# NTSB SEA04FA031: Piper PA-44-180, N53505, Cave Junction, OR, January 2, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 1, 2004, 18:35 local (Jan 2, 2004, 02:35 UTC) - Place: Cave Junction, OR - Coordinates: 42.094165, -123.68222 - Nearby events: https://openairdocs.org/map.md?lat=42.0942&lon=-123.6822&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 3 serious - Status: Completed, report October 28, 2004 - Report: Approved by Office Director - Parties: The New Piper Aircraft, Inc., FAA FSDO, Textron Lycoming - NTSB case key (mKey): 58564 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA04FA031 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58564/pdf - Page: https://openairdocs.org/ntsb/SEA04FA031 ## Probable cause Both the pilot-in-command and the co-pilot allowing the aircraft to enter into an area of adverse weather (icing conditions at low [-20 degrees C] temperatures) resulting in sequential induction icing, induction filter blockage, carburetor icing and the subsequent partial loss of power in both engines followed by tree impact and collision with terrain during an emergency descent/approach. Contributing factors were icing conditions, low temperatures, night conditions and trees. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - weather condition - icing conditions (contributing factor) - flight into known adverse weather - inadvertent, pilot in command (cause) - flight into known adverse weather - inadvertent, copilot/second pilot (cause) - weather condition - temperature,low (contributing factor) - light condition - night (contributing factor) - Loss of engine power(partial) - nonmechanical, cruise - all engines - ram/induction air - ice (cause) - carburetor heat - activated, pilot in command - induction air control,air filter/screen - blocked(partial) (cause) - fuel system,carburetor - ice (cause) - Forced landing, descent - emergency - In flight collision with object, approach - object - tree(s) (contributing factor) - Loss of control - in flight, descent - uncontrolled - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The two commercially certificated flying pilots, accompanied by an airline transport rated pilot and a second passenger, departed Oakland, California, en route to North Bend, Oregon. A weather briefing had been obtained indicating an AIRMET for rime icing from the freezing level to 18,000 feet. The aircraft departed late in the afternoon, climbed to 12,000 feet and occasionally climbed to 13,000 feet for short durations in order to remain VMC above a cloud layer. Night environmental conditions existed when both engines began losing power and the copilot radioed Seattle Center that the aircraft had encountered "way too much induction ice to the engines," declaring an emergency. The pilot-in-command reported the outside air temperature at the power loss was about -20 degrees Celsius and he immediately applied full carburetor heat and began trouble shooting the problem while descending back toward a nearby airport. Application of carburetor heat bypassed the ice blocked induction air filters allowing unfiltered, warmed air to flow directly to the carburetors. Remedial action by the crew failed to regain full power and the aircraft broke out of the cloud bases in heavy snow too far down the runway to effect a landing. The pilot then began a turn to line up and land on the adjacent highway just east of the runway during which the aircraft's right wing struck several trees and the aircraft impacted near the west edge of the highway a short distance beyond. ## Factual narrative HISTORY OF FLIGHT On January 1, 2004, at 1832 Pacific standard time, a Piper PA-44-180, N53505, registered to a limited liability corporation, being operated by Auburn Flight Service, Inc., and being flown by two commercial pilots, accompanied by an airline transport rated passenger and a non-rated passenger, sustained substantial damage during an in-flight collision with trees/terrain while attempting an emergency landing at the Illinois Valley airport, Cave Junction, Oregon (3S4) following a partial loss of power in both engines while in cruise. The left seat pilot and both passengers suffered serious injuries and the right seat pilot was fatally injured. Instrument meteorological conditions existed at the accident site and an IFR flight plan had been filed and activated. The aircraft departed Oakland International airport, Oakland, California, at 1612 on the afternoon of the accident and was destined for North Bend, Oregon. The flight, which was personal, was operated under 14 CFR 91. At 1539:48 the pilot who would occupy the right seat of the aircraft on the return flight from Oakland called Oakland Flight Service via telephone and filed a flight plan from Oakland to North Bend requesting a standard weather briefing for the route of flight. He was advised of the en route weather including "...widespread moderate to heavy rain across the routes, air mass is moist and cool, AIRMETS [Airman's Meteorological information] for icing above uh freezing level to eighteen thousand...." At 1601:56 the right seat pilot obtained the IFR clearance to North Bend and at 1609:06 he declared the aircraft was ready for taxi. The aircraft was cleared to taxi to runway 27 right and at 1611:26 the flight was cleared for takeoff. At 1613:09 the right seat pilot contacted Northern California TRACON [Terminal Radar Approach Control] and the aircraft was ultimately cleared direct Point Reyes and to 6,000 feet. At 1619:05 the right seat pilot contacted Oakland ARTCC [Air Route Traffic Control Center] and the aircraft was cleared to an amended altitude of 8,000 feet and subsequently cleared direct Mendocino. At 1635:01 the right seat pilot requested a climb to 10,000, which was approved, and shortly thereafter a request for direct North Bend along with a climb to 12,000 was made and approved. Between 1701:25 and 1709:27 the right seat pilot communicated with Oakland Flight Watch providing a pilot report and requesting the weather for North Bend, which was provided. At 1714:52 the right seat pilot requested and the aircraft was approved for a climb to13,000 feet. He subsequently requested and received clearance for a descent back to 12,000. At 1737:21 the right seat pilot contacted Seattle ARTCC and then requested a climb to 13,000 feet, which was approved. And, at 1754:19 he requested a descent back to 12,000, which was approved. At 1812:31 the right seat pilot contacted Seattle Flight Watch reporting "...we're about uh forty five minutes away from landing at Newport, like to get current weather at Newport but then we're going to be uh trying to make our way to Seattle uh so kind of like to get uh uh standard briefing on maybe the best route to get us up there to avoid some of this weather...." The Flight Watch Specialist provided weather information and specifically address AIRMETS for "...occasional moderate rime or mixed icing in clouds...." During the course of this communication the right seat pilot indicated the aircraft was about 20 nautical miles due east of Crescent City, California, at 12,000 feet and the outside air temperature was -18 degrees Celsius. At 1823:56 the right seat pilot advised, "...we need a descent ah right now and we need ah vectors for obstacle clearance..." and the aircraft was cleared to descend to 7,300 feet. Radar data showed the aircraft descending through 11,700 feet at this time. At 1824:28 the right seat pilot declared an emergency and requested "...vectors to an airport immediately..." indicating that they had engine problems. The Illinois Valley airport was identified as being at the flight's four o'clock position and radar data showed the aircraft beginning a right turn toward the airport. At 1826:36 the right seat pilot radioed "...I think that the problem we're having is ah induction ice, we've got way too much induction ice to the engines so we've got partial power ah um yeah we're descending at ah we're unable to maintain altitude..." and radar data showed the aircraft descending between 8,800 and 8,600 feet. At 1827:54 the last radar target from the aircraft was received showing the aircraft descending through 7,000 feet (refer to Attachment RD-I and Chart I) and immediately thereafter Seattle ARTCC advised the aircraft they were attempting to get the (Illinois Valley) airport lights on. The last radio transmission received from the flight was at 1829:29 indicating 4,800 feet altitude (refer to Attachments RT-1 through RT-11 and statements ATC-1). The only known witness to the accident, a pilot who was a resident living at the Illinois Valley airport reported that he was inside his residence when he heard the aircraft and described it as a "low power setting." He went outdoors and observed the aircraft proceeding south. He indicated that he thought the aircraft was going to land long and that it banked and then disappeared over trees and he then heard an impact. He also reported that the runway lights were on (refer to Statements JCSO-1 and FSDO-1). The left seat (flying) pilot reported that his first indication of a problem was a manifold pressure and airspeed bleed off. He applied (full ON) carburetor heat, checked the mixtures rich, turned the auxiliary fuel pumps on, tried cross-feeding the engines, and opened the cowl flaps. He indicated that during the descent, cycling of the throttles changed the amount of power and he never completely lost power in either of the engines (refer to Statements PS-1 and PI-1). PERSONNEL INFORMATION Left Seat Pilot: The left seat pilot held a commercial pilot certificate with airplane single/multi-engine and instrument ratings. He also held a current flight instructor's certificate for airplane single/multi-engine and instrument training. His most recent medical examination was conducted on October 9, 2003, and he was issued a first class medical with no restrictions/waivers. According to records provided by the Federal Aviation Administration (FAA) and the Operator, he reported an approximate total 390 hours of flight experience of which 285 hours were as pilot-in-command. He also reported a total of 52 hours in the PA-44 of which 21 hours were as pilot-in-command. Right Seat Pilot: The right seat pilot held a commercial pilot certificate with airplane single/multi-engine and instrument ratings. His most recent medical examination was conducted on June 18, 2003, and he was issued a first class medical with the restrictions that he "must wear lenses for distant - possess glasses for near vision." According to records provided by the FAA and the Operator, he reported an approximate total 440 hours of flight experience of which 283 hours were as pilot-in-command. He also reported a total of 55 hours in the PA-44. Passenger rated pilot: The passenger rated pilot, who occupied the right rear seat, held an airline transport pilot certificate with instrument ratings and airplane multi-engine ratings. She also held commercial privileges in airplane single-engine land. Additionally, she held a current flight instructor's certificate for airplane single/multi-engine and instrument training as well as an advanced ground instructor's certificate. Her most recent medical examination was conducted on October 10, 2003, and she was issued a first class medical with no restrictions/waivers. According to records provided by the FAA and the Operator, she reported an approximate total 2,681 h ## Aircraft - Registration: [N53505](https://openairdocs.org/deregistered/N53505-2004-05-24), registration cancelled 2004-05-24, S/N 4496126, built 2002 (OpenAirDocs) - Reported make and model: Piper PA-44-180 - Registry model: [Piper PA-44-180](https://openairdocs.org/model/piper-pa-44-180) (registry code 7104402) (OpenAirDocs) - Registry engine: [Lycoming O-360 series](https://openairdocs.org/engine/lycoming-o-360-series) (registry code 41575, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 44-96126 - Airframe hours: 1296.8 - Engines: Lycoming LO-360-A1H6 180 horsepower reciprocating; Lycoming O-360-A1H6 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Auburn Flight Service, Inc. - Registered owner: Piper Project II, LLC. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, December 18, 2003, 50.1 hours before - Departed: OAK, Oakland, CA - Destination: OTH, North Bend, OR - Flight plan: IFR - Airport: 3S4, Illinois Valley, runway 36, 5,200 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 23; injuries: serious; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review September 27, 2003; seat: left; flight hours: 390 total, 52 in this make and model, 285 as pilot in command - Co-pilot; age 27; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review October 1, 2002; seat: right; flight hours: 440 total, 55 in this make and model, 283 as pilot in command - Co-pilot; age 27; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review October 1, 2002; seat: right; toxicology performed; flight hours: 440 total, 55 in this make and model, 283 as pilot in command ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 280° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 3,400 ft broken - Temperature: 43 °F, dew point 37 °F - Altimeter: 29.90 inHg - Observed at: CEC, 31 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 20040101000819A](https://openairdocs.org/incident/20040101000819A), Jan 1, 2004: Piper PA44180, Cave Junction, OR, Destroyed, 1 fatal. (-23) The aircraft was on a flight from oakland CA to north bend or. The aircraft was in level flight in clear air at 12,0000 feet when both engines quit. The… 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.