WPR16LA093

The pilot's failure to maintain a proper approach path on landing because he failed to familiarize himself with the airport's unique approach hazards and recommended procedures before the flight. Also causal was the pilot's failure to recognize the airplane's improper approach and to execute a go-around in a timely manner.

The private pilot and non-pilot rated passenger departed for a personal flight to an island airport located on top of a plateau. While on final approach for landing, the airplane descended below the elevation of the runway threshold. The pilot attempted to conduct a go-around but was unable to prevent a collision with the rising terrain. Detailed examination of the airframe and engine did not reveal evidence of any pre-impact mechanical deficiencies or failures that would have precluded normal operation. The airport's website contained information for pilots about its unique operational hazards. The website explicitly warned that there were no visual cues for altitude reference on approach, that there was usually a strong downdraft near the approach end of the runway due to the surrounding terrain and prevailing winds, and that the upslope of the runway could cause approach and flare difficulties for inexperienced pilots. The website further stated that most flying clubs required pilots flying into the airport for the first time to be accompanied by a flight instructor or another pilot familiar with the airport. The pilot reported that the accident flight was his first experience flying to that airport, and that neither his co-owners of the airplane, nor his insurance company, required any checkout flight to that airport.  He reported that he was only vaguely aware of the visual illusions associated with the landing approach; and that he was unaware of, and never saw or used, the pulsating visual approach slope indicator (PVASI) with which the runway was equipped. Review of onboard GPS data revealed that the pilot flew a straight-in approach, instead of the normal and recommended right traffic pattern. The airplane joined the final approach course about 1.4 miles from the runway threshold and about 100 ft below the nominal approach path slope. The airplane descended farther below the nominal approach path and remained in the PVASI flashing red (well below course) indication zone for the entire approach. The pilot initiated the go-around about 8 seconds before impact, as the airplane descended below the elevation of the threshold. The pilot's incomplete preparations for the flight, particularly with regard to the airport's peculiarities and associated hazards, resulted in the pilot conducting an inordinately low final approach. Had the pilot flown the recommended traffic pattern instead of a straight-in approach, he would have provided himself with another opportunity to detect the airport's unusual characteristics and conduct his final approach accordingly. Finally, ground and wind speed data suggest that the airplane was near or at the extreme low end of its normal approach speed range just before the go-around. In combination, these factors placed the airplane in a position and energy state from which recovery was difficult or impossible once the airplane encountered the known downdraft phenomenon just short of the runway threshold.

After departing LGB, the pilot utilized FAA air traffic control (ATC) flight-following services for his channel crossing to the island. He cancelled that service when he neared AVX, and then communicated his arrival on the designated common traffic advisory frequency (CTAF). General Information Santa Catalina Island is located about 20 miles offshore from the southern California mainland. The island terrain is extremely rugged. AVX was situated on a small mesa, at an elevation of about 1,600 feet above mean sea level (msl). According to the Catalina Conservancy, which is the steward agency for AVX, the airport mesa was man-made by removing the tops of two adjacent mountains, and using that material to fill in the lower-elevation region between the two. The airport and runway topography are somewhat unusual. It is very common practice for flight schools and fixed base operators in that region to require airport-specific checkouts prior to allowing any pilot to fly there on his/her own. Runway Information The single paved runway, designated 4/22, measured 3,000 by 75 feet. The threshold of runway 22 was situated at an elevation of 1,553 feet. Over the first 2,000 feet, the runway sloped evenly upward to an elevation of about 1,597 feet msl. This yielded a runway gradient of about 2.2 percent, or about 1.26º. Beyond that point, the runway rose more gradually, to a maximum elevation of about 1,605 feet at the runway 4 threshold. The gradient profile made the runway appear "humped," and rendered aircraft positioned at opposite thresholds invisible to one another. Catalina Conservancy Web Site Information for Pilots The Catalina Conservancy published the following information for pilots on its web site: "The approach end of Catalina's runway 22 begins at the edge of a 1500' cliff. This gives the airport some characteristics similar to landing on an aircraft carrier that is 1,602' in the air. Be Aware: 1) There are no familiar visual cues for altitude reference. You MUST [emphasis original] rely on your Altimeter. [capitalization original] 2) There is usually a strong downdraft at the approach end of the runway caused by the prevailing winds falling over the 1500' cliff. Be prepared for this downdraft and possible loss of altitude during your short final. 3) The uphill slope of Runway 22 can cause approach and flare problems for inexperienced pilots." Approach Path Indication System Runway 22 was equipped with a Pulsating Visual Approach Slope Indicator (PVASI), which was installed in 1993. The PVASI approach path was set to a 3 degree glide path relative to local horizontal. Thus, when on the 3 degree glide path, the actual approach path (and pilot's sight picture) was aligned about 4.3º relative to the runway plane. The PVASI was positioned about 450 feet down runway 22, about 80 feet to the left of the runway 22 centerline. The published PVASI threshold crossing height was 39 feet. According to the PVASI manufacturer's data, the nominal approach path was 0.35º "thick," and indicated to the pilot by a steady white light. The next lower profile, "below course," indicated by a steady red light, was 0.175º thick. The lowest indicated profile, "well below course," indicated by a pulsating red light, was 2.5º thick. Above-nominal glide path was 2.5º thick, and indicated by a pulsating white light. Based on these values, a pilot would observe a steady white light when on an approach path slope between 3.175º and 2.825º. A steady red "below course" indication would appear on approach path slopes between 2.825º and 2.65º, and a flashing red "well below course" indication would appear on approach path slopes between 2.65º and 0.15º AVX Runway 22 Approach Accidents Review of NTSB accident data revealed that between 1985 and 1993, there were five AVX runway 22 approach/landing accidents. Subsequent to 1993, and including this subject accident, there were ten additional AVX runway 22 approach/landing accidents. None of the 15 accidents were fatal. All were personal flights operating certificated, single-engine airplanes in day visual meteorological conditions. Pilot's Flight Preparations and Recollections In a telephone interview with the NTSB investigator, the pilot reported that he had never flown into AVX before. Neither the co-owners nor the insurer of the airplane required or suggested any AVX-specific checkout or dual flight prior to solo flights there. In preparation for the flight, the pilot conducted some research about AVX by speaking with some fellow pilots, and reading on the internet. From that research he learned/recalled that the runway was "bowed," meaning it crested and, after touchdown, appeared shorter than it actually was. The pilot also stated that he learned that there were some "optical illusions" associated with the runway, but other than the "bowed" effect, he was unable to be more specific about what those illusions were. When the pilot was asked whether, as part of his approach path alignment, he saw or used the PVASI, and what its indications were, he responded that he was unaware of its existence, and did not recall seeing or using any light-based approach slope indicators. In his discussion shortly after the accident with a sheriff who was a first responder, the pilot reported that when on the final approach, he realized that he was too low and added power to climb. He stated that the right wing went down, and that he "added rudder" but that rudder application was ineffective. The pilot was able to extract himself from the wreckage, and used his handheld aviation-frequency transceiver to attempt to call for help. Those communications attempts were unsuccessful until N365ES returned and visually located the wreckage. Accident Notification and Location Activities The two witnesses from N365ES who believed that N7133G had crashed could not be certain of the accident due their lack of any definitive aural or visual evidence. Their notification to the airport operations staff prompted that individual to conduct a brief visual search, but that search was unsuccessful. At 1629, which was less than a minute after the accident, the first signal from the airplane's ELT was received by one of the satellites in the detection network. The signal provided the airplane identification, but was insufficient to enable a position solution. Due to the lack of any position information, personnel at the Air Force Rescue Coordination Center (AFRCC) in Florida had to wait for a second detection before they could notify the geographically appropriate search and rescue agency. According to AFRCC personnel, they then began attempting to contact the airplane owners listed on the ELT registration by telephone, but were unsuccessful. Although the airplane was co-owned by five persons, the ELT registration/contact list only contained three names and phone numbers. One of those persons had sold his share to the accident pilot about 6 weeks prior, and the phone number listed for another co-owner was incorrect. At 1647, the third co-owner (initials "FQ") on the list was telephoned by the AFRCC, but FQ was unable to take the call because he was working. The next satellite detection of the ELT occurred at 1649, and enabled the first position solution. That solution indicated that the accident site was situated about 4,300 feet southeast of AVX, which was about 5,300 feet from the actual accident location. Based on that position solution, AFRCC notified the United States Coast Guard (USCG) District 11 Rescue Coordination Center (RCC), whose personnel made contact with the AVX operations staff, who in turn used CTAF to contact an inbound airplane, and request search assistance. That radio call also prompted the pilot of N365ES to turn back towards AVX, and execute an aerial visual search. At 1658, the USCG RCC made telephone contact with co-owner FQ, and notified him that the airplan