Piper PA-34-200 accident near San Dimas, California, October 7, 2000
On October 7, 2000 at about 2:38 am local time, a Piper PA-34-200, registered N222ES, was destroyed in an accident near San Dimas, California (Brackett Field). It was an instructional flight under general aviation rules (Part 91). 2 people were killed. The weather was instrument conditions (cloud, fog or low visibility).
The NTSB's probable cause their words, unchanged
The pilots becoming lost and disoriented during an improperly conducted IFR approach, and subsequent missed approach, that led to a collision with rising mountainous terrain. Also causal was the local controller canceling the IFR approach when the pilot specifically stated he wanted to continue the IFR approach, and the local controller, as well as sector controllers failure to issue a unsafe proximity to terrain safety alert to the pilots (MSAW alert) as required by the Air Traffic Control Handbook.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- October 7, 2000 · about 2:38 am local time
- Place
- San Dimas, California · Brackett Field · map
- Type
- Accident
- Injuries
- 2 people were killed.
- Weather
- instrument conditions (cloud, fog or low visibility)
- Aircraft
- Piper PA-34-200 · all PA-34-200s on the register
- Registration
- N222ES · registry record · serial 34-7250331
- Damage
- Destroyed
- Flight
- Instructional flight · general aviation rules (Part 91)
The NTSB's narrative final · quoted from the NTSB record
The airplane collided with rising mountainous terrain while executing a missed approach procedure in instrument conditions during an instructional flight. At 1929 the TRACON controller (POMR) cleared the airplane for the VOR-A approach, and advised the pilot to contact the tower. The pilot acknowledged, then contacted the ATCT local controller (LC) and stated they were on the VOR-A approach outside of the final approach fix (FAF). Two minutes later the POMR controller, after observing the aircraft's target off course, contacted the LC to ask why the airplane was circling the airport. The LC stated he would find out and get back to the POMR controller. The LC asked the pilot if he wished to cancel IFR or continue the approach. The pilot replied that he wanted to continue and the LC told him to report the runway in sight. The LC, who was monitoring the flight's target track on the tower's DBRITE radar display, also informed the pilot that they appeared to be west of course. At 1932:20 the LC asked if they had the airport in sight. The pilot replied they had the airport in sight. The LC then contacted POMR and advised that the pilot was canceling IFR and had the airport in sight. The POMR controller then dropped the accident airplane's data block from his radar display. 47 seconds later, the LC asked the pilot to confirm he had the runway in sight. The pilot replied in the negative. The controller then asked if the pilot wanted the missed approach. The pilot replied that he had the ground and a freeway in sight. The pilot was 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 LC asked the pilot what he was doing and if he had the airport in sight. The pilot asked if anything was wrong. The controller advised the pilot he was now three miles west of the airport and suggested he turn to a heading of 080-degrees. The controller also told the pilot to maintain visual flight conditions, and to report the runway in sight. At 1936:02 the controller advised the pilot the airport was 1.5 miles at the pilot's 12:00 o'clock position. He also asked if the pilot had the airport in sight. The pilot replied negatively. The controller instructed the pilot to make a 10-degree right turn to enter the downwind. The controller again informed the pilot that the airport was a little over a mile at their 12:00 position. The pilot replied he had the airport in sight. The controller instructed the pilot not to lose sight of the airport again, and cleared him to land. After observing the flight deviate from a track to the airport, at 1939:29 the controller asked the pilot for their current heading. The pilot then requested a missed approach. The controller instructed the pilot to execute the missed approach and to standby for a frequency change. The LC then called the TRACON sector controller and a discussion ensued between the two about the flight's VFR versus IFR status, with the TRACON controller saying that he thought the pilot had cancelled IFR and went VFR. The LC 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 said he could work the pilot and try and get him back to the airport unless POMR wanted to take him. POMR stated that if the pilot was IMC and did not have the airport in sight that "I would have him turn southbound immediately." The LC then told the pilot to turn south and climb immediately to 5,000 feet. There was no response by the flight. Review of the recorded radar data disclosed that beginning at 1933:10 (about 5 minutes before the accident), the Minimum Safe Altitude Warning (MSAW) system was flashing an alert on both the TRACON controllers display and the DBRITE display in the tower; however, after the TRACON controller dropped the airplane's data tag the MSAW alert was automatically suppressed at the TRACON. Review of the recorded air/ground communications tapes disclosed that at no time did either controller issue an alert advisory for terrain avoidance to the flight.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
Flight instructor
- Certificate: flight instructor, commercial pilot
- Ratings: multi-engine land; single-engine land; instructor: airplane multi-engine; instructor: airplane single-engine; instructor: instrument airplane; instrument: airplane
- Flight time: 276 hours in all; 45 in this make and model
- Last flight review: September 1, 2000
- Medical certificate: Class 1 (valid medical--no waivers/lim.)
- Seat: rgt
- Injury: fatal
Dual student
- Certificate: commercial pilot
- Ratings: single-engine land; instrument: airplane
- Flight time: 406 hours in all; 9 in this make and model; 35 in the last 90 days; 16 in the last 30 days; 362 as pilot in command
- Last flight review: September 9, 2000
- Medical certificate: Class 1 (valid medical--no waivers/lim.)
- Seat: left
- Injury: fatal
The aircraft
- Airframe total time: 7,039.6 hours
- Last inspection: 100-hour inspection, September 26, 2000; 54 hours since
- Maximum gross weight: 4,200 lb
- Seats: 6
- Landing gear: retractable
- Engine 1: Lycoming LIO-360-E1A6 (piston); 0 hours total
- Engine 2: Lycoming IO-360-E1A6 (piston); 0 hours total
The flight
- Departed from: CNO Chino CA at 1:30 am
- Destination: POC Brackett Field CA
- Flight plan: IFR
- A second pilot was aboard
Weather at the time
- Light: night
- Wind: from 260° at 8 knots
- Visibility: 2 statute miles
- Sky: overcast at 1,000 ft
- Temperature: 0°F (-18°C), dew point 0°F (-18°C)
- Altimeter: 29.92 inHg
- Observation at 2:47 am from POC, 3 miles away
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Crew | 2 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.
Other NTSB records under N222ES the same tail number, which may have belonged to a different aircraft at the time
2007-06-16DFW07CA136 · accident near Wilsonville, AL · substantial damage · no injuries
1990-02-21LAX90LA100 · accident near Fresno, CA · substantial damage · no injuries
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.