# NTSB LAX06FA089: Piper PA-30, N7291Y, Visalia, CA, January 14, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 13, 2006, 18:19 local (Jan 14, 2006, 02:19 UTC) - Place: Visalia, CA - Coordinates: 36.311389, -119.383888 - Nearby events: https://openairdocs.org/map.md?lat=36.3114&lon=-119.3839&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report March 26, 2007 - Report: Approved by Office Director - Parties: Hartzell Propeller, Inc., Federal Aviation Administration, The New Piper, Textron Lycoming - NTSB case key (mKey): 63107 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX06FA089 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63107/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=63107 - Page: https://openairdocs.org/ntsb/LAX06FA089 ## Probable cause the pilot's failure to maintain airspeed during the landing approach, which resulted in a stall and uncontrolled descent. Contributing factors to the accident were the pilot's impairment due to his prolonged use of a highly sedating over-the-counter sleep aid and fatigue due to lack of sleep. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - vfr pattern - base leg/base to final - airspeed - not maintained, pilot in command (cause) - impairment(drugs), pilot in command (contributing factor) - fatigue(lack of sleep), pilot in command (contributing factor) - stall - inadvertent, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane stalled while the pilot was turning from the base leg to final at his home based airport and impacted the ground in an uncontrolled descent. The airplane came to rest 410 feet from the approach end of the active runway. The ground scars and wreckage deformation signatures indicated the ground impact occurred with a high vertical component and very little horizontal energy. Night visual meteorological conditions existed with calm winds. Examination of the wreckage did not reveal any mechanical anomaly to preclude normal operation of the engines or the airplane control systems. No personal flight records were located for the pilot. Based on interviews with acquaintances and family members, the pilot flew often. On his most recent Federal Aviation Administration airman medical application, dated about 1 year prior to the accident, he noted a total flight time of 5,700 flight hours with 75 hours flown in the past 6 months. Review of the pilot's medical records from his personal physician revealed that the pilot had been experiencing back pain that seemed to significantly interfere with his ability to sleep. The toxicological results were positive for extremely high levels of doxylamine, a highly sedating over-the-counter antihistamine, often used in sleep aids such as Unisom Sleep Tabs. The substance had likely accumulated due to daily use and/or use in excess of the maximum recommended dose. The pilot was likely having difficulty obtaining adequate and/or qualitative sleep. ## Factual narrative 1.1 History of Flight On January 13, 2006, about 1819 Pacific standard time, a Piper PA-30 (Twin Comanche), N7291Y, impacted terrain 410 feet from the approach end of runway 30 at Visalia Municipal Airport, Visalia, California. The commercial pilot was the registered owner of the airplane and operated it under the provisions of 14 CFR Part 91. The pilot and three passengers sustained fatal injuries; the airplane was destroyed. Night visual meteorological conditions prevailed and no flight plan had been filed. The airplane was landing following a flight from Byron Airport, Byron, California, where the pilot had picked up two child passengers and departed at 1711. The airplane was based at Visalia. The airplane was reported overdue to the airport manager at 2145 on January 13. He received information that that the airplane's services were terminated by Fresno Approach Control at 1811, approximately 7 miles north of Visalia. At this point, the airport manager checked the emergency frequency for the transmission of an emergency locator transmitter (ELT) but no aural alarm was heard. He then began a ground search for the airplane and located it near the approach end of runway 30 at 2215. Emergency response personnel were then notified. 1.1.1 Witness Information A witness spoke with investigators the morning following the accident. He was driving parallel to the runway about 1820 on a local road and saw the event. He saw the airplane banking and heard the engines running prior to its impact with the ground. After it impacted, there were no other sounds. The witness described what he saw with his hands and showed the airplane descending, prior to twisting to the left and impacting the ground. The witness noted that it was difficult to see due to the dark lighting conditions. After the accident, the witness drove to the local fire department where he reported the accident and told them that he may have been seeing things due to the darkness. The witness then drove back to the airport fence and noted that there was no immediate fire department response. The fire department was contacted regarding this report and advised that the city of Visalia was conducting an investigation into the report. They did not make any comments regarding the witness' report to the National Transportation Safety Board investigator. A pilot that was flying a King Air from Santa Monica Airport heard the accident pilot on the Visalia airport UNICOM. The accident pilot called downwind and the pilot and accident pilot exchanged general light conversation. The accident pilot then called base and no further transmissions were heard. The witness landed about 1830 and thought the transmissions with the accident pilot occurred between 1820 and 1825. After refueling, the witness departed about 1900 and returned about 2215. The witness flew over the accident site twice during the evening and did not see it. The witness further noted that although he did not personally know the accident pilot, he believed that the accident pilot flew at least 3 to 4 times per week for business purposes. Dark lighting conditions existed with clear skies or high cirrus clouds, and light winds favoring runway 30. The witness also noted that the medium intensity approach lighting system was on when the accident airplane was attempting to land. Another pilot was returning from picking up a student and a coworker. His wife was also in the airplane. The pilot was on downwind and he heard the accident pilot and a King Air pilot on the UNICOM frequency. The King Air pilot told the accident pilot that he had plenty of room to land and to go ahead. The pilot saw the airplane turn onto 1/2-mile final with the King Air pilot about 4 miles out, and everything appeared normal. After that time, the pilot began concentrating on flying the airplane and configuring it for landing. He estimated that he landed about 20 seconds after the airplane crashed. 1.2 Personnel Information 1.2.1 Pilot Information The pilot held a commercial certificate with ratings for single engine, multiengine, and instrument airplanes. His last medical was obtained on February 1, 2005, and it was a third-class. On the pilot's last medical application, he indicated a total flight time of 5,700 flight hours and 75 hours in the previous 6 months. The pilot completed a flight review on January 5, 2005, in a Cessna 172. No personal flight logbooks were located for the pilot. 1.2.2 Pilot 72-Hour History According to the pilot's family, during the days leading up to the accident, he was traveling for work. On January 10, the pilot flew commercially to Portland, Oregon, where he performed work functions and then drove to Seattle. On January 11 and 12, the pilot attended meetings and had some extra personal time prior to his return flight to California. On the evening of January 12, the pilot went to dinner with friends in Seattle and then flew commercially to Fresno after his flight was delayed for 1 hour. Upon arriving in the Fresno area, he offered his business partner a ride home and dropped him off at 0030 on January 13. The pilot is then presumed to have driven home and arrived there about 0130 on January 13. At 1330 on the day of the accident, the pilot made arrangements to pickup the passengers at Byron. At 1650, the pilot and one passenger landed at Byron Airport. They departed with two additional passengers at 1711. 1.3 Aircraft Information 1.3.1 General Aircraft History The Piper PA-30 airplane (serial number 30-329) was manufactured in 1964. In 1984, it had been modified from its original design to have two counter rotating Textron Lycoming engines, which powered two Hartzell propellers. The installed engines were: Textron Lycoming LIO-320-B1A (right) and a Textron Lycoming IO-320-B1A (left). The type certificate data sheet (TCDS), identification A1EA, indicated that the airplane was certified with two Lycoming IO-320-B1A engines, and referenced additional certified engine installations in note 5. In note 5 of the TCDS, it stated that the following engines were eligible for installation: left, IO-520-C1A, and right, LIO-520-C1A. In the maintenance records for the airplane, it was noted that the installation was approved through Federal Aviation Administration (FAA) Form 337, Major Repair and Alteration, dated December 14, 1984. The FAA Form 337 noted that the Piper Counter Rotating Powerplant Conversion Kit was installed per Piper Service Letter 552. Supplement 11 of the PA-30 approved flight manual (AFM) pertained to the installation of a counter rotating power plant on the right side. In the limitations section, the engine model designations were Textron Lycoming LIO-320-B1A (right) and a Textron Lycoming IO-320-B1A (left). The propeller designations were a Hartzell HC-E2YL-2 (left) and a Hartzell HC-E2YL-2BL (right). 1.3.2 Maintenance Information The last annual inspection was performed on November 3, 2005. At the time of the inspection, the total time on the airframe was 2,981.1 hours. During this inspection it was noted that the ELT was inspected in accordance with FAR 91.207 (D). This FAR requires that the ELT be checked for proper installation, battery corrosion, operation of the controls and crash sensor, and the presence of a sufficient signal radiated from its antenna. At the annual inspection, the left engine had accrued 1,998.2 hours since its last major overhaul. The right engine had accrued 1,959.1 hours since its last major overhaul. The times listed in the engine logbooks were logged incorrectly and an attached letter from the maintenance company explaining these discrepancies is included with the docket material for this accident. 1.3.3 Oil Analysis The airplane underwent recurring oil analysis for each engine and the testing was completed at Aviation Oil Analysis. The sample dates dated from October 9, 200 ## Aircraft - Registration: [N7291Y](https://openairdocs.org/deregistered/N7291Y-2006-04-17), registration cancelled 2006-04-17, S/N 30-329, built 1964 (OpenAirDocs) - Reported make and model: Piper PA-30 - Registry model: [Piper PA-30](https://openairdocs.org/model/piper-pa-30) (registry code 7103002) (OpenAirDocs) - Registry engine: [Lycoming IO-320 series](https://openairdocs.org/engine/lycoming-io-320-series) (registry code 41509, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 30-329 - Airframe hours: 2981.1 - Engines: Textron Lycoming LIO-320-B1A 160 horsepower reciprocating; Textron Lycoming IO-320-B1A 160 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 1, 2005 - Departed: C83, Byron, CA - Destination: VIS, Visalia, CA - Airport: VIS, Visalia Municipal, runway 30, 6,559 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review January 1, 2005; seat: left; toxicology performed; flight hours: 5,700 total ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 6 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 46 °F - Altimeter: 29.94 inHg - Observed at: KVIS ## 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 20060113000239A](https://openairdocs.org/incident/20060113000239A), Jan 13, 2006: Piper PA30, Visalia, CA, Destroyed, 4 fatal. (-23) N7291Y a Piper PA-30-30 twin engine aircraft, departed byron, CA (C83) airport VFR on 01/13/2006 at 5:20 pm PST with a destination of Visalia, CA (kvis).… ## Other investigations on N7291Y (1) 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 OAK76DVW33](https://openairdocs.org/ntsb/OAK76DVW33), Aug 4, 1976: Piper PA-30 (N7291Y), Pioche, NV, substantial damage ## Docket (30 files) The files NTSB released with the investigation on January 30, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=63107. - Witness Interview (item 1, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263635&FileExtension=.PDF&FileName=Witness%20Interview-Master.PDF - 72-Hour History (item 2, .PDF, 373 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262136&FileExtension=.PDF&FileName=72-Hour%20History-Redacted.PDF - Fire Department Investigation (item 3, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262138&FileExtension=.PDF&FileName=Fire%20Department%20Investigation-Master.PDF - Visalia AWOS (item 4, .PDF, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262145&FileExtension=.PDF&FileName=Visalia%20AWOS-Master.PDF - Garmin Download (item 5, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262139&FileExtension=.PDF&FileName=Garmin%20Download-Redacted.PDF - Garmin Data Extractions (item 6, .PDF, 563 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263511&FileExtension=.PDF&FileName=Garmin%20Data%20Extractions-Master.PDF - Maintenance Facility Letter (item 7, .PDF, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263492&FileExtension=.PDF&FileName=Maintenance%20Facility%20Letter-Master.PDF - Airframe Maintenance Logbook Excerpts (item 8, .PDF, 219 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262235&FileExtension=.PDF&FileName=Airframe%20Maintenance%20Logbook%20Excerpts-Redacted.PDF - Airframe Logbook Excerpt Noting FAA 337 (item 9, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269549&FileExtension=.PDF&FileName=Airframe%20Logbook%20Excerpt%20Noting%20FAA%20337-Redacted.PDF - Left Engine Maintenance Logbook (item 10, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262232&FileExtension=.PDF&FileName=Left%20Engine%20Maintenance%20Logbook%20-Redacted.PDF - Right Engine Maintenance Logbook (item 11, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262233&FileExtension=.PDF&FileName=Right%20Engine%20Maintenance%20Logbook-Redacted.PDF - Engine Installation FAA 337 (item 12, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269637&FileExtension=.PDF&FileName=Engine%20Installation%20FAA%20337-Redacted.PDF - Left engine Propeller Maintenance Records (item 13, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262253&FileExtension=.PDF&FileName=Left%20engine%20Propeller%20Maintenance%20Records-Redacted.PDF - Right Engine Propeller Logbook (item 14, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262261&FileExtension=.PDF&FileName=Right%20Engine%20Propeller%20Logbook-Redacted.PDF - AFM Supplement 11 (item 15, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269398&FileExtension=.PDF&FileName=AFM%20Supplement%2011-Master.PDF - Hartzell Report (item 16, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262140&FileExtension=.PDF&FileName=Hartzell%20Report-Redacted.PDF - Oil Analysis Results (item 17, .PDF, 258 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262141&FileExtension=.PDF&FileName=Oil%20Analysis%20Results-Redacted.PDF - Photo 1. Wreckage to Runway (Provided by New Piper) (item 18, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263494&FileExtension=.PDF&FileName=Photo%201.%20%20Wreckage%20to%20Runway%20(Provided%20by%20New%20Piper)-Master.PDF - Photo 2. Accident Site (item 19, .PDF, 967 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263495&FileExtension=.PDF&FileName=Photo%202.%20%20Accident%20Site-Master.PDF - Photo 3. Left Side of Wreckage (item 20, .PDF, 879 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263496&FileExtension=.PDF&FileName=Photo%203.%20%20Left%20Side%20of%20Wreckage-Master.PDF - Photo 4. ELT (item 21, .PDF, 980 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263497&FileExtension=.PDF&FileName=Photo%204.%20%20ELT-Master.PDF - Photo 5. Seats (item 22, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263498&FileExtension=.PDF&FileName=Photo%205.%20%20Seats-Master.PDF - Photo 6. Number 3 Bearing from Left Engine (item 23, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263499&FileExtension=.PDF&FileName=Photo%206.%20%20Number%203%20Bearing%20from%20Left%20Engine-Master.PDF - Photo 7. Number 3 Bearing Removed from Left Engine (item 24, .PDF, 907 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263501&FileExtension=.PDF&FileName=Photo%207.%20%20Number%203%20Bearing%20Removed%20from%20Left%20Engine-Master.PDF - Photo 8. Right Propeller (item 25, .PDF, 927 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263502&FileExtension=.PDF&FileName=Photo%208.%20Right%20Propeller-Master.PDF - Photo 9. Right Propeller (item 26, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263503&FileExtension=.PDF&FileName=Photo%209.%20%20Right%20Propeller-Master.PDF - Toxicological Report (item 27, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262143&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 28, .PDF, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262142&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 29, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262146&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Medical Records Information (item 30, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40260562&FileExtension=.PDF&FileName=Medical%20Records%20Information-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.