# NTSB LAX05FA271: Piper PA-24-250, N7342P, Pomona, CA, August 18, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 17, 2005, 19:50 local (Aug 18, 2005, 02:50 UTC) - Place: Pomona, CA - Coordinates: 34.033611, -117.820274 - Nearby events: https://openairdocs.org/map.md?lat=34.0336&lon=-117.8203&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed, report September 14, 2007 - Report: Approved by Office Director - Parties: Piper Aircraft Company, Federal Aviation Administration, Textron Lycoming - NTSB case key (mKey): 62310 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX05FA271 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62310/pdf - Page: https://openairdocs.org/ntsb/LAX05FA271 ## Probable cause A loss of engine power during the landing approach due to fuel starvation caused by debris and corrosion in the carburetor assembly. A factor contributing to the accident was the failure of the owner to comply with the manufacturer's service bulletin regarding overhaul of the carburetor. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, approach - fluid,fuel - starvation (cause) - obstructed (cause) - maintenance,service bulletin/letter - not complied with, other maintenance personnel (contributing factor) - fuel system,carburetor - corroded (cause) - Forced landing, emergency descent/landing - In flight collision with terrain/water, emergency landing - terrain condition - open field ## Analysis While on approach for the destination airport, the pilot reported engine problems, and attempted to land in a field short of the airport. During the forced landing, the left wing contacted the ground, and the airplane tumbled through an impact sequence. During the postaccident engine examination, investigators noted debris and corrosion inside the carburetor and the main jet passage. The airframe and engine inspection revealed no further mechanical anomalies that would have precluded normal operation. A Safety Board metallurgist examined the carburetor and debris/particles. The examination identified that the debris/particles were most likely a combination of lead and soil that had built up over time. The corrosion indicated prolonged exposure to water. The particles probably caused a restricted flow of air-fuel mixture in the main jet that eventually resulted in a reduction or loss of engine power once the particulate contamination had built up to a significant amount. There were no entries in either the airframe or engine logbook indicating that the carburetor had ever been overhauled in its 46-year history. The carburetor manufacturer issued a service bulletin regarding the overhaul of the accident airplanes' carburetor. The recommended time for the overhaul was either at the engine manufacturer's time between overhaul, or every 10 years the carburetor was in service, whichever came first. While service bulletins are not mandatory, had the carburetor been inspected at the manufacturer's recommended intervals, the corrosion and debris may have been identified and source of the fuel system contamination corrected. Investigators noted that the airplane had not been equipped with a shoulder harness restraint system. The fatal injuries for the pilot and front seat passenger were caused by head and upper torso trauma associated with the upper body not being restrained during the impact sequence. The airplane manufacturer had issued Service Bulletin No. 980, Shoulder Harness Installation, in 1995, for the accident make and model airplane. The pilot/owner had purchased the shoulder harness restraint system kit for his airplane, but had not installed them. The still packaged shoulder harnesses were found in the debris field by the investigation team. ## Factual narrative HISTORY OF FLIGHT On August 17, 2005, about 1950 Pacific daylight time, a Piper PA-24-250, N7342P, impacted flat terrain at the Spadra Ranch facility for California Polytechnic State University, Pomona, California. The pilot/owner operated the airplane under the provisions of 14 CFR Part 91 as a personal flight. The airplane sustained substantial damage. The pilot and one passenger were fatally injured. A passenger seated in a back seat sustained serious injuries. Visual meteorological conditions prevailed for the local area flight, and no flight plan had been filed. The flight departed Zamperini Field Airport (TOA), Torrance, California, at an undetermined time. The flight's destination was Chino Airport (CNO), Chino, California. A witness in his backyard heard an airplane's engine 'sputtering and cutting out.' When he looked up he saw the accident airplane flying 'really low' in an easterly direction. He did not see any smoke or fire coming from the airplane. The airplane made a turn northbound, and then returned to a southbound heading. As the airplane continued to circle he could no longer hear the engine. The witness reported that the airplane was "going down" and gliding towards a field. He lost sight of the airplane behind the tree line and then heard it crash. He responded to the accident site and observed the rear seated passenger standing on the passenger side wing. The witness could smell gas and told the passenger to "get away." The passenger told the witness that they were headed towards Chino, but did not indicate what had happened. The National Transporation Safety Board investigator-in-charge (IIC) reviewed communications between the pilot and Brackett airport (POC) Air Traffic Control Tower personnel. At 1948, the pilot made the initial call to POC. A minute later the pilot reported an engine failure near San Antonio College (Mount Sac), about 5.5 miles from the airport. At 1950, the controller calls emergency equipment after he receives no response to his radio communications to the pilot. The controller further reported in his personnel statement that he coordinated with Pomona Air 1 to locate the airplane. The POC controller last observed the position of the accident airplane utilizing DBRITE (Digital Bright Radar Indicator Tower Equipment) about 3 miles southwest of the airport. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed the pilot held a private pilot certificate with an airplane single and multiengine land ratings. The pilot held a third-class medical certificate issued on September 27, 2004. It had the limitations that the pilot must wear corrective lenses. The aeronautical experience listed in this report was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated a total time of 3,200 hours, with 50 hours logged in the last 6 months. AIRCRAFT INFORMATION The airplane was a 1961 Piper PA-24-250, serial number 24-2521. A review of the airplane's logbooks revealed a total airframe time of 3,760.60 hours at the last annual inspection. An annual inspection was completed on August 6, 2004. The entry for the annual inspection stated in part that the mechanic had to tighten some of the electrical leads on system. There were no other discrepancies identified during the annual inspection. The tachometer read 3,841.32 at the accident scene. The airplane was equipped with a Textron Lycoming O-540-A1D5 engine, serial number L-18544-40. Total time on the engine at the last annual inspection was 3,760.60 hours. An engine field overhaul had been completed on June 24, 1993, with an engine total time of 1,098.2 hours. A Marvel-Schebler, MA-4-5 carburetor, serial number R-41-9230, had been installed on the airplane. Service Bulletin MSA-3 Revision 1 dated November 18, 1991, titled Overhaul Periods for Float Carburetors, as issued by Precision Airmotive, LLC, indicated that the accident airplane's carburetor should be overhauled at the engine manufacturer's specified time between overhaul or 10 years in service or last overhauled, whichever occurs first. There were no airframe or engine logbook entries of compliance with Service Bulletin MSA-3 Rev. 1. WRECKAGE AND IMPACT INFORMATION The airplane impacted in a fallow field (Spadra Farm Field) owned by the State of California - Cal Poly Pomona University. The accident site was on the west side of Lanterman State Hospital in Pomona. Responding officers from the Cal Poly-Pomona Police Department noted a strong odor of fuel from the airplane when they arrived on scene. Officers also reported that the pilot and front passenger remained inside the airplane and that both occupants were wearing their "lap seatbelts." The rear seat passenger was outside of the airplane when the officers arrived, and they rendered assistance until the passenger was transported to a local area hospital. The passenger relayed to an officer that they had departed from the Torrance airport en route to Chino. The passenger did not indicate the nature of the emergency that precipitated the accident. Investigators from the Safety Board, the FAA, Piper, and Textron Lycoming, parties to the investigation, responded to the accident site and examined the wreckage. The wreckage was at a Global Positioning System (GPS) coordinates of 34 degrees 02.023 minutes north latitude and 117 degrees 49.215 minutes west longitude. The debris path was along a magnetic bearing of 057 degrees. The first identified point of contact (FIPC) was on a magnetic heading of 118 degrees, and the airplane came to rest upright 122 feet from the FIPC. The empennage partially separated from the aft cabin bulkhead and remained intact, and next to the cabin area. The engine remained attached to the engine mounts, firewall, and airframe; however, it was canted in a nose down attitude with the aft portion of the engine propped up against the instrument panel. The cockpit area of the airplane had been breached during the accident sequence. Three feet of the outboard section of the left wing came to rest about 45 feet from the main wreckage. The aft portion of the airplane had separated along the aft baggage door line and was slightly perpendicular to the fuselage. The propeller assembly remained connected at the crankshaft flange. Both blades were bent near the hub and folded aft. The carburetor had been displaced from the engine; however, it remained intact. After the carburetor was removed, the throttle lever was manually actuated with a discharge of a steady stream of fuel from the accelerator discharge tube. The carburetor was disassembled and investigators noted contaminates at the bottom of the carburetor bowl. The float assembly remained in place and was not damaged. Investigators visually inspected the airplane's fuel tanks and observed fuel in both right fuel tanks, which they estimated to be about 3/4 full. The left fuel tanks had been breached; however, the fuel bladder material was slick to the touch. MEDICAL AND PATHOLOGICAL INFORMATION The County of Los Angeles Department of Coroner, Los Angeles, California, conducted an autopsy on the pilot on August 21, 2005. The cause of death was listed as multiple blunt force trauma. The TC FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed a toxicological analysis from samples obtained during the autopsy. The tests for carbon monoxide and cyanide were not performed. The results of the analysis of the specimens were negative for volatiles and tested drugs. According to the airplane manufacturer, when the airplane was delivered new in 1961, it had not been equipped with a shoulder harness restraint system. The airplane manufacturer indicated that a mandatory Service Bulletin No. 980 titled Should Harness Installation, ## Aircraft - Registration: [N7342P](https://openairdocs.org/deregistered/N7342P-2007-01-23), registration cancelled 2007-01-23, S/N 24-2521, built 1961 (OpenAirDocs) - Reported make and model: Piper PA-24-250 - Registry model: [Piper PA-24-250](https://openairdocs.org/model/piper-pa-24-250) (registry code 7102404) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 24-2521 - Airframe hours: 3841.32 - Engines: Lycoming O-540-A1D5 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: John Shear - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 1, 2004, 80.72 hours before - Departed: TOA, Torrance, CA - Destination: CNO, Chino, CA - Airport: CNO, Chino ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; medical: class 3; seat: left; toxicology performed; flight hours: 3,200 total ## Weather - Conditions: Visual (VMC), Dusk - Wind: calm - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 57 °F - Altimeter: 29.90 inHg - Observed at: CNO, 7 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 20050817025329A](https://openairdocs.org/incident/20050817025329A), Aug 17, 2005: Piper PA24250, Diamond Bar, CA, Destroyed, 2 fatal. (-23) The pilot declared an emergency, aircraft had an engine failure. Aircraft experienced a very hard landing in a large unobstructed field. The aircraft was… ## Other investigations on N7342P (2) 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. - [NTSB LAX77DUG49](https://openairdocs.org/ntsb/LAX77DUG49), Jun 26, 1977: Piper PA-24 (N7342P), Rialto, CA, substantial damage - [NTSB FTW67D0044](https://openairdocs.org/ntsb/FTW67D0044-122317), Jun 21, 1966: Piper PA-24 (N7342P), Tampico, Mexico, substantial damage 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.