LAX05FA106

NTSB accident investigation · Piper PA-28-181 · Yucaipa, CA · March 1, 2005

Accident · FatalField investigationFinal report
Date
February 28, 2005, 19:05 local (Mar 1, 2005, 03:05 UTC)
Place
Yucaipa, CA
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N2954PPiper PA-28-181
Weather
Visual (VMC) · Night
Status
Completed · report February 26, 2007
Report
Approved by Office Director
Parties
New Piper Aircraft Company, Federal Aviation Administration, Lycoming Engines
FAA report
20050228004069A
Case key
61078

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 failure of the private pilot and the flight instructor to maintain adequate terrain clearance while flying in unfamiliar mountainous terrain in dark night conditions.

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.

In flight collision with terrain/waterManeuvering
Light condition - dark night
Terrain condition - blind/box canyon
Clearance - not maintainedPilot in commandCause
Terrain condition - mountainous/hilly

Analysis

The airplane impacted mountainous terrain in a box canyon during a local area instructional night flight approximately 1 hour after nautical twilight ended. The operator reported that the purpose of the flight was for the private pilot, who obtained his certificate 1 month ago, to obtain night Visual Flight Rules (VFR) experience with an instructor on board. The flight was scheduled to fly in the local area and to make night landings at several local airports. Friends of the pilot reported they heard the airplane fly over the private pilot's residence about 1900. The witness said he could see the strobe lights of the airplane, but could not see the airplane registration number due to the low clouds that were in the area. The wreckage site was on a slope in a box canyon, about 100 feet below the ridgeline top, at an elevation of 4,168 feet mean sea level. The private pilot had a total logged flight time of 95 hours, with 3.5 hours of dual instruction received during night conditions. The certified flight instructor had a total logged flight time of 435 hours, with 22 flight hours logged during night conditions. He logged 23 hours in the local area, 2.8 of which were under night conditions. No mechanical abnormalities were found with the airplane or engine during the investigation.

Factual narrative

1.1 History of flight

On February 28, 2005, about 1905 Pacific standard time, a Piper PA-28-181, N2954P, impacted mountainous terrain near Yucaipa, California. M.I. Air Corporation was operating the airplane under the provisions of 14 CFR Part 91. The commercial certified flight instructor (CFI), the private pilot undergoing instruction (PUI), and the private pilot rated passenger sustained fatal injuries; the airplane was destroyed. The local instructional night flight departed Redlands Municipal Airport, Redlands, California, at 1846. Visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 34 degrees 02.258 minutes north latitude and 116 degrees 59.249 minutes west longitude, at an elevation of 4,160 feet.

The operator reported that the purpose of the flight was for the PUI to obtain night Visual Flight Rules (VFR) pilot-in-command time. The flight was scheduled to fly in the local area and to make night landings at Redlands Municipal Airport and other local airports.

Friends of the pilot reported they heard the airplane fly over the PUI's residence about 1900. The witness said he could see the strobe lights of the airplane, but could not see the airplane registration number due to the low clouds that were in the area.

The airplane was reported missing on March 1, 2005, at 0800, when personnel at M.I. Air Corporation came to work and discovered the airplane had not returned. San Bernardino County Sheriff's Department Aero Bureau personnel located the wreckage at about 1400 in mountainous terrain about 9.0 nautical miles (nm) southeast of Redlands Municipal Airport.

1.2 Personnel information

1.2.1 Pilot Under Instruction

A review of Federal Aviation Administration (FAA) airman records revealed that the PUI held a private pilot certificate with an airplane single engine land rating.

The PUI held a third-class medical certificate that was issued on November 8, 2004. It had the limitations that the pilot must wear corrective lenses.

An examination of the PUI logbook indicated a total logged flight time of 95 hours. He logged 78 hours in the last 90 days, and 33 hours in the last 30 days. He had an estimated 13 hours in the accident make and model. He completed a private pilot examination on January 25, 2005.

The accident flight was the PUI's first night VFR flight as pilot-in-command. The PUI had logged 3.5 hours of dual instruction received during night conditions.

1.2.2 Certified Flight Instructor

A review of the FAA airman records revealed that the CFI held a commercial pilot certificate with ratings for airplane single and multiengine land, and instrument airplane. The CFI also held a certified flight instructor certificate with ratings for airplane single engine land and instrument airplane.

The CFI held a first-class medical certificate that was issued on August 2, 2004. It had no limitations or waivers.

An examination of the CFI pilot's logbook indicated an estimated total flight time of 435 hours. He logged 54 hours in the last 90 days and 23 hours in the last 30 days. He had an estimated 31 hours in this make and model. He completed a certified flight instructor, instrument airplane examination, on February 1, 2005. He had a total of 22 flight hours logged during night conditions.

The CFI had been employed by M.I. Air Corporation since February 10, 2005. According to the CFI's logbook, since beginning his employment, he logged 2.8 hours of night flight time in the local area prior to the accident.

According to the CFI's application for employment with M.I. Air Corporation dated January 26, and February 10, 2005, he worked as a pilot for Mesa Airlines from October 2004 to December 2004, based out of Phoenix, Arizona. He was a student pilot with San Juan College located in Phoenix, Arizona, which is a training facility for Mesa Airlines, from April 2004 until October 2004. No prior pilot work experience was reported.

1.3 Aircraft information

The airplane was a Piper PA 28-181, serial number 28-7990587. A review of the airplane's logbooks revealed a total airframe time of 10,796.4 hours at the last 100-hour inspection. The logbooks had an entry for an annual inspection dated July 5, 2004. The tachometer read 4,516.7 at the last inspection. The tachometer read 4,578.5 at the accident scene; the Hobbs hour meter read 1,271.9 at the accident scene.

The engine was a Textron Lycoming O-360-A4M engine, serial number L-23888-36A. Total time on the engine at the last 100-hour inspection was 4,516.7 hours.

Fueling records at M.I. Air Corporation established that the airplane was last fueled on February 27, 2005, with the addition of 8.22 gallons of 100LL octane aviation fuel. Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure.

1.4 Meteorological information

The closest official weather observation station was March Air Reserve Base (RIV), Riverside, California, which was located 16 nautical miles (nm) southwest of the accident site. The elevation of the weather observation station was 1,535 feet mean sea level (msl). An aviation routine weather report (METAR) for RIV was issued at 1853. It stated: winds from 310 degrees at 6 knots; visibility 10 miles; skies few clouds at 3,500 feet, a scattered cloud layer at 20,000; temperature 55 degrees Fahrenheit; dew point 48 degrees Fahrenheit; altimeter 30.10 inHg.

According to the National Transportation Safety Board Sun and Moon program for the geographic coordinates and altitude of Yucaipa, sunset occurred at 1744, and nautical twilight ended at 1809. At the time of accident, the moon was 80 percent illuminated.

1.5 Communications

The investigation did not uncover any communications between the accident aircraft and any airport traffic control tower (ATCT), Terminal Radar Approach Control (TRACON), Air Route Traffic Control Center (ARTCC) Center, or any other facility at the time of the accident.

1.6 Wreckage and impact information

Investigators from the Safety Board, the FAA, and Piper, a party to the investigation, examined the wreckage at the accident scene.

The wreckage site was at the 4,168-foot level, on the southeastern slope of a box canyon, about 100 feet below the ridgeline.

The terrain consisted of a ridgeline radiating westward from Pisgah Peak (1.8 nm to the east), in the San Bernardino National Forest. The wreckage site overlooked Wildwood Canyon to the south. The slope, at an estimated 60-degree incline, consisted of primarily decomposed granite and shale covered by loose topsoil.

The first identified point of contact (FIPC) was a ground scar. The debris path was along a magnetic bearing of 280 degrees. A Bendix/King antenna and pieces of painted fiberglass were located in the initial impact crater. The outboard section of the left horizontal stabilizer was found along the north edge of the impact crater. The main wreckage came to rest right side up 60 feet upslope from the FIPC with the nose of the airplane oriented downslope.

1.6.1 Wings

The left wing separated from the fuselage and came to rest upside down and perpendicular with the fuselage. The leading edge was facing aft in relationship to the fuselage, and was bent in half near wing station 106.19. The aileron cables remained continuous along the length of the wing. The fuselage wing root skin exhibited cable rip from the aileron cables. The aileron surface remained attached to the wing at the outboard and middle hinge. The flap surface remained attached to the wing. The fuel tank sustained ground impact damage and had ruptured. The main landing gear assembly was broken and separated from the wing.

The right wing remained partially attached but sustained ground impact damage. The wing leading edge from the root to about midspan exhibited sev

Aircraft

Registration
N2954P
Reported as
Piper PA-28-181
Category
Airplane
Serial number
28-7990587
Airframe hours
10,858.2
Engine
Lycoming O-360-A4M, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Registered owner
M.I. Air Corporation
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · December 1, 2004 · 61.8 hours before
Departed
L12 · Redlands, CA

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
30
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
January 1, 2005
Seat
Left
Toxicology
Performed
Flight hours
95 total · 13 in this make and model · 78 in the last 90 days · 33 in the last 30 days
Role
Flight instructor
Age
36
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
February 1, 2005
Seat
Right
Toxicology
Performed
Flight hours
435 total · 31 in this make and model · 385 as pilot in command · 54 in the last 90 days · 23 in the last 30 days

Weather

Conditions
Visual (VMC) · Night
Wind
310° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 48 °F
Altimeter
30.10 inHg
Observed at
RIV, 16 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.