Background
An aircraft executing a missed approach procedure in instrument conditions during an instructional flight collided with rising mountainous terrain. The accident occurred following a sequence of communications between the pilot and air traffic controllers.
Flight Sequence
At 1929, the TRACON controller cleared the aircraft for the VOR-A approach and instructed the pilot to contact the tower. The pilot acknowledged and contacted the local controller, stating they were on the VOR-A approach outside the final approach fix. Two minutes later, after observing the aircraft's target off course, the TRACON controller contacted the local controller to inquire why the airplane was circling the airport. The local controller said he would find out.
The local controller asked the pilot if he wished to cancel IFR or continue the approach. The pilot chose to continue, and the controller told him to report the runway in sight. The local controller, monitoring the flight's target on the DBRITE radar display, informed the pilot they appeared to be west of course. At 1932:20, the controller asked if they had the airport in sight, and the pilot replied affirmatively. The local controller then advised TRACON that the pilot was canceling IFR and had the airport in sight. TRACON dropped the aircraft's data block from its radar display.
Forty-seven seconds later, the local controller asked the pilot to confirm having the runway in sight; the pilot replied negatively. The controller asked if the pilot wanted the missed approach. The pilot said he had the ground and a freeway in sight. Instructed to continue and report the airport in sight, a few seconds later the pilot again reported the airport in sight and was cleared to land runway 26L.
At 1934:25, the local controller asked what the pilot was doing and if he had the airport in sight. The pilot asked if anything was wrong. The controller noted the pilot was three miles west of the airport and suggested a heading of 080 degrees, told him to maintain visual flight conditions, and to report the runway in sight. At 1936:02, the controller advised the airport was 1.5 miles at 12:00; the pilot said he did not have it in sight. The controller instructed a 10-degree right turn to enter downwind and again informed the pilot the airport was a little over a mile at 12:00. The pilot then reported the airport in sight. The controller instructed the pilot not to lose sight again and cleared him to land.
After observing the flight deviate, at 1939:29 the controller asked for the current heading. The pilot requested a missed approach. The controller instructed the pilot to execute the missed approach and standby for a frequency change.
ATC Communications and MSAW
Following the missed approach request, the local controller called the TRACON sector controller, and a discussion ensued about the flight's VFR versus IFR status. The TRACON controller thought the pilot had cancelled IFR and went VFR. The local controller stated that "he had cancelled, he had the airport in sight, he lost sight of the airport, and he is asking me now if he can go missed approach so I don't know what to do with him." The local controller offered to work the pilot to return to the airport unless TRACON wanted to take over. TRACON advised that if the pilot was in IMC and did not have the airport in sight, "I would have him turn southbound immediately." The local controller then told the pilot to turn south and climb immediately to 5,000 feet. There was no response.
Review of radar data showed that beginning at 1933:10, the Minimum Safe Altitude Warning system was flashing an alert on both the TRACON and DBRITE displays. However, after TRACON dropped the aircraft's data tag, the MSAW alert was automatically suppressed at TRACON. Review of air/ground communications tapes revealed that at no time did either controller issue an alert advisory for terrain avoidance to the flight.