# NTSB LAX94LA304: Piper PA-28-161, N2500Y, Devore, CA, July 31, 1994 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 30, 1994, 19:17 local (Jul 31, 1994, 02:17 UTC) - Place: Devore, CA - Coordinates: 34.24908, -117.300308 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.2491&lon=-117.3003&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report November 14, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28814 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94LA304 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28814/pdf - Page: https://openairdocs.org/ntsb/LAX94LA304 ## Probable cause was the failure of the pilot to follow checklist and emergency procedures, which resulted in an improper decision to land on a dirt road within two miles of an airport. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, cruise - normal - electrical system,alternator - popped/tripped - procedures/directives - not followed, pilot in command (cause) - On ground/water collision with object, landing - roll - airport - not selected, pilot in command (cause) - planning/decision - improper, pilot in command (cause) - terrain condition - roadway/highway - precautionary landing - attempted, pilot in command - airspeed - excessive, pilot in command (cause) - object - pole - On ground/water encounter with terrain/water, landing - roll - terrain condition - ditch ## Analysis During cruise flight and within 5 minutes, the pilot's number one radio quit, followed by the number two radio, and then the transponder. He became uncertain about his position and was concerned about decreasing visibility and impending darkness. He began a descent and followed a freeway. He stated that all the right side panel instruments then 'went out,' followed 2 minutes later by all of the left side panel instruments. He flew through a valley, saw the words 'San Bernardino' on a building, and concluded that he was east of track. He saw an airport for a precautionary landing, but thought that the runway was not long enough. He then saw a dirt road near the freeway and choose it instead. He was concerned about stalling, so he added 10 knots to his approach speed. The pilot braked hard to avoid going into an intersection, struck a wooden pole, and veered off the road into a ditch. The operator reported that the alternator had 'gone off-line.' ## Factual narrative On July 30, 1994, at 1917 Pacific daylight time, a Piper PA-28-161, N2500Y, sustained substantial damage during a precautionary landing at Devore, California. The aircraft was operated by Van Nuys Flight Center and was on a solo student instructional cross-country flight. Visual meteorological conditions prevailed at the time and a VFR flight plan had been filed for the operation. The flight originated from Van Nuys airport at 1400 on the day of the mishap. The pilot stated that on the initial leg of his flight he did not experience any problems or notice anything unusual. After making a touch-and-go landing at Barstow-Daggett airport, he noticed the aircraft was slow in climbing back to his planned cruising altitude of 7,500 feet. The pilot said he attributed the performance to higher ambient temperatures and continued on to MaCarran International airport, his planned stopover point. The approach and landing were uneventful. The pilot reported being on the ground in Las Vegas, Nevada, for 40 minutes. During this stop, the aircraft was refueled. On engine start, the pilot stated that the aircraft "started rough." Again, he attributed the event to the high ambient temperature. He stated that, as before, his rate of climb to his planned cruising altitude of 8,500 feet was slower than he expected. During the flight, the pilot maintained a close watch on the aircraft's EGT gauge to ensure that the engine was properly leaned. He also noted that the ammeter reading went from 2 to 0 during this leg of the flight. As the pilot crossed Baker, California, he heard a marker beacon aural signal, along with a constant high-pitched tone. He reported that shortly thereafter, the number one communication radio quit. He reached that conclusion because the face of the radio blacked out. Five minutes later, the number two communication radio quit in the same manner, and after less than a minute, the transponder quit as well. He then turned on his hand-held receiver, but only heard static. At a point the pilot estimated was about midway between Daggett and Palmdale, he became uncertain about his location relative to his planned route of flight. He also described a growing concern about what he described as decreasing visibility and impending darkness. In an attempt to identify landmarks along his route, the pilot decided to descend from his cruising altitude of 8,500 to 6,500 feet. The pilot identified what he thought was the 14 Freeway and began following it in a southerly direction and continued descending through 6,500 feet. As the flight progressed, the pilot stated that all the instruments on the right side of the panel "went out." About 2 to 3 minutes later, all the instruments on the left side of the panel "went out" as well. He continued his descent down to 4,500 feet, and then finally down to 3,500 feet, believing he was in the San Gabriel Valley. The pilot stated that he saw the words "San Bernardino" on a building and concluded that he was well east of his intended position. He began a reconnaissance of the area looking for an airport in order to make a precautionary landing, but determined that what he had identified as an airport was not of adequate length. He next identified a dirt road near the freeway and determined that it was adequate for landing. Since he was concerned about stalling the aircraft on approach, he added approximately 10 knots to the normal approach speed. After the aircraft touched down, the aircraft would not stop in time to avoid rolling into an intersection with a paved highway. The aircraft struck a wooden pole, partially veered off the dirt road, and went into a ditch, stopping short of the intersection. The pilot was able to exit the aircraft unassisted. The operator reported that the aircraft's alternator had "gone off line." The pilot did not report any attempts to troubleshoot or identify the problem, nor did he report referring to the aircraft's check list or operator's manual. ## Aircraft - Registration: [N2500Y](https://openairdocs.org/deregistered/N2500Y-1997-09-11), registration cancelled 1997-09-11, S/N 288516073 (OpenAirDocs) - Reported make and model: PIPER PA-28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Category: Airplane - Serial number: 28-8516073 - Airframe hours: 4749 - Engines: LYCOMING O-320-D3G 160 horsepower reciprocating - Damage: Destroyed - Flight: Instructional, Part 91 - Operator: Fredrick Voorhis, doing business as Van Nuys Flight Center - Registered owner: Keith R. Sweitzer - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, July 26, 1994, 13 hours before - Departed: LAS, LAS VEGAS, NV - Destination: VNY, VAN NUYS, CA - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; student; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 114 total, 114 in this make and model, 33 as pilot in command, 16 in the last 90 days, 9 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 12 knots - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 61 °F - Altimeter: 29.00 inHg - Observed at: ONT, 14 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 19940730019669A](https://openairdocs.org/incident/19940730019669A), Jul 30, 1994: Piper PA28161, Devore, CA, Substantial damage. Lost electronics en route. Became lost. Tried land on a road. Overshot struck wood pole and ditch. Alternator quit. 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.