LAX01LA117

NTSB accident investigation · Piper PA-23-160 · Anza, CA · March 14, 2001

Accident · Minor injuriesLimited investigationFinal report
Date
March 14, 2001, 10:10 local (18:10 UTC)
Place
Anza, CA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N333PEPiper PA-23-160
Weather
Visual (VMC) · Day
Status
Completed · report April 17, 2003
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20010314003839A
Case key
51915

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 pilot's failure to maintain control of the airplane following the opening of the cockpit/cabin door. The door came open because of improperly installed upholstery, which resulted in the inability to lock the door.

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.

Miscellaneous/otherCruise
Miscellaneous,airframe - distorted
Maintenance,installation - improperUnknownCause
Door - not securedCause
Operation with known deficiencies in equipment - attemptedPilot in command
Door - openCause
Loss of control - in flightCruise
Aircraft control - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - open field

Analysis

The cabin door opened in cruise flight and the private pilot subsequently lost control of the twin-engine airplane. The airplane entered a descending right turn, and when ground impact was imminent, the pilot shut down the engines and feathered the propellers. The airplane then impacted the ground in a field. According to FAA inspectors, the door would not lock due to improperly installed upholstery. The pilot/owner reported he did not get a certificated mechanic to inspect and sign off on the upholstery modification.

Factual narrative

On March 14, 2001, at 1010 hours Pacific standard time, a Piper PA-23 twin-engine airplane, N333PE, impacted terrain during a loss of control after a door opened in flight near Anza, California. The airplane sustained substantial damage and the private pilot, who was the sole occupant, received minor injuries. The airplane was operated by the pilot/owner under the provisions of 14 CFR Part 91 as a personal flight when the accident occurred. The flight had originated in Fallbrook, California, about 0950, and was destined for Fort Mohave, Arizona. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed.

The pilot reported that he had conducted a preflight inspection and performed a normal departure and climb. Upon leveling out at 9,500 feet, while at approximately 150 knots, the cabin door opened. The pilot stated that the airplane started a turn to the right and entered a descent. He added that the ailerons and rudder were not effective at controlling the airplane. The airplane continued its descent in what the pilot called a "flat spin," and when ground impact was imminent, he shutdown the engines and feathered the propellers. The pilot reported that the airplane "pancaked" into a field and he walked away to find medical attention.

The pilot reported to Federal Aviation Administration (FAA) inspectors that he had his autopilot engaged when the event took place. He could not remember if he disconnected the autopilot or if it disengaged itself. The pilot added that he did not remember changing the aircraft trim settings once the door opened.

According to the FAA inspectors who responded to the accident site, the pitch trim was found in the full nose up position. Examination of the aircraft revealed that pilot's door could not close and properly lock due to improperly installed upholstery. The FAA inspectors reported that a new upholstery installation left a welt of cushion near the door lock and prevented the lock from securing all the way. Two FAA inspectors attempted closing the door with one inspector seated inside the airplane pulling on the door, and the other inspector on the outside of the airplane pushing on the door. Attempts to close and lock the door were unsuccessful. There was no maintenance entry in the aircraft logbook concerning the new upholstery installation. The pilot/owner admitted to not getting a certificated mechanic to inspect and sign off on the upholstery modification.

Aircraft

Registration
N333PE
Reported as
Piper PA-23-160
Category
Airplane
Serial number
2007
Airframe hours
2,200
Engines
Lycoming TO-360, 180 horsepower, reciprocatingLycoming O-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Clyde Edward Bantz
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 30, 2000 · 50 hours before
Departed
L18 · Fallbrook, CA
Destination
A20 · Fort Mohave, AZ

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
74
Injuries
Minor
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
June 5, 2000
Seat
Left
Flight hours
8,500 total · 8,000 in this make and model · 20 in the last 90 days · 5 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
5 statute miles
Lowest ceiling
None
Temperature
59 °F, dew point 46 °F
Altimeter
30.12 inHg
Observed at
KRAL

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.