# NTSB LAX91FA310: Piper PA-23-250, N515TW, Hesperia, CA, July 14, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: July 13, 1991, 19:05 local (Jul 14, 1991, 02:05 UTC)
- Place: Hesperia, CA
- Coordinates: 34.360919, -117.3208 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.3609&lon=-117.3208&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed, report July 13, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 27014
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX91FA310
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27014/pdf
- Page: https://openairdocs.org/ntsb/LAX91FA310

## Probable cause

THE PILOT'S IMPROPER REFUELING AND INADEQUATE PREFLIGHT WHICH RESULTED IN FUEL CONTAMINATION AND THE INADVERTENT STALL.

## Sequence of events

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

- Loss of engine power(total) - nonmechanical, takeoff - initial climb
  - all engines
  - fluid,fuel - contamination (cause)
  - fluid,fuel - incorrect
  - preflight planning/preparation - inadequate, pilot in command (cause)
  - refueling - improper, pilot in command (cause)
- Forced landing, descent - emergency
- Loss of control - in flight, takeoff - initial climb
  - stall/mush - inadvertent, pilot in command (cause)
- In flight collision with terrain/water, descent - uncontrolled
  - remedial action - not possible, pilot in command

## Analysis

THE PILOT WAS SEEN DRAINING ABOUT ONE GALLON OF WATER FROM HIS FUEL TANK 6 WEEKS PRIOR TO THE ACCIDENT.  HE DID NOT FLY FROM THAT TIME UNTIL THE DAY OF THE ACCIDENT. THE PILOT AND A FRIEND WERE OBSERVED RE-FUELING THE AIRCRAFT WITH AUTOMOBILE GAS. THE ENGINES ARE NOT CERTIFIED BY THE FAA FOR THE USE OF AUTO GAS.  HE DID NOT PERFORM A PRE-FLIGHT INSPECTION NOR DRAIN THE FUEL BEFORE HIS TAKEOFF.  AFTER TAKEOFF AT ABOUT 150 FEET AGL BOTH ENGINES FAILED.  THE PILOT HAD ADEQUATE LANDING OPTIONS, BUT SLOWED THE AIRCRAFT IN A NOSE HIGH ATTITUDE UNTIL IT STALLED.  ALTITUDE DID NOT PERMIT RECOVERY FROM THE STALL CONDITION.

## Aircraft

- Registration: [N515TW](https://openairdocs.org/deregistered/N515TW-2013-06-18), registration cancelled 2013-06-18, S/N 27-2302, built 1963 (OpenAirDocs)
- Reported make and model: PIPER PA-23-250
- Registry model: [Piper PA-23-250](https://openairdocs.org/model/piper-pa-23-250) (registry code 7102308) (OpenAirDocs)
- Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 27-2302
- Engines: LYCOMING O-540-A1D5 250 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Personal, Part 91
- Operator: Kbmm Radio, Inc.
- Registered owner: Kbmm Radio, Inc.
- Last inspection: Unknown, January 2, 2000
- Destination: SMO, SANTA MONICA, CA

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 47; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; toxicology performed; flight hours: 800 total

## Weather

- Conditions: Visual (VMC), Day
- Wind: 200° at 10 knots
- Visibility: 20 statute miles
- Lowest ceiling: none

## 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 19910713027409A](https://openairdocs.org/incident/19910713027409A), Jul 13, 1991: Piper PA23250, Hesperia, CA, Destroyed, 1 fatal. Engine quit on climb. Stalled. Fell off to the right. Impacted ground. No pre-flight. Used auto fuel.

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.

---
OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.