LAX97FA330

NTSB accident investigation · Ryan Navion B · Pacoima, CA · September 26, 1997

Accident · FatalField investigationFinal report
Date
September 25, 1997, 18:17 local (Sep 26, 1997, 01:17 UTC)
Place
Pacoima, CA
Injuries
2 fatal, 1 serious
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N5241KRyan Navion B
Weather
Visual (VMC) · Day
Status
Completed · report May 4, 1998
Report
Approved by Office Director
FAA report
19970926029019A
Case key
29634

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 dual student's improper positioning of the fuel selector and the CFI's inadequate supervision, which led to a takeoff with the auxiliary fuel tank selected and resulted in fuel starvation. A contributing factor was the position of the nomenclature on the cockpit fuel tank selector.

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(total) - nonmechanicalTakeoff - initial climb
Fluid,fuel - starvationCause
Fuel tank selector position - improperDual studentCause
Visual/aural perceptionDual studentFactor
Supervision - inadequatePilot in command(cfi)Cause
Forced landingEmergency landing after takeoff
In flight collision with terrain/waterEmergency landing after takeoff
Terrain condition - residential areaFactor

Analysis

The aircraft experienced a loss of engine power in the takeoff initial climb followed by a steep descent into two single-family residences located approximately 1/2 mile from the end of the departure runway. Evidence at the accident site, and interviews with the aircraft's mechanic and the student pilot's flight instructor, indicated that the auxiliary fuel tank may have been supplying the engine during the takeoff and initial climb. Because the 'OFF' nomenclature on the cockpit fuel tank selector was located on the aft side of the selector housing in this aircraft, it would be easy to infer that the long end of the selector handle should be pointed toward the desired fuel tank selection (which is incorrect), particularly if the small arrow head on the opposite end of the handle has been partially obliterated with age as was the case with this aircraft.

Factual narrative

History of flight

On September 25, 1997, at 1817 hours Pacific daylight time, a Ryan Navion-B N5241K, collided with two houses in Pacoima, California, approximately 1/2 statute mile from the end of the runway following a loss of power in the takeoff initial climb. The flight departed the Whiteman Airport on a local instructional flight and no flight plan was filed. The aircraft was destroyed in the collision sequence and postimpact fire. The flight instructor sustained serious injuries, and a student pilot and one passenger received fatal injuries. Two residential dwellings were substantially damaged by impact and fire as a result of the accident. There were no injuries to ground personnel. Visual meteorological conditions prevailed for the personal flight. Witnesses stated that they heard the engine stop running then saw the airplane make an abrupt turn to the right, nose down, and descend at a steep angle to the ground.

Personnel information

The private pilot's partially destroyed logbook was recovered and it documented a total flight time of 252 hours with 10 hours in the last 90 days, of which 8 hours were in the Navion airplane. Of the 8 hours of Navion time, 5 hours were dual under the supervision of a flight instructor.

The flight instructor stated in his report that his total flight time was 2,000 hours, of which 12 hours were in the Navion airplane.

Aircraft information

The aircraft A&P/IA stated that he had performed an annual inspection on the airplane on September 11, 1997, and at that time it had a total flight time of 3,245 hours with no outstanding airworthiness directives.

Inspection of Navion Aircraft Specification No. A782 (attached to this report) indicated that this aircraft was equipped with two main fuel tanks with a useable capacity of 39.5 gallons, plus a 20 gallon auxiliary tank. This specification also contains a statement that the auxiliary fuel tank is not to be used for takeoff or landing. A sketch of the cockpit fuel tank selector used in this aircraft is included in this report.

Wreckage and impact information

The airplane collided with two, single-family residential dwellings that were separated by a breezeway approximately 10 feet in width. The airplane engine, left wing, and fuselage were found imbedded in the rear portion of one house and the right wing in the other house. Both houses had impact holes in the roof and extensive fire damage. The fire consumed the airplane structure to the extent that the continuity of the flight control and fuel systems could not be established, however, the cockpit fuel tank selector was located and found to be in an intermediate position.

The engine and attached propeller were buried in a pile of debris from both the airplane and the house, and were extensively burned. Two of the engine cylinders melted, as did the magnetos and ignition harness; however, external impact damage to the main engine structure was minimal.

Meteorological information

At the time of departure, the weather was reported as thin broken clouds at 6,000 feet agl, broken clouds at 15,000 feet agl, and 30 statute miles visibility. The temperature and dew point were 79 and 66 degrees Fahrenheit, respectively, and the wind was from 290 degrees at 8 knots. Daylight, visual meteorological conditions prevailed, and the altimeter setting was 29.73 inHg.

Medical and pathological information

The Los Angeles County Coroner's toxicological report indicated no evidence of alcohol, controlled substances, prescription drugs, or carbon monoxide in the samples available from the student pilot.

Additional information

On September 30, 1997, the aircraft engine was disassembled and inspected with no evidence of incorrect assembly, excessively worn parts, or internal failure. It was not possible to determine the state of the ignition or fuel systems due to fire damage.

The A&P/IA who performed the most recent inspection of the aircraft stated that the aircraft owner had recently purchased the aircraft and was confused about how the fuel tank selector operated. He also stated that he had attempted to explain how to operate the system to the new owner, but he was not sure his instructions were completely understood.

During postaccident interviews, the A&P/IA and the instructor pilot on the flight gave conflicting information as to how to use the cockpit fuel selector. The A&P/IA stated that the long (handle end) of the selector should be pointed toward the desired fuel tank selection, while the instructor pilot said that the little arrow head on the short end of the selector lever should be pointed toward the desired selection. (The Navion B pilot's handbook indicates that the little arrow should be pointed toward the desired selection.) See the attached sketch.

The instructor pilot also stated during his interview that, although the aircraft had been fueled prior to takeoff, the auxiliary tank was not serviced at that time and he did not know how much fuel may have been in that tank. (The auxiliary fuel is gravity fed to the main fuel system so there is no cockpit quantity indicator.)

Aircraft

Registration
N5241K
Reported as
Ryan Navion B
Category
Airplane
Serial number
NAV-4-2141B
Airframe hours
3,245
Engine
Lycoming GO-435-C2, 260 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Michael D. Boolen
Registered owner
Gordon & Harry Hechter
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 11, 1997 · 12 hours before
Departed
WHP · CA
Airport
WHP · Whiteman, runway 30, 4,120 × 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
44
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
2,000 total · 12 in this make and model · 1,930 as pilot in command · 75 in the last 90 days · 25 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 8 knots
Visibility
30 statute miles
Lowest ceiling
15,000 ft broken
Temperature
79 °F, dew point 66 °F
Altimeter
29.00 inHg
Observed at
WHP, 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.