# NTSB LAX94FA272: Piper PA-28-181, N4321N, So. Lake Tahoe, CA, July 3, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 3, 1994, 16:03 local (23:03 UTC) - Place: So. Lake Tahoe, CA - Coordinates: 38.839496, -120.010269 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.8395&lon=-120.0103&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report May 18, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28539 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94FA272 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28539/pdf - Page: https://openairdocs.org/ntsb/LAX94FA272 ## Probable cause the pilot's failure to maintain adequate airspeed during initial climb under high-density altitude weather conditions and a resultant inadvertent stall/spin. Factors which contributed to the accident were the pilot's overconfidence in his personal ability, and his lack of experience flying the airplane. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - weather condition - high density altitude (contributing factor) - airspeed(vs) - inadequate, pilot in command (cause) - overconfidence in personal ability, pilot in command (contributing factor) - lack of total experience in type operation, pilot in command (contributing factor) - stall/spin - inadvertent, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE PILOT BEGAN HIS TAKEOFF FROM THE BEGINNING OF THE 8,544-FOOT- LONG RUNWAY. AN AIR TRAFFIC CONTROLLER OBSERVED THE AIRPLANE BECOME AIRBORNE AFTER ROLLING BETWEEN 2,500 AND 3,000 FEET. WITNESSES REPORTED THE AIRPLANE PITCHED UP AND DOWN SEVERAL TIMES AND WAS FLYING SLOWLY AS IT CLIMBED BETWEEN 100 AND 200 FEET AGL. WHILE STILL OVER THE RUNWAY AND OUT OF GROUND EFFECT, THE AIRPLANE COMMENCED A STEEP (45 TO 90 DEGREE) LEFT BANK AND CRASHED INTO A FIELD 900 FEET EAST OF THE RUNWAY. WRECKAGE AND GROUND IMPACT SIGNATURES WERE CONSISTENT WITH THE AIRPLANE HAVING COLLIDED WITH THE TERRAIN WHILE IN AN 80-DEGREE LEFT BANK. NO MECHANICAL MALFUNCTIONS WERE FOUND WITH THE AIRPLANE. DURING THE PRECEDING 20-MONTH-LONG PERIOD SINCE THE PILOT RECEIVED A PRIVATE PILOT CERTIFICATE, HE HAD FLOWN AIRPLANES FOR 6 HOURS. HIS TOTAL EXPERIENCE IN THE PIPER AIRPLANE WAS 3.1 HOURS OF WHICH 1.4 HOURS HAD BEEN A CHECKOUT FLIGHT GIVEN BY A CFI. THE CFI REPORTED HE HAD NOT CHECKED OUT THE PILOT AT HIGH-DENSITY ALTITUDE AIRPORTS. THE CALCULATED DENSITY ALTITUDE WAS ABOUT 8,570 FEET. ## Factual narrative HISTORY OF FLIGHT On July 3, 1994, at 1603 Pacific daylight time, a Piper PA-28-181, N4321N, collided with level terrain approximately 1/2 mile south-southeast of the Lake Tahoe Airport, South Lake Tahoe, California. The aircraft was operated by Inbound Aviation of San Jose, California, and rented by the pilot for a personal cross- country flight. Visual meteorological conditions prevailed during the personal flight. The airplane was destroyed by impact forces and postimpact ground fire. The private pilot and two passengers were fatally injured. The flight was originating at the time of the accident. According to the Federal Aviation Administration (FAA) coordinator, at 1518 the pilot received a preflight weather briefing from the Reno Flight Service Station. Thereafter, the pilot filed a VFR flight plan to San Jose, California. Airport personnel reported to the National Transportation Safety Board that prior to the pilot's takeoff the airplane's two fuel tanks were filled to the level of the 17-gallon filler neck indicator tabs. Also, the pilot indicated to a line service person that he was unfamiliar with the airport. At 1553, the pilot contacted the Lake Tahoe ground controller and requested a clearance to taxi for takeoff. The controller reported that he issued the pilot the requested clearance. Also, the controller provided the pilot with wind and temperature information, and advised the pilot to check the density altitude. At 1601, the pilot contacted the Lake Tahoe local controller and requested a clearance to take off. The controller reported that he issued the pilot the requested clearance. During an interview with the Safety Board, the controller reported that he observed the accident airplane taxi onto the beginning of runway 18. However, before beginning its takeoff roll, the airplane remained stationary on the runway for between 15 and 20 seconds. Thereafter, the airplane began its takeoff roll, and nothing unusual was noted. The controller further indicated that the airplane became airborne after rolling between 2,500 and 3,000 feet. In a written statement, the controller reported that after the aircraft took off, he heard the pilot broadcast that he was "in an emergency situation" and then he observed the airplane "in an extreme right wing up/nose-down attitude. The aircraft disappeared behind trees approximately 200 yards east of the runway and burst into flames upon impact." The FAA reported that an emergency locator transmitter (ELT) signal was briefly heard at 1603. Several witnesses reported to the Safety Board that they observed the airplane during its initial climb. None of the witnesses reported hearing any sound from the airplane other than what they described as a normal-sounding engine under power. The witnesses reported that while the airplane was climbing its pitch attitude decreased and increased several times. The airplane gained a maximum altitude of 200 feet. One of the witnesses described the nose-up pitch as being "at a steep angle," and the airplane was flying slowly. Another of the witnesses reported "the nose attitude came up to approximately 25 degrees." All of the witnesses reported observing the airplane commence a left bank turn prior to it reaching the south end of the runway. One of the witnesses described the steepness of the turn as being like a "wingover." In general, the witnesses indicated to the Safety Board that during the turn the airplane's bank angle increased while its nose pitch attitude decreased, and the airplane descended into terrain while in a left bank. All of the witnesses reported that within seconds after they lost sight of the airplane they observed a plume of smoke emanating from a location subsequently determined to be the crash site. PERSONNEL INFORMATION General Experience The Safety Board reviewed airman certification records maintained by the FAA, flight training records in the pilot's personal logbook, and interviewed the certified flight instructor (CFI) who checked out the pilot in the accident airplane. The following facts were noted: In March of 1990, the pilot was issued a Student Pilot Certificate after having received a total of 20 dual flight instruction hours in gliders. The Student Pilot Certificate expired in March, 1992. In November of 1991, the pilot commenced flight training using Cessna 172 airplanes in Prescott, Arizona. After flying for 25 solo hours and 50 dual instruction hours, the pilot graduated from an FAA-approved Private Pilot certification course on December 8, 1992. The next date on which evidence was found indicating the pilot flew an airplane was March 30, 1994. The pilot's flight record logbook indicates that on this date he flew the accident airplane for 1.4 hours. The "REMARKS AND ENDORSEMENTS" column in the pilot's logbook was signed by a CFI. The flight time was listed as "DUAL RECEIVED." The pilot's logbook indicates that he next flew the following day, and again on May 7, 1994. The flights lasted for 0.9 and 0.8 hours, respectively, and were flown in the accident airplane. The flights were logged as "PILOT IN COMMAND (INCL. SOLO)." The pilot's next logged flight occurred on June 10, 1994. On that date, he made two flights, both in a Cessna 172, for a duration of 0.6 and 0.8 hours, respectively. The next recorded flight, which was the last flight listed in the pilot's logbook, took place on June 24, 1994. The logbook record indicates on this date the pilot received a dual instruction flight lesson in a multiengine Beech airplane for 1.2 hours. High-Density Altitude Airport Checkout The CFI who checked out the pilot in the accident airplane reported to the Safety Board that his checkout flight did not include a high-density altitude airport checkout. Accordingly, the pilot was not authorized to fly to Lake Tahoe, which was considered to be a high-density altitude airport. The operator provided the Safety Board with a copy of the flying club's "By Laws/General Rules" agreement form. The form was dated March 29, 1994, and it bore the pilot's signature. In pertinent part, rule number five stated: "I will not land or takeoff from an airport with a field elevation over 4000' MSL prior to receiving a high-altitude checkout." AIRCRAFT INFORMATION The airplane inspection times and hours listed in this report were based upon data provided by the operator. The airplane's weight and balance data, takeoff performance charts, and most of the Piper flight manual were found in the remains of the burned wreckage. The FAA-certificated maximum gross weight for the airplane in the normal category was 2,550 pounds. The Safety Board estimated that on the accident flight the airplane's gross weight was approximately 2,409 pounds. (See attached weight computation data.) METEOROLOGICAL INFORMATION At 1603 Pacific daylight time, the Lake Tahoe weather was reported, in pertinent part, as follows: Scattered clouds at 7,000 feet above ground level; visibility 50 miles; temperature 77 degrees Fahrenheit; wind from 260 degrees at 12 knots; and altimeter 30.09 inches Hg. Based upon these atmospheric conditions, the Safety Board calculated that the density altitude was approximately 8,570 feet. AIRPORT INFORMATION The elevation at the approach end of Lake Tahoe Airport, runway 18, was about 6,250 feet mean sea level (msl). The elevation at the departure end of the runway was about 6,264 feet msl. Runway 18 was 8,544 feet long. In pertinent part, the following remark was printed in the U.S. Government Flight Information Publication entitled "Airport/Facility Directory": "Normal dep Rwy 18 is a wide left downwind dep, left crosswind turn should not be made until reaching the south arpt boundary and 7500'. If sufficient altitude is not reached after tkf for crosswind turn to a downwind departure with safety approximately 1.5 m ## Aircraft - Registration: [N4321N](https://openairdocs.org/deregistered/N4321N-2013-09-12), registration cancelled 2013-09-12, S/N 28-8390080 (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: 28-8390080 - Airframe hours: 4424 - Engines: LYCOMING O-360-A4M 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Inbound Aviation - Registered owner: Jeffrey M. Marconet - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, May 25, 1994, 74 hours before - Destination: RHV, SAN JOSE, CA - Flight plan: VFR - Airport: TVL, Lake Tahoe, runway 18, 8,544 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 21; private; airplane ratings: single-engine land; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 102 total, 4 in this make and model, 26 as pilot in command, 4 in the last 90 days, 3 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 12 knots - Visibility: 50 statute miles - Lowest ceiling: none - Temperature: 77 °F - Altimeter: 30.00 inHg - Observed at: TVL, 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 19940703017439A](https://openairdocs.org/incident/19940703017439A), Jul 3, 1994: Piper PA28181, South Lake Taho, CA, Destroyed, 3 fatal. Stalled in steep nose high climbout. Not authorized by CFI for high altitude. Near gross weight also a factor. 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.