# NTSB LAX91FA106: Piper PA-28-181, N4384L, Fredonia, AZ, February 17, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: February 16, 1991, 19:02 local (Feb 17, 1991, 02:02 UTC)
- Place: Fredonia, AZ
- Coordinates: 36.859336, -112.840644 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=36.8593&lon=-112.8406&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 4 fatal
- Status: Completed, report January 22, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 26980
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX91FA106
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26980/pdf
- Page: https://openairdocs.org/ntsb/LAX91FA106

## Probable cause

THE PILOT'S INATTENTION TO THE AIRSPEED AND SUBSEQUENT LOSS OF AIRCRAFT CONTROL AFTER ATTEMPTING VFR FLIGHT INTO ADVERSE WEATHER CONDITIONS. CONTRIBUTING TO THE ACCIDENT WAS THE PILOT'S FAILURE TO RECOGNIZE HIS LIMITATIONS OF HIS AIRCRAFT.

## Sequence of events

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

- In flight encounter with weather, maneuvering
  - terrain condition - mountainous/hilly (contributing factor)
  - weather condition - clouds (contributing factor)
  - weather condition - low ceiling (contributing factor)
  - weather condition - obscuration (contributing factor)
  - light condition - dark night (contributing factor)
  - flight into known adverse weather - attempted, pilot in command (cause)
  - vfr flight into imc - continued, pilot in command (cause)
- Loss of control - in flight, descent - uncontrolled
  - airspeed - inattentive, pilot in command
  - stall/spin - encountered, pilot in command (cause)
  - remedial action - improper, pilot in command (cause)
  - lack of total experience, pilot in command (contributing factor)
- In flight collision with terrain/water, descent - uncontrolled

## Analysis

THE 22 YEAR OLD PILOT AND HIS THREE PASSENGERS DEPARTED ON A THREE DAY EXCURSION OF BRYCE AND THE GRAND CANYON. THE PILOT HAD LOGGED ABOUT 72 HOURS OF FLIGHT TIME. THE RENTED AIRCRAFT DEPARTED AT NIGHT 68 POUNDS OVER GROSS AND 1 INCH AFT OF THE MOST REARWARD ALLOWABLE C.G. LIMIT. AFTER REACHING THEIR FIRST DESTINATION AND SPENDING THE DAY SIGHTSEEING, THEY DEPARTED AGAIN AT NIGHT FOR THE GRAND CANYON. THE WEATHER WAS MARGINAL WITH SNOW SHOWERS. THE PLANNED 56 MINUTE LEG WAS TRACKED ON RADAR FOR A TOTAL OF 1 HOUR AND 39 MINUTES, A MEANDERING AND UNDULATING TRACK UP TO 13400 FEET MSL WAS RECORDED. THE AIRCRAFT DEPARTED WITH 1 HOUR AND 40 MINUTES OF FUEL IN EACH TANK. AT THE ACCIDENT SITE THE RIGHT TANK WAS FULL AND THE LEFT TANK WAS EMPTY. THE FUEL SELECTOR WAS ON THE LEFT TANK. THE AIRCRAFT IMPACTED MOUNTAINOUS TERRAIN AT ABOUT 7000 FEET MSL IN A FLAT SPIN.

## Aircraft

- Registration: [N4384L](https://openairdocs.org/deregistered/N4384L-1991-12-11), registration cancelled 1991-12-11, S/N 288590021 (OpenAirDocs)
- Reported make and model: PIPER PA-28-181
- Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-8590021
- Engines: LYCOMING O-360-A4M 180 horsepower reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Operator: South Bay Aviation Inc.
- Registered owner: Thomas Nosek
- Last inspection: Unknown, January 2, 2000
- Departed: BCE, BRYCE CANYON, UT
- Destination: GCN, GRAND CANYON, AZ

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 22; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; toxicology performed; flight hours: 72 total, 35 in this make and model, 40 as pilot in command, 11 in the last 90 days, 1 in the last 30 days

## Weather

- Conditions: Instrument (IMC), Night/dark
- Wind: 250° at 16 knots, gusting 27
- Visibility: 20 statute miles
- Lowest ceiling: 3,000 ft broken
- Observed at: BCE, 75 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 19910216002619A](https://openairdocs.org/incident/19910216002619A), Feb 16, 1991: Piper PA28181, Fredonia, AZ, Destroyed, 4 fatal. Wreckage indicates flat spin to impact. Fuel selector empty tank. Overcast and snowshowers. Dark. No ground lights.

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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