LAX89FA140

NTSB accident investigation · Piper PA-60-601P · Newport Beach, CA · March 31, 1989

Accident · FatalField investigationFinal report
Date
March 31, 1989, 08:35 local (16:35 UTC)
Place
Newport Beach, CA
Injuries
5 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
CGWPSPiper PA-60-601P
Weather
Visual (VMC) · Day
Status
Completed · report May 15, 1992
Report
Approved by Office Director
Case key
26220

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 to attain adequate airspeed before maneuvering (turning) back toward the airport, which resulted in a loss of aircraft control. A factor related to the accident was: improper maintenance/installation of a fuel injector reference air line, which allowed contamination of the injectors and loss of power in the right engine.

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 engine power(total) - mech failure/malfTakeoff
1 engine
Induction air control/system - improperFactor
Maintenance,installation - improperOther maintenance personnelFactor
Fuel system,injector - contaminationFactor
Loss of control - in flightManeuvering
Precautionary landing - initiatedPilot in command
Maneuver - initiatedPilot in command
Airspeed - inadequatePilot in commandCause
Aircraft control - not maintainedPilot in commandCause
Overconfidence in personal abilityPilot in commandFactor
Self-induced pressurePilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

Svrl mechanic witnesses at the arpt said the rgt eng backfired & trailed black smoke during the takeoff ground roll. Rprtdly, the takeoff roll was about 80% longer than normal. Witnesses said the acft staggered off the ground, was slow & never got above 100 feet AGL. The plt rprtd to the tower that the flt had to come back to the rwy. Shortly thereafter, witnesses saw the acft enter a steep left turn, apparently stall, then crash into some tennis courts. An investigation revealed evidence that the rgt eng had lost power. A modification kit for the fuel injector reference air lines was incorrectly installed & allowed an unfiltered air source. Spectral analysis of residue (from the rgt eng turbo charger compressor) revealed that it had the same composition as the alternate air door seal. Traces of the material were found in the fuel injector reference air line.

Aircraft

Registration
CGWPS
Reported as
Piper PA-60-601P
Category
Airplane
Serial number
61P-0522-219
Airframe hours
1,908
Engine
Lycoming IO-540-S1A5, 290 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Anthony Deis
Registered owner
Richardsons Jewellery Ltd.
Airworthiness certificate
Standard, Normal
Last inspection
Unknown · July 18, 1988 · 204 hours before
Departed
SNA
Destination
PIH · Pocatello, ID
Flight plan
IFR
Airport
SNA · John Wayne, runway 19R, 5,700 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
35
Certificates
Private, Foreign
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
1,490 total · 243 in this make and model · 1,440 as pilot in command · 75 in the last 90 days · 24 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
4 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 55 °F
Altimeter
30.00 inHg
Observed at
SNA, 2 nm away