WPR10FA107 · Piper PA-32-300

The non-instrument-rated pilot was on the return leg of his regular 63-nautical-mile commute between two islands. He was cleared for a visual flight rules arrival, which entailed passing over a very high frequency omni-directional radio aid (VORTAC), continuing over a golf course, and then following a freeway before entering the traffic pattern. The approach controller told the pilot to proceed to the VORTAC, but the pilot replied that he wanted a vector. The controller provided a vector and the pilot said that he did not have the island in sight. The controller told the pilot to resume his own navigation. The airplane flight path crossed over the VORTAC and proceeded north into mountainous terrain instead of the cleared arrival path. While the pilot said that he was in the rain at the golf course, radar data indicate that he was actually about 2.5 miles to the east of that location. About 1 minute 20 seconds later, the pilot said that he was inbound for landing, and the controller told him that he was heading toward the mountains. The pilot immediately requested a vector "to intercept landing," which was the last transmission he made. The controller told the pilot to make either a left or right turn southbound to a 180-degree heading. The airplane was substantially off course for almost 1 minute 30 seconds before impact. A group of hikers who were near the accident site heard the airplane operating in the clouds prior to impact. Weather at the time of the accident included light to moderate rain showers and reduced visibility that would have been encountered by the airplane. A postaccident examination revealed no evidence of a mechanical malfunction or failure with the airframe or engine prior to impact.

Despite the pilot’s two radio calls suggesting disorientation during the flight’s final 90 seconds, the controller did not issue a safety alert to the pilot. Although the responsibility for flight navigation rests with the pilot, Federal Aviation Administration Order 7110.65, paragraph 2-1-6, directs controllers, in part, to “Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude which, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft.” The investigation concluded that the controller had sufficient information to determine that a low altitude alert was necessary, as evidenced by her attempt to turn the airplane. A timely low altitude alert may have enabled the pilot to climb and avoid the accident. When the controller recognized that there was a problem with the airplane, she concentrated on correcting his lateral track rather than helping him immediately climb to a safe altitude.

Verbatim NTSB analysis and probable cause from the NTSB dataset