# NTSB LAX94LA153: Piper PA-23-180, N2142P, Fairfield, AZ, March 5, 1994 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 5, 1994, 11:00 local (18:00 UTC) - Place: Fairfield, AZ - Coordinates: 33.474074, -112.13538 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.4741&lon=-112.1354&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious, 2 uninjured - Status: Completed, report November 18, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28689 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94LA153 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28689/pdf - Page: https://openairdocs.org/ntsb/LAX94LA153 ## Probable cause THE FLIGHT INSTRUCTOR'S INADVERTENT MOVEMENT OF THE LEFT ENGINE PROPELLER CONTROL INTO THE FEATHER POSITION, HIS DECISION TO BY-PASS SUITABLE LANDING SITES IN AN ATTEMPT TO RESTART THE LEFT ENGINE AS THE AIRCRAFT ENERGY AND PERFORMANCE CAPABILITY DETERIORATED, HIS FAILURE TO MAINTAIN AN AIRPSEED AT OR ABOVE VMC, HIS FAILURE TO MAINTAIN CONTROL OF THE AIRCRAFT, AND HIS INADEQUATE SUPERVISION OF THE FLIGHT. ## 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 - switched off - propeller feathering - inadvertent, pilot in command(cfi) (cause) - Loss of control - in flight, descent - emergency - in-flight planning/decision - inadequate, pilot in command(cfi) (cause) - airspeed(vmc) - not maintained, pilot in command(cfi) (cause) - aircraft control - not maintained, pilot in command(cfi) (cause) - supervision - inadequate, pilot in command(cfi) (cause) - In flight collision with terrain/water, descent - uncontrolled ## Analysis DURING THE ACCIDENT FLIGHT, THE CFI WAS IN THE FINAL PROCESS OF PREPARING THE SECOND PILOT TO TAKE HIS MULTIENGINE CFI CHECK RIDE. AFTER COMPLETING A TOUCH-AND-GO LANDING, THE AIRPLANE CLIMBED TO BETWEEN 200- AND 300-FEET AGL. THE CFI ATTEMPTED TO RETARD THE LEFT ENGINE'S THROTTLE, BUT ACCIDENTALLY RETARDED THE LEFT ENGINE'S PROPELLER CONTROL INTO THE FEATHER DETENT. THE CFI MANEUVERED THE AIRPLANE WHILE ATTEMPTING TO RESTART THE LEFT ENGINE. DURING THIS TIME, THE AIRCRAFT BY-PASSED SEVERAL SUITABLE LANDING SITES AND ENDED UP OVERFLYING HILLY TERRAIN AS THE AIRCRAFT CONTINUED A GRADUAL DESCENT. THE PILOT LOST CONTROL OF THE AIRPLANE AS THE AIRSPEED DECREASED; THE AIRCRAFT ROLLED TO THE LEFT AND COLLIDED WITH HILLY TERRAIN. THE LEFT ENGINE AND PROPELLER COMBINATION WAS REMOVED FROM THE AIRCRAFT AND INSTALLED IN AN ENGINE TEST CELL. THE ENGINE, PROPELLER, AND PROPELLER GOVERNOR WERE FOUND TO FUNCTION NORMALLY THROUGHOUT THEIR NORMAL OPERATING RANGES. ## Factual narrative On March 5, 1994, at 1100 mountain standard time, a Piper PA-23- 180, N2142P, collided with terrain following an in-flight loss of control near Fairfield, Arizona. The accident sequence was precipitated by the flight instructor inadvertently feathering the left propeller. The aircraft was operated by Proflight of Las Vegas, Nevada, and was on a dual instructional flight. Visual meteorological conditions prevailed at the time of the instructional flight. The airplane was substantially damaged upon colliding with terrain about 10 miles south of the airport in the state of Arizona. The airline transport certificated instructor pilot and the second pilot, who was receiving instruction for a multiengine flight instructor rating, were seriously injured. The two passengers were not injured. The flight originated from Las Vegas, Nevada, on March 5, 1994, at 0815 Pacific standard time as a dual instructional flight. According to the pilot under instruction and the passengers, during the accident flight the flight instructor was in the final process of preparing the second pilot to take his multiengine flight instructor check ride. At the completion of the (accident) flight, the second pilot had planned to use the airplane for the check flight. The occupants further reported that after completing a touch-and- go landing at St. George, Utah, the airplane climbed between 200 and 300 feet above the 2,938-foot mean sea level field elevation. Then, the flight instructor attempted to retard the left engine's throttle, but accidentally retarded the left engine's propeller control. The left engine's propeller blades feathered. The flight instructor maneuvered the airplane over lower elevation terrain while attempting to restart the left engine; however, the aircraft ended up crossing the Arizona border and overflying hilly terrain. The pilot lost control of the airplane as the airspeed decreased. The left wing lowered and the airplane collided with hilly terrain. The pilot under training reported that the instructor retarded the left engine propeller control as the landing gear was retracting. The only engine-driven hydraulic pump is located on the left engine and the flight instructor had to pump the landing gear completely up by hand. During this time, the aircraft continued a gradual descent toward the ground. The pilot under training and the two passengers reported that the flight instructor by-passed several suitable forced landing sites in his attempt to restart the left engine. After recovery of the aircraft, the left engine and propeller combination was removed from the aircraft and installed in an engine test cell. Under supervision of a Federal Aviation Administration (FAA) inspector, the engine was started three times, twice with the propeller feathered. During all three test runs, the engine started immediately and was exercised throughout its normal operating range. The propeller governor was noted to function smoothly and maintained control of the propeller rpm; the propeller blades were exercised into and out of the feather position easily with no hesitation. ## Aircraft - Registration: [N2142P](https://openairdocs.org/deregistered/N2142P-2012-08-24), registration cancelled 2012-08-24, S/N 23-737, built 1956 (OpenAirDocs) - Reported make and model: PIPER PA-23-180 - Registry model: [Piper PA-23](https://openairdocs.org/model/piper-pa-23) (registry code 7102302) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 23-737 - Airframe hours: 4805 - Engines: LYCOMING IO-360-B1B 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Proflight - Registered owner: James D. Hossler - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, January 25, 1994, 31 hours before - Departed: L15, LAS VEGAS, NV - Destination: SGU ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 6,343 total, 190 in this make and model, 4,763 as pilot in command, 125 in the last 90 days, 55 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 50 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 19940305003689A](https://openairdocs.org/incident/19940305003689A), Mar 5, 1994: Piper PA23, Fairfield, AZ, Substantial damage. CFI feathered left prop instead throttle for demo engine out. Unable raise gear due pump on same. Wont fly dirty. 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.