LAX89FA277

NTSB accident investigation · Piper PA-23-250 · Lake Tahoe, CA · August 14, 1989

Accident · FatalField investigationFinal report
Date
August 14, 1989, 11:12 local (18:12 UTC)
Place
Lake Tahoe, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N4838PPiper PA-23-250
Weather
Visual (VMC) · Day
Status
Completed · report September 9, 1992
Report
Approved by Office Director
FAA report
19890814029129A
Case key
26240

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

Disablement of the stabilator flight control system. A contributing factor was: inadequate maintenance.

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.

Airframe/component/system failure/malfunctionApproach
Flt control syst,stabilator control cable/rod - binding(mechanical)Factor
Maintenance,annual inspection - inadequateOther maintenance personnelFactor
Loss of control - in flightDescent - uncontrolled
Flight control,stabilator - jammed
Flt control syst,stabilator control - disabledCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

Approaching the arpt, the plt received ldg instructions. Seconds later, his transmissions were abruptly terminated. Witnesses observed the acft abruptly nose over & descend into water at a high rate of speed. It fragmented upon impact & immediately sank. The acft had recently undergone maintenance involving the removal & installation of its wings, & installation of an autopilot & electric trim. Following this work, the acft was flight tested. During the test, the plt experienced a loss of control & the acft pitched down in a manner similar to that described by witnesses to the accident. Exam of the upper stabilator pulley assembly revealed that its respective control cable had been working against the side of the pulley. The pulley was fractured, & the cable had become wedged in the pulley, which (in turn) had become wedged against the side of its support bracket. This action restricted stabilator movement.

Aircraft

Registration
N4838P
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-408
Airframe hours
2,554
Engine
Lycoming O-540-A1D5, 250 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
John W. Buchanan, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 2, 1989 · 25 hours before
Departed
S21 · Sunriver, OR
Destination
TVL · Lake Tahoe, CA
Airport
TVL · Lake Tahoe

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
66
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
2,091 total · 680 in this make and model · 12 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 8 knots
Visibility
50 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 39 °F
Altimeter
30.00 inHg
Observed at
TVL, 21 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.