LAX07LA186

NTSB accident investigation · Piper PA-34-200 · Upland, CA · June 4, 2007

Accident · Serious injuriesLimited investigationFinal report
Date
June 4, 2007, 10:22 local (17:22 UTC)
Place
Upland, CA
Injuries
1 serious, 2 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N4463TPiper PA-34-200
Weather
Instrument (IMC) · Day
Status
Completed · report September 26, 2008
Report
Approved by Office Director
Parties
Piper Aircraft Corporation, Federal Aviation Administration, Textron Lycoming
FAA report
20070604010389A
Case key
65928

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

Failure of the pilot under instruction to maintain the minimum single engine control airspeed (air) and directional control while turning to final approach. Also causal was the flight instructor's inadequate supervision and delayed remedial actions.

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.

Loss of control - in flightApproach - vfr pattern - base leg/base to final
Procedures/directives - inadequatePilot in command(cfi)Factor
Airspeed(vmc) - not maintainedDual studentCause
Directional control - not maintainedDual studentCause
Supervision - inadequatePilot in command(cfi)Cause
Remedial action - delayedPilot in command(cfi)Cause
In flight collision with objectDescent - uncontrolled
Object - residence

Analysis

A Certified Flight Instructor (CFI) was providing multiengine instruction to the pilot. They were in the traffic pattern, approximately 800 feet above ground level (agl), after completing several touch-and-go landings. The CFI stated that his regular method for setting up practice engine-out landings for a student was to close the mixture, allow the student to go through the process of controlling the airplane, and simulating the procedures to feather the inoperative engine's propeller. The instructor would then return the mixture to full rich, and verify engine operation. This would occur on downwind, and then the landing would be completed with the simulated inoperative engine at idle. On downwind, the instructor closed the mixture on the left engine. During this maneuver, the pilot turned the airplane left from base to final and the airspeed decreased. The airplane rolled sharply to the left and lost altitude. The instructor reduced both throttles and regained control of the airplane just as it collided with the roof of one house, bounced across another roof, and came to rest on top of a third house. The Federal Aviation Administration recommends that in-flight simulated engine failures at altitudes below 3,000 feet agl be introduced only by reduction of the throttle. Post-crash inspection of the engine and airframe found no anomalies that would have prevented normal operation.

Factual narrative

History of flight

On June 4, 2007, about 1022 Pacific daylight time, a Piper PA-34-200, N4463T, collided with houses on final approach to Cable Airport, Upland, California. Roxy Corporation was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The certified flight instructor (CFI) pilot, the commercial pilot undergoing instruction (PUI), and one passenger sustained minor injuries; the airplane sustained substantial damage. The cross-country instructional flight departed Van Nuys, California, at an undetermined time en route to Upland. Instrument meteorological conditions prevailed at the nearest official reporting station, and an instrument flight plan had been filed.

The PUI was receiving instruction to prepare for a reexamination of a portion of the commercial pilot multiengine practical examination. The Designated Pilot Examiner (DPE) noted that, during the initial examination 2 days prior to the accident, the PUI failed to maintain minimum best single-engine rate of climb speed (Vyse) when simulating a loss of engine power on takeoff. After restoring controls to the PUI, the DPE noted that the approach to landing was high and fast. They did a go-around. On the second approach to landing, the PUI lined up on the left side of the runway and in a 30-degree bank. The PUI's instructor indicated that he had not seen this type of performance.

A Federal Aviation Administration (FAA) inspector interviewed the PUI. He was receiving multiengine instruction from the CFI. They were in the landing pattern, and completed several touch-and-go landings. On downwind, the CFI reduced power on one engine. As they turned left from base to final, the bank angle got steep. The airplane lost altitude, and collided with the roof of one house, bounced across another roof, and came to rest on top of a third house.

In a written statement, the CFI reported that they had departed Van Nuys under instrument flight rules (IFR). Upon arrival at Cable Airport, the PUI executed an instrument approach to the runway. The CFI noted that visual meteorological conditions prevailed at the airport, and they cancelled IFR with air traffic control and continued the flight under visual flight rules at a traffic pattern altitude of about 800 feet above ground level (agl).

The CFI reported that he wanted to perform engine-out landing practice with the PUI. He listed the following as his own procedure for the maneuver, which he stated he had performed hundreds of times:

1. At pattern altitude, close the mixture of one engine

2. Wait until the student goes through the immediate procedure of: controlling the airplane, adding full power, cleaning up flaps and gear, identifying the dead engine, verifying the dead engine with the throttle (by closing the dead engine throttle), feather (touch the correct propeller control to simulate feather).

3. Open the dead engine mixture to full.

4. Verify that the engine is working by advancing the closed throttle a little, and then close it again.

The CFI noted that all the above is done while the airplane is still on downwind. The simulated engine-out practice continues with the engine at idle and not really out.

The PUI performed one such maneuver, which the CFI reported was marginal, and the PUI initiated a touch-and-go on the runway in order to perform the engine-out procedure again. The CFI reported that he initiated the same maneuver with the steps listed above for the left engine, while on the downwind leg for the pattern. The CFI noted that due to the tight traffic pattern, the PUI initiated a 180-degree turn from the downwind leg to the final approach leg. During the turn, the CFI noticed the airspeed decrease to 100 miles per hour (mph), and notified the PUI not to slow below the blue line. The CFI stated that the blue line (Vyse) is 105 mph for the airplane. The airplane then rolled abruptly to the left, and the CFI took over control of the airplane. The CFI stated that he recovered from the sharp turn, and then attempted to recover from the descent by advancing both engine throttles. The CFI felt an asymmetrical thrust, closed both throttles, and flared the airplane as it collided with the roofs below.

The CFI also commented that he was puzzled as to why the airplane lost control at 100 mph, when the recommended safe speed (Vsse) for engine-out procedures in the airplane is 90 mph, with a red line (minimum controllable single-engine speed (Vmc)) of 80 mph.

On-scene observations

The National Transportation Safety Board investigator that examined the wreckage on scene reported the following information.

The debris path from the first identified point of contact (FIPC) to final resting place was 100 feet in length along a 220-degree magnetic heading. Pieces of airplane were distributed over several adjacent residential rooftops. The elevation of the main wreckage was 1,450 feet. Cable Airport was a distance of 0.61 nautical miles (nm) on a magnetic bearing of 237 degrees.

The FIPC consisted of the landing gear and other exterior airplane parts. These pieces were on the roof of the first struck residence. Imbedded in the roof and east-facing wall of the next residence was the right engine with the propeller still attached. On top of this residence was the portion of the left wing that was aft of the spar with the aileron and flap attached. On top of a third residence was the main wreckage consisting of the fuselage, right wing, forward portion of the left wing, and empennage. The left wing remained attached at the wing root area. The right wing remained attached at its front fitting, but the rear fitting was detached. The left engine remained with the main wreckage, but was detached from the wing. The front right seat separated from the airframe, and was on the south side of this residence in the grass along with some minor airframe parts. Investigators found a spar embedded in the grass near the seat.

First responders moved several switches prior to the investigator's arrival. They moved the magneto switches to the OFF position, the electric boost pump to the OFF position. They did not touch the fuel valves. The MASTER switch was still on when investigators arrived.

The airframe investigator found the fuel valves in the cross-feed position. He noted that it was possible that they could have been moved due to displacement of the wings. He noted that for landing, only one should be in the cross-feed mode.

The engine controls for both engines were at their respective stops. The propeller was at low pitch (high revolutions per minute) stop. The mixture control was at idle cutoff.

Follow up examination

Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on November 13, 2007.

Left Engine

Investigators slung the engine from a hoist, and removed the top spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.

A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head.

Investigators manually rotated the crankshaft with the propeller. The crankshaft rotated freely, and the valves moved approximately the same amount of lift in firing order. The gears in the accessory case turned freely. Investigators obtained thumb compression on all cylinders in firing order.

Investigators manually rotated the magnetos, and both magnetos produced spark at all posts.

The vacuum pump drive gear remained unbroken, and the vacuum pump turned freely. All vacuum pump vanes were whole, in position, and moved freely.

The oil sump screen was clean and open; the oil filter was clean.

The fuel injection servo remained undamaged and securely attached at the mounting flange. The throttle and mixture controls were se

Aircraft

Registration
N4463T
Reported as
Piper PA-34-200
Category
Airplane
Serial number
34-7250102
Airframe hours
5,704
Engines
Lycoming IO-360-C1E6, 200 horsepower, reciprocatingLycoming LIO-360-C1E6, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Roxy Corp
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 1, 2007
Departed
VNY · Van Nuys, CA
Destination
CCB · Upland, CA
Airport
CCB · Cable, runway 24, 3,864 × 75 ft, asphalt

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
Flight instructor
Age
52
Injuries
Serious
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2
Last flight review
September 1, 2005
Seat
Right
Flight hours
4,219 total · 270 in this make and model · 4,116 as pilot in command · 125 in the last 90 days · 62 in the last 30 days · 4 in the last 24 hours
Role
Student pilot
Age
18
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Seat
Left
Flight hours
212 total · 10 in this make and model · 135 as pilot in command

Weather

Conditions
Instrument (IMC) · Day
Wind
190° at 3 knots
Visibility
2.5 statute miles
Lowest ceiling
25,000 ft broken
Temperature
64 °F, dew point 55 °F
Altimeter
29.96 inHg
Observed at
ONT, 5 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.