# NTSB LAX04FA330: Bushmaster 2000, N750RW, Fullerton, CA, September 25, 2004 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: September 25, 2004, 13:23 local (20:23 UTC) - Place: Fullerton, CA - Coordinates: 33.875556, -117.966667 - Nearby events: https://openairdocs.org/map.md?lat=33.8756&lon=-117.9667&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious, 2 minor; on the ground: 2 minor - Status: Completed, report July 31, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 60210 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04FA330 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60210/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60210 - Page: https://openairdocs.org/ntsb/LAX04FA330 ## Probable cause the inadequate preflight inspection by the pilot-in-command, where the pilot failed to remove the makeshift gust lock attached to the rudder and left elevator of the airplane. As a result, the airplane veered off the runway surface during the takeoff roll, became airborne, and immediately began an uncontrolled descending left roll until impacting vehicles and the ground. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - flight control,gust lock - not removed (cause) - aircraft preflight - inadequate, pilot in command (cause) - flight controls - restricted (cause) - In flight collision with object, descent - uncontrolled - object - vehicle (contributing factor) - On ground/water encounter with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane crashed onto a street adjacent to the airport shortly after takeoff. As the airplane started its takeoff roll, it began to veer to the left off of the runway. About midway down the runway the airplane lifted off the ground and flew over a crowd of people assembled at the airport for an airport appreciation day. The airplane climbed to about 50 feet, made a steep roll to the left, flying in-between the control tower and a light pole, and crossed over the boundary fence where the left wing struck a moving vehicle before coming to rest against several parked cars. Numerous photographs (including video footage) were taken by witnesses on the airport of the airplane on the takeoff ground roll and throughout the accident sequence. The photographs clearly show a nylon strap connecting the left elevator and rudder. It was surmised that the use of the nylon strap was as a flight control/gust lock for the airplane. During the investigation, a nylon strap was observed hanging from an S-hook that was attached to the vertical stabilizer/rudder hinge attach point. The loop at the other end of the strap had come apart, and when investigators looked under the left stabilizer/elevator hinge attach area they noted a similar S-hook attached to the hinge attach area. ## Factual narrative HISTORY OF FLIGHT On September 25, 2004, at 1323 Pacific daylight time, a tri-motor Bushmaster Aircraft 2000, N750RW, impacted the ground during the takeoff initial climb from runway 24 at Fullerton Municipal Airport (FUL), Fullerton, California, and struck a car on an adjacent street. The pilot operated the airplane under the provisions of 14 CFR Part 91. The airplane was destroyed. The commercial pilot and the private pilot rated passenger sustained serious injuries. The two people in the car sustained minor injuries from the deployment of their airbags. The local area flight departed at 1522. Day visual meteorological conditions prevailed, and no flight plan had been filed. The accident occurred during the Fullerton Airport Appreciation Day. A spectator at the airport videotaped the accident sequence, and provided the footage to the National Transportation Safety Board investigator-in-charge (IIC). In addition to the videotape, spectators at the airport submitted numerous photographs. One such photograph, enhanced by the Safety Board vehicle recorders specialist, clearly showed a strap connecting the left elevator to the rudder. According to witnesses, as soon as the airplane began its takeoff roll, it started to veer to the left of the runway. The airplane departed the runway, went into the grass area that separated the runway from the taxiway, struck a runway light, and crossed over to the taxiway. The airplane rolled towards a crowd surrounding parked airplanes on the ramp prior to lifting off the ground. Witnesses said that the airplane continued in a left turn and went between the air traffic control tower and a light pole, and crashed. Witnesses reported that the airplane was about 50 to 100 feet above the ground, and the wings were 90 degrees to the ground, when it passed between the air traffic control tower and the light pole. Witnesses further reported that they did not hear anything abnormal with the engines when the airplane powered up for takeoff or at any point during the accident sequence. One witness reported that prior to the airplane impacting the ground he thought he heard an engine, or all of the engines power back. Air traffic control personnel indicated that they issued a takeoff clearance for the pilot and after takeoff there were no further communications. PERSONNEL INFORMATION Flying Pilot The pilot held a commercial pilot certificate with ratings for airplane single and multiengine land, and instrument airplane. He also held a certified flight instructor (CFI) certificate with ratings for airplane single and multiengine land, and instrument airplane. The pilot held a second-class medical certificate issued on September 24, 2003. It had the limitation that the pilot must wear corrective lenses. The pilot had a total flight time of 3,700 hours. He logged 31 hours in the last 90 days, and 12 in the last 30 days. He had an estimated 54 hours in the accident make and model. He completed a flight review on June 18, 2003, in the accident make and model, which he also held a type rating for. Non-Flying Pilot/Mechanic The passenger was a certificated private pilot, with a rating for airplane single engine land. He reported about 1,000 hours of flight time, none of which was in the accident make and model. The private pilot also held an airframe and power plant mechanic certificate, with a Federal Aviation Administration inspection authorization. AIRCRAFT INFORMATION The airplane was a tri-motor Bushmaster Aircraft 2000, serial number 2. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 1,420 hours at the last annual inspection, which was completed on March 1, 2004; there were no engine times recorded during the inspection. The tachometer for the number 1, 2, and 3 engines read 588.1, 479.1, and, 588.1, respectively, at the last 100-hour inspection dated February 29, 2004. METEOROLOGICAL INFORMATION The closest official weather observation station was Fullerton (FUL), located at the accident site. An aviation routine weather report (METAR) for FUL was issued at 1253. It stated: winds from 230 degrees at 7 knots; visibility 7 statute miles; skies clear; temperature 30 degrees Celsius; dew point 17 degrees Celsius; altimeter 29.88 inches of Mercury. WRECKAGE AND IMPACT INFORMATION Investigators from the Safety Board and the Federal Aviation Administration (FAA) examined the wreckage at the accident scene. The airplane came to rest in an industrial section of Fullerton about 300 feet south of the airport on Commonwealth Avenue on a magnetic heading of 360 degrees. The first identified point of contact was a concrete divider that separated Commonwealth Avenue and a frontage road. On the north facing side of the concrete divider was a scrape mark with paint transfer. Adjacent to the concrete divider was a green electrical box that had a piece of airplane metal embedded in it. A road sign in the same area showed evidence of a clean cut, which is indicative of a propeller strike. About 5 feet from the concrete divider was the car that was struck by the airplane. Approximately 12 feet of the outboard section of the left wing was embedded in the front end of the car. The airplane, with the exception of the outboard section of the left wing, remained intact and came to rest about 20 feet from the car. Propeller marks were found in the road between the car and the airplane's final resting point. All of the engines' propellers exhibited signs of S-bending, leading and trailing edge gouging, and chordwise scratches. While photographing the area, a Safety Board investigator observed a nylon tie down strap hanging from the vertical stabilizer/rudder hinge attach point. When examined, the IIC noted an S-hook at the hinge attach point. The other end of the nylon strap had been folded over and stitched together to make a loop. The IIC noted that the stitching had been pulled apart and there was no S-hook attached to it. The IIC examined the underneath portion of the left horizontal stabilizer/elevator area, and found an S-hook at the hinge attach point. ADDITIONAL INFORMATION The Safety Board IIC released the wreckage to the owner's representative on February 5, 2005. ## Aircraft - Registration: [N750RW](https://openairdocs.org/deregistered/N750RW-2017-06-15), registration cancelled 2017-06-15, S/N 2, built 1985 (OpenAirDocs) - Reported make and model: Bushmaster Aircraft 2000 - Registry model: [Bushmaster 2000](https://openairdocs.org/model/bushmaster-2000) (registry code 0350406) (OpenAirDocs) - Registry engine: [Pratt & Whitney R-985 series](https://openairdocs.org/engine/pratt-whitney-r-985-series) (registry code 52008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2 - Airframe hours: 1420 - Engines: Pratt & Whitney R985 450 horsepower reciprocating; Pratt & Whitney R985 450 horsepower reciprocating; Pratt & Whitney R985 450 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Richard Fuchs - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2004, 588.1 hours before - Departed: FUL, Fullerton, CA - Destination: FUL - Airport: FUL, Fullerton Muni, runway 24, 3,121 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: serious; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2; last flight review June 1, 2003; seat: left; flight hours: 3,700 total, 54 in this make and model, 3,441 as pilot in command, 31 in the last 90 days, 12 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Dawn - Wind: 230° at 7 knots - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 63 °F - Altimeter: 29.87 inHg - Observed at: FUL ## 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 20040925024259A](https://openairdocs.org/incident/20040925024259A), Sep 25, 2004: Bushms BUSHMSTR2000, Fullerton, CA, Destroyed. (-23) Mr. Jay yoshinaga, pilot and [privacy data omitted], mechanic, were departing runway 24 at ful when the aircraft made a left turn departing the runway… ## Docket (15 files) The files NTSB released with the investigation on May 3, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60210. 9.5 MB in all. - Pilot-operator aircraft accident report NTSB form 61201-pilot in command (item 1, PDF, 6 pages, 257 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985316&FileExtension=pdf&FileName=Pilot-Operator%20Aircraft%20Accident%20Report%20NTSB%20Form%2061201-Pilot%20in%20Command-Rel.pdf - Pilot-operator aircraft accident report NTSB form 61201-pilot rated passenger (item 2, PDF, 6 pages, 258 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985319&FileExtension=pdf&FileName=Pilot-Operator%20Aircraft%20Accident%20Report%20NTSB%20Form%2061201-Pilot%20Rated%20Passenger-Rel.pdf - Witness statement (item 3, PDF, 14 pages, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985352&FileExtension=pdf&FileName=Witness%20Statement-Rel.pdf - Weather report (item 4, PDF, 1 page, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985321&FileExtension=pdf&FileName=Weather%20Report-Master.pdf - Reports from federal agencies-excerpt ATC package personnel statements (item 5, PDF, 2 pages, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985349&FileExtension=pdf&FileName=Reports%20from%20Federal%20Agencies-Excerpt%20ATC%20Package%20Personnel%20Statements-Rel.pdf - Release of aircraft wreckage NTSB form 612015 (item 6, PDF, 2 pages, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985324&FileExtension=pdf&FileName=Release%20of%20Aircraft%20Wreckage%20NTSB%20Form%20612015-Rel.pdf - Engine logbook excerpts (item 7, PDF, 6 pages, 886 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985327&FileExtension=pdf&FileName=Engine%20Logbook%20Excerpts-Rel.pdf - Airframe logbok excerpt (item 8, PDF, 2 pages, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985330&FileExtension=pdf&FileName=Airframe%20Logbok%20Excerpt-Rel.pdf - Pilot's operating handbook (item 9, PDF, 4 pages, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985332&FileExtension=pdf&FileName=Pilot%27s%20Operating%20Handbook-Master.pdf - Witness videotape of accident sequence (item 10, PDF, 1 page, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985346&FileExtension=pdf&FileName=Witness%20Videotape%20of%20Accident%20Sequence-Master.pdf - Photo 1-airplane veering left on runway witness photo (item 11, PDF, 1 page, 931 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985334&FileExtension=pdf&FileName=Photo%201-Airplane%20veering%20left%20on%20runway%20Witness%20Photo-Master.pdf - Photo 2-view along debris path vehicle involved in accident and propeller marks on pavement visible FAA (item 12, PDF, 1 page, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985338&FileExtension=pdf&FileName=Photo%202-View%20along%20debris%20path%20Vehicle%20involved%20in%20accident%20and%20propeller%20marks%20on%20pavement%20visible%20FAA-Master.pdf - Photo 3-main wreckage NTSB (item 13, PDF, 1 page, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985340&FileExtension=pdf&FileName=Photo%203-Main%20Wreckage%20NTSB-Master.pdf - Photo 4-cargo strap found on rudder at accident site NTSB (item 14, PDF, 1 page, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985344&FileExtension=pdf&FileName=Photo%204-Cargo%20Strap%20Found%20on%20Rudder%20at%20Accident%20Site%20NTSB-Master.pdf - Photo 5 -picture of tiedown strap enhancement by NTSB (item 15, PDF, 1 page, 450 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=985313&FileExtension=pdf&FileName=Photo%205-Picture%20of%20tiedown%20strap%20enhancement%20by%20NTSB-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.