LAX02FA073
LAX02FA073

HISTORY OF FLIGHT

On January 30, 2002, at 1854 Pacific standard time, a Piper Aerostar 601P twin engine airplane, N3636M, was destroyed when it impacted mountainous terrain near Stonyford, California. The private pilot, who was the sole occupant, was fatally injured. The airplane was registered to a private individual and was operated by the pilot as a business flight under 14 CFR Part 91. The flight departed Chico, California, at 1837, and was destined for Ukiah, California. Night visual meteorological conditions prevailed at the time of the accident, and a flight plan was not filed.

Federal Aviation Administration (FAA) records indicated the pilot contacted the Oakland Air Route Traffic Control Center (ARTCC) at 1849:22, and requested flight following and radar vectors to the Ukiah Airport. The controller requested the pilot verify his position, to which he responded, he was approximately halfway between Ukiah and Chico on about the 230 radial from the Chico VOR. The air traffic controller determined the airplane was not in his area of responsibility and instructed the pilot to contact Oakland Center (same ARTCC, different sector) on a different radio frequency.

At 1850:55, the pilot contacted the other Oakland Center sector and advised, "I'm about halfway between Chico and Ukiah enroute Ukiah at sixty seven hundred descending, squawking VFR (visual flight rules). I'd appreciate flight following and vectors to Ukiah." The controller radar identified the airplane, confirmed the altitude, and requested the pilot's current heading. The pilot indicated the airplane was flying a 230-degree heading. At 1852:15, the controller advised the pilot to fly a heading of 220 degrees to reach Ukiah. The pilot acknowledged the suggested heading.

The air traffic controller transferred position responsibility to another controller after briefing him on the traffic situations. The second controller was present and observed the first controller identify N3636M and issue the suggested heading of 220 degrees.

At 1853:18, the pilot requested distance information to Ukiah. The second controller informed the pilot that Ukiah was 34 miles away. At 1853:31, the pilot asked the air traffic controller if they were depicting a ground speed of 181-185 knots. The controller responded the radar system depicted the aircraft speed at 182 knots. That was the last communication with the pilot.

At 1854:38, the airplane's last radar return was received. At 1855:46, the radar data information indicated the radar track entered a "coast" status and could not associate the flight plan information with the radar returns.

At 1856:00, the air traffic control (ATC) attempted to transmit to the pilot that radar contact was lost, and he probably would not receive radar information until the aircraft was about 5-10 miles from Ukiah "due to [his] limited radar coverage in that area." The pilot did not respond to that transmission, and the controller made several radio calls attempting to contact the pilot of N3636M, to no avail.

The controller requested other pilot's in the area to transmit to N3636M via common traffic advisory frequencies. He also had controllers, who were working the high-altitude sector, to ask other flight crews to monitor emergency frequencies for emergency locator transmitter signals. The control center then began search and rescue notification.

The wreckage was located near the peak of St. John's Mountain at 39:26:11 north latitude and 122:41.44 west longitude. The accident site was located at the 6,700-foot level of the 6,746-foot mountain.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with single engine land, multiengine land, and instrument airplane ratings. He held a second-class medical certificate that was issued on May 1, 2000, with a limitation that he "must wear corrective lenses and poses glasses for near and interim vision." According to an aviation insurance renewal application, the pilot accumulated approximately 2,830 total flight hours, of which approximately 750 hours were accumulated in multiengine airplanes. The pilot listed July 18, 2000, as the date of his last biennial flight review.

The pilot logbooks were not located during the investigation. It is unknown how much night flight time and instrument flight time the pilot accumulated. It is also unknown how much flight time the pilot had accumulated in the accident airplane make and model.

Prior to the accident flight (from Chico to Ukiah), the pilot flew to Chico to pickup two passengers, flew them to Oakland, and then returned them to Chico. According to one of the passengers, the pilot lost his near vision glasses while they were in Oakland. The passenger had a pair of near vision prescription glasses he obtained from his personal optometrist, and at his suggestion, lent them to the pilot for the remainder legs of the flight. The pilot kept the glasses after dropping off the passengers in Chico and agreed to mail the glasses to the passenger after returning to Ukiah.

AIRCRAFT INFORMATION

The 6-seat airplane was powered by two 290-horsepower Lycoming IO-540-S1AD engines. Review of the aircraft's maintenance records revealed the airplane underwent its last annual inspection on December 1, 2001, at an aircraft total time of 1,275.1 hours. The altimeter/static and altitude reporting equipment systems were last tested and inspected on July 10, 2000, at an airplane total time of 1,227.5 hours. At the time of the accident, the Hobbs meter indicated 1,284.4 hours. At the time of the accident, the left engine accumulated 700.6 hours since its last overhaul, and the right engine had accumulated 1,284.4 hours since new.

METEOROLOGICAL INFORMATION

At 1848, the weather observation facility at Chico Municipal Airport, which is located 32 miles northeast of the accident site, reported the wind from 340 degrees at 5 knots; visibility 100 statute miles; scattered clouds at 20,000 feet; and an altimeter setting of 30.26 inches of mercury.

At 1856, the weather observation facility at the Ukiah Airport, which was 30 miles to the southwest of the accident site, reported the wind from 260 degrees at 3 knots; visibility 10 statute miles; clear sky; temperature 5 degrees Celsius; dew point -2 degrees Celsius; and an altimeter setting of 30.27 inches of mercury.

According to the U.S. Naval Observatory, on the evening of the accident, the time of sunset was 1736, with an end to civil twilight of 1804. At the time of the accident, the moon's illumination was 93 percent; however, the altitude of the moon was 8.5 degrees below the horizon.

AIR TRAFFIC CONTROL INFORMATION

An Air Traffic Control group was formed on February 1, 2002, to examine the details as they related to air traffic control. The following information was extracted from the Safety Board's Air Traffic Control Factual Report.

The Chico Municipal Airport is located in central northern California and is approximately 70 miles northwest of the Ukiah Airport. The Ukiah Municipal Airport is located nearer the California coastline southeast of the Sanhedrin Mountain range. Mountainous terrain varying from 3,000 feet to just over 7,000 feet lies in the lower southwest area between the two airports. The highest peak is 7,056 feet, which is located at Snow Mountain; about 35 miles northeast of the Ukiah Airport.

An area of class G airspace lies to the northeast of the St. John Mountain extending up to 8,500 feet mean sea level (msl). The remainder of the area along N3636M's route of flight is class E airspace.

The air traffic control sector that was in radio and radar contact with the accident flight (sector 42), was responsible for FL230 and below, and received radar data on the accident flight from the Red Bluff radar location. According to the air route traffic control center controllers, radar contact is commonly lost with airplanes flying at 6,500 feet along similar routes to that of N3636M, but radio communication is normally maintained. The controllers indicated the area in the vicinity of the accident site is a common corridor for pilots flying between the Chico and Ukiah Airports. Pilots routinely fly this corridor VFR at altitudes varying between 6,500 and 10,500 feet, day or night.

It was noted that the sector 42 radar video map did not depict symbology representing terrain or obstructions in the vicinity where the wreckage was located. Maps and sectional charts were located overhead of the controller position and to the left of the workstation.

The general procedures followed at sector 42 allowed radar vector service in accordance with FAA Order 7110.65, paragraph 5-6-1. The chapter states in part:

"Vector Aircraft:
b) In class G airspace only upon pilot request and as an additional service.
NOTE - VFR aircraft not at an altitude assigned by ATC may be vectored at any altitude. It is the responsibility of the pilot to comply with the applicable parts of CFR Title 14."

The facility's stance on issuance of safety alerts is outlined in FAA Order 7110.65, paragraph 2-1-6. The paragraph states in part:

"Immediately issue/initiate an alert to an aircraft if you are aware the aircraft is at an altitude which, in your judgment, places it in unsafe proximity to terrain/obstructions."

Both air traffic controllers who handled N3636M were interviewed. For the purposes of this narration, the controllers will be listed as controller 1 (the second Oakland Center controller to speak with the pilot), and controller 2 (the controller who later took control responsibility from controller 1).

Controller 1 had been working at the Oakland ARTCC since March 1985, and worked in the same control area since his employment started. The controller described the traffic on the day of the accident as normal with no complexity, and indicated there were very good VFR weather conditions. He reported the sector does a lot of flight following and approach service to 2 towered and about 20-25 nontowered general aviation airports. He added that he was on position for about an hour when the accident pilot called informing the controller he was between Chico and Ukiah, descending from 6,700 feet, requesting flight following and a vector to Ukiah. About that time, controller 2 asked controller 1 if he wanted a break, to which controller 1 responded he did.

Controller 1 then radar identified N3636M, and used the range/bearing function (a computer entry that aids controllers in determining the magnetic bearing and distance between two points on their radar display) to issue the suggested heading of 220 degrees. He then began the position relief briefing with controller 2, who observed controller 1 radar identify N3636M.

Controller 1 added N3636M flew a track commonly taken by other VFR pilots between Chico and Ukiah, and has often seen VFR airplanes in that area at 6,500 feet. He was not exactly sure where the pass was located, but reported N3636M did not appear unique. Controller 1 reported they commonly lose radar contact with aircraft in that area, but not radio contact.

Controller 1 added he has issued safety advisories in the past "when circumstances warrant." He normally would not provide an advisory of the minimum instrument flight rules altitude (MIA) value to a VFR pilot, but might ask if "terrain is in sight." He said he would bring up the MIA map if he felt "uncomfortable" but he didn't for N3636M. He said he knew the area and knew the pilot was entering a 9,100-foot section but did not know what the controlling obstacle for that section was; it is not marked on the radar display.

Controller 2 also had been employed at the Oakland ARTCC since his hiring in March 1989. He also described the traffic as normal, and said it was a good VFR day. Just prior to taking over control responsibility, he had taken a break. He reported seeing controller 1 radar identify N3636M and he received a position relief briefing. He noted it was not busy, with about 4 or 5 airplanes in the sector, and controller 1 briefed controller 2 on the location and destination of N3636M.

He stated the pilot of N3636M requested distance information from Ukiah, and the controller measured the distance with the range/bearing function and responded "34 miles." He also reported the pilot asked about his groundspeed to which the controller responded with the indicated groundspeed. Approximately 2 minutes later he reported radar contact was lost on the aircraft, and that he attempted to contact the pilot, but did not get a response.

Controller 2 stated it was common to lose radar coverage of aircraft in the area of St. John's Mountain. He also reported that aircraft routinely traverse the area at various altitudes day or night, and he usually loses radar coverage at 6,500 feet or below.

Controller 2 reported there was no way of knowing the specific height of the terrain in that area because it is not depicted on the video map. He added the only obstructions on the video map are Mount Shasta and Mount Lassen, both of which are far from the accident site.

He added he knew it was night light condition when N3636M was being handled; however, the weather was clear and he recalled being able to see Ukiah easily during a recent familiarization flight. When asked if he had ever issued safety alerts he responded "yes." He stated he issues safety alerts when in his judgment he feels the aircraft is in close proximity to terrain or obstructions. He did not feel a safety alert was warranted in this case. Nothing indicated to him that the pilot was in danger.

The Oakland ARTCC National Airspace System computer is equipped with an E-MSAW (Enroute Minimum Safe Altitude Warning) feature, which alerts the controller when a tracked aircraft is below or predicted by the computer to go below a predetermined altitude. E-MSAW is not automatically activated for VFR airplanes; however, controllers may enable the display of E-MSAW processing for one or more VFR airplanes under his/her control by utilizing a computer entry at their specific radar position. Activation of E-MSAW is required only under emergency situations or by pilot request. Both controllers reported they never had a pilot request MSAW information and did not know how to activate the system for VFR airplanes.

WRECKAGE AND IMPACT INFORMATION

The Safety Board did not travel to the accident site because it was situated in rugged snow covered mountainous terrain. The Glenn County Sheriff personnel provided photographs from the accident site.

Review of photographs taken at the accident site revealed the aircraft impacted just below the crest of the mountain. The debris field was spread out in a heading consistent with the radar's ground track.

The wreckage was removed from the accident site and transported to Plain Parts, Pleasant Grove, California, where it was examined by the Safety Board and representatives from New Piper Aircraft,and Lycoming on July 17, 2002.

The fuselage cockpit and cabin area sustained aft crushing. The forward cockpit, encompassing the instrument panel, was fragmented and reliable information was not attainable from the instruments. The left seat lap belt was found fastened together and the shoulder harness button was found bent. The left seat frame was bent and fragmented. The left and right fuel selectors were found destroyed and in the on position, respectively. The throttle quadrant was separated from the control panel.

The left wing was fragmented and destroyed. The left wing's outboard tip was separated at the splice, and the root was separated from the fuselage. All four spar bolts remained attached to the root area. The left aileron flight control continuity was compromised due to the extent of the damage. The left flap remained partially attached to the inboard wing segment. The flap was separated into two pieces in the area of the outboard flap track. The flap appeared to be retracted. The left landing gear remained attached and was found retracted into the wheel well area.

The right wing was also fragmented and destroyed. The wing was separated into three main sections; the outboard tip (separated at the splice), a center section (from the splice to just outboard of the right landing gear and inboard of the engine nacelle), and the root (which remained attached to the fuselage). The wing skin forward of the spar was missing. The right aileron was separated from the wing and its control continuity was also compromised from the damage. The right landing gear appeared undamaged and was in the retracted position.

The empennage was separated from the fuselage and sustained aft accordion crushing. The vertical stabilizer, with the rudder intact and attached, was separated from the empennage. The horizontal stabilizers and elevators remained attached to the aft end of the tail cone. The rudder trim actuator was measured and found extended 3 inches, which equated to a neutral position. The left elevator trim tab actuator was measured and found extended 2.80 inches, which corresponded to a 1/4 nose up setting.

Both engines were separated from their wings and both propellers were found separated from their engines. Visual examination of the left engine revealed no evidence of preimpact catastrophic mechanical malfunction or engine compartment fire. The top spark plugs were removed and the crankshaft was rotated manually utilizing a toolbar at the crankshaft flange. Thumb compression was confirmed in the proper order on all six cylinders. Continuity was confirmed throughout the drive system, the cylinder valves, pistons, and the accessory section. The cylinders' combustion chambers were examined through the spark plug holes utilizing a lighted borescope. The combustion chambers were undamaged and did not display any evidence of foreign object ingestion. The gas path and combustion signatures observed at the spark plugs, combustion chambers, and exhaust system components displayed coloration consistent with normal operation. The left turbocharger remained intact and its compressor was rotated freely by hand. Significant ductile bending was noted on the exhaust system components.

The left engine's left and right magnetos remained intact and attached to the accessory section and their ignition harnesses. The magneto-to-engine timing could not be determined due to the damage sustained by the flywheel. Each magneto produced a spark at their leads during manual rotation of the drive. The left engine fuel lines were displaced and damaged. The fuel injection servo was displaced from the engine. No obstructions were noted in the servo. The throttle/mixture controls were found securely attached at their respective control arm of the servo. The servo's fuel inlet screen was found properly installed and free of contamination. The fuel flow divider remained in place and secure to the top of the engine. The fuel lines remained secure at each flow divider fitting and fuel injector. No evidence of internal malfunction or obstruction to fuel flow was noted when the flow divider was disassembled.

The left propeller was separated from the engine at the crankshaft flange. The propeller blades remained attached at the hub; however, the spinner and dome were separated. The propeller blades were marked L1, L2, and L3 for identification and narrative purposes. Propeller blade L1 was bent aft 90 degrees and was missing 5.75 inches of material at the blade tip. The blade displayed leading edge gouging and chordwise striations across its cambered surface. Propeller blade L2 was bent aft approximately 10 degrees at midspan, and did not display significant damage. Propeller blade L3 was bent aft 45 degrees and was missing approximately 13 inches of material from the blade tip. The blade displayed trailing edge gouging and chordwise striations across the cambered surface. The left propeller's governor was displaced from its mounting pad its drive remained intact and free to rotate.

The right engine sustained significant damage, encompassing the induction plenum and the rocker box casting areas of the number 2, 4, and 6 cylinder assemblies. There was no evidence of preimpact mechanical damage or engine fire. The top spark plugs were removed and the crankshaft was rotated manually. The rotation of the crankshaft was limited due to internal rust and corrosion. The engine drive system and rocker arms did not display any evidence of preimpact damage. The cylinder chambers were examined through the spark plug holes and they remained mechanically undamaged and there was no evidence of foreign object ingestion. The valves were intact and undamaged. The gas path and combustion signatures displayed coloration consistent with normal operation.

The right engine's left and right magnetos remained intact and secured to their respective mounting pads. The ignition harness was secure to each magneto. The magneto-to-engine timing could not be ascertained due to the destruction of the flywheel. The magnetos were removed and their drives were rotated manually. The left magneto produced a spark at each respective spark plug lead; however, the right magneto would not produce a spark when rotated manually. The fuel injection servo was displaced from the engine and its throttle/mixture control arms were found securely attached to their control cables. No obstructions were noted in the servo or in its fuel inlet screen. The right engine fuel flow divider remained secure at its mounting on the top of the engine. The flow divider fittings for the number 2 and 4 cylinders were fractured. The rest remained secure and attached at the divider and cylinder fittings. Internal examination of the divider revealed its diaphragm was intact and undamaged. The injector nozzles were removed and examined and the number 2 nozzle appeared partially obstructed at the discharge end. The turbocharger was intact and in place and was its compressor was free to rotate.

The right propeller (with its blades labeled R1, R2, and R3) was separated from the crankshaft flange. The blades remained attached to their hub and the spinner and propeller dome were separated from the hub. Propeller blade R1 was bent aft 25 degrees near the hub and exhibited twisting damage with trailing edge "S" bending. Propeller blade R2 was bent aft 30 degrees near the hub. Propeller blade R3 was bent aft approximately 30 degrees near the hub and exhibited blade tip damage and trailing edge "S" bending. The propeller governor remained attached to its mounting pad with the pitch control rod securely attached at the control wheel. Once the governor was removed from the mounting pad its gasket was found free from debris or contamination and its drive was found intact and free to rotate.

PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot at the Glenn County Coroner's Office. According to the coroner's report, the pilot died as a result of massive blunt force injuries.

Toxicological tests for ethanol and drugs were negative.

ADDITIONAL INFORMATION

Review of the San Francisco Sectional Aeronautical Chart revealed that a straight-line ground track between Chico and Ukiah would have taken the flight just south of the St. John Mountain and Snow Mountain. An area of lower terrain through the mountain chain was approximately 5 miles to the south of N3636M's flight track. The sectional depicts a maximum elevation figure (MEF) for the accident site quadrant as 7,400 feet. The MEF is based on information available concerning the highest known feature in each quadrangle, including terrain and obstructions (trees, towers, antennas, etc.). The MIA for the area is 9,100 feet.

The Aeronautical Information Manual (AIM) recommends the following during Mountain Flying: "Plan your route to avoid topography which would prevent a safe forced landing. The route should be over populated areas and well known mountain passes. Sufficient altitude should be maintained to permit gliding to a safe landing in the event of engine failure." The section on mountain flying continues by indicating, "VFR flight operations may be conducted at night in mountainous terrain with the application of sound judgment and common sense. Proper pre-flight planning, giving ample consideration to winds and weather, knowledge of the terrain and pilot experience in mountain flying are prerequisites for safety of flight."

The AIM's Pilot/Controller Glossary has a listing for "flight following;" however, it then instructs one to "see traffic advisories." The traffic advisory section in the glossary does not refer to any altitude clearance information. Section 4-1-15 of the AIM covers the Safety Alert, which is "issued to pilots of aircraft being controlled by ATC if the controller is aware the aircraft is at an altitude which, in the controller's judgment, places the aircraft in unsafe proximity to terrain, obstructions or other aircraft. The provision of this service is contingent upon the capability of the controller to have an awareness of a situation involving unsafe proximity to terrain, obstructions and uncontrolled aircraft."

The AIM also instructs pilots on the use and issuance of MSAW and reiterates that the service is automatic for IFR operations; however, VFR aircraft have to request MSAW.

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