LAX95FA053

NTSB accident investigation · North American NAVION-A · Big Bear City, CA · December 19, 1994

Accident · FatalField investigationFinal report
Date
December 19, 1994, 13:52 local (21:52 UTC)
Place
Big Bear City, CA
Injuries
2 fatal, 1 serious
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N8794HNorth American NAVION-A
Weather
Visual (VMC) · Day
Status
Completed · report May 18, 1995
Report
Approved by Office Director
FAA report
19941219041789A
Case key
28902

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

the pilot's initial overrotation, his failure to attain the proper climb airspeed, and an inadvertent entry into a stall mush condition. A factor in the accident was the high-density altitude.

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 control - in flightTakeoff - initial climb
Weather condition - high density altitudeFactor
Rotation - excessivePilot in commandCause
Airspeed - not attainedPilot in commandCause
Stall/mush - inadvertentPilot in commandCause
In flight collision with objectTakeoff - initial climb
Object - tree(s)
In flight collision with terrain/waterDescent - uncontrolled
Fuel system - ruptured
Fluid,fuel - fire

Analysis

Witnesses reported that the aircraft lifted off runway 8 in an unusually nose-high attitude with a shallow climb angle. The aircraft continued on the runway heading until it settled into a group of trees 0.4 miles from the end of the runway. The aircraft owner's manual indicated the distance required to take off and clear a 50-foot obstacle under no wind conditions would be approximately 4,700 feet. The 5,850-foot-long, hard-surfaced runway has a slight rise in the center, but otherwise has no slope. Winds were 7 knots from 080 degrees. Wing flaps were not utilized. The stand of trees off the end of the runway was between 25 to 35 feet in height and situated on slightly rising terrain. No significant discrepancies were noted in the examination of the engine or airframe. The safety board concurs with the technician that the abnormality found in the carburetor had no role in the cause of this accident. The airport elevation is 6,750 feet and the temperature was about 51 degrees. The density altitude was calculated to be 7,600 feet.

Factual narrative

History of flight

On December 19, 1994, at 1352 Pacific standard time, a North American Navion-A, N8794H, was destroyed by impact and postcrash fire at Big Bear City, California. The aircraft was privately owned and operated, and was on a personal cross-country flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for the operation. The certificated commercial pilot and one of the two passengers sustained fatal injuries. The remaining passenger, a certificated private helicopter pilot, received serious injuries. The flight originated from Whiteman airport at approximately 1030 on the day of the accident.

The owner stated that before takeoff from Whiteman airport, he and the pilot discussed several possible destinations, including Big Bear. When that destination was mentioned, they referred to the aircraft owner's manual and concluded that the takeoff performance would be marginal after considering the aircraft gross weight and density altitude at Big Bear. The owner stated that he told the pilot that he thought they should fly to Santa Barbara instead. He also stated that, initially, the pilot-rated passenger had expressed an interest in going to Big Bear.

The pilot-rated survivor stated that he had wanted to go north along the coast, but the pilot suggested Big Bear. He said that the owner told them it would be alright for them to go to either Santa Barbara or Big Bear. He stated that the owner and pilot performed a weight and balance using estimated weights for the passengers. He also reported that the owner cautioned the pilot to be careful if he went to Big Bear, because the aircraft would be heavy and Big Bear was a high-altitude airport. The owner told the survivor that the first hour of operation was to be at his own expense but, after that, the passenger/pilot would have to pay for the fuel.

According to the survivor, after completing preflight and before takeoff checks, the pilot flew to Big Bear. Upon arrival, the pilot parked the aircraft and all three ate lunch. When they returned after lunch, the pilot had difficulty in starting the aircraft. After several unsuccessful attempts, the battery ran down. The pilot then went back inside the airport to call for assistance. A line technician brought out a portable battery and the next start attempt was successful. The survivor reported that the pilot initially connected the jumper cables "backwards," which caused a large "spark." The line technician did not mention the incident during his interview.

The survivor, who was seated in the right front seat, said that after start, the engine idled roughly and the pilot performed a magneto check. He said he recalled that there had been an rpm drop on the left magneto, but no drop when switched to the right magneto. Prior to takeoff, the pilot made a "quick" magneto check and an adjustment to the engine controls.

When asked, he did not recall if the pilot made a power check. He stated that the engine ran smoothly during the takeoff ground roll and initial lift-off. After lift-off, however, the aircraft did not seem to climb very well and the pilot seemed to have difficulty maintaining control.

Witnesses reported seeing the aircraft lift-off in a nose-high attitude with a shallow climb angle. The aircraft climbed straight out to between 100 and 200 feet agl when it began to "mush" in a nose-high, wobbly, wing-level attitude, until it gradually settled into a group of trees.

The survivor reported that the aircraft initially climbed to an altitude of 400 feet agl. He stated that during the climb, the pilot became agitated and began making a series of control adjustments while uttering a series of expletives. Both he and two witnesses on the ground reported that the engine "popped," and then "popped" again, just before the aircraft struck the trees.

The airport manager stated that he was watching out the window as the aircraft departed. Prior to departure, he had provided airport advisory information to the pilot over the airport UNICOM frequency. Shortly after the takeoff, he heard a short radio transmission consisting of "Oh no," followed by a 2-second pause, and then "Holy (expletive deleted)." He said he was certain that both transmissions came from the accident aircraft since he had just communicated with the pilot and recognized his voice. He then went outside and saw a column of black smoke beyond the departure end of the runway. He made several attempts to call "911," but found the telephone lines to be busy. After the crash, he also heard an emergency locator transmitter (ELT) over the UNICOM guard frequency, but reported that the signal stopped less than a minute later.

He preceded to the accident site and found one of the occupants on the ground outside the aircraft. He asked the survivor where his flight originated, but the survivor was unable to recall the name of the airport. The survivor stated that the aircraft was owned by Kenneth Woods, but that Mr. Woods had not been on board. He observed that the survivor had sustained what appeared to be both burns and lacerations, particularly to his face and hands.

Personnel information

The owner reported that the pilot had previously flown the accident aircraft approximately 70 hours and was familiar with the aircraft systems and procedures. He also stated that he and the pilot had previously flown into the Big Bear airport, but on that occasion had taken off on runway 26.

Aircraft information

The aircraft main tanks were topped off with 21.4 gallons of 80/87 aviation fuel at the Whiteman airport just prior to takeoff. According to the aircraft owner, the capacity of the main tanks is slightly more than 20 gallons each. Both tanks are interconnected to a gravity-fed accumulator tank with a 3/4-gallon capacity. The owner also reported that the aircraft was equipped with two auxiliary tanks which contained 2 or 3 gallons each in order to keep the seals "wet."

Fuel is normally supplied to the engine from the accumulator tank by an engine-driven fuel pump. However, the aircraft owner's manual specifies that during takeoff, the electric fuel boost pump switch should be in the "on" position. The owner confirmed that this procedure was followed whenever he had flown with the pilot.

According to the weight and balance table in the aircraft owner's manual, investigators estimated that the aircraft gross weight at the time of the accident was approximately 2,500 pounds. Interpolating from the takeoff table in the aircraft owner's manual, investigators estimated the distance required to take off and clear a 50-foot obstacle would be approximately 4,700 feet.

Airport information

According to the airport manager, the single runway has a slight rise in the center, but otherwise has no slope. Approximately 0.4 miles off the departure end of runway 08 is a stand of trees. Investigators estimated the average height varied from 25 to 35 feet. There were no other significant obstacles identified along the initial departure path.

Wreckage and impact information

The aircraft impacted in a grove of trees about 0.4 mile beyond the departure end of the runway. The initial impact mark was about 20 feet from the base of a tree 35 feet in height. The diameter of the tree at the point of impact was approximately 18 inches. Several tree limbs were severed during the impact and were found near the base of the tree. The left stabilizer was found 36 feet beyond the initial impact point and was displaced laterally about 12 feet to the right along an axis of 050 degrees from the first strike. A 6-foot section of the right wing tip was found about 1 foot from the base of the tree.

The second tree strike was approximately 39 feet beyond the first and was displaced laterally about 8 feet to the left along an axis of 050 degrees from the second strike. The second impact mark was at

Aircraft

Registration
N8794H
Reported as
North American NAVION-A
Category
Airplane
Serial number
NAV-4-794
Airframe hours
3,993
Engine
Continental E-185, 205 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Kenneth R. Woods
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 7, 1993 · 128 hours before
Destination
WHP · Pacoima, CA
Airport
L35 · Big Bear City, runway 8, 5,850 × 75 ft, asphalt

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
29
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
600 total · 70 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
80° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
52 °F, dew point 10 °F
Altimeter
30.00 inHg
Observed at
L35

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.