# NTSB LAX04FA168: Alon A2, N6374V, Cameron Park, CA, March 21, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 21, 2004, 12:10 local (20:10 UTC) - Place: Cameron Park, CA - Coordinates: 38.669445, -120.970001 - Nearby events: https://openairdocs.org/map.md?lat=38.6694&lon=-120.9700&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 25, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Teledyne Continental Engines - NTSB case key (mKey): 58930 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04FA168 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58930/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58930 - Page: https://openairdocs.org/ntsb/LAX04FA168 ## Probable cause The pilot's failure to maintain an adequate airspeed while maneuvering for a forced landing, which resulted in a stall/spin. Also causal was the partial loss of engine power due to improperly secured magnetos. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, takeoff - initial climb - maintenance - improper, unknown (cause) - ignition system,magneto - loose part/bolt/nut/clamp/etc (cause) - Forced landing, descent - emergency - Loss of control - in flight, maneuvering - turn to landing area (emergency) - airspeed - not maintained, pilot in command (cause) - stall/spin - encountered, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane collided with the ground while maneuvering for a forced landing following a partial loss of engine power during the takeoff initial climb. A pilot who had taken off immediately following the accident airplane heard the pilot say on the common traffic radio frequency: "seven four Victor starting a left turn to return to the airport." A ground witness saw the airplane flying slowly with the engine making a very low constant humming sound. Initially, the airplane's wings and nose were level with the horizon. Suddenly, the airplane turned left. The nose went "straight down" and the airplane rapidly descended while reversing course. The airplane collided with the ground in a nose down attitude and was destroyed. The engine had been operated about 54 hours since receiving a major overhaul. According to logbook records, the pilot had performed the last maintenance on the airplane about 3.1 operational hours prior to the accident flight. In part, the maintenance consisted of changing the oil and filter. During the post impact wreckage examination, both of the engine's magnetos were found with finger tight mounting bolts. Evidence was observed of the magnetos having worked back and forth on their mounts through their adjustment range. No other preimpact mechanical malfunctions or failures were identified. Fuel was found in the pump, lines, and carburetor, and a significant quantity spilled from the ruptured fuel tanks. ## Factual narrative HISTORY OF FLIGHT On March 21, 2004, about 1210 Pacific standard time, an Alon A2, N6374V, experienced a partial loss of engine power during initial climb from the Cameron Airpark, Cameron Park, California. The pilot reversed course and commenced heading back toward the departure airport. The pilot lost control of his airplane while maneuvering during a forced landing on a dirt trail. The airplane impacted the ground in a nose down attitude and was destroyed. The private pilot and passenger were fatally injured. The airplane was owned and operated by the pilot under the provisions of 14 CFR Part 91. Visual meteorological conditions prevailed at the time of the personal flight, and no flight plan was filed. The flight originated from Cameron Airpark about 1208. According to a pilot flying a Cessna airplane who had taken off immediately following the accident airplane, he heard the pilot broadcast the following statement on the common traffic radio frequency: "seven four Victor starting a left turn to return to the airport." The Cessna pilot estimated that the total length of the Alon's flight was 2 minutes. A witness, who was standing in a parking lot about 0.36 nautical miles (nm) south of the accident site reported observing the accident airplane flying slowly. The witness indicated that the airplane's engine was making a very low constant humming sound, and it was not revving up. Initially, the airplane's wings and nose were level with the horizon. Suddenly, the airplane turned left. The nose went "straight down" and the airplane rapidly descended while reversing course. Another witness, who was located about 0.2 nm southwest of the accident site, reported observing the accident airplane in a right bank. The witness estimated that the bank angle was likely 60 degrees. Also, the airplane's nose was pointing about 45 degrees downward. PERSONNEL INFORMATION The pilot held a private pilot certificate with the following ratings: airplane single engine land and instrument airplane. A review of the pilot's personal flight record logbooks indicated that he began flight training in 1960. He received a private pilot certificate in 1961, and an instrument rating in 2000. The pilot's last flight review was completed in July 2003. By the accident date, the pilot's approximate total flight time was 1,342 hours. He had flown the accident model of airplane about 118 hours. The pilot had flown about 8 hours during the 90-day period preceding the accident date. AIRCRAFT INFORMATION The airplane was manufactured in 1965. The pilot acquired the airplane in April 2002. The logbook records indicate that the engine was overhauled on January 12, 2003. On March 21, 2003, the airplane received an annual inspection and had new cylinders installed at an airframe total time of 1,502.4 hours. The recording engine tachometer indicated 178.8 hours at the time of this maintenance. The accident pilot performed the last recorded maintenance on November 13, 2003. The logbook indicates that the pilot performed, in part, an oil and filter change, and test ran the engine. The listed tachometer time was 229.1 hours. Following this maintenance, the pilot flew his airplane on four flights, for a total of about 3.1 hours until the accident occurred. There was no indication in the records that any other person flew his airplane or performed maintenance during this period. METEOROLOGICAL INFORMATION The Auburn Municipal Airport, about 18 nm from the accident site, reported its local weather at 1145. In part, the sky was clear, the wind was from 210 degrees at 4 knots, and the temperature/dew point were 21/12 degrees Celsius, respectively. First responders to the accident site and witnesses reported to the National Transportation Safety Board investigator that the sky was clear and the wind was light and variable. WRECKAGE AND IMPACT INFORMATION The Safety Board investigator's on scene examination of the accident site and airplane wreckage revealed the airplane impacted the near level terrain on Bureau of Land Management property in an estimated 45-degree nose low pitch attitude, at the following global positioning satellite coordinates: 38 degrees 40.17 minutes north latitude by 120 degrees 58.19 minutes west longitude. The terrain (dirt trail) was surrounded by native vegetation several yards higher than the cockpit, and several yards narrower than the airplane's wingspan. The accident site is about 0.9 nm east-southeast (121 degrees, magnetic) from the departure end of Cameron Airpark's runway 13. The airport's elevation is 1,286 feet mean sea level (msl), and the accident site's estimated elevation is 1,400 feet msl. Fragments from the wingtip navigation light lenses were located in the soil beneath both wingtips. The native vegetation surrounding the main wreckage appeared intact. No evidence of ground scar was noted leading up to the main wreckage. There was no evidence of fire. First responders to the accident site reported observing fuel draining from the engine area. A damp soil area with a fuel-like odor was noted by the Safety Board investigator beneath and downslope from the cockpit and engine areas. The area was about 6 feet long by 2.5 feet wide, and had a maximum depth of 2.5 inches. The airplane was observed in an upright attitude, and it was oriented toward 163 degrees, magnetic. The propeller was at ground level. The nose gear, engine, and instrument panel were found displaced in an aft direction relative to the airframe's longitudinal axis. The empennage was found bent in an upward and forward direction. The leading edges of the wings were crushed with accordian-like folds in an aft direction (see photographs). The throttle control in the cockpit was in the full forward position, and the carburetor heat control was in the full (forward) cold position. The magneto switch was in the "both" position, and the key was broken off in the switch. The engine's primer was found in the closed and locked position. The Safety Board investigator unlocked and pumped the primer. Fuel was observed spraying out of a crack in a primer line in an impact-damaged area of the engine. Fuel was also found in the line routed to the header fuel tank. The engine's impact damaged recording tachometer was observed registering about 233 hours. MEDICAL AND PATHOLOGICAL INFORMATION The pilot's last aviation medical certificate was issued in the third class on May 7, 2002. The certificate bore the limitation that the pilot must wear corrective lenses. An autopsy was performed on the pilot by the coroner, County of El Dorado, Placerville, California, 95667. The El Dorado County coroner and the Federal Aviation Administration's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology tests on the pilot. The tests revealed no evidence of carbon monoxide, ethanol, or any screened drugs. TESTS AND RESEARCH Fuel. The Cameron Park Airport District personnel reported to the Safety Board investigator that the pilot's bank charge card had been used on March 21, 2004, for the purchase of 10.8 gallons of 80-octane aviation fuel. The transaction was time stamped 11:55 am. Airframe Examination. The airplane was initially examined during the Safety Board investigator's on scene inspection. Thereafter, the airframe and engine were recovered from the accident site and were partially torn down for accomplishment of a detailed examination. In summary, all of the flight control surfaces were found with the airplane. The continuity of the flight control system was confirmed. Propeller Examination. No evidence of torsional deformation was observed on the propeller's spinner. One of the propeller blades was bent approximately 45 degrees in an aft direction, and the blade did not exhibit any evidence of chordwise scratches. The ## Aircraft - Registration: [N6374V](https://openairdocs.org/deregistered/N6374V-2004-09-17), registration cancelled 2004-09-17, S/N A-50, built 1965 (OpenAirDocs) - Reported make and model: Alon A2 - Registry model: [Alon A2](https://openairdocs.org/model/alon-a2) (registry code 0540102) (OpenAirDocs) - Registry engine: [Continental C90 series](https://openairdocs.org/engine/continental-c90-series) (registry code 17009, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: A-50 - Airframe hours: 1557 - Engines: Continental C-90-16F 90 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2003, 54 hours before - Departed: O61, Cameron Park, CA - Destination: O22, Columbia, CA - Airport: O61, Cameron Airpark, runway 13, 4,051 × 50 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review July 1, 2003; seat: left; toxicology performed; flight hours: 1,342 total, 118 in this make and model, 1,181 as pilot in command, 8 in the last 90 days, 4 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 54 °F - Altimeter: 30.09 inHg - Observed at: AUN, 18 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 20040321007219A](https://openairdocs.org/incident/20040321007219A), Mar 21, 2004: Univar A2ALON, Cameron Park, CA, Destroyed, 2 fatal. (-23) During the initial climb from Cameron airport, Cameron Park, CA, N6374V experienced a loss of engine power. The pilot reversed course and commenced… ## Docket (20 files) The files NTSB released with the investigation on January 24, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58930. 5.6 MB in all. - Witness Statements (item 1, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244478&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Wreckage Diagram (item 2, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244479&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Report from Teledyne Continental Motors (item 3, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244544&FileExtension=.PDF&FileName=Report%20from%20Teledyne%20Continental%20Motors-Redacted.PDF - Toxicological Report (item 4, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211008&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Toxicological Report - El Dorado County Coroner (item 5, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244481&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20El%20Dorado%20County%20Coroner-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244482&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Extract from Aircraft Logbook (item 7, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244483&FileExtension=.PDF&FileName=Extract%20from%20Aircraft%20Logbook-Redacted.PDF - Extract from Engine Logbook (item 8, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244484&FileExtension=.PDF&FileName=Extract%20from%20Engine%20Logbook-Redacted.PDF - Extract from Pilot's Airplane Usage Record (item 9, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244485&FileExtension=.PDF&FileName=Extract%20from%20Pilot%27s%20Airplane%20Usage%20Record-Redacted.PDF - Extract from Pilot's Flight Record Log (item 10, .PDF, 610 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244486&FileExtension=.PDF&FileName=Extract%20from%20Pilot%27s%20Flight%20Record%20Log-Redacted.PDF - Photo 1 - Airplane, Front View (item 11, .PDF, 436 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244488&FileExtension=.PDF&FileName=Photo%201%20-%20Airplane,%20Front%20View-Master.PDF - Photo 2 - Airplane, Rear View (item 12, .PDF, 460 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244489&FileExtension=.PDF&FileName=Photo%202%20-%20Airplane,%20Rear%20View-Master.PDF - Photo 3 - Cockpit (item 13, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244490&FileExtension=.PDF&FileName=Photo%203%20-%20Cockpit-Master.PDF - Photo 4 - Propeller and Engine (item 14, .PDF, 483 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244491&FileExtension=.PDF&FileName=Photo%204%20-%20Propeller%20and%20Engine-Master.PDF - Photo 5 - Spinner (item 15, .PDF, 421 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244492&FileExtension=.PDF&FileName=Photo%205%20-%20Spinner-Master.PDF - Photo 6 - Wing, Left (item 16, .PDF, 426 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244493&FileExtension=.PDF&FileName=Photo%206%20-%20Wing,%20Left-Master.PDF - Photo 7 - Wing, Right (item 17, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244494&FileExtension=.PDF&FileName=Photo%207%20-%20Wing,%20Right-Master.PDF - Photo 8 - Propeller (item 18, .PDF, 398 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244495&FileExtension=.PDF&FileName=Photo%208%20-%20Propeller-Master.PDF - Photo 9 - Empennage (item 19, .PDF, 399 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244496&FileExtension=.PDF&FileName=Photo%209%20-%20Empennage-Master.PDF - Photo 10 - Right Magneto (item 20, .PDF, 437 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244497&FileExtension=.PDF&FileName=Photo%2010%20-%20Right%20Magneto-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.