LAX92MA183

NTSB accident investigation · de Havilland DHC-6-200 · Perris, CA · April 22, 1992

Accident · FatalMajor investigationFinal report
Date
April 22, 1992, 11:09 local (18:09 UTC)
Place
Perris, CA
Injuries
16 fatal, 6 serious
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N141PVde Havilland DHC-6-200
Weather
Visual (VMC) · Day
Status
Completed · report August 5, 1993
Report
Approved by Office Director
Safety recommendations
Yes
FAA report
19920422010579A
Case key
27783

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

The pilot-in-command's inadvertent feathering of the wrong propeller following an engine power loss, and the failure of the operator to assure that the pilot was provided with adequate training in the airplane. Factors related to the accident were: water contamination of fuel in the airport storage tanks, the operator's lack of fuel quality control procedures, improper fuel servicing, improper preflight by the pilot(s), and exceeding the gross weight/forward CG limits of the airplane.

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) - nonmechanicalTakeoff - initial climb
1 engine
Fluid,fuel - contaminationFactor
Fluid,fuel - waterFactor
Airport/facilities - not maintainedFactor
Maintenance,service of aircraft/equipment - inadequateCompany/operator managementFactor
Aircraft preflight - inadequatePilot in commandFactor
Loss of engine power(total) - nonmechanicalTakeoff - initial climb
1 engine
Wrong propeller feathered - inadvertentPilot in commandCause
Improper initial trainingCompany/operator managementCause
Loss of control - in flightTakeoff - initial climb
Aircraft weight and balance - exceededPilot in commandFactor
In flight collision with terrain/waterTakeoff - initial climb

Analysis

The ground loader had fueled the airplane from the airport fuel truck. He stated that the flight crew did not sump the fuel tanks after they were fueled. Immediately after takeoff the right engine lost power, the right wing lowered to about 90 deg, and the airplane impacted the ground adjacent to the runway. Then forward fuel tank, which provides fuel to the right engine, was found to contain about 8 gals of a heavily contaminated mixture composed of water, an emulsifying agent, and bacterial growth. The fuel from the airport fuel truck and main underground tank contained the same mixture. Fuel had been transfered from the underground tank to the truck on the evening preceding the accident. The left propeller control was found seized in the feather position; left propeller blades in the near-feather position.

Aircraft

Registration
N141PV
Reported as
de Havilland DHC-6-200
Category
Airplane
Serial number
141
Airframe hours
29,391
Engine
P&W PT6A-20A, 550 horsepower, turbo prop
Damage
Destroyed
Flight
Skydiving · Part 91
Operator
Perris Valley Aviation Svcs
Registered owner
Conaster, Bennie E.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 2, 1992 · 50 hours before
Airport
L65 · Perris Valley, runway 15, 5,100 × 65 ft, asphalt

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
44
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
4,300 total · 100 in this make and model

Weather

Conditions
Visual (VMC) · Day
Visibility
15 statute miles
Lowest ceiling
None
Temperature
70 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.