# NTSB LAX05FA262: Piper PA-28-235, N8540W, Big Bear City, CA, August 8, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 8, 2005, 12:58 local (19:58 UTC) - Place: Big Bear City, CA - Coordinates: 34.25111, -116.850555 - Nearby events: https://openairdocs.org/map.md?lat=34.2511&lon=-116.8506&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed, report December 28, 2006 - Report: Approved by Office Director - Parties: Piper Aircarft Company, Federal Aviation Administration - NTSB case key (mKey): 62185 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX05FA262 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62185/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=62185 - Page: https://openairdocs.org/ntsb/LAX05FA262 ## Probable cause The pilot's failure to maintain aircraft control and adequate airspeed while executing an evasive maneuver during an aborted landing, which resulted in a cross-controlled accelerated stall and impact with terrain. Contributing to the accident was the probable presence of another aircraft on the runway traveling in the opposite direction. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Abrupt maneuver, landing - flare/touchdown - aborted landing - initiated, pilot in command - object - aircraft moving on ground (contributing factor) - evasive maneuver - attempted, pilot in command (contributing factor) - Loss of control - in flight, landing - flare/touchdown - flight controls - improper use of, pilot in command (cause) - airspeed - inadequate, pilot in command (cause) - stall - encountered, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ditch ## Analysis The airplane made a sudden steep turn to the right, rolled inverted, and impacted the ground just after the landing flare. Witnesses observed the airplane make a normal landing approach to runway 08 and flare. The engine suddenly went to full power, the nose pitched up, and the plane abruptly turned to the right. It then continued to roll right and impacted the ground inverted at the south edge of the airport boundary. The airplane's sudden turn and right roll is consistent with the result of a cross-control stall to the right, as described by the Airplane Flying Handbook. Two witnesses stated that they saw an airplane takeoff from runway 26 (in the opposite direction) moments after the crash. Approximately 5 minutes after the accident radar data identified a contact 2 miles east of the airport, traveling at 85 knots, departing the vicinity. Four minutes would be the approximate amount of time required for an airplane traveling at 85 knots to perform a downwind departure from the airport and appear on radar 2 miles to the east, if it followed the approximate 5.5-mile downwind departure route. Radar coverage to pattern altitude was not possible due to the mountainous terrain in which the airport is located. Examination of the airplane revealed no evidence of a preimpact malfunction or failure of the control system or power plant. ## Factual narrative HISTORY OF FLIGHT On August 8, 2005, at 1258 Pacific daylight time, a Piper PA-28-235, N8540W, veered off the runway during landing and impacted terrain at Big Bear City, California. The airplane was operated by the pilot-owner under the provisions of 14 CFR Part 91. The private pilot and one passenger were fatally injured, and the other passenger was seriously injured; the airplane was destroyed. Visual meteorological conditions prevailed, and a flight plan had not been filed. The flight originated at Henderson Field, Las Vegas, Nevada, about 1130. Witnesses reported to the National Transportation Safety Board investigator that they observed the airplane make a normal landing approach to runway 08 and flare. The engine suddenly went to full power, the nose pitched up, and then the airplane abruptly turned to the right. It then rolled to the right and impacted the ground inverted at the south edge of the airport boundary. Emergency crews located the airplane in a large drainage ditch. The plane was inverted and there was no fire. Statements were taken from eight witnesses. Two of the witnesses interviewed were located at the west end of the airport and had a view of the approach end of runway 08; however, the departure half of the runway is blocked from view by a hangar. They observed the accident airplane make an uneventful approach to landing (from the west), disappear behind the hangar, and then they heard a loud crash. Within a few seconds after hearing the crash, an airplane crossed by them in the opposite direction about 100 feet over the runway heading west. None of the other witnesses recall observing another aircraft in the vicinity at the time of the accident. The Big Bear office personnel who respond to the airport UNICOM radio transmissions did not recall hearing any aircraft announce its arrival nor an aircraft announce its departure during the time surrounding the accident. Radar data files obtained from the Federal Aviation Administration (FAA) when plotted depict a track originating at Henderson, Nevada, at 1142 PDT, identified with a transponder code of 1200, and arriving in the vicinity of Big Bear Airport at 1250 PDT. The radar track ends over the north shore of Big Bear Lake at 8,000 feet mean sea level (msl), approximately 1.5 miles west of the airport. At 1303, about 5 minutes after the accident, a radar target is identified about 2 miles to the northeast of the airport at 6,900 feet, climbing at 85 knots ground speed, and is identified with a transponder code of 1200. The target travels in a northwest then westerly direction around the north side of Delmar Mountain. The elevation of Big Bear Airport is 6,748 feet msl, the runways available are 08 and 26, and the traffic pattern is prescribed to be flown on the south side of the runway. The approximate ground distance an airplane would cover performing a downwind departure would be 5.5 miles before the airplane left the vicinity of the airport to the east. Distance measurements are based on the Big Bear Airport arrival-departure pilot guide and the Los Angeles Sectional Chart. The floor of long-range radar coverage in the Big Bear area is limited between 7,300 feet msl in the east, 8,300 feet msl to the west, and 8,500 feet msl directly over the runway. The airport pattern altitude is 7,948 feet msl and is beneath the floor of radar coverage. Terrain usually masks targets below these altitudes. PERSONNEL INFORMATION A review of the FAA airman records revealed that the pilot held a private pilot certificate issued on February 11, 1988, with a rating for airplane single engine land. The pilot held a third-class medical certificate that was issued on August 2, 2004. It had the limitation that the pilot must wear corrective lenses. An examination of the pilot's logbook indicated that he had accumulated a total flight time of 534.1 hours, with 475.3 of those hours as pilot-in-command. His latest flight review was dated February 22, 2004. Since April 2002 the pilot logged 39.2 hours in the accident airplane, and the last logbook entry was a 1.5-hour flight dated August 5, 2005. AIRCRAFT INFORMATION The airplane was a single engine, low wing airplane with fixed landing gear, manufactured by Piper as a PA-28-235, serial number 28-10041. The engine was a Lycoming O-540-B2B5, serial number L-6580-40, rated for 235 horsepower at 2,575 rpm. A review of the airplane's logbook revealed a total tachometer time of 3,159 hours, and 1,959 hours since major overhaul (SMOH). The last annual inspection was dated June 12, 2005. WRECKAGE AND IMPACT INFORMATION The wreckage was located on the south side of the airport along the airport boundary fence and in the drainage ditch that runs along the fence. The drainage ditch was about 20 yards wide,10 feet deep, and runs in the east-west direction. The ditch was populated with shrubs, grass, and some small pine trees. The airplane rested inverted along a bearing of 220 degrees and the nose was up against the south side of the drainage ditch. The wreckage coordinates were 34 degrees 15.753 minutes north latitude by 116 degrees 51.493 minutes west longitude. To ease the examination, the wreckage was moved 15 yards to the north onto the asphalt apron. The wreckage was examined on scene by the Safety Board investigator and a technical representative from the Piper Aircraft Company. Three ground scar areas were identified on the asphalt apron just prior to the ditch. The center scar area consisted of two parallel linear gouges in the asphalt; a shallow gouge measuring 1 foot 4 inches in length, followed by a deeper gouge measuring 2 feet 3 inches in length. The two gouges were parallel and separated by 2 feet 1 inch. On a bearing of 180, and perpendicular to the parallel gouges, was a deep, approximately 2-foot-long, gouge in the asphalt. On a bearing of 030 degrees, and 17 feet away, was a linear paint streak with a distinct point of origin. On a bearing of 210 degrees, and 17 feet away, was a wedge like area of stained wet asphalt with a distinct origin point. The parallel asphalt gouges were approximately 14 yards from the main wreckage. The left wing separated at the wing root spar. The spar fracture surfaces were all similar with a matte gray color, granular surface, and 45-degree shear lips. The flap had separated from its upper and lower hinge points, and laid next to the wing. The aileron was present on its hinge and the control balance weight was present. The outboard 5 feet of wing tip leading edge exhibited aft and downward crushing. There was an 8-inch flat indentation along the leading edge forward of the fuel cap. The wing tip fuel tank was ruptured and the red position light was present. The right wing was present and attached to the fuselage. The fiberglass wing tip fuel tank was separated and found against the fence on the far side of the drainage ditch. The remaining wing tip area exhibited a 2 foot 3 inch long, 30-degree inboard to outboard crush. The flap was present on its hinges in a 25-degree down position. The aileron and control balance weight was present on its hinge. Fuel was observed in the main wing tank. The fuselage and empennage was pulled away from the left side of the aft wing spar line. The fuselage exhibited some oil canning of the skin. The horizontal stabilator was present on the tail. The underside of the right side of the stabilator exhibited a witness mark at the root and 45-degree skin buckling was evident along its span. The right side appeared undamaged. The stabilator balance weight was present. The trim tab position was oriented at about 15 degrees up. Four and a half threads were exposed on the stabilator trim jackscrew. The vertical stabilizer was rotated aft approximately 30 degrees about the base of vertical spar. The bottom 5 inches of the rudder was buckled in "z" pattern. The top of the rudder ex ## Aircraft - Registration: [N8540W](https://openairdocs.org/deregistered/N8540W-2017-05-15), registration cancelled 2017-05-15, S/N 28-10041, built 1963 (OpenAirDocs) - Reported make and model: Piper PA-28-235 - Registry model: [Piper PA-28-235](https://openairdocs.org/model/piper-pa-28-235) (registry code 7102810) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-10041 - Airframe hours: 3177 - Engines: Lycoming O-540-B2B5 235 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Michael DeFilippo - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 1, 2005, 18 hours before - Departed: KHND, Las Vegas, NV - Destination: KL35, Big Bear City, CA - Airport: KL35, Big Bear City, runway 08, 5,850 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3; last flight review February 1, 2004; seat: left; toxicology performed; flight hours: 534 total, 40 in this make and model, 475 as pilot in command, 4 in the last 90 days, 4 in the last 30 days ## Weather - Conditions: Visual (VMC) - Wind: 50° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 9,000 ft overcast - Temperature: 75 °F, dew point 54 °F - Altimeter: 30.29 inHg - Observed at: KL35 ## 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 20050808017869A](https://openairdocs.org/incident/20050808017869A), Aug 8, 2005: Piper PA28235, Big Bear, CA, Destroyed, 2 fatal. (-23) Aircraft was on approach for landing at Big Bear, CA. Made abrupt right turn until upside down crashing in a drainage ditch south of the runway. ## Docket (14 files) The files NTSB released with the investigation on October 20, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=62185. 13.1 MB in all. - Witness Statements (item 1, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259083&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Accident Location Airport Map (item 2, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259084&FileExtension=.PDF&FileName=Accident%20Location%20Airport%20Map-Master.PDF - Wreckage Diagram (item 3, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259085&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Photo 1- Airplane as located in drainage ditch. (item 4, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259086&FileExtension=.PDF&FileName=Photo%201-%20Airplane%20as%20located%20in%20drainage%20ditch.-Master.PDF - Photo 2- Wreckage being moved onto the tarmac. (item 5, .PDF, 783 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259087&FileExtension=.PDF&FileName=Photo%202-%20Wreckage%20being%20moved%20onto%20the%20tarmac.-Master.PDF - San Bernardino County Sheriff's Report (item 6, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259088&FileExtension=.PDF&FileName=San%20Bernardino%20County%20Sheriff%27s%20Report-Redacted.PDF - Toxicological Report (item 7, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259089&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259090&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40260078&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Big Bear Departure & Arrival Guidance (item 10, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259091&FileExtension=.PDF&FileName=Big%20Bear%20Departure%20%26%20Arrival%20Guidance-Master.PDF - Pilot Logbook (item 11, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259092&FileExtension=.PDF&FileName=Pilot%20Logbook-Redacted.PDF - Aircraft Logbook (item 12, .PDF, 7.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259093&FileExtension=.PDF&FileName=Aircraft%20Logbook-Redacted.PDF - Radar Plots (item 13, .PDF, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259130&FileExtension=.PDF&FileName=Radar%20Plots-Master.PDF - NTAP radar data files (item 14, .PDF, 208 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259131&FileExtension=.PDF&FileName=NTAP%20radar%20data%20files-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.