The Go/No-Go Decision

The NTSB recently completed its investigation of an accident in which the pilot and passengers had spent at least eight hours waiting at the airport in hopes that the weather would clear. Although the reported weather at several ground observation stations in the departure area was VFR, the pilot knew that conditions were spotty and that only a brief heading and/or altitude deviation could lead him into the "soup."

On June 6, 2003, at 3:55 p.m., a Beechcraft A36TC crashed into a three-story apartment building in the Fairfax District of Los Angeles. The airplane dived straight down through the roof, and came to rest in a parking lot on the first floor. The private pilot owned the airplane and was operating it on a Part-91 personal flight. The pilot and three passengers sustained fatal injuries. One person in the apartment building also was killed, and seven people on the ground received serious injuries. The airplane was destroyed by the post-crash fire.

The flight originated at the Santa Monica Municipal Airport (SMO), Santa Monica, Calif., about 10 minutes before the crash. The pilot had planned to stop in Las Vegas, and then proceed to Sun Valley, Idaho.

At 8:03 a.m., the pilot phoned the Hawthorne Automated Flight Service Station and asked for a weather briefing for a proposed VFR flight from SMO to Sun Valley. He also made a special request for weather information for a departure out of the Los Angeles area east toward the direction of Ontario, Calif. The briefer told him that the forecast called for overcast cloud conditions in the Los Angeles basin with bases from 2,000 feet to 3,000 feet, and tops of 4,000 feet. An AIRMET was in effect for IFR conditions and mountain obscuration, and predicted widespread ceilings below 1,000 feet, with three miles visibility in mist. The pilot again called the Hawthorne AFSS at 11:25, and was told that VFR flight was not recommended.

At 1:01 p.m., the pilot made a third call to the AFSS and asked for specific weather information for a route of flight from Los Angeles toward Ontario. He indicated that he could fly VFR under the layer of clouds toward Ontario and "get up through it somewhere." The pilot inquired if he could "legally" fly VFR, to which the briefer replied that the weather reports indicated minimums for flight under visual flight rules were being reported, but weather conditions were marginal.

At 3:45:38, the pilot advised the SMO tower local controller that he was ready for departure and requested a right downwind departure. He then asked if the controller heard if the weather was clearing up to the east. The controller responded, "No," and mentioned that Disneyland was cloudy. The pilot replied that he was going to try and get out of the basin via Ontario, and he would try to "pop up" through the "broken layers and broken stuff" in the area. The SMO controller cleared the Beech A36TC for takeoff and approved the right downwind departure. The pilot requested a frequency change and requested that the tower advise him when he could switch to Southern California Terminal Radar Control (SOCAL TRACON).

At 3:50:48, the pilot requested a frequency change. The SMO controller issued traffic at the pilot's 12 o'clock position, two miles at 2,000 feet. The pilot advised that he did not have the traffic in sight, and would remain on the SMO frequency for a bit longer.

At 3:51:31, the SMO controller again issued the traffic to the pilot, advising that it was now at his 11 o'clock position, one mile distant and at 2,000 feet. The pilot reported that he had the traffic in sight. The pilot advised that he was leaving the frequency, and the SMO controller acknowledged. SOCAL TRACON had no record of the pilot contacting them.

Investigators reviewed recorded radar data from SOCAL. The radar data indicated a mode-C secondary 1200 (VFR) beacon code return in a location and time frame consistent with the accident airplane's departure from Santa Monica.

The recorded radar data indicated that the airplane was headed in an easterly direction. The target maintained a mode-C reported altitude of 2,200 feet MSL for a little less than a minute, then started a climb to an altitude of 2,600 feet MSL.

At 3:52, the mode-C return indicated another climb to 3,100 feet MSL. About five seconds later, the mode-C return indicated that the airplane was at 3,300 feet MSL. The last radar return, at 3:52:19, indicated a mode-C altitude of 2,400 feet MSL.

One witness told investigators that he observed the airplane flying straight and level. This witness reported seeing the nose of the airplane pitch up, after which the airplane began to climb. The witness lost sight of the airplane as it entered the clouds. When he saw the airplane again, it was in a nose-down attitude, spinning toward the ground. He lost sight of the airplane behind some trees and buildings.

Other witnesses also indicated that they saw the airplane in a nose-down attitude, spinning toward the ground. Some witnesses said that the engine was not sputtering, while others said it was "cutting in and out."

A witness who was standing outside of his home near the accident site thought that the airplane was doing aerobatics. He reported seeing the airplane in a vertical dive and estimated that it completed at least three 360-degree turns. Investigators learned that the pilot held a private-pilot certificate with a rating for airplane single-engine land, but did not hold an instrument rating. His third-class medical certificate was current with no limitations or waivers.

At the time of his most recent medical examination, on August 2, 2001, the pilot reported having a total time of 1,250 hours. His logbook, recovered at the accident site, showed that through March 25, 2002, his total flight time was 1,089 hours. The NTSB noted that the last logbook entry was on August 15, 2002, and flight times had been entered sporadically.

Logbooks for the Beech A36TC were not made available for investigators to review. Work orders from a repair station indicated that at the last annual inspection, on November 26, 2002, the airframe had 2,888 hours, and the engine and propeller both had 486 hours. Weather observed at the Santa Monica Municipal Airport at 3:51 was overcast ceiling at 3,100 feet; visibility at 10 miles; winds from 240 degrees at 10 knots; temperature at 64 degrees F; dew point at 57 degrees F; altimeter at 29.93. Weather observed at the Burbank-Glendale-Pasadena Airport at 3:53 indicated scattered clouds at 2,700 feet; visibility at 10 miles; winds from 220 degrees at six knots; temperature at 70 degrees F; dew point at 59 degrees F; altimeter at 29.90. At 3:49, the weather that was observed at the El Monte Airport, 15 nm east of the accident site, was broken clouds at 2,000 feet; overcast ceiling at 3,000 feet; visibility at five miles with haze; winds from 190 degrees at five knots; altimeter at 29.92.

The AIRMET, which the pilot had been given, warned of IFR with widespread ceilings below 1,000 feet and visibility at three miles in mist and mountains obscured in clouds and mist. The accident site was in the area covered by the portion of the AIRMET calling for mountain obscuration.

The FAA's Toxicology and Accident Research Laboratory in Oklahoma City performed toxicological testing. Although some alcohol was detected, it could not be ascertained whether or not the alcohol detected in the lab was the result of ingestion by the pilot or was a natural by-product occurring after death. Traces of cocaine were detected.

On-scene and follow-up examinations found no problems with the engine, propeller or accessory equipment, including the vacuum-pump drive. The spark plugs, however, showed signs of wear. Flight control continuity was established by measuring flight-control cables and identifying the associated hardware.

The NTSB determined that the probable cause of this accident was the pilot's in-flight loss of control due to spatial disorientation and his failure to maintain airspeed, which resulted in a stall and spin. Also causal was the pilot's disregard of the weather information that was provided and his attempt to continue VFR flight into IMC. A factor in the accident was the pilot's self-induced pressure to complete the flight.

Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.