# NTSB LAX01FA199: Piper PA-28-180, N5413S, Big Bear City, CA, June 4, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 4, 2001, 08:55 local (15:55 UTC) - Place: Big Bear City, CA - Coordinates: 34.259723, -116.873611 - Nearby events: https://openairdocs.org/map.md?lat=34.2597&lon=-116.8736&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 2, 2004 - Report: Approved by Office Director - Parties: FAA FSDO, Textron Lycoming, The New Piper Aircraft, Inc. - NTSB case key (mKey): 52402 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01FA199 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/52402/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=52402 - Page: https://openairdocs.org/ntsb/LAX01FA199 ## Probable cause the student pilot's selection of a takeoff runway conducive to a tailwind weather condition and his failure to maintain airspeed and his inadvertent stall during takeoff initial climb. Factors in the accident were the partial loss engine power resulting from the inoperative right magneto and the high density altitude weather condition. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, takeoff - initial climb - ignition system,magneto - inoperative (contributing factor) - maintenance,service bulletin/letter - not complied with, company/operator management (contributing factor) - Loss of control - in flight, takeoff - initial climb - weather condition - high density altitude (contributing factor) - weather condition - tailwind (contributing factor) - wind information - misread, pilot in command (cause) - wrong runway - selected, pilot in command (cause) - airspeed - not maintained, pilot in command (cause) - stall - inadvertent, pilot in command - In flight collision with object, descent - uncontrolled - object - tree(s) ## Analysis The student pilot lost control of the single engine airplane during the takeoff initial climb with a tailwind and collided with trees while descending in the crosswind turn. The student departed with an 8-knot tailwind. The UNICOM frequency was reported to be in operation; however, no one reported hearing the accident airplane request departure information or make a position report. According to a pilot witness, the airplane was unable to gain altitude after leaving ground effect and the nose pitched up and to the left, and began to "oscillate back and forth as if it was having difficulty in trying to climb." The witness added the airplane made a shallow left-hand turn and the nose began to pitch up, then the airplane "stalled and the aircraft went nose down." The student pilot was a paraplegic and had obtained approximately 74 total hours of flight time, of which approximately 25 hours were accumulated in the same make and model as the accident airplane. The student had accumulated approximately 6 hours of solo flight time prior to the accident flight. The aircraft utilized a rudder hand control, which allowed the pilot to operate the rudder pedals manually. The student had performed a demonstrated ability flight utilizing the hand control 5 days before the accident. A post accident examination of the wreckage revealed the propeller had sliced through 4-inch thick tree branches. The right magneto would not operate following the accident and it was noted that the breaker points would not open, oil and dirt were found in the magneto housing, and the magneto's drive was excessively loose. At the time of the last annual inspection, the engine's magneto timing was checked. A service bulletin issued for the affected magneto required an inspection of the magnetos every 500 hours. At the time of the accident, the magneto had accumulated a total time in service of 1,256.36 hours, and there was no entry indication the service bulletin had been complied with. No other anomalies were noted with the airplane and engine. The density altitude was computed to be 8,400 feet. ## Factual narrative HISTORY OF FLIGHT On June 4, 2001, at 0855 Pacific daylight time, a Piper PA-28-180 single engine airplane, N5413S, collided with a tree while turning crosswind after takeoff at Big Bear City, California. The airplane was destroyed and the student pilot, who was the sole occupant, received fatal injuries. The airplane was registered to and operated by Aero Haven, Inc., Big Bear City, and the instructional solo flight was conducted under 14 CFR Part 91 when the accident occurred. The flight was originating from the Big Bear City Airport at the time of the accident. Visual meteorological conditions prevailed at the time of the accident and no flight plan had been filed for the local flight. A flight instructor was standing near midfield as the airplane departed. The winds were from 080 degrees at 8 knots. Before the accident airplane departed, another airplane took off on runway 08, flying directly over the accident airplane. The UNICOM was reported to be in operation; however, no one reported hearing the accident airplane request departure information or make a position report. The airplane took off from runway 26, initiating the departure from the approach end. At midfield, the pilot rotated and the airplane began what was described as a normal climb out. After gaining about 250 agl, the attitude of the airplane leveled and began to sink, losing about 50 to 75 feet of altitude. The pilot then began a 45-degree banked turn to the left. After about 90 degrees of turn, the airplane began approaching some 200-foot-tall pine trees that were growing along the left side of the departure path. As the airplane neared the trees, the bank angle steepened and the nose of the airplane suddenly dropped as the right wing contacted several branches near the top of one of the trees. The right wing separated from the airplane and both it and the airplane impacted the ground within a few feet of the base of the tree. According to anther pilot-rated witness, he was at the airport and observed the accident airplane taxi for takeoff on runway 26. The witness thought it was "odd because the winds were out of the east and the Piper was preparing to takeoff to the west, which would be a downwind takeoff." The witness added that a Cessna 150 had departed from runway 08 and overflew the Piper just before it departed. The witness stated the Piper took off, but was "unable to gain altitude." He observed the aircraft pitch nose up and to the left, and began to "oscillate back and forth as if it was having difficulty in trying to climb." The witness added the airplane made a shallow left-hand turn and the nose began to pitch up. He then reported the airplane "stalled, the aircraft went nose down." PERSONNEL INFORMATION The student pilot was a paraplegic and was issued a third-class medical certificate on April 19, 2001, with a limitation to wear corrective lenses. He had obtained approximately 74 total hours of flight time, of which approximately 25 hours were in the same make and model as the accident airplane. The student had accumulated approximately 6 hours of solo flight time prior to the accident flight. The student was issued a Statement of Demonstrated Ability on May 30, 2001, which required a special flight test. The student had completed a demonstrated ability flight with a Federal Aviation Administration (FAA) inspector on June 1, 2001. The flight lasted 0.3 hours. According to the demonstrated ability flight requirements, the pilot must demonstrate "the ability to reach and operate effectively all controls which would normally require the use of that extremity (or those extremities)." As the pilot demonstrates his flying ability, the inspector is to "note any unusual body position the applicant may use to compensate for the defect and what effect that position has on the applicant's field of vision." The pilot is also supposed to demonstrate the "ability to satisfactorily perform emergency procedures relative to flight, such as recovery from stalls..." AIRCRAFT INFORMATION The airplane was equipped with a 180-horsepower Textron Lycoming O-360-A1A engine. The aircraft utilized a "Blackwood" rudder hand control, which allowed the pilot to operate the rudder pedals manually. The rudder hand control was installed via a supplemental type certificate (STC SA1741WE). The control utilized a handle, that, when installed, would be moved forward (downward force) by the pilot to apply left rudder and aft (upward force) to apply right rudder. The hand control was positioned just aft of the throttle/mixture positions. During takeoff, the pilot applies full throttle and tightens the friction lock. The pilot then repositions his right hand to the rudder hand control to maintain directional control of the airplane during the takeoff sequence. Review of the aircraft's maintenance records revealed the engine was overhauled on June 6, 1999, at a tachometer time of 6,078.3 hours. Since its overhaul, the engine had accumulated a total of 1,374.06 hours. On July 30, 1999, the right magneto was installed new at an engine tachometer time of 6,196.0 hours. The engine was removed, disassembled, inspected, reassembled, and reinstalled as a result of a propeller strike dated September 29, 1999, at a tachometer time of 6,363.6, at which time the engine had accrued 285.1 hours of operation since the June 1999 field overhaul. The engine maintenance record included a FAA Airworthiness Approval Tag for a repaired cylinder assembly dated April 9, 2001. The cylinder was placed in the number 3 cylinder position on April 11, 2001, at an aircraft tachometer time of 7,350.41 hours. The airplane/engine underwent its last annual inspection on May 9, 2001, at a tachometer time of 7,396.74 hours. At the time of the annual inspection, the engine's magneto timing was checked. Maintenance worksheets from Calaway Aviation, (a local maintenance facility utilized to maintain N5413S) were reviewed. On May 25, 2001, mechanics removed and cleaned the bottom spark plugs, replaced the induction pipe gaskets, and replaced the valve cover gaskets. On May 29, 2001, the engine cowling was removed and the bottom spark plugs were cleaned and reinstalled at a tachometer time of 7,434.55 hours, and a compression check of the number 4 cylinder was checked. The result of the compression check was not reported on the worksheet. On May 31, 2001, a compression check was conducted with the following results: No. 1 70/80, No. 2 78/80, No. 3 79/80, No. 4 79/80, and the bottom spark plugs were cleaned and reinstalled. On June 1, 2001, the No. 2 and No. 4 spark plugs were cleaned after lead fowling. None of the aforementioned work was depicted or endorsed in the engine's maintenance records. METEOROLOGICAL INFORMATION At 0900, the weather observation facility at the Big Bear City Airport reported the wind from 080 degrees at 8 knots; visibility 10 statute miles; sky clear; temperature 17 degrees Celsius; dew point -08 degrees Celsius; and altimeter setting of 29.99 inches of Mercury. The observation also reported a density altitude of 8,400 feet msl. AERODROME INFORMATION The Big Bear City Airport (L35) elevation is 6,748 feet msl, and is positioned a latitude and longitude of 34 degrees 15.82 minutes north and 116 degrees 51.27 minutes west. The airport utilizes one runway, 08-26. The total length of the runway is 5,850 feet, and runway 26 has a 600-foot displaced threshold. The remarks section of the airport facility directory indicates that mountains are present in all quadrants. A noise abatement procedure exists at the airport that indicates after "takeoff, make 10-degree left turn at end of runway to avoid...elementary school to the west of airport." WRECKAGE AND IMPACT INFORMATION The airplane came to rest at a latitude and longitude position of 34 degrees 15.581 minutes north, and 116 degrees 52.423 minu ## Aircraft - Registration: [N5413S](https://openairdocs.org/deregistered/N5413S-2002-01-03), registration cancelled 2002-01-03, S/N 28-7105140, built 1971 (OpenAirDocs) - Reported make and model: Piper PA-28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (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: 25-7105140 - Airframe hours: 7396.7 - Engines: Lycoming O-360-A1A 180 horsepower reciprocating - Damage: Destroyed - Flight: Instructional, Part 91 - Registered owner: Aero Haven, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 9, 2001, 55.5 hours before - Departed: L35, Big Bear City, CA - Destination: L35, Big Bear City, CA - Airport: L35, Big Bear City, runway 26, 5,850 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; student; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 74 total, 25 in this make and model, 7 as pilot in command, 25 in the last 90 days, 25 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 18 °F - Altimeter: 29.98 inHg - Observed at: L35 ## 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 20010604010819A](https://openairdocs.org/incident/20010604010819A), Jun 4, 2001: Piper PA28180, Big Bear, CA, No damage, 1 fatal. (.19)On June 4, 2001, at 0855 hours pacific daylight time, a Piper PA-28-180, N5413S, collided with a tree while turning crosswind after takeoff at Big Bear… ## Other investigations on N5413S (2) 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. - [NTSB LAX99LA055](https://openairdocs.org/ntsb/LAX99LA055), Dec 18, 1998: Piper PA-28-180 (N5413S), Big Bear, CA, substantial damage. Probable cause: The pilot's misjudged landing flare, which lead to an inadvertent stall/mush 10 feet above the ground. - [NTSB FTW75DRD21](https://openairdocs.org/ntsb/FTW75DRD21), Dec 26, 1974: Piper PA-28 (N5413S), Lockport, LA, substantial damage ## Docket (36 files) The files NTSB released with the investigation on December 12, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=52402. 25.5 MB in all. - San Bernardino Sheriff's Report (item 1, .PDF, 435 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185658&FileExtension=.PDF&FileName=San%20Bernardino%20Sheriff%27s%20Report-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 350 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409028&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - The New Piper Aircraft, Inc. Report (item 3, .PDF, 841 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409049&FileExtension=.PDF&FileName=The%20New%20Piper%20Aircraft,%20Inc.%20Report-Redacted.PDF - Textron Lycoming Report (item 4, .PDF, 659 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409050&FileExtension=.PDF&FileName=Textron%20Lycoming%20Report-Redacted.PDF - Ignition System Information (item 5, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185662&FileExtension=.PDF&FileName=Ignition%20System%20Information-Master.PDF - Blackwood Hand Control Information (item 6, .PDF, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409051&FileExtension=.PDF&FileName=Blackwood%20Hand%20Control%20Information-Redacted.PDF - Engine Records Excerpts (item 7, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409052&FileExtension=.PDF&FileName=Engine%20Records%20Excerpts-Redacted.PDF - Aircraft Records Excerpts (item 8, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409056&FileExtension=.PDF&FileName=Aircraft%20Records%20Excerpts-Redacted.PDF - Maintenance Worksheet (item 9, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185667&FileExtension=.PDF&FileName=Maintenance%20Worksheet-Master.PDF - Magneto Inspection (item 10, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409060&FileExtension=.PDF&FileName=Magneto%20Inspection-Redacted.PDF - Statement of Demonstrated Ability (item 11, .PDF, 410 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185669&FileExtension=.PDF&FileName=Statement%20of%20Demonstrated%20Ability-Master.PDF - Student's Records and Endorsements (item 12, .PDF, 673 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409064&FileExtension=.PDF&FileName=Student%27s%20Records%20and%20Endorsements-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 303 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409048&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Toxicological Report (item 14, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185673&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 1. Tree (Piper photo) (item 15, .PDF, 879 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185674&FileExtension=.PDF&FileName=Photo%201.%20%20Tree%20%20(Piper%20photo)-Master.PDF - Photo 2. Closer view of tree (Piper photo) (item 16, .PDF, 968 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185675&FileExtension=.PDF&FileName=Photo%202.%20%20Closer%20view%20of%20tree%20(Piper%20photo)-Master.PDF - Photo 3. Cut limbs (Piper photo) (item 17, .PDF, 755 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185676&FileExtension=.PDF&FileName=Photo%203.%20%20Cut%20limbs%20(Piper%20photo)-Master.PDF - Photo 4. More cut tree limbs (Piper photo) (item 18, .PDF, 687 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185677&FileExtension=.PDF&FileName=Photo%204.%20%20More%20cut%20tree%20limbs%20(Piper%20photo)-Master.PDF - Photo 5. Limb in left wing (Piper photo) (item 19, .PDF, 698 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185678&FileExtension=.PDF&FileName=Photo%205.%20%20Limb%20in%20left%20wing%20(Piper%20photo)-Master.PDF - Photo 6. Right wing indentation (Piper photo) (item 20, .PDF, 683 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185679&FileExtension=.PDF&FileName=Photo%206.%20%20Right%20wing%20indentation%20(Piper%20photo)-Master.PDF - Photo 7. Right wing indentation (Piper photo) (item 21, .PDF, 670 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185680&FileExtension=.PDF&FileName=Photo%207.%20%20Right%20wing%20indentation%20(Piper%20photo)-Master.PDF - Photo 8. Empennage (Piper photo) (item 22, .PDF, 704 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185681&FileExtension=.PDF&FileName=Photo%208.%20%20Empennage%20%20(Piper%20photo)-Master.PDF - Photo 9. Engine at accident site (Piper photo) (item 23, .PDF, 700 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185682&FileExtension=.PDF&FileName=Photo%209.%20%20Engine%20at%20accident%20site%20(Piper%20photo)-Master.PDF - Photo 10. Spark Plugs 1 (Piper photo) (item 24, .PDF, 628 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185683&FileExtension=.PDF&FileName=Photo%2010.%20%20Spark%20Plugs%201%20(Piper%20photo)-Master.PDF - Photo 11. Spark plugs 2 (Piper photo) (item 25, .PDF, 628 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185685&FileExtension=.PDF&FileName=Photo%2011.%20%20Spark%20plugs%202%20(Piper%20photo)-Master.PDF - Photo 12. Propeller with dirt (Piper photo) (item 26, .PDF, 683 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185686&FileExtension=.PDF&FileName=Photo%2012.%20%20Propeller%20with%20dirt%20(Piper%20photo)-Master.PDF - Photo 13. Cockpit Cabin Area (item 27, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185687&FileExtension=.PDF&FileName=Photo%2013.%20%20Cockpit%20Cabin%20Area-Master.PDF - Photo 14. Engine accessory section (item 28, .PDF, 842 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185688&FileExtension=.PDF&FileName=Photo%2014.%20%20Engine%20accessory%20section-Master.PDF - Photo 15. Left magneto mount (item 29, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185689&FileExtension=.PDF&FileName=Photo%2015.%20%20Left%20magneto%20mount-Master.PDF - Photo 16. Propeller (item 30, .PDF, 856 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185690&FileExtension=.PDF&FileName=Photo%2016.%20%20Propeller-Master.PDF - Photo 17; right magneto 1 (item 31, .PDF, 897 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185691&FileExtension=.PDF&FileName=Photo%2017;%20right%20magneto%201-Master.PDF - Photo 18; right magneto 2 (item 32, .PDF, 976 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185693&FileExtension=.PDF&FileName=Photo%2018;%20right%20magneto%202-Master.PDF - Photo 19; right magneto 3 (item 33, .PDF, 929 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185694&FileExtension=.PDF&FileName=Photo%2019;%20right%20magneto%203-Master.PDF - Photo 20; right magneto mount (item 34, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185695&FileExtension=.PDF&FileName=Photo%2020;%20right%20magneto%20mount-Master.PDF - Photo 21; rudder hand control attachment (item 35, .PDF, 916 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185696&FileExtension=.PDF&FileName=Photo%2021;%20rudder%20hand%20control%20attachment-Master.PDF - Photo 22; rudder hand control (item 36, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40185697&FileExtension=.PDF&FileName=Photo%2022;%20rudder%20hand%20control-Master.PDF 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.