# NTSB FTW90FA077: Piper PA-24-180, N5354P, Fabens, TX, March 4, 1990

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: March 4, 1990, 12:45 local (19:45 UTC)
- Place: Fabens, TX
- Coordinates: 31.50023, -106.150764 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=31.5002&lon=-106.1508&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 2 fatal, 1 serious
- Status: Completed, report August 17, 1992
- Report: Approved by Office Director
- ADs cited in the narratives: [AD 90-04-06 R1](https://openairdocs.org/ad/90-04-06-R1) (OpenAirDocs)
- NTSB case key (mKey): 23013
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW90FA077
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/23013/pdf
- Page: https://openairdocs.org/ntsb/FTW90FA077

## Probable cause

THE PILOT'S FAILURE TO MAINTAIN ADEQUATE AIRSPEED DURING A TAKEOFF WITH LESS THAN FULL POWER RESULTING IN A STALL. CONTRIBUTING FACTORS WERE THE PILOT'S FAILURE TO LEAN THE MIXTURE TO COMPENSATE FOR THE HIGH DENSITY ALTITUDE, AND THE GROSS IMPROPER, INADEQUATE MAINTENANCE THAT HAD BEEN PERFORMED ON THE ENGINE RESULTING IN AN UNAIRWORTHY ENGINE.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power, takeoff - initial climb
  - weather condition - high density altitude (contributing factor)
  - mixture - improper use of, pilot in command (contributing factor)
  - propeller system/accessories,governor - leak (contributing factor)
  - maintenance,compliance with ad - not performed, other maintenance personnel (contributing factor)
  - propeller system/accessories,governor - contamination (contributing factor)
  - propeller system/accessories,governor - blocked(partial) (contributing factor)
  - fuel system,carburetor float - worn (contributing factor)
  - engine assembly,rocker arm/tappet - improper (contributing factor)
  - maintenance,installation - improper, other maintenance personnel (contributing factor)
  - engine assembly,bearing - worn (contributing factor)
  - engine assembly,crankcase - worn (contributing factor)
  - engine assembly,piston - worn (contributing factor)
  - maintenance - inadequate, other maintenance personnel (contributing factor)
- Loss of control - in flight, takeoff - initial climb
  - airspeed - not maintained, pilot in command (cause)
  - stall - inadvertent, pilot in command

## Analysis

AFTER LIFTOFF, THE AIRPLANE APPEARED TO STOP CLIMBING AT ABOUT 90-100 FT AGL; ITS WINGS ROCKED SIDE-TO-SIDE, AND IT THEN PITCHED NOSE DOWN INTO THE GROUND. THE ENGINE WAS HEARD UNTIL IMPACT. MIXTURE CONTROL FOUND IN FULL RICH POSITION; DENSITY ALTITUDE APRX 5,000 FT. OIL STAIN FOUND NEAR PROP GOVERNOR; AD 90-04-06 AND LYCOMING SB NO. 488, PROP GOV LINE & ELBOW FITTING, NCW. ENGINE TEARDOWN SHOWED PROP GOV SCREEN BLOCKED WITH NUMEROUS CONTAMINANTS; METALLIC FLAKES ON OIL FILTER; CARB BODY DIRTY; CARB FLOAT ATTACH PIN WORN; PLUGS SHOWED RICH FUEL CONDITION; MAG TIMING 3 DEG OFF; INTAKE/EXHAUST ROCKER ARMS IMPROPERLY INSTALLED; PISTON RINGS WORN BEYOND LIFE LIMITS; NO.2 CYL TOP RING BROKEN; NUMEROUS ROD CAPS & BEARINGS INSTALLED BACKWARDS; ALL CRANK PINS WORN BEYOND SERVICE LIMITS; ALL MAIN BEARINGS WORN BEYOND SERVICE LIMITS. SERIAL NUMBER ON DATA PLATE DID NOT MATCH CASE NUMBER OF THE ENGINE. AIRPLANE WAS PURCHASED 1/23/90 BY THE PILOT.

## Aircraft

- Registration: [N5354P](https://openairdocs.org/deregistered/N5354P-2003-09-03), registration cancelled 2003-09-03, S/N 24-402, built 1958 (OpenAirDocs)
- Reported make and model: PIPER PA-24-180
- Registry model: [Piper PA-24](https://openairdocs.org/model/piper-pa-24) (registry code 7102402) (OpenAirDocs)
- Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 24-402
- Engines: LYCOMING O-360-A1A 180 horsepower reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Operator: Rufus C. Cain
- Destination: 9F0, DUBLIN, TX
- Airport: E35, Fabens, runway 26, 4,200 × 60 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 56; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; toxicology performed; flight hours: 745 total, 17 in this make and model, 690 as pilot in command, 22 in the last 90 days, 15 in the last 30 days, 3 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 110° at 3 knots
- Visibility: 50 statute miles
- Lowest ceiling: 25,000 ft broken
- Temperature: 68 °F, dew point 34 °F
- Altimeter: 29.00 inHg
- Observed at: ELP, 20 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 19900304003119A](https://openairdocs.org/incident/19900304003119A), Mar 4, 1990: Piper PA24, Fabens, TX, Destroyed, 2 fatal. Stalled on climbout. Vertical impact. Engine not airworthy. Most components worn or installed incorrect.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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