# NTSB LAX95FA157: Piper PA-28R-180, N3904T, Pollack Pines, CA, April 8, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 8, 1995, 14:12 local (21:12 UTC) - Place: Pollack Pines, CA - Coordinates: 38.740943, -120.57064 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.7409&lon=-120.5706&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report January 29, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 28922 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95FA157 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28922/pdf - Page: https://openairdocs.org/ntsb/LAX95FA157 ## Probable cause The pilot's disregard of a hazardous weather advisory; his decision to fly into known adverse weather conditions; his failure to maintain control of the airplane with an accumulation of airframe ice; and his improper use of the flight controls during recovery from the inflight upset exceeding the airplane's stress limits. The adverse weather and airframe ice were factors in the accident. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - normal - weather condition - high wind (contributing factor) - weather condition - turbulence,terrain induced (contributing factor) - weather condition - icing conditions (contributing factor) - hazardous weather advisory - disregarded, pilot in command (cause) - weather evaluation - misjudged, pilot in command (cause) - flight into known adverse weather - continued, pilot in command (cause) - Airframe/component/system failure/malfunction, descent - uncontrolled - wing - ice (contributing factor) - aircraft control - not maintained, pilot in command - empennage - overload - design stress limits of aircraft - exceeded, pilot in command (cause) - empennage - separation - In flight collision with terrain/water, descent - uncontrolled - terrain condition - mountainous/hilly ## Analysis THERE WAS NO RECORD THAT THE PILOT RECEIVED A PREFLIGHT WEATHER BRIEFING FROM THE FAA OR NWS SYSTEMS. THE PILOT TOLD THE OPERATOR HE CHANGED HIS DESTINATION DUE TO HIGH WINDS TO AN AREA WITH BETTER WEATHER. THE PILOT CHANGED HIS DESTINATION A SECOND TIME WITHOUT TELLING THE OPERATOR TO AN AIRPORT THAT WOULD REQUIRE CROSSING THE SIERRA NEVADA MOUNTAINS. HIGH WINDS WERE ALSO FORECASTED FOR THE MOUNTAINS. A CENTER WEATHER WATCH WAS BROADCASTED BY APPROACH CONTROL, WHILE THE PILOT WAS ON THE FREQUENCY, FORECASTING MODERATE AND OCCASIONAL SEVERE TURBULENCE, STRONG UP-AND-DOWN DRAFTS, LOW LEVEL WIND SHEAR, AND WIND GUSTS UP TO 45 KNOTS. THE CLOSEST WEATHER OBSERVATION STATION WAS UPWIND OF THE ACCIDENT SITE. THE STATION HAD TAKEN SIX SPECIAL WEATHER OBSERVATIONS IN ADDITION TO TWO SCHEDULED OBSERVATIONS DUE TO CHANGING WEATHER CONDITIONS. THE AIRPLANE WAS OBSERVED DESCENDING UNCONTROLLED WITHOUT THE TAIL BY NUMEROUS WITNESSES. ICE WAS OBSERVED ON THE WINGS, IN AN INDUCTION HOSE, AND THE RAM AIR PORT OF THE PITOT STATIC SYSTEM AFTER THE ACCIDENT. ## Factual narrative History of the Flight On April 8, 1995, at 1412 hours Pacific daylight time, a Piper PA-28R-180, N3904T, separated in flight and descended uncontrolled and collided with terrain in Pollock Pines, California. The airplane was destroyed and the certificated private pilot and three passengers received fatal injuries. The airplane was being operated by S & S Flight Center, Bakersfield, California. The pilot rented the airplane from the operator to conduct a personal flight. The flight departed Bakersfield about 1205 hours, and was destined for South Lake Tahoe, California. The pilot had scheduled the accident airplane for an overnight trip to Las Vegas, Nevada, beginning at 1200 hours on April 8, 1995, to 1800 hours on April 9, 1995. The airplane operator had called the pilot approximately 1000 hours to confirm the airplane reservation because the en route weather to Las Vegas was not suitable due to high winds. The pilot told the airplane operator that he changed his destination to Sacramento because the weather was clear. The pilot and passengers arrived at the Bakersfield Municipal Airport about 1140 hours. At the time, the accident airplane was being flown by a flight instructor administering dual instruction to another pilot. The airplane operator contacted the flight instructor on radio and informed him the airplane needed to be back by 1200 hours. At 1145 hours, the pilot met the flight instructor on the ramp with his passengers and their baggage. The flight instructor spoke to the pilot. The flight instructor told the pilot the airplane was in good condition and everything was operational. The pilot told the flight instructor his destination was Lake Tahoe. The flight instructor recommended to the pilot the he not fly in instrument or poor weather conditions. The pilot told the flight instructor the weather was good "VFR" (visual flight rules). There was no record found during the investigation of the pilot receiving an aviation weather briefing. The operator maintains a computer in the flight planning area for pilots to obtain weather information and file flight plans. According to the operator, the pilot did not use their flight planning area on the day of the accident. At 1208 hours, the pilot contacted the Bakersfield Approach Control and informed the sector controller that he had departed Bakersfield Municipal Airport, climbing to 5,500 feet above mean sea level (msl) in VFR conditions. The pilot also requested radar traffic advisories and informed the sector controller his destination was Lake Tahoe. The sector controller then radar identified the airplane climbing through 4,500 feet, issued an altimeter setting, and provided routine VFR flight following. At 1212 hours, the sector controller broadcasted a "Center Weather Advisory" pertinent to the accident airplane's route of flight to Lake Tahoe. The Center Weather Advisory issued warnings of moderate and occasional severe turbulence, possible strong up-and-down drafts, low level wind shear, mainly near the mountains, and moderate-to-severe wind gusts, possibly up to 45 knots. At 1232 hours, the Bakersfield Approach terminated radar service with the pilot and advised the pilot of the Fresno Approach Control frequency for further VFR flight following. At 1935 hours, the pilot called Fresno Approach Control for radar traffic advisories and was radar identified 15 miles southeast of Visalia, California. At 1300 hours, the pilot reported climbing from 8,500 feet msl to 10,500 feet msl. The Fresno Approach sector controller terminated radar services and advised the pilot he could contact Oakland Center for further radar advisories. There was no record found of the pilot contacting Oakland Center. Review of Oakland Center radar data, NTAP (National Track Analysis Program) disclosed a VFR beacon code (1200) disappeared from radar over the accident site at 1412 hours. There were 36 other radar hits in the vicinity of the accident site in the NTAP data over a 7-minute period. The NTAP data was graphically plotted in time sequence. The first data point was at 1405:03 hours at a position 9.04 nautical miles east-southeast of the accident site at an altitude of 11,200 feet msl. A scaled overlay of the NTAP data revealed, as time progressed, subsequent radar hits that moved closer to the accident site. There were 14 radar hits in time sequence that contoured the north shore of Jenkinson Lake in a descent from an altitude of 10,700 feet msl to 10,400 feet msl. The third from the last radar hit indicated an altitude of 9,400 feet msl. The last radar hit was 24 seconds later at 4,300 feet. There was no altitude data displayed for the second to last radar hit record 12 seconds before the last. Numerous witnesses stated their attention was drawn to the airplane by the sound of its engine. Several of the witnesses reported hearing a loud "bang" noise. They then looked up and saw the airplane descending uncontrolled without its tail. Other witnesses saw falling debris. Many of the witnesses then reported the accident to the El Dorado County Sheriff's Department. The witnesses stated that it was snowing at the time of the accident. Several sheriff's deputies and one homeowner reported an accumulation of ice ranging from 1/4- to 1/2-inch thick on a separated wing, and a wing still attached to the airplane. Pilot Information The pilot held a private pilot certificate which was issued on June 6, 1974, with a single engine airplane rating. The pilot did not possess an airplane instrument rating. The most recent third-class medical certificate was issued to the pilot on May 26, 1993, and contained the limitation that correcting lenses must be worn while exercising the privileges of his airman certificate. No personal flight records were located for the pilot, and the aeronautical experience listed in this report was obtained from the operator's accident report and the experience gained during the accident flight. Aircraft Information A standard airworthiness certificate was issued for the airplane after it was manufactured on November 11, 1967. The airplane had accumulated a total time in service of 2,291 hours. According to the airframe manufacturer, the airplane is not certified for flight into icing conditions. Meteorological Information The closest official weather observation station is McClellan Air Force Base, which is located 38.4 nautical miles west of the accident site. The elevation of the weather observation station is 75 feet msl. The weather facility normally takes hourly scheduled weather observations and special weather observations when weather changes significantly. From 1255 hours to 1355 hours, weather observers at McClellan AFB took six unscheduled special weather observations, in addition to the two scheduled observations. At 1428 hours, an unscheduled special surface observation was reporting in part: sky condition and ceiling, 3,000 foot scattered, measured 5,000 foot broken, 7,000 feet overcast; visibility, 8 miles light rain; winds 210 degrees at 7 knots. Wreckage and Impact Information The fuselage came to rest at 38 degrees 45.20 minutes north latitude and 120 degrees 34.58 minutes west longitude. The accident site is located in a residential area of Pollack Pines, California. The average elevation in the area is 3,500 feet msl. The residential area is mountainous and covered by numerous mature trees with 2-foot diameter trunks, and some as high as 150 feet above the ground. The site is about 3,500 feet south of State Highway 50. The highway follows the American River Valley, and according to residents of Pollock Pines, is used frequently by pilots to navigate from Sacramento to South Lake Tahoe. The airplane's fuselage with porions of both wings came to rest on sloping terrain behind a residence located at 6434 Topaz Drive. The airplane contacted trees before hi ## Aircraft - Registration: [N3904T](https://openairdocs.org/deregistered/N3904T-1996-05-17), registration cancelled 1996-05-17, S/N 28R30238 (OpenAirDocs) - Reported make and model: PIPER PA-28R-180 - Registry model: [Piper PA-28R-180](https://openairdocs.org/model/piper-pa-28r-180) (registry code 7102809) (OpenAirDocs) - Category: Airplane - Serial number: 28R-30238 - Airframe hours: 2921 - Engines: LYCOMING IO-360-B1E 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: S & S Flight Center - Registered owner: Winters, Connie - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 21, 1995, 8 hours before - Departed: L45, BAKERSFIELD, CA - Destination: TVL, SO. LAKE TAHOE, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 400 total, 9 in this make and model, 2 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 210° at 7 knots - Visibility: 8 statute miles - Lowest ceiling: 5,000 ft broken - Altimeter: 30.00 inHg - Observed at: MCC, 39 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 19950408007339A](https://openairdocs.org/incident/19950408007339A), Apr 8, 1995: Piper PA28R180, Pollock Pines, CA, Destroyed, 4 fatal. Wreckage indicates loss of control exceeded vne in a dive and pullout. Ice on airframe. Pitot iced. Heat not on. 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.