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LAX03FA072
HISTORY OF FLIGHT
On January 23, 2002, at 1653, Pacific standard time, a Cirrus SR 20, N893MK, collided with power lines near San Jose,
California. The private pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The airplane was destroyed.
The pilot, the sole occupant, sustained fatal injuries. The personal cross-country flight departed Napa County Airport (APC),
Napa, California, at 1600, en route to Reid-Hillview Airport of Santa Clara County (RHV), San Jose. Day instrument meteorological
conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The primary wreckage was located at
37 degrees 16 minutes north latitude and 121 degrees 43 minutes west longitude.
During the investigation, the recorded voice channels from the Federal Aviation Administration (FAA) Northern California
Terminal Radar Approach Control (NCT), Palo Alto ATCT, and Reid-Hillview ATCT were examined. Recorded radar data from the
NCT ARTSIIIA system was also reviewed.
During the initial portions of the flight after takeoff from Napa, ATC issued numerous radar vectors and altitude assignments
to the pilot for traffic avoidance purposes. Review of the radar data disclosed that the pilot complied with all instructions.
At 1627, when the airplane was approximately abeam Oakland International Airport, the NCT Saratoga sector controller instructed
the pilot to proceed to navigational fixes near Palo Alto airport (PAO). The pilot questioned the clearance, and in the subsequent
exchanges the controller acknowledged his mistaken belief that the pilot was destined to PAO and that the flight was actually
destined to RHV. The controller asked the pilot from which fix he would like to initiate the approach, and the pilot requested
vectors to the approach "around OZNUM." OZNUM is the Final Approach Fix (FAF) on the RHV GPS 31R procedure. The
controller issued a clearance direct to OZNUM. After this exchange, radar indicated the airplane turned almost 90 degrees
to the right, and tracked on a course consistent with proceeding direct to PAO. The controller noticed the course deviation,
and queried the pilot. The controller provided no specific headings, but told the pilot to make a right turn to avoid traffic
associated with San Jose International Airport, and to proceed to OZNUM, which he said was "on the east side of RHV."
The pilot acknowledged and made a right turn of approximately 270 degrees, briefly tracking on an approximately southbound
course, which did not appear to be aligned with any relevant navigational fix. After approximately 3 miles on that course,
the pilot turned left to a track consistent with proceeding direct to OZNUM. The radar data showed that this ground track
resulted in the airplane flying overhead RHV, on approximately the reciprocal of the final approach course, i.e., aligned
with RHV, and the fixes OZNUM, then ECYON.
In his interview, the first NCT LICKE sector controller (L1) said he became aware of N893MK when he overheard the Saratoga
sector controller correcting the pilot's course to OZNUM. The L1 controller said he believed the pilot required extra attention
and intended to provide what assistance he could.
Comparing the voice transcripts to the recorded radar data showed that upon the pilot's initial contact with the LICKE
sector, the airplane had passed OZNUM, and begun a slight left turn to the east. At this point the pilot had no further clearance
to follow, since the Saratoga controller had cleared him direct to OZNUM with the expectation that L1 would provide vector
service. L1's initial instruction was for the pilot to proceed direct to ECYON; the pilot's response was to question the fix.
According to L1's statements, he recalled that the airplane was in a position coincident with a downwind leg, and the turn
toward ECYON would work out to be the same as a vector to final. Recorded radar data indicates the airplane was flying a course
approximately aligned with the Initial Approach Fix (IAF) ZUXOX. Shortly after this exchange, L1 noted the airplane appeared
to begin a left turn towards OZNUM, but he instructed the pilot to turn right toward ECYON in order to remain clear of a higher
terrain area. At this time, OZNUM was directly behind the airplane, and ECYON at about the four o'clock position. The pilot
completed a right turn, briefly flying a course consistent with tracking towards OZNUM, then made a slight left turn and flew
a course consistent with the published segment between ZUXOX and ECYON. L1 said he observed the pilot on this course and issued
clearance for the approach.
FAA Order 7110.65 specified that Standard Instrument Approach Procedures "shall commence at an Initial Approach Fix
or an Intermediate Approach Fix if there is not an Initial Approach Fix. Where adequate radar coverage exists, radar facilities
may vector aircraft to the final approach course [by assigning] headings that will permit final approach course interception
on a track that does not exceed 30 degrees." The order further states that vectors should be issued if required to intercept
the final approach course. ECYON was not an IAF. Review of the radar derived ground track revealed that the intercept angle
was about 40 degrees.
While the flight was progressing between ECYON and OZNUM, a controller change occurred at LICKE sector. L1 advised the
second controller (L2) that N893MK was on the approach and the only remaining task was to issue frequency change to RHV tower.
As the airplane passed just northwest of OZNUM, L2 instructed the pilot to contact the tower on frequency "118.6."
This frequency is actually assigned to PAO tower. The pilot queried the controller if that was actually correct. The controller
insisted, "Yes sir, it is." The pilot complied and contacted PAO tower. The pilot and the PAO controller discussed
that he was on the wrong frequency and the pilot said he would switch to the RHV frequency of 119.8. During this conversation,
radar indicated the airplane began a turn to the right, with the first target visibly displaced from the final approach course
at 1652:33, approximately over JOPAN waypoint. At 1652:50, the pilot reported to RHV tower "descending from JOPAN two
thousand feet five point four miles from missed approach point." Radar data agreed with the pilot's report; however,
the course had diverged almost 90 degrees from the final approach course.
Within 2 seconds of the pilot making initial contact with RHV tower, the ARTS Minimum Safe Altitude Warning System (MSAW,
see ATC Group factual report in docket material) provided a visual and audible alert at the RHV tower and NCT. In response
to the pilot's call, the RHV tower controller cleared the pilot to land then said "low altitude alert, check your altitude
immediately." The MSAW system activates whenever the targets projected track will encounter higher terrain, or, when
the mode C reported altitude is below the minimum safe altitude for the navigational segment being flown. Based on the radar
data, the airplane's projected track was diverging away from the centerline of the approach, and toward higher terrain. At
the time of the alert the airplane was at about 1,900 feet, and the minimum altitude for the final segment is 1,440 feet.
About 30 seconds later, the tower controller notified the pilot that he appeared off course. The pilot made a brief unintelligible
transmission and no further radio or transponder signals were received.
The radar track of the airplane was lost in the area of high-tension power lines, located 6.7 miles south east of RHV
at an altitude of 1,600 feet mean sea level (msl). The last radar data with an altitude return was at 16:53:40, and showed
the airplane at a mode C reported altitude of 1,700 feet.
PERSONNEL INFORMATION
A review of FAA airman records revealed the pilot held a private pilot certificate with an airplane single engine land
and instrument airplane rating. The pilot was issued a third-class medical on June 8, 2001, with the limitations the pilot
must wear lenses for distant vision, and possess glasses for near vision.
An examination of the pilot's logbook indicated a total flight time of 460.7 hours, of those 362.4 hours were dual received.
The pilot had logged his total IFR time as 150.3 hours of which 10.7 hours were actual IFR. He had 334 hours in this make
and model; 84.8 hours were logged in the last 90 days.
The pilot had completed and passed an instrument airplane check ride on January 6, 2003. The designated examiner (DE)
was interviewed and related the pilot was very detail orientated, and also very knowledgeable about the Cirrus SR 20.
AIRCRAFT INFORMATION
The airplane was a Cirrus SR 20, serial number 1038. A review of the airplane's logbooks disclosed the annual inspection
was completed on February 20, 2002. Total airframe time was listed as 67.8 hours and a Hobbs time of 67.8 hours. The airplane
had a total time of 369.3 hours.
The transponder and altimeter/static and altitude reporting systems were inspected on February 20, 2002.
A Teledyne Continental Motors IO-360ES-6B engine, serial number 357190, was installed in the airframe in May 2000. The
engine had a total time of 369.3 hours.
An aircraft weight and balance report dated February 18, 2002, revised the airplane's weight and balance data sheet. It
listed the new empty weight as 2121.23 pounds; total moment of 296507.35-inch pounds, and listed the empty center of gravity
as 139.78 inches aft of the datum.
The Cirrus SR 20 uses conventional flight controls for ailerons, elevator, and rudder. The control surfaces are pilot
controlled through either of two single-handed side control sticks mounted on each side of the airplane's cockpit.
The neutral position of the left side stick is at a 45-degree angle to the right. The neutral position of the right side
stick is a 45-degree angle to the left. The accident airplane was being flown from the left pilot seat. A pilot flying from
the left seat would rest his left-hand on the side control stick; any inadvertent pressure applied by the pilot could potentially
induce an unintentional right turn of the airplane.
The accident airplane (SN 1038) was originally equipped with the factory "Avionics Configuration C" package
which included dual Garmin GNS 430's. The GNS 430 is a combination global positioning satellite (GPS) receiver, communication,
and navigation system. The GNS 430's were mounted in the center console of the airplane below the ARNAV ICDS 2000 display.
A major repair and alteration (FAA Form 337) dated February 20, 2002, was filed reporting an upgrade in the avionics,
which were installed in the airplane. The transponder was upgraded; a Ryan 9900BX traffic collision avoidance detection (TCAD)
system; and a WX-500 stormscope system were installed.
AIRPORT, NAVIGATION FACILITIES AND APPROACH INFORMATION
The Airport/ Facility Directory, Southwest U. S., indicated RHV runway 31R was 3,101 feet long and 75 feet wide. The runway
surface was asphalt. The only IFR approach into RHV is the GPS RWY 31R.
According to a review of facility records, all relevant ATC and navigational equipment was operating. There were no NOTAMs
or other evidence of any GPS anomalies in the vicinity of RHV. The GPS 31R approach procedure was a fairly new procedure,
prior to the establishment of this approach, RHV did not have any Standard Instrument Approach Procedures.
During interviews with the controllers at NCT and RHV they reported that they had been briefed on the approach procedure,
and were generally familiar with it, although it did not receive heavy use.
The RHV GPS 31R approach course was established in a congested area of high traffic density associated with the airports
in the southern San Francisco Bay area. The final approach course closely paralleled the SJC approach course to the southwest,
such that airplanes established on these approaches were separated by the minimum allowed lateral distance. To the northeast,
terrain rose rapidly, leaving very little room to maneuver for airplanes below 4,000 feet.
Review of the radar display terminals at NCT disclosed that video mapping did not directly depict the GPS 31R final approach
course. In order to visualize the course, controllers had to visualize a line between the airport symbol, and the OZNUM and
ECYON waypoint symbols.
The RHV Tower Remote ARTS Color Display (R-ACD) video map did include a depiction of the final approach course as a series
of dashed lines. Depictions of JOPAN and OZNUM waypoints also appeared on the map. In their interviews, the controllers noted
the waypoint symbols are quite large; the investigators observed that the "points" on the symbols extended approximately
0.75 miles beyond the centerline of the approach course.
ARTS radar targets on the controllers display were oriented such that the longer dimension of the return was aligned perpendicular
to the azimuth from the radar site, (i.e. "broadside") and a target whose track is diverging from the final approach
course would not be readily apparent. This topic is discussed in detail in the ATC Group Factual Report, which is contained
in the docket for this accident.
METEOROLOGICAL CONDITIONS
The closest official weather observation station was Reid-Hillview Airport of Santa Clara County (RHV), San Jose, located
6.7 nautical miles (nm) northwest of the accident site. The elevation of the weather observation station was 133 feet msl.
A special aviation weather report (METAR) for RVH was issued at 1653. It stated: skies 1,200 feet broken, 8,000 feet overcast;
visibility 4 miles; winds from 280 degrees at 12 knots; temperature 60 degrees Fahrenheit; dew point 59 degrees Fahrenheit;
and altimeter 30.24 inHg.
WRECKAGE AND IMPACT
The terrain at the accident site was mountainous. The airplane came to rest approximately 650 feet on a bearing of 032
degrees from the first identified point of contact (IPC). The accident site was at the bottom of a ravine. The airplane came
to rest on a magnetic heading of 056 degrees at an almost level attitude on the upslope side of a 45-degree slope.
The first identified point of contact (IPC) was the west side static line approximately 100 feet south of the Pacific
Gas and Electric (PG&E) high-tension power line tower number 130. The second identified point of contact was the pair
of 500 KV power lines located on the east side of the PG&E tower number 130. One of the power lines was lying on the ground
adjacent to tower number 130; it had pieces of fiberglass imbedded in a broken bracket, which is used to suspend the power
lines from the tower. Approximately 6 feet north of the broken bracket were witness marks on the wire that appeared to be
at a 45-degree cut into the power line. The power lines are approximately 2 inches across.
All of the airplane's flight control surfaces were at the accident site. The rudder, elevators, and horizontal stabilizer
assemblies were attached to the empennage. All control surfaces and their associated mass balance weights were in the debris
field.
The outboard section of the left wing was in a tree approximately 160 feet northeast of the IPC. The left wing section
displayed charring. On the left wing section approximately 3 feet inboard from the wing tip, there was a semicircular depression
approximately 2 inches across.
The airplane was equipped with an emergency ballistic parachute system. The ballistic parachute system had not been deployed.
The safety pin, which is used to prevent inadvertent deployment, was still in place. The safety pin had a tag attached to
it that is red in color with white lettering and read, "SAFETY PIN REMOVE BEFORE FLIGHT."
MEDICAL AND PATHOLOGICAL INFORMATION
The Santa Clara County Coroner completed an autopsy. The FAA Toxicology and Accident Research Laboratory performed toxicological
testing of specimens of the pilot. The results of analysis of the specimens were negative for carbon monoxide, cyanide, and
volatiles.
Results for tested drugs were; 0.015(ug/ml, ug/g) Dextromethorphan detected in blood, Dextromethorphan present in urine,
Dextrorphan detected in blood, Dextrorphan present in urine, Ephedrin detected in urine, Phenylpropanolamine detected in blood,
Phenylpropanolamine present in urine, Pseudoephedrine present in blood, Pseudoephedrine present in urine, and 29.5(ug/ml,
ug/g) Acetaminophen detected in urine.
TESTS AND RESEARCH
Investigators examined the wreckage at Plain Parts, Sacramento, California, on January 26-27, 2003.
Investigators removed the engine. The engine was suspended from a hoist; the top spark plugs were removed. All spark plugs
were clean with no mechanical deformation. The spark plug electrodes were gray in color, which corresponded to normal operation
according to the Champion Aviation Check-A-Plug AV-27 Chart.
Investigators attempted to rotate the engine using the accessory side of the engine but were unable to manually rotate
the engine. The crankshaft flange was broken off, and bent.
Investigators manually rotated the magnetos, and both magnetos produced spark at all posts for cylinders.
The vacuum pump was broken from the engine mounting point. The coupler was bent but in tact. The pump could not be rotated
by hand. Disassembly of the vacuum pump revealed that the rotor was fractured in three places radialy from the center out,
and the vanes were in tact.
The oil sump screen was clean and open. The governor screen was clean. The oil screen filter was clean.
The fuel pump's rubber diaphragm was unbroken and investigators blew air through the lines. The plunger in the fuel distribution
valve moved freely, the rubber diaphragm was unbroken, and investigators did not observe any contamination. The fuel nozzles
were open and the screens were clean.
The fuel selector valve was between the left and right positions, slightly towards the right tank.
The aircraft uses three cable loops to control the aircraft's three-axis control surfaces: ailerons, rudder, and elevator.
All cables start and end their runs from the front of the airplane and are routed to the various controls via a (forward)
six and (aft) four gang pulley system. The ailerons use two "kick-out" pulleys to route the aileron cables from
the front of the aircraft outboard to the aileron pulleys located in the outboard one third of each wing. The right aileron
cable was intact and on the right aileron pulley. The left aileron cable was intact and on the left aileron pulley. The elevator
and rudder cables are routed to the 306-bulkhead pulley cluster that activates the rudder and elevator control arms attached
to their respective pulleys. The aircraft utilizes a rudder / ailerons interconnect system ("RAI") to add rudder
input when the pilot deflects the ailerons.
The forward (six-gang) and aft (four-gang) control cable pulleys were intact and the control cables were still on their
respective pulleys. The cable retainer on the six-gang pulley was bent, but secure. The four-gang pulleys were also intact,
although the four control cables were slack since recovery personnel had purposely cut them during the retrieval process.
Inspection of the Rudder Aileron Interconnect (RAI) revealed that all RAI components were intact. All cables were intact
and on their respective pulleys.
The central aileron pulley was bent aft at the 5-7 o'clock position; the cable was attached and intact. The cable was
attached and intact on the central pitch pulley sectors. The rudder cables were attached and intact on their rudder bars.
Control cable continuity was established throughout the control system.
The right-hand side controller linkages to the main control pulley and pulley sectors were intact; the left side controller
linkages were destroyed by the impact forces and could not be inspected.
The flap actuator was measured at 11 inches. The factory representative reported this corresponded to the fully retracted
(Up) position. The elevator pitch trim motor was toward a "nose up" position.
The airplane was equipped with an ARNAV ICDS-2000, which is a VFR moving map, and with the installed EMM-35 (engine monitoring
module) also displayed engine data. The displayed data included cylinder head temperature (CHT), engine gas temperature (EGT),
engine rpm, and fuel flow. The ICDS stores the data in 1-minute intervals. The ICDS-2000 and the EMM-35 were removed from
the airplane and shipped to the manufacturer for further analysis.
On March 17, 2003, a National Transportation Safety Board investigator was present at the RNAV Systems Inc., Puyallup,
Washington, during the inspection of the ARNAV ICDS-2000 and the EMM-35. The data recovered from the data storage card indicated
that the accident airplane, on the date of the accident had departed RHV, flown to APC, shut down the aircraft systems for
43 minutes, and then flown from APC to the area of the accident. The total elapsed time was 3 hours 5 minutes.
The engine assembly was removed from the airframe and shipped to the engine manufacturer, Teledyne Continental Motors
(TCM) for further examination.
On April 23, 2003, investigators from the Safety Board, Cirrus Design, and TCM examined the engine at the TCM factory
Mobile, Alabama.
The engine was disassembled and examined. No abnormalities were found to preclude engine operation prior the impact.
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