LAX95FA088

NTSB accident investigation · Piper PA-28-180 · Big Bear City, CA · January 28, 1995

Accident · FatalField investigationFinal report
Date
January 28, 1995, 10:35 local (18:35 UTC)
Place
Big Bear City, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N9602JPiper PA-28-180
Weather
Visual (VMC) · Day
Status
Completed · report August 31, 1995
Report
Approved by Office Director
FAA report
19950128000899A
Case key
28911

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 improper preflight inspection during which he failed to insure removal of the induction air system inlet covers. This action resulted in a partial loss of engine power during initial climb. A factor which contributed to the accident was the pilot's decision to not follow published takeoff procedures which would have permitted flight over lower elevation terrain.

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) - nonmechanicalTakeoff - initial climb
Misc eqpt/furnishings,engine inlet covers - not removed
Aircraft preflight - improperPilot in commandCause
Induction air control/system - blocked(partial)Cause
In flight collision with terrain/waterManeuvering - turn to landing area (emergency)
Terrain condition - rising
In-flight planning/decision - improperPilot in command
Procedures/directives - not followedPilot in commandFactor
Emergency procedure - initiatedPilot in command

Analysis

Witnesses reported observing nothing unusual during the airplane's takeoff, except that the airplane only climbed to about 300 feet above ground level as it passed the departure end of runway 08. The airport's published departure procedure is to turn 10 degrees left of the runway heading and overfly level terrain. Seconds after takeoff, the airplane was observed beginning a right crosswind turn over rising terrain, and it collided with trees and a snow-covered mountainside about 0.76 miles southeast of the airport. Examination of the airplane revealed the engine compartment air induction system was partially blocked by the presence of 2-inch-thick foam rubber cowl plugs. The plugs had been located in front of the no. 1 and 2 cylinders, and inside the carburetor air scoop inlet. The plugs exhibited a handmade appearance.

Factual narrative

History of flight

On January 28, 1995, at 1035 Pacific standard time, a Piper PA- 28-180, N9602J, owned and operated by the pilot, experienced a partial loss of engine power during takeoff from runway 08 at the Big Bear City Airport, Big Bear City, California. The airplane collided into mountainous terrain about 0.76 nautical miles southeast of the airport. Visual meteorological conditions prevailed at the time of the personal flight to Parker, Arizona, and no flight plan was filed. The airplane was destroyed. The private pilot and his wife were fatally injured. The family dog survived. The flight was originating at the time of the accident. The estimated takeoff time was around 1032.

Witnesses reported observing the airplane become airborne about midfield, and no unusual engine sounds were detected. Upon passing the over the departure end of the runway, witnesses observed the airplane commence a right turn at an estimated altitude of 250 to 300 feet above ground level. The witnesses further reported that as the airplane continued on the crosswind leg, it gradually descended until finally impacting terrain.

Personnel information

Based upon information contained in the pilot's flight record logbook, the pilot initiated flight training in August of 1993. On April 4, 1994, he was issued a private pilot certificate. All flight training was conducted in Cessna 150 airplanes. On April 9, the pilot received a check-out in a Cessna 172, and he flew that model of airplane during the following two months.

On August 6, 1994, the pilot received a check-out in the accident airplane, and he purchased it several days later. The pilot flew the airplane on over 40 occasions during his 6 months of ownership. By the accident date, the pilot had logged 38 hours of flight time in the accident airplane. His total logged flight time was about 113 hours.

During the 6-day period which preceded the accident, it had snowed in the Big Bear area. The pilot did not fly his airplane.

Aircraft information

The airplane was equipped with an exterior, electric, oil sump heater. The heater was used to preheat the engine oil before starting the engine in periods of cold weather

Airport departure procedures

Terrain rises to the south of the airport. The published airport takeoff and departure procedures for runway 08 were, in part, to execute a 10-degree left turn at the end of the runway, and then to climb out over the Big Bear Lake.

Wreckage and impact information

On January 28, 1995, the National Transportation Safety Board examined the airplane wreckage at the accident site. The on-scene examination revealed the presence of numerous felled trees and severed tree limbs on the snow-covered mountainside along a magnetic track of 060 degrees. The airplane was located on its right side at the bottom of a ravine, on a magnetic heading of 130 degrees, and it was partially resting on top of severed branches.

The airplane's right wing was located at ground level, and the left wing was pointed in a near-vertical upward direction. The engine remained attached to the firewall, and it was also on its right side at ground level. All flight control surfaces remained attached to the airframe structure.

The estimated crash site elevation was 7,000 feet mean sea level.

The geographic coordinates for the accident site main wreckage were 34 degrees, 15.20 minutes north latitude, by 116 degrees, 50.74 minutes west longitude.

During the examination of the airplane, the master switch was turned on, and the stall warning light was observed to illuminate. The starter was turned on, and the starter motor engaged. Control cable continuity was established between the aft baggage compartment and the rudder and stabilator assemblies.

The fuel tank caps were found seated on both tank filler necks. The caps were removed and inspected. The rubber sealing cap gaskets were found bearing circular marks which were off-center, with respect to the geometric center of the gaskets. The gaskets did not fit snugly on the base of the caps. The outside diameter of the gaskets contained nicks. The gaskets had a hand-made appearance (see photograph).

Medical and pathological information

An autopsy was performed on the pilot by the San Bernardino County Coroner's Office in San Bernardino, California. Toxicology tests were performed by the Federal Aviation Administration, Civil Aeromedical Institute, Oklahoma City, Oklahoma. No drugs or ethanol were detected.

Tests and research

On January 30, 1995, the airplane wreckage was additionally examined following its recovery to the Long Beach, California, facilities of National Aircraft. All eight spark plugs were removed and visually examined. The Lycoming engine participant opined that they appeared low time and in a serviceable condition.

Fuel was found in the gascolator bowl, in the main fuel inlet line to the carburetor, and inside the carburetor. No evidence of water was observed. The fuel inlet screen was found free of contamination. During hand rotation of the crankshaft, the vacuum pump drive gear was observed to rotate, and the continuity of the valve and gear train was established.

During the examination of the engine compartment, four pieces of pre-cut 2-inch-thick foam rubber material were found. Two of the pieces appeared to match the shape of the opening at the front of the engine cowl. Portions of the foam material bore indentation marks which matched the pattern of several partially crushed cylinder cooling fins. A foam fragment was found wedged against the front of the engine's No. 1 cylinder. A fragment from another piece of foam rubber was found squeezed between cooling fins at the front of the No. 2 cylinder. A 2-inch-thick foam plug was found inside the engine's lower cowl air scoop which routes induction air to the carburetor.

The Safety Board removed the plug from the air scoop and examined it. The foam plug was observed shaped to match the inside dimensions of the air scoop, and fit snugly inside it (see photographs). The edges/sides of all the foam rubber material exhibited an uneven texture and shape, and had the appearance of having been cut by hand to its existing form.

Additional information

The airplane wreckage was released to the assigned insurance adjuster on January 31, 1995. No parts were retained.

Aircraft

Registration
N9602J
Reported as
Piper PA-28-180
Category
Airplane
Serial number
28-3748
Airframe hours
3,546
Engine
Lycoming O-360-A4A, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Dennis & Roslyn Lutz
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 22, 1994 · 41 hours before
Departed
L35
Destination
P20 · Parker, AZ
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
47
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
113 total · 38 in this make and model · 64 as pilot in command · 19 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 6 knots
Visibility
50 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 27 °F
Altimeter
30.00 inHg
Observed at
L35, 1 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.

Other investigations on N9602J · 1

Matched to the same aircraft by N-number and date.