LAX01FA004
LAX01FA004

1.1 HISTORY OF FLIGHT

On October 6, 2000, at 1938 Pacific daylight time, a Piper PA-34-200, N222ES, collided with mountainous terrain while executing the missed VOR-A approach procedure at Brackett Field (POC), La Verne, California. Air Desert Pacific operated the airplane under the provisions of 14 CFR Part 91. The airplane was destroyed. The certified flight instructor (CFI) and the commercial single-engine instrument student sustained fatal injuries. The local instructional flight originated at POC about 1830. Instrument meteorological conditions prevailed for the local area instructional flight, that included an approach into the Chino Airport (CNO), Chino, California. An instrument flight rules (IFR) flight plan had been filed. The primary wreckage was at 34 degrees 08.572 minutes north latitude and 117 degrees 47.870 minutes west longitude.

The Safety Board investigator-in-charge (IIC) reviewed transcripts of recorded radio transmissions between the pilot's and various FAA Southern California air traffic control (SoCal ATC) facilities. The transcripts indicated that the pilots were in contact with Pomona Associate (POMA), Pomona Radar Sector (POMR), Riverside Radar Sector (RALR), and the POC local controller (LC).

No discrepancies were noted with the IFR flight to CNO that culminated in a missed approach or the request for the VOR-A approach to POC.

At 1927 POMR radar identified the accident airplane and radar vectors were issued for the VOR-A approach to POC. The POMR controller asked the pilot if he had POC ATIS information "Lima". The pilot acknowledged the call, and then asked if they could have a frequency change to get the ATIS information. The POMR controller issued the ATIS weather and runway information.

At 1929 POMR cleared the airplane for the VOR-A approach, and advised the pilot to contact POC. The pilot acknowledged the instructions. The pilot contacted the LC and stated they were on the VOR-A approach outside of GOLDI. The local controller instructed the pilot to report GOLDI. Two minutes later POMR contacted the LC to ask why the airplane was circling the airport. The LC stated he would find out and get back to POMR.

Between the times 1932:05 to 1932:20 the LC asked if the pilot wished to cancel IFR or continue the approach. The pilot replied that he wanted to "continue." The LC told him to report the runway in sight, and the pilot acknowledged the request. The LC also informed the pilot that they appeared to be west of course.

At 1932:20 the LC asked if they had the airport insight. The pilot replied they had the airport insight. The LC then contacted POMR and advised the pilot was canceling IFR and had the airport insight. POMR dropped the accident airplane's data block from its display.

At 1933:07 the controller asked the pilot to confirm he had the runway in sight. The pilot replied in the negative. The controller then asked if the pilot wanted the missed approach. The pilot replied that he had the ground and Interstate-10 in sight. The pilot was instructed to continue, report the airport in sight, and cleared to land runway 26L, which he acknowledged. The pilot reported the airport in sight, and was again cleared to land runway 26L.

At 1934:25 the LC asked the pilot what he was doing and if he had the airport in sight. The pilot asked if anything was wrong. The LC asked them their current heading. The pilot stated 280-degrees and then corrected the heading to 250-degrees.

The controller advised the pilot he was three miles west of the airport and suggested he turn to a heading of 080-degrees. The controller also instructed the pilot to report he was established on an eastbound heading, to maintain visual flight rules (VFR) flight conditions, and to report the runway in sight. The pilot acknowledged all of the controller's requests.

At 1936:02 the controller advised the pilot the airport was 1.5 miles at the pilot's 12:00 o'clock position. He also asked if the pilot had the airport in sight. The pilot replied negatively.

The controller instructed the pilot to make a 10-degree right turn to enter the downwind. The controller again informed the pilot that the airport was a little over a mile at their 12:00 position. The pilot replied he had the airport insight. The controller instructed the pilot not to lose sight of the airport again, and cleared him to land.

From 1936:46 until 1937:06 the controller was in contact with another airplane that was inbound from GOLDI for landing behind the accident airplane. The controller queried the accident pilot as to their current heading. The pilot requested a missed approach. The controller instructed the pilot to execute the missed approach and to standby for a frequency change.

Between the times of 1937:29 to 1937:31 the LC informed POMR that the accident airplane was executing the missed approach. The POMR controller told the LC to instruct the pilot to execute the missed approach and "maintain three thousand, actually have him climb up to four."

At 1937:50 the POMR controller commented to the LC that he (POMR) thought the pilot had cancelled IFR and went VFR. The LC controller stated that "he [the pilot] had cancelled, he had the airport in sight, he lost sight of the airport, and he is asking me now if he can go missed approach so I don't know what to do with him."

At 1938:00 the LC said he could work the pilot and try and get him back to the airport unless POMR wanted to take him. POMR stated that if the pilot was IMC and did not have the airport insight that "I would have him turn southbound immediately."

At 1938:12 the LC instructed the pilot to turn to the south, and stated that he should have been executing the missed approach. The LC then asked if the pilot knew what the missed approach was. The pilot stated they were trying to get back to the VOR and that they were making a turn to a heading of 150-degrees.

At 1938:30 the LC instructed the pilot to make an immediate climb to five thousand feet. The controller attempted to reestablish radio communications with the accident pilots. The controller informed POMR a search would have to be initiated. Both the local and POMR controllers stated that the accident airplane had not established radio communications on either frequency.

At 1941:40 POMR contacted Pomona Air One and advised them of a missing airplane. The controller stated that the last radar contact with the accident airplane was three miles north of the airport at 1,700 feet. Pomona Air One proceeded to the area to search for the accident airplane. Pomona Air One was unable to continue the search due to a "setting ceiling."

A discussion ensued between the LC and POMR. POMR asked if the pilot had cancelled IFR. The LC stated he had cancelled IFR with the airport in sight. POMR asked where the pilot was at when he cancelled IFR. The LC replied he was over KELLOGG, a VFR checkpoint, about a mile and half southwest of the airport.

During the ensuing discussion, POMR was informed that the LC had queried the pilot as to what heading was currently being flown. The pilot replied that he was on a heading of 270-degrees. The LC indicated that heading would take him away from the airport. The LC then instructed the pilot to turn to an easterly heading, and to let him know when the pilot had the airport in sight.

The pilot stated he had the runway in sight, at which point the LC cleared him to land. He stated that the pilot started to head to the north and didn't answer any transmissions, except to say that he (the pilot) wanted a missed approach. The LC cleared him for the missed approach; however, the airplane continued northbound. He then told the pilot to turn to a southerly heading, and to climb and maintain, what he believed was, five thousand feet. The LC indicated that there were no further transmissions from the pilot.

1.5 PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed the CFI held a commercial certificate with ratings for airplane single-engine land, multi-engine land, and instrument airplane. The CFI also held a certified flight instructor certificate with ratings for airplane single-engine land, multi-engine land, and instrument airplane. The CFI held a first class medical certificate that was issued on April 15, 2000. It had no limitations or waivers. Family members were unable to locate the CFI's personal logbook.

A review of the CFI's employee hire record and customer flight report from Air Desert Pacific revealed that the CFI was hired on May 12, 2000. He reported on the PILOT REGISTRATION form a total flight time of 205 hours. The company's customer flight report showed a total flight time of 71.6 hours from the period of May 30, 2000 to October 6, 2000.

A review of FAA airman records revealed the student held a commercial certificate with ratings for airplane single-engine land and airplane instrument. The student held a first class medical that was issued on August 25, 2000, with no limitations or waivers.

A review of the student's logbook revealed an estimated total flight time of 406 hours. He logged 35 hours in the last 90 days, and 16 in the last 30 days. The estimated total simulated instrument time logged was 58 hours; the estimated total time logged in actual instrument conditions was 3 hours. The pilot had an estimated 9 hours in this make and model.

1.6 AIRCRAFT INFORMATION

The airplane was a Piper PA-34-200, serial number 34-7250331. A review of the airplane's logbooks revealed a total airframe time of 7,039 hours at the time of the accident. An annual inspection was completed on September 26, 2000. The tachometer read 4,373 at the last inspection. The tachometer read 4,427.60 at the accident scene.

The airplane had a Lycoming IO-360-E1A6 engine, serial number L-9380-51A, installed on the left side. The 100-hour inspection was completed on September 25, 2000, and the total engine time was 6,985 hours.

The airplane had a Lycoming LIO-360-E1A6 engine, serial number L-434-67A, installed on the right side. The 100-hour inspection was completed on September 25, 2000, and the total engine time was 6,985 hours.

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

1.7 METEOROLOGICAL CONDITIONS

The routine aviation surface weather (METAR) report from Brackett Field at 1847 reported winds from 260-degrees at 8 knots with 2 miles visibility. Mist obscured 3/8's to 4/8's of the sky, with an overcast ceiling at 1,500 feet above ground level (agl). At 1947, visibility had been reduced to 1 mile. Mist obscured 3/8's to 4/8's of the sky, with an overcast ceiling of 1,000 feet msl. Two AIRMET's (WA's) had been issued for the area for IFR conditions and mountain obscuration.

1.10 AERODROME INFORMATION

1.10.1 Missed Approach Procedure

The missed approach procedure for POC was a climbing left turn to 4,000 feet direct to the POM VOR. The MVA in the area of the accident site was about 6,000 feet.

1.10.2 Minimum Safe Altitude Warning (MSAW)

At the time of the accident POC tower was not equipped with an audible MSAW warning system. The FAA issued notice 7210.485, "Minimum Safe Altitude Warning for Remote Tower Displays," addressing the installation of aural alarms at "visual flight rules terminal facilities that receive radar information from a host radar control facility and would otherwise receive only a visual MSAW alert." Notice 7210.485 was issued on November 2, 1999. POC was scheduled to receive an aural alarm system by April 2001.

The recorded minimum safe altitude warning (MSAW) data from the Southern California (SoCal) Terminal Radar Approach Control (TRACON) showed that MSAW issued an alert beginning at 1933:10 that continued for the remainder of the flight. The alert would have been visually displayed to the local controller on the digital bright radar indicator tower equipment (DBRITE) as a flashing "LA" in the data block that was the accident airplane. The alert would not have been available to POMR controllers, as they had already dropped the data block from their radar due to the cancelled IFR.

1.12 WRECKAGE AND IMPACT INFORMATION

The Los Angeles County Sheriff Search and Rescue (SAR) crew located the accident site at 0417 on October 7, 2000, in the Angeles National Forest near Ham and Sycamore Canyons. Investigators from the Safety Board, the FAA, and New Piper Aircraft, a party representative to the accident, examined the wreckage at the accident scene.

The airplane came to rest in a ravine on a 50-degree slope, at 2,150 feet. The accident site was located 3.66 miles northwest of POC on a magnetic bearing of 332-degrees, in rugged rising mountainous terrain, with trees and scrub brush. A ground scar was present on the eastern face of the ravine the length of the airplane from wing tip to wing tip. Navigational light lens fragments from each of the wing tips were found embedded on the eastern face of the ravine.

All of the airplane's major components were contained at the accident site. The airplane came to rest with the fuselage on a 020-degree magnetic heading. The tail section of the airplane was bent over the fuselage in the direction of the right wing.

The right wing was destroyed in the impact sequence; however, it remained partially attached to the fuselage. The aileron was found approximately 1-foot in front of the wing along with a portion of the door. The right fuel tank had ruptured. The right engine separated from the right wing; however, it was located in its approximate location under the wing.

The left front seat was ejected from the airplane and located next to the left wing tip. The left wing remained partially attached to the fuselage. It was crushed span wise from leading to trailing edge. The flap and aileron remained attached to the wing. The left engine separated from the left wing; however, it was located in its approximate location under the wing.

The empennage partially separated from the fuselage. The stabilator sustained impact damage to the right side. The stabilator control cables remained attached to the control tee-bar assembly, and the rudder cables were separated at the eyebolt attachment point. The trim cable remained attached to the trim drum.

1.13 MEDICAL AND PATHOLOGICAL INFORMATION

The Los Angeles County Coroner completed the autopsies. Toxicological analysis was performed by the FAA Civil Aeromedical Institute (CAMI), Oklahoma City, Oklahoma, from samples obtained during the autopsy.

The results of the analysis for the CFI were negative for drugs. Carbon monoxide, and cyanide tests were not conducted.

The report contained the following positive results: 13 (mg/dL, mg/hg) ethanol detected in Kidney, 4 (mg/dL, mg/hg) acetaldehyde detected in Kidney, 1 (mg/dL, mg/hg) N-Propanol detected in Kidney, 20 (mg/dL, mg/hg) ethanol detected in muscle, 1 (mg/dL, mg/hg), N-Butanol detected in muscle, 1 (mg/dL, mg/hg) N-Propanol detected in muscle.

The results of the analysis for the student pilot were negative for drugs. Carbon monoxide and cyanide tests were not conducted.

The report contained the following positive results: 10 (mg/dL, mg/hg) ethanol detected in muscle, 54 (mg/dL, mg/hg) ethanol detected in Kidney, 22 (mg/dL, mg/hg) acetaldehyde detected in Kidney, 4 (mg/dL, mg/hg) N-Propanol detected in Kidney.

There was a NOTE attached to the VOLATILES section that stated "The ethanol found in this case may potentially be from postmortem ethanol formation and not from the ingestion of ethanol.

1.16 TESTS AND RESEARCH

1.16.1 Air Traffic Control

An Air Traffic Control Group was formed on October 14, 2000. A review was conducted of taped air traffic control transmissions, transcripts, airport diagrams and other documentation. The air traffic control tower (ATCT) local controller, the sole occupant in the tower at the time of the accident, was also interviewed, and his training records were examined.

On October 24, 2000, controllers from the Southern California Terminal Radar Approach Control (SoCal TRACON) were interviewed via telephone concerning automation records and voice transcripts.

The local controller (LC) for POC interview revealed that he began working for the FAA on May 6, 1974, with his experience mostly in Southern California. In 1981 he left FAA service and returned to work at POC ATCT on July 22, 1997. His records indicated that he was fully certified for the POC ATCT position and had completed DBRITE training on August 4, 1997. On the day of the accident the LC was working a 12:15 to 21:15 (9) hour shift.

The LC stated he became aware of the airplane when he observed it on the DBRITE, south of the airport as an inbound IFR flight. The airplane had been a handoff from SoCal TRACON.

When the pilot contacted the tower, the LC instructed him to report the GOLDI intersection. The LC noted, via the DBRITE, that the airplane was 1/2 mile west of GOLDI moving away from the radial that forms the VOR-A approach course, in a northwest direction.

The LC advised the pilot he appeared to be off-course. The pilot stated he had the airport in sight, and a landing clearance was issued. The LC then stated the airplane was west of the airport proceeding westbound. He queried the pilot as to his intentions. The pilot advised him that he was on a 280-degree heading. At that point the LC had visual contact with the airplane and instructed the pilot to turn to a heading of 080-degrees in order to return to the airport vicinity. He also instructed the pilot to report the airport in sight.

The pilot initiated the turn to 080-degrees and reported the airport and freeway (Interstate-10) in sight. The LC instructed the pilot to keep "the airport in sight", and cleared him to land.

The LC stated that after some time had passed the pilot contacted him and asked for the missed approach. The LC authorized the missed approach and contacted SoCal TRACON Pomona sector to coordinate. After the LC completed the coordination for the missed approach, he observed the airplane on a northerly heading and reissued missed approach instructions. The LC observed that the airplane "disappeared" from the DBRITE display. He made repeated attempts to contact the pilot; however, he did not receive a response.

The LC stated that approved usage of the DBRITE included runway instructions for arriving traffic after first contact had been made, and traffic advisories for VFR aircraft. He felt that he had used the DBRITE correctly and that the issuance of the 080-degree heading was based on a visual observation of the airplane, not by reference to the DBRITE.

The LC stated the DBRITE did not have the capability to display minimum vectoring altitudes (MVA), and he could not recall what the MVA was north of the airport. The LC recalled that he was provided with a printed map depicting various altitudes in the airport vicinity during training for the local control position.

According to the air traffic control handbook (Federal Aviation Administration order 7110.65) a safety alert (2-1-2 Duty Priority, 2-1-6 Safety Alert) is REQUIRED and ISSUED when an aircraft is in unsafe proximity to terrain or other aircraft. The LC stated that he was responsible for issuance of a safety alert if one was required. However, in this case, he did not issue the safety alert because the pilot had already asked for a missed approach.

The LC further stated that he had no training on when to inform an aircraft to perform a missed approach, nor did he consider issuing that instruction to the accident pilot because the pilot stated he had the airport in sight on two different occasions.
A Letter of Agreement (LOA) containing procedures for handling IFR arrivals existed between POC and SoCal TRACON. The LC did not recall the specifics, but stated that SoCal initiates the handoffs prior to the final approach fix. POC ATCT then takes the handoff, and SoCal instructs the aircraft to contact POC on tower frequency. The LC is then required to notify SoCal if a pilot requests a missed approach.

During the interview the LC reported that he saw the accident airplane on a northerly heading, but did not consider specifically instructing the pilot to make a turn to the south. The last altitude that the LC saw for the accident airplane was approximately 1,700 feet mean sea level (msl) in an area where the terrain was 1,700 to 2,000 feet msl.

When the pilot stated that he was conducting the missed approach procedure, the LC believed that the airplane would enter a climbing turn to the south. The LC coordinated the missed approach with SoCal, and returned his attention to the DBRITE where he observed the accident airplane on a northerly heading.

According to the LC, he did not recall seeing any Minimum Safe Altitude Warning (MSAW) alerts on the DBRITE, which included the period when the accident airplane was heading north towards the mountains. The POC tower's DBRITE system is not equipped with an aural alert tone to draw the attention of the LC to the DBRITE MSAW display. The LC stated that when an MSAW alert is received he should advise the pilot to check his altitude immediately. Normally when the MSAW alert occurs SoCal TRACON will call the tower to ensure that the LC is aware of the alert.

When the LC was queried as to whether he considered the airplane to be IFR or VFR, he stated IFR. He then changed his mind and stated that he handled the accident airplane as a VFR airplane after the pilot cancelled his IFR flight plan in flight. The LC further stated that under normal circumstances an IFR flight plan is closed when the aircraft lands.

The LC reported that there are approximately 70 IFR flights daily into POC; about 80-percent of those flights conduct the VOR-A approach. The LC felt that pilots have become disoriented on the approach in the past. The LC stated that he has seen pilots attempt to land at Ontario (ONT) thinking it was POC. He concluded the interview by stating that he does not know of anything that could be mistaken for the airport west of airport.

1.16.2 SoCal TRACON Interviews

1.16.2.1 Pomona Radar Associate Controller

The Associate Controller began work for the FAA on September 28, 1990. He had transferred to SoCal TRACON on April 8, 1995.

According to the Associate Controller, on the evening of the accident he had been assisting on the Pomona sector radar position. This position was responsible for coordination, monitoring traffic, and flight data management. The accident airplane had been under control of the Riverside (RAL) sector controller, and was handed off to the Pomona sector controller after a planned missed approach from CNO. No discrepancies were noted with the accident airplane's missed approach from CNO. The associate controller stated that there were no problems with the pilot's ability to follow clearances, hold assigned headings and altitudes.

He noted that the weather at POC was below basic VFR minimum due to low clouds and haze. The RAL sector controller informed the associate controller that the accident airplane had requested the VOR-A approach into POC. The airplane was transferred to POC from SoCal by handoff via the DBRITE. He monitored the approach and noted that the approach was normal and heard the local controller (LC) instruct the pilot to report outside GOLDI.

The associate controller observed the accident airplane pass GOLDI and that the airplane was west of the airport, deviating further to the west. He called the LC to find out what the pilot was doing. The LC stated that he would find out and call back. The LC called back and said that the pilot had the airport insight and was canceling IFR.

The associate controller noted that the airplane was about 2 miles west of the airport near the I-10 freeway. The only thing that caught his attention was that the airplane was headed in the wrong direction, away from the airport.

The associate controller believed that the accident airplane was now conducting VFR operations so he suppressed the data block for the Pomona radar display. He further indicated that he did not see an MSAW alert at the time he suppressed the data block. He also stated that normal practice for IFR arrivals was to keep the data block up until the aircraft had landed.

The associate controller was queried as to how the pilot was able to cancel his IFR flight plan when POC weather was below VFR minimums. The associate controller thought the pilot was going to request a special VFR (SVFR) clearance, which would have permitted the VFR flight with only one-mile visibility. He further indicated that had the pilot requested an SVFR clearance, the LC would not have been required to notify SoCal that they [POC] were handling the airplane as an SVFR flight.

The associate controller did not observe any MSAW alerts for the airplane. The LC subsequently called Pomona to inform them that the airplane was on the missed approach because the pilot had lost sight of the airport. The associate controller made an entry into the data block for the airplane. He stated that at this time he observed the airplane about 2 miles north of the airport at an altitude of about 2,400 feet. He stated that normally missed approaches are cleared to climb to 3,000 feet msl; however, he cleared the accident airplane to 4,000 feet.

The associate controller reported that shortly thereafter he called POC tower back to instruct the airplane to climb to 5,000 feet for terrain avoidance. The associate controller observed the airplane continuing northbound, even though he expected him to be heading southbound.

The associate controller stated that he considered the accident airplane to be an IFR flight once the airplane had requested the missed approach for POC.

1.16.2.2 Pomona Sector Radar Controller (POMR)

The Radar Controller (POMR) began work for the FAA on April 15, 1974, with his experience mostly in Southern California. He left FAA service in 1981, and was rehired at SoCal TRACON on April 16, 1998.

The radar controller stated that he first became aware of the accident airplane after a planned missed approach at CNO. He directed the accident airplane westbound and vectored the airplane onto the POC VOR-A final approach course. He stated that he instructed the pilot to contact POC ATCT outside of GOLDI, the final approach fix. The radar controller stated that during that period there were no problems observed with the pilot's performance. The airplane's flight path appeared normal until passing GOLDI; the airplane began to deviate to the west off the final approach course.

The radar controller stated that the associate controller called POC ATCT to find out what the pilot was doing and thought perhaps the pilot had requested an Special Visual Flight Rules (SVFR) clearance and that was why he was canceling the IFR approach. He indicated that when an IFR approach is cancelled and an SVFR clearance is issued, pilots are not required to change their beacon code.

The radar controller stated that there would be no way to tell from looking at the radar display that the pilot had requested an SVFR clearance. The LC was not required to call POMR and inform them an SVFR clearance had been issued.

The radar controller stated that he kept the data block for that sector on display and saw the airplane on about a 325- to 330-degree heading west of the final approach course and deviating further west. He observed the airplane turn back toward the airport and then make a turn northbound.

The radar controller further stated that the minimum safe altitude warning (MSAW) sounded about 30 to 40 seconds prior to the airplane disappearing from the screen. He did not believe a safety alert was necessary because the airplane had already been issued the missed approach clearance and he was expecting the airplane to turn around and start climbing.

During this time the radar controller kept the data block up and when the radar target disappeared from the data block the altitude showing was 2,100 feet.

1.16.3 Follow-up Inspection

Investigators examined the wreckage at Aircraft Recovery Service, Compton, California, on October 24 and 27, 2000. Representatives from The New Piper Aircraft and Textron-Lycoming were parties to the investigations.

The airframe was inspected; with flight control continuity established by identifying control cables and associated hardware. Aileron cables remained attached to bellcrank assemblies. Both counterweights separated from their respective ailerons; however, they were found with the main wreckage.

An examination of the throttle control quadrant revealed that all of the engine control levers were trapped in the forward position.

The left engine vacuum pump separated from the engine at the mounting pad. The right engine vacuum pump remained attached to the engine. No discrepancies were noted with either engine's vacuum pumps.

Both left and right manifold lines had separated from the metal tube assembly in their respective wings. The hoses were cut length wise and inspected for contamination. No discrepancies were noted with the lines.

Visual examination of the propeller blades from both engines showed evidence of S-bending as well as chordwise scratching.

The tachometer, found at the site, read 4427.60. The tachometer reading obtained from the aircraft check out sheet read 4427.05. The artificial horizon was disassembled and examined. No rotational scoring of either the rotor or the housing was observed.

No mechanical anomalies were encountered with the airframe.

The left engine was visually inspected prior to removal. The engine mount remained attached to the forward section of the engine, and was partially displaced from the firewall. The propeller remained attached at the crankshaft flange; however, both components had separated from the crankshaft. The investigators removed the left engine and placed it on a hoist. The top spark plugs were removed. According to the Champion Aviation Check-A-Plug chart AV-27, the electrodes were gray in color, which corresponded to normal operation.

The engine was manually rotated via the vacuum pump drive pad utilizing the drive pad. Mechanical continuity was established throughout the engine. Vacuum pump drive rotation produced thumb compression in each cylinder in proper firing order, with accessory gear and valve train continuity established.

The cylinder combustion chambers were inspected utilizing a lighted borescope. No evidence of foreign object ingestion was observed. The valves were found undamaged and no evidence of valve to piston face contact was observed.

The propeller governor remained attached at the mounting pad with the control arm connected. The control arm was near the low pitch, high rpm stop. The propeller governor was removed and examined with no mechanical anomalies encountered.

Magneto to engine timing could not be ascertained. Both magnetos were separated from their respective mounting pads. However, the clamping hardware remained attached to the mounting pad. The left magneto's impulse coupler drive was intact and safetied. The right magneto's drive was intact and safetied. Both magnetos were manually rotated and produced spark at all four of their respective leads.

The fuel injection servo was partially separated from its mounting pad. The servo and the induction system were inspected with no discrepancies noted. The fuel servo inlet screen was free of contamination. The fuel flow divider remained secure at its mounting bracket. The fuel lines were secure at each fitting, and at each fuel injector at each cylinder. The fuel pump was inspected with no internal mechanical anomalies noted.

The oil filter and oil suction screen were removed and inspected. The oil suction screen was packed with large amounts of gasket material and large flakes of non-ferrous metal flakes. The oil filter membrane was contaminated with non-ferrous metal flakes.

A teardown of the left engine was conducted to determine the source of the contaminants found in the oil filter and oil suction screen. No discrepancies were noted with the tear down, and the source of contamination could not be determined. No further discrepancies of the engine were noted.

The right engine was visually inspected prior to removal. The engine mount remained attached to the forward section of the engine. The engine was partially displaced from the firewall. The propeller remained attached at the crankshaft flange. The investigators removed the right engine and placed it on a hoist. The top spark plugs were removed. According to the Champion Aviation Check-A-Plug chart AV-27, the electrodes were gray in color, which corresponded to normal operation.

The engine was manually rotated via the vacuum pump drive pad utilizing the drive pad. Mechanical continuity was established throughout the engine. Vacuum pump drive rotation produced thumb compression in each cylinder in proper firing order, with accessory gear and valve train continuity established.

The cylinder combustion chambers were inspected utilizing a lighted borescope. No evidence of foreign object ingestion was observed. The valves were found undamaged and no evidence of valve to piston face contact was observed.

The propeller governor remained attached at the mounting pad with the control arm connected. The control arm was near the low pitch, high rpm stop. The propeller governor was removed and examined with no mechanical anomalies encountered.

Magneto to engine timing could not be ascertained. The left magneto was separated from the mounting pad; however, the clamping hardware remained attached to the mounting pad. The impulse coupler drive was intact and safetied. The right magneto was secure at its mounting pad. The magneto was removed and the drive was intact and safetied. Both magnetos were manually rotated and produced spark at all four of their respective leads.

The fuel injection servo was partially separated from its mounting pad. The servo and the induction system were inspected with no discrepancies noted. The fuel servo inlet screen was free of contamination. The fuel flow divider remained secure at its mounting bracket. The fuel lines were secure at each fitting, and at each fuel injector at each cylinder. The fuel pump was inspected with no internal mechanical anomalies noted.

The oil filter and oil suction screen were removed and inspected. The oil suction screen was packed with large amounts of gasket material and large flakes of non-ferrous metal flakes. The oil filter membrane was contaminated with non-ferrous metal flakes.

The engine was disassembled to determine the source of the contaminants. No mechanical discrepancies were observed with the crankshaft, connecting rods, camshaft, accessory gears, or the crankshaft gear and dowel assembly. There was also no evidence of lubrication depravation.

The main bearings were inspected. No discrepancies were noted with the Nos. 1, 2, and 4 main bearings. The No. 3 main bearing's locating dowel pinhole was elongated, with the propagation on the side opposite to the direction of crankshaft rotation. Fretting was observed on the backside of the bearing. The surface exhibited smearing of the bearing material. The Nos. 2 and 3 connecting rod bearings showed bearing wear.

The part number for the No.3 bearing noted during the inspection corresponded with a .003 inches undersize. The remaining main bearings were standard size. The dimensional check of the crankshaft found that the No. 3 main bearing journal diameter was .0035 inches smaller than the other main bearings.

Review of the engine overhaul documents revealed the subject crankshaft had been polished to .003 at the No. 3 main journal, and that the remaining main and rod journals remained standard size. According to the manufacturer's direct drive engine overhaul manual, part number 60294-7, section 7, paragraph 7-45 (note) stated, '…if one surface is polished to .003 or .006 undersize, all corresponding surfaces must be polished to same size.'

According to the engine manufacturer at the 100-hour inspection, the inspection checklist requires the removal and inspection of the oil filter and oil suction screen for contaminates. According to the logbook entry there was no mention made of any contamination.

According to the manufacturer's Mandatory Service Bulletin 480D, titled Oil and Filter Change and Screen Cleaning, section 1, paragraph D, it recommends that the oil filter and screen be changed/inspected at 50-hour intervals. It further recommends that the filter be visually inspected for contaminants "that would indicate premature or excessive engine component wear."

No further discrepancies were noted with the engine.

1.18 ADDITIONAL INFORMATION

According to 14 CFR Part 91.3, the pilot is responsible for the safety of the flight. This included deciding whether or not to continue the approach or conduct the missed approach procedure when the airplane had reached the missed approach point (MAP). The MAP for the VOR-A approach was the VORTAC. The airplane was approximately 2 1/2 miles north of the VORTAC and the airport.

The IIC released the wreckage to the owner's representative.



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