby attitude indicator, and a two-axis autopilot system, which interfaced with the airplane's horizontal situation indicator (HSI). METEOROLOGICAL INFORMATIONThe 1126 automated weather observation at Livermore Municipal Airport (LVK), Livermore, California, located about 8 miles east of the accident site, included wind from 260° at 15 knots, 10 miles visibility, broken cloud layers at 1,300 and 3,200 ft, temperature 15°C, dew point 12°C, and an altimeter setting of 29.82 inches of mercury.
The 1154 automated weather observation at Hayward Executive Airport (HWD), Hayward, California, located about 7 miles west of the accident site, included wind from 270° at 11 knots, 9 miles visibility, broken ceiling at 3,900 ft, overcast ceiling at 5,000 ft, temperature 14°C, dew point 12°C, and an altimeter setting of 29.85 inches of mercury.
A weather computer model balloon sounding for the accident site about 1100 showed clouds likely from the surface through 6,000 ft msl, with drizzle and light rain. Weather satellite information about the time of the accident showed clouds over the area of the accident site moving northwest to southeast. Weather radar animation for the area of the accident site at the time of the accident showed light precipitation.
The area forecast, issued at 0345 and valid through the time of the accident, included overcast ceilings at 1,000 ft above ground level (agl) and visibilities of 3 to 5 miles in light rain and mist.
AIRMET advisories issued between 0645 and 0730, valid for the time of the accident, warned of moderate turbulence below 18,000 ft msl, IMC due to precipitation and mist, and mountain obscuration. Instrument conditions were forecast to improve between 1000 and 1300; however, the mountain obscuration conditions were forecast to continue beyond 1300. AIRPORT INFORMATIONThe airplane was manufactured in 2001 and registered to the pilot in July 2007. It was equipped with a Lycoming TIO-540-AH1A, 300-horsepower, turbocharged, reciprocating engine, which drove a Hartzell HK732B constant-speed propeller. Review of maintenance logs indicated that the airplane's most recent annual inspection was completed on November 17, 2015, at a total airframe and engine time of 1,479.8 hours. The airplane was equipped with Garmin 430 and 530 panel-mounted GPS units, an electrically-driven standby attitude indicator, and a two-axis autopilot system, which interfaced with the airplane's horizontal situation indicator (HSI). WRECKAGE AND IMPACT INFORMATIONThe accident site was located on a heavily-wooded hillside about 12 nautical miles southeast of OAK at an elevation about 1,400 ft. The initial impact point was identified by several fallen trees and large branches. From the initial impact point, the wreckage path extended downhill about 300 ft on a magnetic heading about 330°. The cockpit and cabin area was largely consumed by a post-crash fire.
The wreckage was recovered to a secure facility for examination due to its heavy fragmentation and the difficult terrain at the accident site. All major components of the airplane were accounted for during reconstruction of the wreckage, and there was no evidence of an inflight breakup.
The cabin and cockpit area, including all flight instruments and the autopilot, were destroyed by impact and fire. The left and right aileron control cables remained attached to the control chain. Both stabilator cables remained attached to the lower stabilator t-bar assembly. The left and right rudder control cables remained attached to the rudder control arm assemblies.
The left and right wings were separated from the fuselage at their respective roots and displayed varying degrees of impact and fire damage. Neither left nor right wing aileron bellcrank stops exhibited indications of flutter, and all control cable separations exhibited signatures of overstress. The fuel selector was in the left tank position, and the filter was free of contaminants. The fuel system was breached in multiple locations. The landing gear down-locks displayed no damage, consistent with the landing gear having been in a retracted position at the time of impact. Measurement of the wing flap actuator threads corresponded to a flaps-retracted position.
The empennage displayed significant impact damage and was separated into several sections. The right side horizontal stabilizer exhibited thermal damage. Both stabilator cables remained attached to the stabilator arm assembly, and the left and right rudder cables remained attached to the rudder bellcrank assembly.
The propeller was separated from the engine at the crankshaft flange. All three propeller blades remained attached at the hub and exhibited varying degrees of torsional twisting and s-bending. The propeller governor remained attached at its mounting pad with the pitch control rod securely attached to the control wheel. The governor was removed for examination; the drive was intact and free to rotate, and the gasket screen was free of contamination...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# WPR16FA042