# NTSB LAX99FA261: Porterfield CP-65, N32409, Johnson Valley, CA, August 2, 1999 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 2, 1999, 13:32 local (20:32 UTC) - Place: Johnson Valley, CA - Coordinates: 34.329914, -116.510459 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.3299&lon=-116.5105&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report May 9, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 47044 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX99FA261 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/47044/pdf - Page: https://openairdocs.org/ntsb/LAX99FA261 ## Probable cause The failure of the pilot to maintain adequate airspeed while attempting to make a precautionary landing, which resulted in a stall/spin and collision with the terrain. A factor in his failure to maintain an adequate airspeed is the pilot's likely diverted attention to the oil loss problem and pending engine failure. An additional factor is the pilot/mechanic's improper installation of an unapproved oil hose, which ruptured under pressure. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, emergency landing after takeoff - lubricating system,oil hose - unapproved part (contributing factor) - maintenance,installation - improper, owner/pilot mechanic (contributing factor) - lubricating system,oil hose - ruptured (contributing factor) - fluid,oil - leak (contributing factor) - airspeed(vs) - not maintained, pilot in command (cause) - diverted attention, pilot in command (contributing factor) - stall/spin - encountered, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled ## Analysis The airstrip manager arrived at the airstrip and found the aircraft parked on the ramp. The pilot informed him that he had noticed a drop in oil pressure during his flight and had landed and 'fixed the problem.' The pilot asked for oil and the airport manager gave him 6 quarts of automotive oil. The manager saw the pilot pour 3 quarts of oil into the oil tank and put the additional 3 quarts of oil in the back of the aircraft cockpit. He hand-propped the aircraft and the engine fired immediately with no apparent difficulties. After the pilot took off, the manager noticed dark smoke coming from the exhaust. The airplane completed a crosswind and downwind traffic pattern leg, and appeared to be headed back toward the airport. The airstrip manager stated that as the airplane turned from base to final about 300 feet agl, it stalled, entered a 180-degree spin, and impacted the ground in a near vertical, nose down attitude. There were streaks of oil underneath the engine outward to the left wing and wheel pants, and the bottom of the fuselage was covered in oil. The oil line that provides the reading for the oil pressure gauge was found to be split approximately 180 degrees in circumference at the hose fitting, and was split in two other locations. The hose was a soft, pliable rubber material, and testing revealed that it was pressure-rated at 10 psi. Oil is pumped through the line about 40 to 45 psi during normal operations. The oil pressure hose fitting on the engine was not equipped with a restricted orifice to prevent the escape of fluid in case of line failure as required by regulation. ## Factual narrative HISTORY OF FLIGHT On August 2, 1999, approximately 1332 hours Pacific daylight time, a Porterfield CP-65, N32409, collided with terrain while on approach to runway 09 at the private Valley Vista airstrip, Johnson Valley, California. The airplane, owned and operated by the pilot, was destroyed. The private pilot was fatally injured. The personal cross-country flight was conducted under the provisions of 14 CFR Part 91 and originated at the Tehachapi, California, airport, at an unknown time, and was en route to Brownwood, Texas. Visual meteorological conditions prevailed and no flight plan was filed, nor were any air traffic control (ATC) services provided. The manager of the Valley Vista airstrip, who resided on the field, returned from an errand and found the accident airplane parked on the ramp. The pilot informed him that while en route from Tehachapi he had noticed a drop in oil pressure during his flight and had landed and "fixed the problem." The pilot did not specify how he fixed the problem, but stated that he was "ready to go," and planned to stop at the Twentynine Palms airport (approximately 35 miles away) for "more gas and oil." The pilot asked the airstrip manager for oil, and was given 6 quarts of 10W30 automotive oil. The manager observed the pilot pour 3 quarts of oil into the oil tank (according to Teledyne Continental the engine's nominal capacity is 4 quarts) and put the additional 3 quarts of oil in the back of the aircraft cabin. The airstrip manager reported that he hand-propped the engine for the pilot and the engine started immediately with no apparent difficulties. He heard the pilot perform a run-up and did not notice any unusual sounds or smoke emanating from the engine. The manager reported that after the pilot took off from runway 09, he noticed dark smoke coming from the exhaust and observed that the aircraft appeared to have trouble climbing. The airplane completed a crosswind and downwind traffic pattern leg and appeared to be headed back toward the airport. The manager stated that as the aircraft turned from base to final about 300 feet agl, it stalled, entered a 180-degree spin, then impacted the ground in a near vertical, nose down attitude. The aircraft was then blown over by the wind and came to rest inverted. The airstrip manager contacted emergency services and drove over to the accident site. He stated that there was no smoke or fire. The airstrip manager reported that there were no fuel or maintenance services available at the airstrip. The Safety Board investigator estimated the density altitude to be approximately 6,200 feet at the time of the accident, based on a reported temperature of 93 degrees Fahrenheit, and a field elevation of 3,370 feet msl. PERSONNEL INFORMATION Certified copies of the pilot's airman and medical certification records were obtained from the Federal Aviation Administration (FAA. According to the files, the pilot held a private pilot certificate with a single engine land rating. The original date of issuance of the certificate was listed as November 27, 1965. He also held an airframe and powerplant certificate, and an inspection authorization. He received his airframe and powerplant certificate in 1960. The records reflected that his inspection authorization was last renewed on March 4, 1999. The FAA aeromedical certification files revealed that the pilot held a third-class medical issued June 24, 1998, with the limitation that the pilot must have glasses available for near vision. The pilot's medical records from the FAA Civil Aeromedical Institute (CAMI) were reviewed and are appended to this file. The pilot had been denied an FAA airman medical certificate in 1991 due to a "history of depression requiring the use of disqualifying medication." Later in 1991, the pilot was again denied a medical certificate for the same reason. The pilot applied for a medical certificate in 1992, checking the block marked "Yes" under medical history next to "Mental disorders of any sort: depression, anxiety, etc." The instructions for filling out that section of the application indicate to "Answer 'Yes' for every condition you have ever had in your life." He listed his only current medication as one for glaucoma. He was issued a third-class medical with an accompanying letter, which stated that "operation of aircraft is prohibited at any time new symptoms or adverse changes occur or any time medication is required for depression." In 1994, when the pilot reapplied for a medical certificate, he checked the block marked "No" under medical history next to "mental disorders of any sort: depression, anxiety, etc." The only medication listed was "Contac - occasional use only - do not fly when using this." The FAA issued the pilot a medical certificate, but cautioned that "because of your history of glaucoma, operation of aircraft is prohibited at any time new symptoms or adverse changes occur or if you experience side effects or require a change in medication." There was no mention of depression in this letter. In the pilot's 1996 application for medical certificate renewal, he indicated "Yes" next to "mental disorders of any sort: depression, anxiety, etc." and noted that he was "treated several years ago - occasionally used Paxil in past." Medications were listed as "Paxil occasionally" and "Anacin occasionally." After requesting further information regarding the pilot's treatment for depression, the FAA issued him a medical certificate. When the pilot applied for and was issued a third-class medical certificate in 1998, he checked the block marked "No" under medical history next to "Mental disorders of any sort: depression, anxiety, etc." The only medications listed were Anacin and Aleve. The pilot's personal flight records were not located. His application for the 1998 medical certificate listed his total flight time as 1,360 hours. According to the pilot's son, the pilot had accumulated approximately 800 hours in the accident aircraft. AIRCRAFT INFORMATION The airframe and engine maintenance records were reviewed. The last recorded inspection was an annual inspection completed on November 1, 1998. The records indicated that at the time of the annual inspection, the total airframe time was 2,807 hours, and the tachometer time was 925 hours. At that time, the engine had a total time of 2,125 hours, with 1,002 hours since major overhaul. The only entry recorded in the maintenance logbooks after the annual inspection was for the overhaul and reinstallation of the airspeed indicator on April 29, 1999. The tachometer time at the time of the accident was 980. The pilot's son reported that his father performed most of the maintenance to the accident airplane. WRECKAGE AND IMPACT An on-site examination of the wreckage was conducted. The airplane was found inverted, 203 yards from the approach end of runway 09, in an area of flat desert terrain, surrounded by low scrub bushes approximately 3 to 7 feet high. Mountains bordered the airstrip to the south. The nose of the airplane was facing the runway. The magnetic bearing from the nose of the airplane to the runway was 117 degrees. The left and right wingtips, nose, and tail had impacted bushes directly underneath these components; however, none of the surrounding bushes displayed any limb breakage or disturbance. All components were located in the immediate vicinity of the aircraft. There was no visible ground scarring or terrain disturbance around the aircraft. There was no evidence of postcrash fire. The nose of the aircraft was deformed and crushed aft. One of the wooden propeller blades was splintered and was missing approximately 15 inches of the blade, as measured from the spinner to the blade tip. The blade tip and splintered fragments of the blade were located in a bush adjacent to the center section of the aircraft. Both propeller blades dis ## Aircraft - Registration: [N32409](https://openairdocs.org/deregistered/N32409-2012-10-02), registration cancelled 2012-10-02, S/N 839, built 1940 (OpenAirDocs) - Reported make and model: Porterfield CP-65 - Registry model: [Porterfield CP-65](https://openairdocs.org/model/porterfield-cp-65) (registry code 6480118) (OpenAirDocs) - Registry engine: [Continental A&C65 series](https://openairdocs.org/engine/continental-a-c65-series) (registry code 17003, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 839 - Airframe hours: 2807 - Engines: Continental A65-8F 65 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Larry Trager - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 1, 1998, 55 hours before - Departed: 6CA5 - Destination: TNP, TWENTY NINE PAL, CA - Airport: 6CA5, Johnson Valley, runway 9, 2,800 × 40 ft, dirt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: front; toxicology performed; flight hours: 1,360 total, 800 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 110° at 5 knots - Visibility: 7 statute miles - Temperature: 91 °F, dew point 46 °F - Altimeter: 30.00 inHg - Observed at: NXP, 21 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 19990802010609A](https://openairdocs.org/incident/19990802010609A), Aug 2, 1999: Norwst CP65PORTFLD, Yucca Valley, CA, Destroyed, 1 fatal. Acft crashed on take-off under unknown circumstances and was destroyed, the pilot/sole occupant suffered fatal injuries. (.19) on August 2, 1999, approximately… 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.