Pilot Debrief

Beech V35 near La Verne, CA — 2018-10-01

Final reportWPR19FA001
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Date
2018-10-01
Location
La Verne, CA, USA
Airport
POC
Aircraft
Beech V35
Registration
N7997M
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's failure to maintain clearance from trees during a visual approach for landing. Contributing to the accident was the pilot's distraction during the approach.

Contributing factors

Contributing to the accident was the pilot's distraction during the approach.

NTSB narrative

The pilot was approaching his home airport in day visual meteorological conditions at the conclusion of a cross-country flight. The tower controller cleared the pilot for a straight-in approach to runway 8R and advised him that another airplane about 1 mile ahead was inbound for landing on the parallel runway, 8L. A short time later, the controller asked the accident pilot if he had the other airplane in sight. The pilot responded that he was looking for the traffic and was inbound for runway 8L. The controller immediately corrected the pilot and verified he was cleared to land on runway 8R, which the pilot confirmed. Shortly thereafter, the pilot told the controller that he had the other airplane in sight and that it was aligned with runway 8R. The controller queried the pilot of the other airplane and verified that that airplane was cleared for landing on runway 8L, then confirmed with the accident pilot that the accident airplane was cleared for 8R. About 20 seconds later, the controller asked the accident pilot if he was landing 8R and subsequently instructed him to go-around and offset his flight path to the right. There was no further communication from the accident airplane. Witnesses, who were at the site of an aircraft accident that occurred the previous day near the end of the runways, heard the accident airplane impact trees. They turned to see the airplane in a left banking, nose-low attitude that progressively steepened before the airplane impacted the ground, a post-impact fire ensued. Radar data showed the accident airplane proceeding toward the airport left of the runway 8R centerline until it was about 0.76 nautical mile (nm) west of the runway 8R, when it turned right, then left. The final 3 radar targets showed a right turn toward runway 8R. Radar data showed that the other airplane was flying right of the runway 8L centerline until about 0.64 nm of runway 8L, when it turned left toward runway 8L. Examination revealed no anomalies with the airframe or engine that would have precluded normal operation. Given the apparent confusion regarding the inbound airplanes' runway assignments and the multiple communications with air traffic control, it is likely that the pilot's attention was diverted from the task of flying the airplane throughout the approach. It is likely that the pilot's distraction resulted in his failure to recognize that the airplane had descended below a proper approach path, and the airplane's subsequent collision with trees.

Analysis

Primary failure mode
Automation / mode confusion
First missed decision gate
Pilot could have maintained approach to runway 8R instead of attempting to land on 8L.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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