# NTSB LAX04LA029: North American T-28B, N28AF, Hornbrook, CA, October 28, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: October 28, 2003, 14:50 local (22:50 UTC) - Place: Hornbrook, CA - Coordinates: 41.8675, -122.470275 - Nearby events: https://openairdocs.org/map.md?lat=41.8675&lon=-122.4703&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report October 31, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 58258 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04LA029 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58258/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58258 - Page: https://openairdocs.org/ntsb/LAX04LA029 ## Probable cause a catastrophic engine failure from oil exhaustion due to inadequate maintenance installation of the lubricating system hoses. ## 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, cruise - fluid,oil - starvation/exhaustion (cause) - lubricating system,oil hose - loose part/bolt/nut/clamp/etc (cause) - maintenance,installation - inadequate, other maintenance personnel (cause) - Forced landing, emergency descent/landing - In flight collision with object, maneuvering - turn to landing area (emergency) - object - tree(s) ## Analysis The airplane collided with trees during a forced landing following a loss engine power. Witnesses reported that smoke was trailing from the airplane just before it hit the trees. One witness said that the engine was sputtering, and he heard a couple of "bangs." As the airplane turned to line up with a clear landing area it clipped the tops of some trees and crashed on an embankment adjacent to a dirt road. The owner of a fixed base operator received flight instruction from the certified flight instructor (CFI) in the accident airplane immediately before the accident flight, and noted no mechanical discrepancies. Fifteen minutes later, witnesses watched the airplane takeoff on the accident flight, and reported that the airplane and engine looked and sounded normal. A Federal Aviation Administration (FAA) inspector examined the wreckage on scene and found a significant amount of oil on the right side of the airplane aft of the firewall. The engine separated from the airplane, and came to rest about 15 feet upslope from the wreckage. He noted heavy oil deposits on the bottom cylinders and accessories; the top cylinders were clean. Oil coated the accessory section of the engine. The area around the pre-oil port fitting on the accessory section of the engine was saturated in oil, and the B-nut for that oil line to fitting connection was only finger tight. An examination of the engine revealed damage and thermal distress signatures consistent with an oil starvation catastrophic failure, with no oil present inside the engine. A maintenance logbook entry noted that maintenance technicians had replaced all flexible engine hoses 21 hours prior to the accident. ## Factual narrative HISTORY OF FLIGHT On October 28, 2003, at 1450 Pacific standard time, an experimental North American/Armoflex, Inc., T-28B, N28AF, collided with trees during a forced landing following a loss of engine power near Hornbrook, California. The private pilot/owner operated the airplane under the provisions of 14 CFR Part 91. The airplane was destroyed. The pilot/owner received serious injuries. The certified flight instructor (CFI), who was in the rear seat, sustained fatal injuries. Visual meteorological conditions prevailed for the local area flight, and no flight plan had been filed. The flight departed the Siskiyou County Airport (SIY), Montague, California, about 1430. Witnesses reported to the Siskiyou County Sheriff's Department that an airplane was flying low in the area with smoke trailing from it. A few minutes later, the sheriff's department received a call that an airplane had crashed. A witness was outside and observed the accident airplane flying low. The airplane was sputtering, and he heard a couple of "bangs." It turned on final and clipped the tops of some trees. It then struck another tree and came to rest on an embankment adjacent to a dirt road. Another witness stated that they cut the seat belt to remove the front pilot. He noted a very strong odor of fuel. Witnesses at a local fixed base operator (FBO) at SIY said that the airplane had flown in from Medford, Oregon, a couple of hours before the accident. The owner of the FBO received flight instruction from the CFI in the accident airplane and noted no mechanical discrepancies during that flight. After they returned to the airport, the FBO owner indicated that the accident pilots were on the ground for 15 minutes prior to their departure. Witnesses at the FBO stated that they watched the airplane takeoff. It looked and sounded normal. PERSONNEL INFORMATION Pilot/Owner A review of the Federal Aviation Administration (FAA) airman records revealed that the pilot held a private pilot certificate with ratings for airplane single engine land and sea. The pilot held a third-class medical certificate issued on July 7, 2003. It had the limitations that the pilot must wear lenses for distant vision and possess glasses for near vision. An examination of the pilot's logbook indicated an estimated total flight time of 610 hours. He logged 35 hours in the last 90 days, and 14 in the last 30 days. He had an estimated 16 hours in this make and model. CFI A review of the FAA airman records revealed that the CFI held a commercial pilot certificate with ratings for airplane single engine land and sea, multiengine land and sea, rotorcraft-helicopter, and instrument airplane. He had a type rating for the L-P38 limited to visual flight rules (VFR) only. The pilot also held a CFI certificate with ratings for airplane single engine and multiengine land. He held a mechanic airframe and powerplant certificate with Inspection Authorization. The CFI held a second-class medical certificate issued on June 30, 2003. It had no limitations or waivers. No personal flight records were located for the CFI. The National Transportation Safety Board investigator-in-charge (IIC) obtained the aeronautical experience listed in this report from the FAA who indicated that he had a total flight time of 3,500 hours. AIRCRAFT INFORMATION The airplane was a North American experimental T28B, serial number 138321. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 15,120 hours at the last conditional inspection dated January 1, 2003. The Hobbs hour meter read 226.1 at that inspection. The logbook entry noted that maintenance technicians changed the oil, and replaced all flexible hoses on the engine. An entry in the logbooks on September 4, 2003, noted a nose wheel tire change at a Hobbs time of 238.2 hours. The pilot's personal flight logbook showed an additional 9 hours of flight time in the airplane from the September 4, 2003, entry. The engine was a Lycoming R-1820-86, serial number 520454. Total time estimated on the engine at the last condition inspection was 260 hours since major overhaul. Medford Air Service reported that they added 62.3 gallons of 100LL (low lead) aviation fuel before the flight to Montague. WRECKAGE AND IMPACT The area surrounding the accident site was an open area and sparsely covered with trees. The airplane came to rest on Black Mountain Road (north/south orientation), about 1/2 mile south of Ager Road, at the approximate global positioning system (GPS) coordinates of 41 degrees 51.58.9 minutes north latitude and 122 degrees 28.13.1 minutes west longitude, at an elevation of 2,383 feet. According to a deputy from the Siskiyou County Sheriff's Department, the airplane struck a large tree, impacted the ground, and after crossing Black Mountain Road, came to rest on an embankment adjacent to the road. An FAA inspector examined the wreckage on scene. He found a significant amount of oil on the right side of the airplane aft of the firewall. He found pieces of windscreen about the crash site, but found no oil on these pieces. The engine separated at the firewall, and came to rest about 15 feet upslope from the main wreckage. He noted heavy oil deposits on the bottom cylinders and accessories; the top cylinders were clean. He reported that two of the propeller blades were bent back, and one blade remained straight. Oil residue covered all three blades near the hub. MEDICAL AND PATHOLOGICAL INFORMATION A doctor completed an autopsy on the pilot on October 29, 2003, under the auspices of the Sheriff-Coroner for Yreka County. The doctor noted massive head trauma, and listed the cause of death as central nervous system damage resulting from blunt force trauma caused by an airplane accident. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the CFI. Analysis of the specimens contained no findings for carbon monoxide, cyanide, volatiles, and tested drugs. Survival Factors A Siskiyou county sheriff's deputy reported that, when he arrived on-scene, the CFI was seated in the rear of the airplane, and remained belted in his seat. He reported that the CFI was not wearing a helmet, and had sustained massive head trauma. TESTS AND RESEARCH The Safety Board IIC conducted an examination of the airframe at Plain Parts, Pleasant Grove, California, on November 1, 2003. She observed oil covering both sides of the airframe (top and bottom) to include the inboard wing sections. A majority of the oil was coating the right side of the airframe. Oil thickly coated the top and bottom of the right inboard section of the horizontal stabilizer. The IIC further noted that most of the flexible hoses remained attached to the engine. The IIC supervised an engine teardown at Airpower, Inc., in Lakeport, California, on January 6, 2003. A visual examination of the engine revealed that engine oil coated the accessory side of the engine. The flexible lines were either destroyed or separated from the engine. The oil pump housing was disassembled. Oil was still present in the housing; however, foreign debris was in the housing. Mechanics removed cylinders from the engine. The inside of the engine was illuminated through the cylinder holes, and the IIC noted bronze, blue, and ash discoloration of the internal components of the engine, as well as extensive mechanical damage. The IIC further noted that a connecting rod arm had broken at the piston connection interface, and there was piston deformation and damage on another cylinder. She observed no lubrication inside the engine. Maintenance personnel noted that the master rod journal had a blue discoloration. They also noted that the pre-oil port at the accessory section of the engine was saturated in oil, and the B-nut to it was finger tight. ## Aircraft - Registration: [N28AF](https://openairdocs.org/deregistered/N28AF-2007-01-23), registration cancelled 2007-01-23, S/N 138321 (OpenAirDocs) - Reported make and model: North American T-28B - Registry model: [North American/Armoflex T-28B](https://openairdocs.org/model/north-american-armoflex-t-28b) (registry code 6402501) (OpenAirDocs) - Category: Airplane - Serial number: 138321 - Airframe hours: 15120 - Engines: Lycoming R-1820-86 1425 horsepower reciprocating - Damage: Destroyed - Flight: Instructional, Part 91 - Registered owner: Ron D. Coffman - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, January 1, 2003, 21 hours before - Departed: SIY, Montague, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 64; injuries: fatal; commercial, flight instructor; airplane ratings: multi-engine sea, single-engine sea, multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2; seat: rear; toxicology performed; flight hours: 3,500 total - Pilot; age 57; injuries: serious; private; airplane ratings: single-engine land, single-engine sea, multi-engine land; medical: class 3; seat: front; flight hours: 610 total, 16 in this make and model, 330 as pilot in command, 35 in the last 90 days, 14 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: 3,900 ft broken - Temperature: 52 °F, dew point 43 °F - Altimeter: 29.79 inHg - Observed at: LMT, 45 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 20031028028499A](https://openairdocs.org/incident/20031028028499A), Oct 28, 2003: Namer T28B, Hornbrook, CA, Destroyed, 1 fatal. (-23) On October 28, 2003 at 1450, a north american/armoflex, inc., T-28B, N28AF, lost engine power, collided with trees and came to rest in a field. The… ## Docket (15 files) The files NTSB released with the investigation on August 22, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58258. 12.6 MB in all. - Witness Statement (item 1, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261980&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - FAA Inspector's Report (item 2, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262009&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Report-Redacted.PDF - Excerpt report from Siskiyou County Sheriff's Department (item 3, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262005&FileExtension=.PDF&FileName=Excerpt%20report%20from%20Siskiyou%20County%20Sheriff%27s%20Department-Redacted.PDF - Aircraft Logbooks (item 4, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262011&FileExtension=.PDF&FileName=Aircraft%20Logbooks-Redacted.PDF - Fuel Receipt (item 5, .PDF, 264 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262014&FileExtension=.PDF&FileName=Fuel%20Receipt-Redacted.PDF - Excerpt Pilot Logbook (item 6, .PDF, 756 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262017&FileExtension=.PDF&FileName=Excerpt%20Pilot%20Logbook-Redacted.PDF - Toxicological Report (item 7, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262021&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262023&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263084&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1 - Aerial View (Siskiyou Co. Sheriff) (item 10, .PDF, 259 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261981&FileExtension=.PDF&FileName=Photo%201%20-%20Aerial%20View%20(Siskiyou%20Co.%20Sheriff)-Master.PDF - Photo 2 - Aerial View 1 (Siskiyou Co. Sheriff) (item 11, .PDF, 273 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261982&FileExtension=.PDF&FileName=Photo%202%20-%20Aerial%20View%201%20(Siskiyou%20Co.%20Sheriff)-Master.PDF - Photo 3 - First Point of Contact - Tree (Siskiyou Co. Sheriff) (item 12, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261983&FileExtension=.PDF&FileName=Photo%203%20-%20First%20Point%20of%20Contact%20-%20Tree%20(Siskiyou%20Co.%20Sheriff)-Master.PDF - Photo 4 - Main Wreckage Looking Towards Tree (Siskiyou Co. Sheriff) (item 13, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261984&FileExtension=.PDF&FileName=Photo%204%20-%20Main%20Wreckage%20Looking%20Towards%20Tree%20(Siskiyou%20Co.%20Sheriff)-Master.PDF - Photo 5 - Wreckage Area (Siskiyou Co. Sheriff) (item 14, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261985&FileExtension=.PDF&FileName=Photo%205%20-%20Wreckage%20Area%20(Siskiyou%20Co.%20Sheriff)-Master.PDF - Photo 6 - Engine and Airframe (Siskiyou Co. Sheriff) (item 15, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261986&FileExtension=.PDF&FileName=Photo%206%20-%20Engine%20and%20Airframe%20(Siskiyou%20Co.%20Sheriff)-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.