Pilot Did Not Obtain A Weather Briefing, Continued VFR Into IFR
An accident in California which resulted in the fatal injury of
two moderately experienced pilots was caused by pilot error,
according to the NTSB. The two people on board the Piper PA-28-235
were a husband and wife. She was flying at the time of the
accident, and her logbook showed over 750 hours in the accident
airplane, but no instrument rating. Her husband was also a licensed
pilot with a current medical, but had stopped acting as PIC,
according to his family.
NTSB Identification: WPR10FA234
14 CFR Part 91: General Aviation
Accident occurred Sunday, May 09, 2010 in Livermore, CA
Probable Cause Approval Date: 05/19/2011
Aircraft: PIPER PA-28-235, registration: N56626
Injuries: 2 Fatal.
The flight departed in visual flight rules flight conditions and
the non-instrument-rated pilot was returning to her home airport.
There was no evidence the pilot obtained a weather briefing prior
to departure. An analysis conducted by an NTSB meteorology
specialist determined that precipitation passed through the area of
the accident site near the time of the accident. A witness that
heard the airplane and its subsequent collision with terrain
indicated that there was low fog at the time of the accident. Radar
data showed that the airplane flew in a straight-line pattern from
the northeast to the southwest between its departure and
destination and then turned to the southwest when approaching an
area of higher terrain. Based on witness information, it is likely
that the weather conditions were poor in this area and the pilot
was attempting to maneuver the airplane to improved weather
conditions at lower elevations on the other side of the higher
terrain. Postaccident inspection of the airplane did not disclose
evidence of any preimpact anomaly of the engine or airplane
systems. The pilot was on a prescription antidepressant medication
that would not have been expected to impair her performance.
Additionally she also had ingested quinine, which may in some cases
contribute to spatial disorientation, although its effect in this
accident, if any, could not be determined.
The National Transportation Safety Board determines the probable
cause(s) of this accident to be the pilot's continued visual flight
into instrument meteorological conditions, which resulted in a
collision with obstacles and terrain.
HISTORY OF FLIGHT
On May 9, 2010, at 1028 Pacific daylight time (PDT), N56626, a
Piper PA 28-235, collided with trees and terrain approximately 8
miles northeast of the Livermore Municipal Airport, Livermore,
California. The pilot was operating the airplane under the
provisions of Title 14 Code of Federal Regulations Part 91. The
private pilot and passenger, who also held a private pilot
certificate, were fatally injured. The airplane sustained
substantial damage. Witness information indicated that instrument
meteorological conditions prevailed at the accident site. The pilot
departed in visual flight rules (VFR), requested and received
flight following after departing from Auburn Municipal Airport,
Auburn, California, about 0945, and was destined for the San Carlos
Airport, San Carlos, California.
According to family members of the pilot, the pilot and
passenger were visiting family in the Auburn area and wanted to
return to their home in San Carlos for an afternoon meeting.
A witness that lives near the accident site was outside when the
accident occurred. She heard the airplane but did not see it due to
fog. She stated that the airplane sounded lower than most that fly
in the area, and the engine sounded normal. She then heard what she
believed was the sound of the airplane's impact with terrain.
The pilot was in communication with Northern California Terminal
Radar Approach Control (TRACON). According to Federal Aviation
Administration (FAA) air traffic control information, the pilot had
requested a flight following clearance to San Carlos Airport, and
the pilot was authorized to fly at an altitude of the pilot's
discretion. There were no distress calls from the pilot.
A Safety Board Air Traffic Control specialist completed a plot
of the radar data for the accident airplane. The plot showed a
flight track from the northeast to the southwest at about 3,000
feet. In order to reach San Carlos, the airplane would have crossed
over an area of hilly terrain that rose to about 2,300 feet. When
the track reached the hilly terrain, the radar targets showed a
descent to 2,600 feet and a turn to the south-southeast. The last
radar target was at 2,799 feet at 1028. The accident site was about
10 miles southeast of the straight-line path from Auburn to San
The pilot, age 75, held a private pilot certificate for airplane
single-engine land, and a third-class airman medical certificate
issued December 4, 2008, with limitations that she must wear
corrective lenses. Review of the pilot's logbook showed that she
had 983 flight hours, with 751 hours in the accident airplane. The
pilot had flown 3 hours in the past 90 days, 2 hours in the past 30
days, and 1 hour over the past 24 hours.
The passenger, the pilot's husband, was also a rated pilot with
a current medical; however, family members indicated that he no
longer flew as pilot-in-command.
The four-seat, low-wing, fixed-gear airplane, serial number
28-7410016, was manufactured in 1973. It was powered by a Lycoming
Engines O-540-B4B5 250-hp engine, and equipped with a Hartzell
HC-C2YK-1BF fixed-pitch propeller. Review of copies of maintenance
logbook records showed an annual inspection was completed on April
1, 2010, at a recorded tachometer reading of 3,171.74 hours. The
tachometer read 3,175.65 hours at the accident site. The airplane
was equipped with a Garmin (Apollo) CNX 80 global positioning
system integrated avionics unit, and maintenance records showed
that the main software had been upgraded on April 19, 2010.
According to a representative from Lockheed Martin Flight
Service, no weather services were provided. Additionally, there was
no record of a weather briefing being obtained from either DUAT
A Safety Board meteorologist completed a weather study. The
closest official weather observation station was Livermore,
California. At 1053, an aviation routine weather report (METAR) was
reporting the following conditions: wind from 210 degrees at 7
knots, 190 degrees variable to 250 degrees; visibility 10 statute
miles; clouds few 2,200 feet, broken 4,000 feet; temperature 14
degrees Celsius; dew point 9 degrees Celsius; altimeter, 30.02
inches of Mercury.
The National Weather Service (NWS) Surface Analysis Chart for
1100 PDT depicted a shortwave trough in northern California
extending from near the California/Oregon border out into the
Pacific Ocean north of Mendocino, California. Station models in and
near the San Francisco, California Bay Area indicated generally a
westerly flow with overcast skies to the west of the accident site.
Light rain was reported north of the accident site.
A region mosaic of composite reflectivity data from WSR-88D
stations indicated light rain was likely falling in limited areas
of the San Francisco Bay Area. These radar data give no indication
of severe weather in northern California at this time.
The closest WSR-88D weather radar to the accident location was
KMUX located in the Santa Cruz Mountains south of the San Francisco
Bay Area. The radar was located approximately 40 miles south of the
accident site at an elevation of 3,469 feet. At this distance and a
radar tilt of 0.53°, hydrometeors above the accident site were
detected between approximate altitudes of 4,700 and 8,800 feet
(assuming a standard refraction of “1.33”). Highest
reflectivities in the immediate area of the accident site are 20-25
dBz, corresponding to light precipitation, which had an observed
movement to the east through the area before the accident.
Radar imagery at 1013 PDT indicated light precipitation passed
through the accident airplane’s eventual flight path near the
accident site about 12-15 minutes prior to the airplane. Although
unconfirmed, it is likely that falling precipitation reached flight
altitudes. Radar imagery at 1025 PDT indicated no precipitation was
falling at the accident site near the accident time.
WRECKAGE AND IMPACT INFORMATION
The first identified point of impact was an area of 50-foot tall
trees, at an elevation of 2,412 feet mean sea level. Pieces
identified from the left wing were located in the area of the
trees. The debris path continued in a direction of about 100
degrees magnetic, with additional pieces of the left wing. The
first identified ground impact was approximately 110 yards from the
trees. The debris field continued with large sections of the left
and right wings, the main wreckage and empennage, and the engine.
The length of the overall debris field was approximately 290
The Contra Costa County Coroner completed an autopsy on the
pilot. The cause of death was reported as multiple blunt impact
The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma
City, Oklahoma, performed forensic toxicology on specimens from the
pilot. The toxicology report stated no carbon monoxide or ethanol
was detected. Drug screening showed that fluoxetine, norfluoxetine,
and quinine were detected. FAA toxicology staff indicated records
accompanying the specimens noted that the blood provided was
“cavity blood.” FAA toxicology staff also indicated
that the blood was not tested for the presence of quinine.
TESTS AND RESEARCH
The airframe was examined. Both wings were in multiple pieces.
The left wing consisted of a circular indentation 12 inches from
the inboard of the wing root that ran from the leading edge and
pushed the skin aft to the spar. A 2-foot section of the flap
remained attached to this section. The next section was 6 feet in
length and contained the remainder of the left flap, the left
landing gear, and a 3-inch inboard section of the aileron. Two
smaller pieces of leading edge were identified with two circular
indentations, similar in size and shape to the tree branches found
at the site. Moving outboard from this section the leading edge and
trailing edge of the wing had separated into two pieces, and the
remainder of the aileron had separated. The tip tank had separated
from the wing. The right wing had separated into four sections. The
largest section was the inboard portion of the wing that extended
outboard to the tip tank. The flap and aileron remained attached. A
4-foot outboard leading edge panel of the wing had separated and
was crushed. The tip tank had separated from the wing and was found
in two pieces. There were no circular indentation marks on this
wing. All control surfaces were accounted for.
The control cables were traced to the ailerons and all
separations were broomstrawed. The flap control surfaces appeared
retracted and there was no damage on the trailing edges. Control
cables were traced from the cockpit attach points and then aft. All
cables were still secure at their attach points.
The engine was examined. Mechanical continuity was obtained via
manual rotation of the propeller. Thumb compression was obtained on
all cylinders and the valves produced the same amount of lift.
Manual rotation of the magnetos produced spark at all posts. The
engine driven fuel pump was not found. The spark plugs were
examined and all electrode gapping was similar. Spark plugs 2, 4,
and 6 were oil coated. There was no evidence of catastrophic
malfunction or fire. The cylinders were borescoped and there was no
evidence of foreign objects or detonation. The carburetor remained
secured at the mounting pad and the respective control arms
attached. The carburetor was removed and then disassembled.
Approximately 3 ounces of fuel remained in the bowl and was
consistent in color and smell to 100 low lead (LL). No evidence of
water was found. The floats were intact and secure on their
Examination of the recovered airframe and flight control system
components revealed no evidence of pre-impact mechanical