FTW95FA030

NTSB accident investigation · Piper PA-28-235 · Aurora, CO · October 26, 1994

Accident · FatalField investigationFinal report
Date
October 25, 1994, 19:06 local (Oct 26, 1994, 01:06 UTC)
Place
Aurora, CO
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N8954WPiper PA-28-235
Weather
Visual (VMC) · Night/dark
Status
Completed · report August 23, 1995
Report
Approved by Office Director
FAA report
19941025035849A
Case key
19195

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

THE CFI's FAILURE TO MAINTAIN AIRCRAFT CONTROL DUE TO SPATIAL DISORIENTATION. FACTORS WERE: A DARK, MOONLESS NIGHT WITH NO VISIBLE HORIZON AND RECENCY OF NIGHT EXPERIENCE BY THE FLIGHT INSTRUCTOR.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterTakeoff - initial climb
Light condition - dark nightFactor
Aircraft control - not maintainedPilot in command(cfi)Cause
Spatial disorientationPilot in command(cfi)Cause
Lack of recent experiencePilot in command(cfi)Factor

Analysis

While conducting a night check out instructional flight, and while in the pattern, the aircraft struck the ground while in a left turn off the end of the departure runway. Weather conditions were clear, dark night with no moon. There was no visible horizon in the direction the aircraft was flying at the time of impact. The flight instructor had no night experience in the recent past.

Factual narrative

History of flight

On October 25, 1994, at 1906 mountain daylight time, a Piper PA- 28-235, N8954W, was destroyed by ground impact and postimpact fire near Aurora Airpark, Aurora, Colorado. Both pilots sustained fatal injuries. Visual meteorological conditions prevailed for this local area instructional flight and no flight plan was filed. The flight originated about 1800.

Persons at the airpark stated that they received a request for an airport advisory from the aircraft about 1900 on the UNICOM frequency. About 1910, the airport manager saw a fire burning southeast of the field and went to investigate. He found the aircraft in flames with both occupants still on board. Emergency crews arrived about 5 minutes later. They were notified by another person who saw the fire and called 911.

The accident site is located approximately 900 feet off the southeast end of runway 14 at Aurora Airpark. Runway 14 was the preferred runway in use at the time of the accident.

According to personnel at the airpark, the owner of the aircraft was receiving a night check out. The flight had been airborne about an hour and had returned to the pattern when the accident occurred.

The terrain off the end of the runway where the accident occurred consists of farm fields. There is a farm house with a yard light approximately a mile off the end of the runway, and a second farm house with a yard light about one half mile to the east of the runway end. Those are the only lights off the end of the runway where the accident occurred.

Personnel information

According to persons who knew the flight instructor, he had flown out of Aurora Airpark for some time and was familiar with the area. Available information indicates that he had not flown at night in the recent past.

Records provided by the airpark indicate the owner of the aircraft, who was receiving instruction, had flown for six tenths of an hour on October 1, 1994, and one hour on October 21, 1994. No other records of recent flight time were found. FAA records provided information that this pilot had 145 hours total flight time and his certificate was issued on March 15, 1994.

Meteorological information

According to the National Weather Service, weather at the time of the accident was clear skies with 40 miles of visibility. Persons at the airpark stated that it was dark and there was no moon. Observation by this investigator, the night following the accident, provided information that on a clear, dark, moonless night there was no visible horizon to the south and southeast off the end of runway 14.

Aerodrome information

Aurora Airpark is a private airport open to the public and is located 11 miles east of the city of Aurora. It is bordered on the north by an interstate highway and on the other three sides by open farm land. Lighting consists of threshold and runway lights which are pilot controlled. The airport is VFR only.

Wreckage and impact information

The first ground scar found consisted of a shallow gouge which contained the pitot tube. From that witness mark, the ground scar track was on a base heading of 74 degrees. Fifteen feet from the first mark was a deep gouge which contained some engine oil residue.

Twenty two feet to the southeast from the deep gouge the left wing was found. The wing was fire damaged and the tip tank was missing.

The fuselage, oriented towards the northeast, was located 37 feet beyond the deep gouge. The engine was attached and the forward half of the fuselage and engine were fire damaged.

The right wing remained attached to the fuselage by cables and was oriented to the north. The aileron was attached and flight control continuity through the wing was established. The tip tank was attached. The left tip tank was found 31 feet to the northwest of the fuselage. The tip tank was damaged. (Refer to wreckage diagram.)

Fuel was not found in the left wing. However, the wing had burned and evidence of a fuel fire was present along with a fuel odor in the vicinity of the wing. The right wing tank was about one half full and the fuel selector in the fuselage was positioned on the right main tank. Neither tip tank contained fuel or evidence that they had contained fuel at the time of the accident.

The engine sustained some fire damage around the bottom of cylinders 2 and 4. In addition, the following damage was observed.

Number 2 intake pipe was pushed back. Number 2 exhaust pipe was flattened into number 4 intake pipe. Number 4 exhaust pipe was pushed back into number 6 intake pipe. The alternator was displaced rearward. The carburetor was broken off just below the mounting flange. Three ignition leads were smashed at the right magneto cap. The top of the mounting flange of the left magneto was broken. Five of the ignition leads from the left magneto were smashed at the cap. The airbox was smashed up against the bottom of the carburetor.

The above noted damage was associated with impact forces and fire.

The propeller remained attached and both blades were bent rearward. One blade exhibited chordwise scratches.

The empennage was intact and sustained minor damage. All flight control surfaces were properly attached and flight control continuity was established.

Medical and pathological information

An autopsy and toxicological examination was conducted on both victims by the Arapahoe County Medical Examiner. No abnormalities were noted and death was attributed to blunt force trauma associated with impact forces.

Tests and research

An engine examination was conducted at the facilities of Beegles Aircraft Services, Greeley, Colorado. That examination is detailed as follows:

Following removal of one spark plug from each cylinder, engine continuity was checked and found to be normal. The crankshaft was rotated and thumb compression was confirmed on cylinders 2,3,4, and 6. Compression on cylinder number 3 was noticeably lower than 2,4, and 6. There was no compression found on cylinders 1 and 5.

All cylinders were removed and examined. Number 5 cylinder exhibited some scuffing near the top of the barrel. Corresponding scuffing was noted near the top of the piston. The top compression ring was broken into six pieces. Rubbing damage to several of the fracture surfaces provided evidence that the engine had operated with the broken ring for some time. Visual examination of the ring revealed wear on the sides. The corresponding ring groove exhibited a similar wear pattern. The second compression ring was intact and free in the groove.

Number 1 cylinder had light scuffing near the top of the barrel and corresponding scuffing near the top of the piston. The top compression ring was broken near the gap. The broken section measured approximately .375 inches in length. The second compression ring and the oil ring were both intact and free in the piston ring grooves.

The other cylinders had varying degrees of scuffing in the barrels and on the pistons. The piston rings were intact and free in the ring grooves. The valves and valve springs all appeared normal. No evidence was found to indicate why the compression in number 3 cylinder was low.

The accessory housing was removed and all accessory drive gears were intact. The crankshaft gear bolt, lockplate, and dowel were intact and showed no evidence of wear. The oil pump turned freely by hand. Disassembly of the pump revealed that the gears and shaft were intact and operable.

The right magneto was a Bendix S6LN-20 (red label), S/N 863093. Spark was produced at all lead towers when the shaft was rotated with an electric drill.

The left magneto was a Bendix S6LN-21 (blue label), S/N 450276. It produced spark at all lead towers when the shaft was turned with an electric drill. The impulse coupling functioned.

The carburetor was

Aircraft

Registration
N8954W
Reported as
Piper PA-28-235
Category
Airplane
Serial number
28-10527
Airframe hours
2,253
Engine
Lycoming O-540-B4B5, 235 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Registered owner
Krama, Desha K.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 21, 1994
Departed
O1V
Airport
O1V · Aurora Airpark, runway 14, 4,694 × 40 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
62
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
5,220 total · 45 in this make and model · 5,110 as pilot in command · 265 in the last 90 days · 43 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
80° at 5 knots
Visibility
40 statute miles
Lowest ceiling
None
Temperature
52 °F, dew point 19 °F
Altimeter
30.00 inHg
Observed at
DEN, 5 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.