# NTSB LAX92MA183: de Havilland DHC-6-200, N141PV, Perris, CA, April 22, 1992

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Major investigation · Final report
- Date: April 22, 1992, 11:09 local (18:09 UTC)
- Place: Perris, CA
- Location: 33.7646° N, 117.2190° W: Placed by OpenAirDocs at PERRIS VALLEY (L65), within about a mile (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=33.7646&lon=-117.2190&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 16 fatal, 6 serious
- Status: Completed, report August 5, 1993
- Report: Approved by Office Director
- Safety recommendations: Yes
- NTSB case key (mKey): 27783
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX92MA183
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27783/pdf
- Page: https://openairdocs.org/ntsb/LAX92MA183

## 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

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

- Loss of engine power(total) - nonmechanical, takeoff - initial climb
  - 1 engine
  - fluid,fuel - contamination (contributing factor)
  - fluid,fuel - water (contributing factor)
  - airport/facilities - not maintained (contributing factor)
  - maintenance,service of aircraft/equipment - inadequate, company/operator management (contributing factor)
  - aircraft preflight - inadequate, pilot in command (contributing factor)
- Loss of engine power(total) - nonmechanical, takeoff - initial climb
  - 1 engine
  - wrong propeller feathered - inadvertent, pilot in command (cause)
  - improper initial training, company/operator management (cause)
- Loss of control - in flight, takeoff - initial climb
  - aircraft weight and balance - exceeded, pilot in command (contributing factor)
- In flight collision with terrain/water, takeoff - 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](https://openairdocs.org/deregistered/N141PV-2003-03-06), registration cancelled 2003-03-06, S/N 141 (OpenAirDocs)
- Reported make and model: de Havilland DHC-6-200
- Registry model: [Dehavilland DHC-6 TWIN OTTER](https://openairdocs.org/model/dehavilland-dhc-6-twin-otter) (registry code 2802606) (OpenAirDocs)
- Category: Airplane
- Serial number: 141
- Airframe hours: 29391
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 44; 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 (OpenAirDocs).

- [Accident 19920422010579A](https://openairdocs.org/incident/19920422010579A), Apr 22, 1992: Dhav DHC6200, Perris, CA, Destroyed, 16 fatal. Lost right engine on initial climb. Left engine feathered. Rolled. Cartwheeled. Water in fuel. 2000 lbs over gross.

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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