LAX94LA189

NTSB accident investigation · Piper PA-28-140 · Hesperia, CA · April 16, 1994

Accident · No injuriesLimited investigationFinal report
Date
April 15, 1994, 22:32 local (Apr 16, 1994, 05:32 UTC)
Place
Hesperia, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N4129JPiper PA-28-140
Weather
Visual (VMC) · Night/dark
Status
Completed · report April 7, 1995
Report
Approved by Office Director
FAA report
19940415007919A
Case key
28718

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

Loss of engine power due to an air leak at the gascolator gasket, which was improperly installed during maintenance. Darkness was a related factor.

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(partial) - mech failure/malfTakeoff - initial climb
Fuel system,gascolator - leakCause
Maintenance,installation - improperOther maintenance personnelCause
Forced landingEmergency landing after takeoff
In flight collision with terrain/waterLanding - flare/touchdown
Light condition - dark nightFactor
Terrain condition - high vegetation

Analysis

The pilot departed at night from an uncontrolled airport after an en route stop. During the initial climb, about 200' above the ground, the engine began to lose power. The pilot was unable to restore power & selected a forced landing area. During the landing, the airplane struck a bush, separating the airplane's left wing. The pilot recovered the airplane & conducted several post-crash inspections. An examination of the engine by an FAA inspector revealed a leak at the gascolator gasket. Further examination revealed the gascolator was not safety wired & the fuel screen was missing. Also, the lip of the gascolator bowl had 2 gouges, the gasket was too small for the installation, & the gasket appeared to have allowed air into the fuel system. The FAA inspector could not determine to what extent the pilot's post-crash inspection had on the airworthiness of the airplane. The airplane received an annual inspection about 25 flight hours before the accident.

Factual narrative

On April 15, 1994, about 2232 hours Pacific daylight time, a Piper PA28-140, N4129J, collided with terrain during a forced landing, about 3/4 mile east of Hesperia, California. The airplane was being operated as a visual flight rules (VFR) cross- country personal flight to Big Bear City, California, when the accident occurred. The airplane, owned by Avionix Inc, Las Vegas, Nevada, and operated by the pilot, sustained substantial damage. The certificated private pilot, the sole occupant, was not injured. Visual meteorological conditions prevailed. The flight originated at Hesperia airport about 2230 hours.

In a telephone interview, the pilot reported that after departure from runway 21 and climbing to about 400 feet above the ground, the engine began to lose power. The pilot pumped the throttle several times and the engine rpm increased; however, it was not enough to continue flying. The pilot noted that the engine fuel pressure gauge was indicating normal fuel pressure. The pilot selected a forced landing area east of the airport. During the landing, the airplane struck several trees and the left wing separated from the fuselage.

An airworthiness inspector, Federal Aviation Administration (FAA), Riverside Flight Standards District Office, inspected the aircraft after it was recovered by the pilot. An investigator from Textron Lycoming Engines assisted in the examination. The FAA inspector reported that during the initial engine run, fuel was observed leaking from the top of the gascolator. Further examination revealed that the gascolator was not safety wired and was missing the fuel screen. The lip of the gascolator bowl exhibited two gouges. The gasket was too small for the intended installation and appeared to allow air into the fuel system. The gasket had a groove worn where it had been pinched by the gascolator bowl. Installation of a proper gasket resulted in the engine running rough at 2,000 rpm.

The examination also revealed that the right magneto was hot at all times. The carburetor heat butterfly would not close completely. The spark plugs exhibited carbon buildup.

Following the accident, the pilot was sent an NTSB Form 6120.1/2, Pilot/Operator Report. It was returned unclaimed on May 11, 1994. Another form was sent to the pilot via regular mail. A completed 6120.1/2 was not returned by the pilot.

The pilot was present during the FAA's examination of the engine. He reported that he would supply aircraft records to his insurance company. The pilot's insurance adjuster provided a copy of the pilot's submission to National Transportation Safety Board investigators. Contained in the information was a "crash report" from the pilot. The statement documented the flight and several postcrash inspections conducted by the pilot, including removal of carburetor plugs. The FAA inspector was unable to determine the extent that the pilot's postcrash inspections had on the airworthiness of the aircraft.

No personal flight records were submitted by the pilot and the aeronautical experience listed on page 6 of this report was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City. On the most recent application for medical certificate, the pilot reported having accrued 500 hours of total time, with 50 hours being accrued in the previous 6 months.

Examination of the maintenance records submitted to the pilot's insurance company revealed that the most recent annual inspection of the engine and airframe was accomplished on February 2, 1994. As of that date, the recording hour meter reflected a tach time of 4,550 hours. The pilot noted that the aircraft had accrued 25 hours since the annual inspection.

The engine log contained a notation that the carburetor venturi was replaced with a one-piece part in compliance with an airworthiness directive during the annual inspection. Visual examination of the carburetor by Safety Board investigators did not reveal any mechanical discrepancies. The carburetor was returned to the pilot's insurance company on June 7, 1994.

Aircraft

Registration
N4129J
Reported as
Piper PA-28-140
Category
Airplane
Serial number
28-22450
Airframe hours
4,550
Engine
Lycoming O-320-E2A, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
George Abernathy
Registered owner
Avionix Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 2, 1994 · 25 hours before
Destination
L35 · Big Bear City, CA

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
37
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
500 total

Weather

Conditions
Visual (VMC) · Night/dark
Wind
280° at 6 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
66 °F
Observed at
DAG, 38 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.