# NTSB LAX01FA113: Piper PA-32R-300, N1965H, Essex, CA, March 9, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 9, 2001, 09:50 local (17:50 UTC) - Place: Essex, CA - Coordinates: 34.960227, -115.310028 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.9602&lon=-115.3100&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 6, 2002 - Report: Approved by Office Director - Parties: Consolidated Fuel Systems, Textron Lycoming, The New Piper Aircraft Co., FAA Flt Stnds Dist Office - NTSB case key (mKey): 51896 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01FA113 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/51896/pdf - Page: https://openairdocs.org/ntsb/LAX01FA113 ## Probable cause Rupture of the fuel injection flow divider diaphragm due to improper manufacture of the raw material stock from which the diaphragm was fabricated. The diaphragm tear resulted in complete engine power loss, which required the pilot to descend into an undercast. The undercast obscured the mountain, which the airplane impacted. A factor in the accident was the manufacturer's inadequate quality control. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, climb - to cruise - fuel system,fuel flow divider/distributor - other (cause) - fuel system,fuel flow divider/distributor - tear/torn (cause) - material defect, manufacturer (cause) - inadequate quality control, manufacturer (contributing factor) - Forced landing, descent - emergency - In flight collision with terrain/water, emergency landing - terrain condition - mountainous/hilly - weather condition - obscuration ## Analysis The airplane did not return to the departure airport and an ELT signal directed searchers to the wreckage. The airplane had impacted a steep rock face near the top of a 4,900-foot mountain. Witnesses reported that, about the time of the accident, the mountain tops in the area were obscured in clouds above about 4,000 feet. The wreckage showed the airplane had "pancaked" against the side of the mountain while in a 45-degree left bank. Both communication radios were tuned to the emergency frequency. During the wreckage examination, the fuel injection flow divider diaphragm was found to have a tear in it. A tear in the diaphragm during flight would cause the engine to abruptly and completely cease operating. Examination of the diaphragm revealed that the Dacron fabric was not centered in the elastomer as called for in the manufacturer's drawing. The lack of centering in the elastomer led to micro buckling failure of the Dacron fibers due to tensile fatigue. ## Factual narrative HISTORY OF FLIGHT On March 9, 2001, at 0950 Pacific standard time (PST), a Piper PA-32R-300, N1965H, was destroyed when the airplane impacted a mountain 15 miles south-southeast of Essex, California. The airline transport certificated pilot and one passenger were fatally injured. The personal flight was operated by the pilot under 14 CFR Part 91. The flight departed from Eagle Airpark at Bullhead City, Arizona, at 1030 mountain standard time (MST), and the destination was unknown. Visual meteorological conditions prevailed and no flight plan was filed. The operator of the Eagle Airpark said that the pilot of the accident aircraft had a contract with the Bank of America to deliver bank mail (primarily cancelled checks). The route was from Burbank to Imperial and then to Needles (California). The pilot normally left Burbank in the morning, flew to Imperial and then on to Needles, landing at Eagle Airpark because it was closer to the city center than the municipal airport. The airplane normally stayed in Needles (Eagle) during the day until about 1930 MST when the flight returned to Burbank via Imperial with the evening mail. The trip was repeated daily, Monday through Friday. The airport operator said the accident flight was not part of the bank flight itinerary. The pilot departed about midday with the passenger. The pilot had told the operator that he was considering getting into the agricultural application business and had identified two possible existing businesses for acquisition. The operator speculated that the pilot intended to fly to one or both of them. The airplane did not return to Needles to pickup the evening bank mail. The operator said that the bank courier normally brought the mail to the airport and left it in the airplane if the pilot was not there, or, left it in the pilot's van if the airplane was not there. The day following the accident (Saturday, March 10) the van was at the airport with the previous day's bank mail still in it. A flight instructor, who operated a flight school at Eagle Airpark, was acquainted with the pilot of the accident aircraft and recognized the airplane. She recalled that on the day of the accident she was a little late for her 1000 MST student appointment, and they taxied out about 1020. She recalled sharing the run-up area with the accident airplane, and, because the run-up area is small, she told the pilot (on the radio) to go ahead and takeoff. The time was about 1030. According to the Air Force Rescue Coordination Center (AFRCC) at Langley AFB, Virginia, they received the first signal from an emergency locator transmitter (ELT) beacon at 1003 PST. The AFRCC assigned the signal a mission number (01M0442) and subsequently refined the position of the beacon, passing the information to the San Bernardino County Sheriff's Department, who then located the wreckage at 1113 PST on March 10, 2001. PERSONNEL INFORMATION According to the San Bernardino County Coroner's Deputy, the male occupant was found in the left front seat and the female occupant was outside the aircraft on the left side of the fuselage. The stitched end of the outboard seatbelt attachment was separated on the right, front seat. The pilot's logbook was not located after the accident. Hours contained in this report are from the pilot's certificate application dated 09/28/00. AIRCRAFT INFORMATION The airport operator reported that the airplane was fueled at 0926 MST on the morning of the accident and received 70.63 gallons of 100 octane, low-lead fuel. According to the aircraft logbook, the airplane received an annual inspection on January 1, 2001, at a recording tachometer time (tach time) of 4,734.7 hours. After recovery of the wreckage, the tachometer read 4,928.32. The last pitot-static and transponder system were performed on January 3, 1999. According to the engine logbook, the engine was overhauled on September 25, 2000; however, there was no entry in the airframe logbook showing when the engine was installed in the aircraft. There was an entry in the engine logbook of a 50-hour inspection performed on October 29, 2000, at tach time 4,552.2 hours. With the engine overhaul records was an airworthiness approval tag, FAA Form 8130-3, dated September 15, 2000, pertaining to the "newly overhauled" fuel injection system fuel servo and flow divider. The aircraft was equipped with a Honeywell/King KLN-88 LORAN radio receiver; however, a spokesman for Honeywell/King reported there was no flight track history memory in that model radio. METEOROLOGICAL INFORMATION The airport operator reported that the weather was "bad" the day of the accident. Needles is in a valley and it was clear overhead; however, the mountain tops were obscured in dark clouds in all directions. The mountain tops were obscured above 4,000 feet. The flight instructor at Eagle Field who observed the pilot depart recalled the weather at Needles was "fine" but there were some rain showers moving through the area. The mountain tops were obscured in clouds and the accident location was "probably" obscured in clouds. A Safety Board staff meteorologist evaluated the weather and the specialist's factual report is attached. A trough of low pressure extended from a low pressure area near Bishop, California, southeastward, passing near the accident site. Surface observations (METAR's) at Needles at 0856 reported few clouds at 3,100 feet (agl), scattered clouds at 4,900 feet, and broken clouds at 9,500 feet. At 0956, the sky condition was few clouds at 3,500 feet. According to the Federal Aviation Administration (FAA) Southwest Region Quality Assurance Office, the pilot contacted Riverside Automated Flight Service Station at 0602 on the morning of the accident and filed an instrument flight rules (IFR) flight plan from Burbank to Palm Springs (California). The pilot was offered a weather briefing, Notices to Airmen (NOTAM's) and flight precaution advisories but declined; saying that he already had the information. There was no other record of FAA briefing, and FAA Direct User Access Terminal (DUAT's) vendors advised that no services were provided to the pilot. WRECKAGE AND IMPACT INFORMATION The accident site is in the eastern California desert near the Colorado River and the border with Arizona. The site is in the Old Woman Mountains, on a steep, rocky, desert mountain slope about 100 feet below a local peak. Because of early responder's description of the hazardous nature of accessing the site, the Safety Board did not respond to the scene. Deputies from the San Bernardino (California) Sheriff's Department (SBSD) reported that the location was latitude 34 degrees 30.2 minutes north and longitude 115 degrees 06.765 minutes west (GPS). The elevation was about 4,800 feet msl. SBSD deputies, who were lowered into the site by hoist from a hovering helicopter, said the site is about 100 feet below the crest, on the northeast face, of the mountain marked "4882" (peak elevation) on the Phoenix Sectional aeronautical chart. The wreckage was lying at the base of a vertical rock face and there was a black mark resembling engine oil on the rock directly in front of the nose of the fuselage. There was shiny aluminum debris embedded in the rock face above the resting location of the wreckage oriented on approximately a 45-degree angle from the blackened area extending up and to the right a distance approximately equal to the span of one wing. Looking back to the northeast, Needles was visible in the distance. The wreckage was recovered on March 22, 2001, and was examined by the Safety Board investigator on March 29, 2001, at the facilities of Aircraft Recovery Services, Compton, California. The wreckage was not involved in fire. The fuselage and wings of the aircraft were destroyed and disintegrated from the nose aft to the trailing edge of the wing. The engine was separated from the ai ## Aircraft - Registration: [N1965H](https://openairdocs.org/deregistered/N1965H-2002-02-19), registration cancelled 2002-02-19, S/N 32R-7780211, built 1977 (OpenAirDocs) - Reported make and model: Piper PA-32R-300 - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32R7780211 - Airframe hours: 4928 - Engines: Lycoming IO-540-K1G5D 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Jay Black - Registered owner: Aero Alliance LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 1, 2001, 193 hours before - Departed: AO9, Bullhead City, AZ - Destination: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: fatal; commercial, flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 13,000 total, 250 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 30 °F - Altimeter: 29.90 inHg - Observed at: EED, 29 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 20010309003849A](https://openairdocs.org/incident/20010309003849A), Mar 9, 2001: Piper PA32R300, Needles, CA, Destroyed, 2 fatal. (.19) On March 9, 2001, about 0950 hours PST, a Piper PA-32R-300, N1965H, was destroyed when the airplane impacted a mountain at the 4,800 foot MSL level,… 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.