# NTSB LAX89LA263: Piper PA-23-180, N4376P, Lancaster, CA, August 4, 1989

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: August 4, 1989, 12:40 local (19:40 UTC)
- Place: Lancaster, CA
- Coordinates: 34.720672, -118.150703 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.7207&lon=-118.1507&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Minor injuries
- Injuries: 1 minor
- Status: Completed, report June 30, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 26467
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX89LA263
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26467/pdf
- Page: https://openairdocs.org/ntsb/LAX89LA263

## Probable cause

THE PILOT'S FAILURE TO FOLLOW ESTABLISHED PROCEDURES IN RESTARTING THE ENGINE THAT DRIVES THE HYDRUALIC PUMP AND HIS FAILURE TO FOLLOW PUBLISHED EMERGENCY LANDING GEAR EXTENSION PROCEDURES. THE PILOT'S DECISION TO SHUT DOWN AN ENGINE AND FEATHER THE PROPELLER BEFORE ASSURING HIMSELF THAT THE PROPELLER WOULD UNFEATHER AND HIS INADEQUATE TRAINING IN EMERGENCY PROCEDURES WERE FACTORS IN THE ACCIDENT.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(partial) - nonmechanical, cruise - normal
  - 1 engine
  - propeller feathering - intentional, pilot in command
  - starting procedure - improper, pilot in command (cause)
  - inadequate training(emergency procedure(s)), pilot in command (contributing factor)
- Gear not extended, approach - vfr pattern - final approach
  - hydraulic system,pump - inoperative (contributing factor)
  - landing gear,emergency extension assembly - not engaged (cause)
  - emergency procedure - not performed, pilot in command (contributing factor)
  - inadequate training, pilot in command (contributing factor)
- In flight collision with terrain/water, go-around (vfr)
  - aircraft performance,engine out capability - exceeded
  - descent - not corrected, pilot in command

## Analysis

AFTER COMPLETION OF AN ANNUAL INSPECTION, THE AIRCRAFT OWNER ELECTED TO CONDUCT A MAINTENANCE TEST FLIGHT. WHILE AIRBORNE, HE SHUT DOWN THE RIGHT ENGINE, THEN FEATHERED AND UNFEATHERED THE PROPELLER, AND RESTARTED THE ENGINE BY LETTING THE PROPELLER WINDMILL. WHEN HE FOLLOWED THE SAME PROCEDURE WITH THE LEFT ENGINE AND PROPELLER, THE PROPELLER FAILED TO UNFEATHER AND HE COULD NOT RESTART THE ENGINE. THE PILOT RETURNED TO THE AIRPORT WITH ONE ENGINE OPERATING AND ATTEMPTED TO EXTEND THE LANDING GEAR DURING PATTERN ENTRY. THE LANDING GEAR DID NOT EXTEND AND THE PILOT INITIATED A GO-AROUND. THE AIRCRAFT DID NOT CLIMB AND BEGAN TO LOOSE ALTITUDE. EVENTUALLY, IT COLLIDED WITH THE GROUND OFF AIRPORT DURING AN UNARRESTED DESCENT. THE LANDING GEAR EXTENSION AND RETRACTION SYSTEM WAS HYDRAULIC AND POWERED BY A PUMP ON THE LEFT ENGINE. THE FLIGHT MANUAL PROVIDED TWO ALTERNATE MEANS OF EMERGENCY GEAR EXTENSION, NEITHER OF WHICH THE PILOT ATTEMPTED ON THE FIRST LANDING APPROACH.

## Aircraft

- Registration: [N4376P](https://openairdocs.org/deregistered/N4376P-1991-03-28), registration cancelled 1991-03-28, S/N 231881 (OpenAirDocs)
- Reported make and model: PIPER PA-23-180
- Registry model: [Piper PA-23-160](https://openairdocs.org/model/piper-pa-23-160) (registry code 7102304) (OpenAirDocs)
- Category: Airplane
- Serial number: 23-1881
- Engines: LYCOMING O-360-A1D 180 horsepower reciprocating
- Damage: Substantial damage
- Flight: Part 91
- Operator: Simanski, Donald E.
- Departed: WJF
- Airport: GWF, Gen. William J. Fox, runway 24, 5,001 × 150 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 49; commercial; airplane ratings: single-engine land, multi-engine land; medical: class 1, valid medical--w/ waivers/lim; flight hours: 1,159 total, 155 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 240° at 18 knots
- Visibility: 59 statute miles
- Lowest ceiling: none
- Temperature: -0 °F, dew point -0 °F
- Altimeter: 29.00 inHg
- Observed at: WJF, 1 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 19890804027359A](https://openairdocs.org/incident/19890804027359A), Aug 4, 1989: Piper STCPA23, Lancaster, CA, Substantial damage. On test flight unable to unfeather left engine that has hydraulic pump. Lacked knowledge of alternate procedures.

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.

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