LAX97FA292

NTSB accident investigation · Piper PA-34-200T · Kernville, CA · August 18, 1997

Accident · Serious injuriesField investigationFinal report
Date
August 17, 1997, 17:44 local (Aug 18, 1997, 00:44 UTC)
Place
Kernville, CA
Injuries
1 serious, 4 minor
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N6654APiper PA-34-200T
Weather
Visual (VMC) · Day
Status
Completed · report February 28, 2000
Report
Approved by Office Director
FAA report
19970817022599A
Case key
29631

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 partial loss of engine power due to the operator's inadequate engine maintenance relating to excessively rich mixtures (high fuel flow rates) and spark plug/magneto deficiencies. Contributing factors were degraded climb performance resulting from the high density altitude and the airplane loading which exceeded maximum weight and aft center of gravity limits.

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
Weather condition - high density altitudeFactor
Maintenance - inadequateCompany/operator managementCause
2 engines
Fuel injection control/system - excessive flow/outputCause
Ignition system,magneto - arcingFactor
Ignition system,spark plug - wornFactor
Misc eqpt/furnishings,cargo restraints - disconnected
DitchingEmergency landing after takeoff
Aircraft performance,climb capability - deterioratedFactor
Aircraft weight and balance - exceededPilot in commandCause
Shoulder harness - not usedPilot in command
Shoulder harness - not usedPassenger
Planning/decision
Lack of certificationCompany/operator managementFactor
Inadequate surveillance of operationFaa(organization)
Lack of certificationPilot in commandFactor

Analysis

Seconds after takeoff, the engines lost partial power. Witnesses saw black smoke trailing from the airplane. Unable to climb, the pilot ditched and sank in 20-foot-deep water, 1.25 miles from the airport. During the month preceding the accident, black smoke had been observed trailing from the airplane on two other occasions, but no evidence of maintenance was noted in the logbooks. The airplane was recovered and examined. The engines were placed into a test cell and run and numerous maintenance related deficiencies were found. Although full power was obtained, the fuel flow rates to both engines exceeded design specifications, thus creating overly rich mixtures and black smoke. Additionally, the right engine's left magneto internally arced, and 5 of the 12 spark plugs were worn beyond limits. The density altitude was computed at 4,300 feet. Also, the maximum certificated gross weight was exceeded by at least 160 pounds, and the center of gravity was 1.09 inches aft of the rear limit. The pilot said he had not asked for a weather briefing prior to departure, nor had he performed weight and balance computations. The fare-paying passengers had not been advised to secure their shoulder harnesses prior to takeoff, and their aft loaded baggage was unsecured because of the previous removal of the tie down straps. The pilot did not provide the Safety Board with evidence of his recent flying currency or complete the required report form. The passengers chartered the flight in response to the operator's yellow page advertisement for such availability. The operator did not possess a 14 CFR 135 certificate, and the FAA's surveillance of the FBO was nil.

Factual narrative

History of flight

On August 17, 1997, at 1744 hours Pacific daylight time, a Piper PA-34-200T, N6654A, operated by the Aero Club, Van Nuys, California, experienced a partial loss of engine power during takeoff from runway 17 at the uncontrolled Kern Valley Airport, Kernville, California. Witnesses reported observing black smoke trailing from the airplane during its initial climb. The pilot reported that the airplane failed to climb or adequately increase airspeed, so he elected to ditch into Isabella Lake, about 1.25 miles south of the airport. The airplane sank in about 20-foot-deep water and was destroyed. The airline transport pilot and three passengers sustained minor injuries. The fourth passenger was seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the flight.

The pilot reported to the Safety Board that on Friday, August 15, he flew the passengers from Van Nuys to Kernville. By prior arrangement, he was to pick up the passengers 2 days later and fly them back to Van Nuys. On August 17, the pilot flew the airplane in solo flight from Van Nuys back to Kernville. The flight lasted about 0.9 hours and was flown at 180 miles per hour (mph) at a cruise altitude of 8,500 feet mean sea level (msl). The pilot reported that he landed at Kernville about 1730.

The passengers were all waiting for the pilot at the airport for their return flight home. The passengers boarded the airplane, and according to the pilot, no instructions were given on how to fasten their seat belts because the "passengers had previously been briefed on seat belt operation . . . ."

The pilot further stated that "after a couple of attempts a hot (engine) start was performed," which was followed by running up the engines "to verify that all were in operating condition." The pilot verbally reported that although he did run-up both engines to 2,000 rpm and tested their magneto rpm drop, which was each between 50 and 100 rpm, he did not cycle the propellers.

The pilot reported he then taxied to the approach end of the runway and tookoff with both mixture controls in the full rich position.

According to the pilot, during the takeoff roll the airplane's acceleration appeared normal, and he rotated at 100 mph. The airplane further accelerated to 120 mph while climbing 100 feet. Then, the engines sounded as though they had reduced their power to half.

The pilot reported that he responded to the situation by retracting the landing gear, and attempting to restore engine power. He verified that both fuel valves were on, the mixture, propeller, and throttle controls were full forward, the auxiliary fuel pump switches were off, and the magneto switches were on. The fuel pressure gauges for both engines indicated "0" pounds of fuel pressure.

The pilot further reported he then moved the left engine's auxiliary fuel pump switch to the "on" and "off" position two times, and the engine developed (more) power. The left engine's fuel pressure gauge then "registered full fuel pressure."

The pilot attempted the same procedure with the right engine, but as soon as he turned the auxiliary fuel pump switch "on" the engine made a distinct sputtering sound, so he switched the pump off.

The pilot maneuvered around a hill, and the airplane continued descending and losing airspeed. The pilot verbally reported that throughout the flight both engines continued operating, and the propellers rotated between 2,400 and 2,450 rpm. The pilot indicated that he elected to ditch in the water rather than to lose control of the airplane.

Injuries to persons

The left rear seat passenger was the only seriously injured occupant. This passenger was located in front of the aft baggage compartment. The other five occupants received minor injuries.

Personnel information

By letter dated August 27, 1997, the Safety Board requested that the pilot complete the required Aircraft Accident Report Form, No. 6120.1/2, and submit for inspection his personal flight records. On October 20, 1997, through the pilot's counsel, a flight record logbook was submitted.

An examination of the logbook revealed the pilot's flying activities between 1989 and August 1992. No more recent flights were noted. The pilot's counsel indicated that the pilot would search for additional evidence of more recent flight activity, and he would provide the evidence when located.

As of July, 1998, neither additional documentation nor the 6120.1/2 form have been received by the Safety Board. Accordingly, the pilot's recent flying experience and currency pertinent to the accident flight could not be established.

Aircraft information

Fuel Pump Switch Design.

The pilot verbally reported that the airplane's auxiliary fuel pump rocker type switches had only two positions. The switches could be set to either the "on" or the "off" position.

The Safety Board's examination of the accident airplane's fuel pump's switches revealed that they were designed with three positions, as follows: "low," "high," and "off." Positioning the switches into the "high" position first required moving a guard cover away from the switches.

Aft Baggage Compartment Tie Down Straps.

During an August 18, 1997, interview with the right front seated passenger, he reported that no one secured the two bags which he observed placed into the aft baggage compartment just behind the rear seats.

According to the airplane's flight manual, the aft baggage compartment was equipped with tie down straps. An examination of the airplane revealed the presence of four bolt-sized holes beneath the carpeted baggage compartment floor. No tie down straps were located. The Piper participant reported that the "bolt holes" appeared to be located where bolts/tie down straps had once been installed. No other device was observed in the baggage compartment area for securing the passenger's luggage.

Weight and Balance Computation.

The pilot reported that he did not compute the airplane's weight and balance prior to taking off from Kernville. He simply performed a visual estimate for the weights of the passengers and their baggage. The pilot stated that he has never used the Airplane Flight Manual which he believed was carried in the airplane.

Weight and Balance Computation.

The Federal Aviation Administration (FAA) certificated maximum gross weight for the airplane is 4,570 pounds. The aft center of gravity (CG) limit at that weight is 94.6 inches.

Based upon weight and balance data provided by The New Piper Aircraft, Inc., the weights of the occupants and their baggage, and the estimated fuel onboard, the Safety Board calculated that upon departure the airplane's gross weight was not less than approximately 4,730 pounds, and its CG was about 95.69 inches aft of datum.

History of Black Smoke.

The Safety Board interviewed the two pilots who had flown together in the airplane immediately prior to the accident pilot's flights. They reported that between approximately July 17 and August 10, 1997, they had taken off from the Van Nuys Airport. During departure, control tower personnel alerted them that black colored smoke was observed trailing from the airplane. The pilots leaned the mixture control(s) and made a low pass by the tower. No further evidence of smoke was reported, and they continued their flight without mishap.

On August 15, 1997, as the accident pilot was departing from Kernville, two of the passengers which had just exited the airplane observed black smoke trailing from the airplane. On August 17, when the accident pilot returned to Kernville to transport the passengers for the return (accident) flight to Van Nuys, one of the passengers informed the pilot of his earlier observations. The passenger reported to the Safety Board that the pilot had similarly observed the black smoke during his previous departure.

On

Aircraft

Registration
N6654A
Reported as
Piper PA-34-200T
Category
Airplane
Serial number
34-7670138
Airframe hours
6,551
Engine
Continental TSIO-360-E, 200 horsepower, reciprocating
Damage
Destroyed
Flight
Other work use · Part 91
Operator
Aero Club
Registered owner
Jet Set Aircraft
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 2, 1997 · 80 hours before
Departed
L05
Destination
VNY · Van Nuys, CA
Airport
LO5 · Kern Valley, runway 17, 3,500 × 50 ft

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
49
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine sea, Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Invalid Medical for flight
Seat
Left
Flight hours
2,100 total · 1,950 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 5 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
86 °F
Altimeter
30.00 inHg

FAA reports on this event · 1

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