History of Flight
On March 14, 2009, at 1115 Pacific daylight time, a Piper PA-28-236, N129AB, struck elevated terrain in Pomona, California. The aircraft was operated by the owner under 14 CFR Part 91. Both private pilots aboard were killed, and the airplane was destroyed. Instrument meteorological conditions prevailed, and an IFR flight plan was filed. The flight departed Brackett Field Airport, La Verne, California, around 1112, destined for Mojave, California. The accident site was 2.15 miles south of Brackett Field.
Weather at Brackett Field at 1147 included winds variable at 5 knots, 1-statute-mile visibility in mist, and a 500-foot overcast. Ontario Airport, 10 miles east, reported at 1053 winds 150 degrees at 4 knots, 2.5-statute-mile visibility in mist, and an 800-foot overcast. A pilot who departed ahead of the accident aircraft reported encountering IMC at 500 feet agl and solid IMC until emerging above the cloud layer at 3,100 feet msl.
Witnesses observed the male pilot in the left seat and the female pilot in the right seat before departure. The pilot received an IFR clearance from Brackett ground control at 1046: climb via Brackett departure 26 (heading 159 to 1,400 feet msl, then left turn heading 130 to intercept the Pomona VOR 164 radial outbound to PRADO intersection), then follow V16 to Paradise VORTAC. The pilot was to climb to VFR-on-top conditions; if not on top by 4,000 feet, maintain 4,000 feet and advise ATC.
Radar data from Southern California TRACON tracked the flight. The first return at 1112:16 showed 1,300 feet over the west end of runway 26. The track made a climbing left turn to 146 degrees. At 1113:46, at 2,500 feet, a right-hand turn began, tightening into a spiral. At 1114:20, after 90 degrees of turn at 2,600 feet, the pilot acknowledged instructions to climb to 4,000 feet. Twenty seconds later, at 2,900 feet, the controller asked if the pilot had canceled. The pilot responded, “Negative, nine alpha bravo still climbing.” The track had turned 180 degrees and was at 2,700 feet. This was the last transmission. Five seconds later, at 2,600 feet, the controller asked, “Ok, where are you going? Turn right heading 130…” The last radar return was at 1114:49, 2,600 feet, directly over the accident location.
Personnel Information
The pilot, age 52, held a private pilot certificate with single-engine land and instrument airplane ratings, issued August 29, 2006. He held a third-class medical certificate issued November 2, 2007, with no limitations. His instrument rating application reported 190.9 total flight hours. An electronic logbook from January 20, 2007 to February 28, 2009 showed 286.9 hours, with 0.8 hours actual instrument, 0.8 hours simulated instrument, and 4 instrument approaches. The most recent instrument approach was October 29, 2008, in an SR-22; the prior was April 28, 2007, in the accident airplane. His CFI conducted a BFR on August 22, 2008, focused on VFR techniques; no practice approaches or simulated instrument conditions were flown. Total flight time was estimated at 478 hours.
The second pilot, age 48, held a private pilot certificate with single-engine land rating, issued March 3, 2007. She held a third-class medical certificate issued September 25, 2007, with a limitation for glasses for near vision. She reported 180 total hours. She began instrument flight instruction on August 23, 2008, with the same CFI, accumulating 1.3 hours actual instrument and 37 hours simulated instrument.
Aircraft Information
The four-seat, low-wing, fixed landing gear airplane, serial number 28-7911303, was manufactured in 1979. It was powered by a Lycoming O-540-J3A5D 235-hp engine and a Hartzell constant-speed propeller. An annual inspection was completed on March 6, 2009, at a tachometer reading of 1125.3 hours, airframe total 4,297.8 hours, and engine TSMOH 2,291.4 hours. Lycoming recommends 2,000 hours between overhauls. Damage prevented reading the Hobbs meter and tachometer. The instrument panel included a single attitude gyro in front of the left seat, a directional gyro below it, a vertical card compass, two CDI and glide slope indicators, two Garmin GNS-430s, a Garmin GPSMap 496 on the left yoke, and a tablet computer mounted in front of the right panel.
Wreckage and Impact
The wreckage rested on a hillside at 916 feet elevation on a 40-degree slope, with rock, dirt, and grass terrain. A post-impact fire destroyed the cockpit and center fuselage. The vertical stabilizer, horizontal stabilator, and left wing were located together; all control cable ends were attached to bell cranks, and separated ends showed broomstraw characteristics. A 5-foot outboard section of right wing was found 585 feet northeast, with damage consistent with ground impact. The engine separated, the case fractured, revealing the crankshaft and missing three cylinders and pistons. Both propeller blades separated, exhibited twisting and leading edge damage. The left wing and vertical stabilizer had leading edge crushing aft along their length. Smaller debris lay downslope.
On April 3, 2009, an examination by an FAA inspector and manufacturer representatives under Safety Board supervision revealed a completely destroyed cockpit; instruments, tablet, and GPS components were fragmented. A recovered SD card and PCMCIA card were sent to the Vehicle Recorder Laboratory; the PCMCIA card was too damaged, and the SD card contained no recoverable data. The vacuum system integrity could not be verified. Control cables were laid out; all separations had broomstraw appearances consistent with overload. The engine crank case was fragmented; the forward crankshaft bearing showed no pitting or over temperature, no heat distress on rotating components, and exhaust elements had similar gray coloration.
Medical and Pathological Information
Autopsies performed on March 20, 2009, by the Los Angeles County Coroner ascribed the cause of death for both pilots to multiple blunt force injuries. The condition of the victims prevented blood sample collection. Forensic toxicology on tissue specimens from the male pilot by the FAA Forensic Toxicology Research Team showed carbon monoxide and cyanide tests not performed; volatiles included less than 13 mg/dl ethanol in muscle. Results were negative for all tested drugs.
Additional Information
The Instrument Flying Handbook (FAA-H-083-15A) defines spatial disorientation as "the lack of orientation with regard to position in space and to other objects." It describes that a pilot in a prolonged coordinated, constant-rate turn may experience the illusion of not turning; during recovery, the pilot may sense turning in the opposite direction, potentially returning the aircraft to its original turn. The absence of turning sensation creates the illusion of a level descent, leading the pilot to pull back on controls, tightening the spiral and increasing altitude loss—a "graveyard spiral" that can lead to loss of control.