# NTSB LAX95FA082: Piper PA-38-112, N4279E, Joshua Tree, CA, January 20, 1995 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Field investigation · Final report - Date: January 20, 1995, 08:45 local (16:45 UTC) - Place: Joshua Tree, CA - Coordinates: 34.149871, -116.270706 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.1499&lon=-116.2707&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report May 18, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28910 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95FA082 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28910/pdf - Page: https://openairdocs.org/ntsb/LAX95FA082 ## Probable cause the operator's inadequate annual inspection by failing to find that the flight control's horizontal section of the 'T' bar was rubbing against the vacuum hoses behind the instrument panel. The jammed 'T' bar and the rough terrain were factors in this accident. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, takeoff - roll/run - flt control syst,elevator control cable/rod - jammed (contributing factor) - maintenance,annual inspection - inadequate, company maintenance personnel (cause) - Overrun, takeoff - aborted - Nose gear collapsed, takeoff - aborted - terrain condition - rough/uneven (contributing factor) - landing gear,nose gear strut - overload ## Analysis THE STUDENT PILOT WAS UNABLE TO RAISE THE ELEVATORS DURING THE TAKEOFF GROUND ROLL. THE PILOT ABORTED THE TAKEOFF, BUT THE REMAINING RUNWAY WAS INSUFFICIENT TO STOP THE AIRPLANE ON THE RUNWAY. THE AIRPLANE OVERRAN THE RUNWAY AND THE NOSE GEAR COLLAPSED WHEN IT ENTERED THE ROUGH/UNEVEN TERRAIN. THE POSTACCIDENT EXAMINATION REVEALED THAT THE HORIZONTAL 'T' BAR JAMMED AGAINST THE ATTITUDE INDICATOR HOSES. THIS JAMMING INHIBITED REARWARD MOVEMENT OF THE FLIGHT CONTROL WHEEL. THE VACUUM HOSES AND THE AVIONICS INSTALLATION BOX BRACKETS EXHIBITED NUMEROUS RUBBING AND CHAFING SIGNATURES. A 100-HOUR/ANNUAL INSPECTION WAS ACCOMPLISHED 2 MONTHS BEFORE THE ACCIDENT. THE AIRPLANE ACCRUED 99 HOURS SINCE THE INSPECTION. ## Factual narrative HISTORY OF FLIGHT On January 20, 1995, at 0845 hours Pacific standard time, a Piper PA-38-112, N4279E, overran runway 6 after the pilot aborted the takeoff ground run at Hi Desert Airport, Joshua Tree, California; the nose gear collapsed when the airplane entered the rough/uneven terrain. The pilot was beginning a local area visual flight rules solo instructional flight. The airplane, operated by Hi Desert Airport, sustained substantial damage. The student pilot received minor injuries. Visual meteorological conditions prevailed. The pilot reported in the aircraft accident report that she initially intended to fly to Palm Springs Airport to practice takeoffs and landings at a controlled airport. Hi Desert Airport is a noncontrolled airport. However, after checking the current Palm Springs Airport weather, she elected to practice takeoffs and landings at Hi Desert Airport. The pilot conducted a preflight inspection of the airplane. During the inspection, she checked the flight controls twice for proper and freedom of movement. She also checked the flight controls before taking the runway for the flight. She said that the flight controls operated normally and smoothly. During the takeoff roll, after reaching the proper lift-off speed (about 60 knots), she applied rearward control pressure. The control wheel went back, but the airplane did not respond to the control wheel movement. Realizing that the airplane was not going to lift-off, she retarded the throttle and applied heavy braking. The airplane struck a berm at the west end of the runway and the nose gear collapsed. The operator observed the accident. He said that the airplane was traveling down the runway and then the pilot applied the brakes. The remaining runway was insufficient to stop the airplane on the runway. The airplane exited the east side of the runway and collided with the terrain. The operator also said that the pilot told him that the airplane would not respond to the elevator control movements. Realizing the airplane would not lift-off, the pilot aborted the takeoff and applied the brakes. A Federal Aviation Administration (FAA), Riverside (California) Flight Standards District Office operations inspector conducted the on-scene investigation. The inspector reported that the elevator control mechanisms were binding. He said that the nose landing gear collapsed and was found beneath the flight controls "T" bar. PERSONNEL INFORMATION The pilot held a student pilot/third-class medical certificate. A certified flight instructor endorsed the student pilot's certificate for solo flight. The medical certificate did not contain any limitation endorsements. National Transportation Safety Board investigators did not review the pilot's flight hours logbook. The flight hours reflected on page 3 of this report were obtained from the aircraft accident report. The pilot showed that she accrued 116 total flight hours. All of the flight hours were flown in the accident airplane. During the preceding 90 days of the accident, the pilot accrued 28 flight hours and 30 days before the accident she accrued 8 hours. She logged 13.1 hours of solo flight. The pilot's husband is her instructor. She said that he approved the flight and also monitored her preflight inspection. AIRCRAFT INFORMATION The airplane is registered to Gordon M. and Edith Y. Poppell, Twentynine Palms, California, and is operated by Hi Desert Airport. The operator said that he hired the mechanic/inspector to perform the last annual inspection. Safety Board investigators recovered the airplane's No. 2 airframe and engine logbooks. Examination of the logbooks revealed an aircraft mechanic with airframe, powerplant, and inspection authorization ratings did the last annual inspection on November 10, 1994. The airplane accrued 3,448.98 hours and the engine accrued 948.25 hours since a major overhaul at the time of the inspection. The airplane accrued 3,547.98 hours at the time of the accident. The annual inspection logbook entry stated that the inspection was conducted according to the Piper PA-38 100-hour checklist. The logbooks' examination revealed that another mechanic showed that he "straightened and tightened the artificial horizon (attitude indicator)." This work was accomplished on January 19, 1991, and the airplane accrued 2,397.33 hours. No recorded maintenance entries were found that showed the attitude indicator or any of its vacuum hoses had been removed or replaced. WRECKAGE AND IMPACT INFORMATION Safety Board investigators examined the airplane at AirCraftsman, Chino, Airport, Chino, California, on January 27, 1995. Both wings and elevators were removed from their respective attach points. Continuity of the control cables to the elevators and rudder bellcrank was established. The flight control wheels are connected with a "T" bar and a "bicycle" chain. The elevator controls move forward (toward the nose of the airplane) and aft. The horizontal portion of the "T" bar is beneath the attitude indicator's vacuum hoses and the lower avionics housing installation brackets. Safety Board investigators found binding, chafing, and rubbing marks on the vacuum hoses connected to the attitude indicator. The control tube bicycle chain exhibited multiple rub marks on the lower side of the avionics installation brackets. Investigators also found a wrapped bundle of avionics red wire resting on the bicycle chain. When the flight control wheel was pushed forward (elevator down), the horizontal section of the "T" bar seized against the attitude indicator vacuum hoses. This seizure also inhibited rearward (elevator up) movement. MEDICAL AND PATHOLOGICAL INFORMATION The pilot was treated for minor injuries at a local hospital and released. Toxicological examinations were not conducted nor were they requested. Tests and Research Piper PA-38 100-hour checklist The 100-hour checklist requires that all instrument panel hoses be inspected for rubbing and chafing. Title 14 CFR 43.15 (a) General. Each person performing an inspection required by Part 91, 123, 125, or 135 of this chapter shall - (1) Perform the inspection so as to determine whether the aircraft, or portion(s) thereof under inspection, meets all applicable airworthiness requirements. . . . 14 CFR 43 - Appendix D (c) Each person performing an annual or 100-hour inspection shall inspect (where applicable) the following components of the cabin and cockpit group; (1) Generally - for uncleanliness and loose equipment that might foul the controls. (5) Flight and engine controls - for improper installation and improper operation. (7) All systems - for improper installation, poor general condition, apparent and obvious defects, and insecurity of attachment. ADDITIONAL INFORMATION The Safety Board released the aircraft wreckage to AirCraftsman, Chino Airport, Chino, California, on January 27, 1995. The Safety Board did not retain any airplane documents or components. ## Aircraft - Registration: [N4279E](https://openairdocs.org/deregistered/N4279E-2014-10-09), registration cancelled 2014-10-09, S/N 38-78A0527, built 1978 (OpenAirDocs) - Reported make and model: PIPER PA-38-112 - Registry model: [Piper PA-38-112](https://openairdocs.org/model/piper-pa-38-112) (registry code 7103812) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 38-78A0527 - Airframe hours: 3547 - Engines: LYCOMING O-235-L2C 118 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Hi Desert Airport - Registered owner: Poppell, Gordon H. & Edith Y. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 10, 1994, 99 hours before - Airport: L80, Hi Desert, runway 6, 2,493 × 50 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; student; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 116 total, 116 in this make and model, 13 as pilot in command, 28 in the last 90 days, 8 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 25 statute miles - Lowest ceiling: none - Temperature: 45 °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 19950120000689A](https://openairdocs.org/incident/19950120000689A), Jan 20, 1995: Piper PA38112, Joshua Tree, CA, Substantial damage. On takeoff roll found yoke binding. Unable rotate. Aborted. Overran runway. T bar siezed on misplaced vacuum hoses. 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.