SEA04FA133

NTSB accident investigation · Piper PA-23-160 · Ontario, OR · July 15, 2004

Accident · FatalField investigationFinal report
Date
July 15, 2004, 08:19 local (14:19 UTC)
Place
Ontario, OR
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N4439PPiper PA-23-160
Weather
Visual (VMC) · Day
Status
Completed · report June 8, 2005
Report
Approved by Office Director
Parties
Lycoming, Boise FSDO, The New Piper Aircraft, Inc
FAA report
20040715014079A
Case key
59686

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 pilot's failure to maintain airspeed resulting in an aerodynamic stall while maneuvering for an approach to land.

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 control - in flightManeuvering
Airspeed - not maintainedPilot in command(cfi)Cause
Stall - inadvertent
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The FAR Part 91 instructional flight was the second pilot's third flight in two days in the multi-engine airplane. The second pilot had recently purchased the airplane to pursue a multi-engine rating. Witnesses reported that they observed the airplane traveling toward the airport from the southeast in a level flight attitude. A witness stated the airplane was traveling slowly "as if on a landing procedure." The witness stated that shortly thereafter the airplane appeared to "auger" toward the ground in a left wing low attitude. The witness reported that the airplane made approximately three revolutions before impacting the terrain in a nose low attitude. During the post crash examination of the airframe, it was noted that the emergency hydraulic pump handle was observed in the full aft (extended) position. The accident site was located approximately two miles from the destination airport. Examination of the airframe and both engines revealed no evidence of a pre crash failure or anomaly.

Factual narrative

History of flight

On July 15, 2004, about 0819 mountain daylight time, a Piper PA-23-160, (Apache) N4439P, was destroyed when it collided with terrain approximately two miles from the Ontario Municipal Airport, Ontario, Oregon. The airplane was owned by the second pilot, and was being operated as a visual flight rules (VFR) instructional flight under the provisions of Title 14, CFR Part 91, when the accident occurred. The first pilot, a certified flight instructor (CFI), and the second pilot, a certified commercial pilot working toward a multi engine rating, were fatally injured. No flight plan had been filed for the flight that originated from Ontario, approximately 1 hour and 20 minutes prior to the accident.

Witnesses reported that they observed the airplane traveling toward the airport from the southeast in a level flight attitude. A witness stated the airplane was traveling slowly "as if on a landing procedure." The witness stated that shortly thereafter the airplane appeared to "auger" toward the ground in a left wing low attitude. The witness reported that the airplane made approximately three revolutions before impacting the terrain in a nose low attitude.

The second pilot had recently purchased the airplane and was utilizing it to complete his multi-engine rating/training. Logbook records indicated this was his third instructional flight in the airplane. All of the instructional flights were completed with the first pilot.

The pilots departed Ontario on the morning of the accident and proceeded to Boise, Idaho, (Gowen Field) to complete practice instrument approaches.

The airplane was returning to Ontario when the accident occurred.

Personnel information

The first pilot held a commercial pilot certificate with airplane single-engine land, multi-engine land and instrument airplane ratings. In addition to the commercial certificate, the pilot held a T33 type rating and a certified flight instructor certificate with ratings for airplane single-engine land, multi-engine land, and instrument airplane.

The first pilot's most recent FAA second-class medical certificate was issued on September 16, 2003, and contained a limitation requiring the pilot to possess glasses for near and intermediate vision.

No personal flight records were located for the first pilot and the aeronautical experience listed in this report was obtained from a review of the FAA medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated that as of a medical examination on September 16, 2003, the pilot had a total flight time of approximately 6,000 hours with 200 hours logged in the six months preceding the medical examination.

The second pilot held a commercial pilot certificate with airplane single-engine land and instrument airplane ratings. The commercial pilot certificate was issued on May 25, 2004.

The second pilot's most recent FAA second-class medical certificate was issued on March 22, 2004, and contained limitations that the pilot shall wear corrective lenses for vision.

Examination of the second pilot's logbook indicated an estimated total flight time of approximately 705 hours. The pilot logged approximately 24 hours in the 30 days preceding the accident. Two flights in the accident airplane, totaling 3.5 hours, were logged on July 14. These were the pilot's only logged flight hours in the accident airplane.

Aircraft information

The accident airplane, a Piper Apache PA-23-160 (serial number 231956) was manufactured in 1956. The four-place light twin was powered by two Textron Lycoming O-320's rated at 160 HP each.

The tachometer for both engines read 3319 at the accident scene.

Maintenance records for the airplane were not located and the information listed in this report was obtained from a review of FAA records and actual observations during the onsite investigation.

Meteorological information

The closest weather observation facility to the accident site is the Ontario Municipal Airport, approximately 2 miles to the southeast. On July 15, 2004, at 0753 MDT, the hourly Aviation Routine Weather Report (METAR) was, in part, wind from 290 degrees (true) at 3 knots; visibility 10 statute miles; sky conditions clear; temperature 18 degrees C; dew point 8 degrees C; altimeter 30.00 inches.

Wreckage and impact information

Personnel from the National Transportation Safety Board, Federal Aviation Administration, Lycoming and Piper accessed the wreckage site on July 15-16, 2004.

The wreckage was located on level terrain near the center of a 16-acre mature onion field at 43 degrees 59 minutes' north latitude, and 117 degrees .096 minutes' west longitude. The wreckage site elevation was approximately 2,190 feet above mean sea level. The wreckage came to rest approximately two miles southeast of the Ontario airport.

The airplane came to rest oriented on a northerly heading, in the upright position. The forward section of the airplane, from mid cabin forward, sustained extensive impact related damage. The aft cabin area and empennage remained attached to the main wreckage. Damage was noted longitudinally along the aft section of the fuselage. Extensive damage was noted to the entire wing assembly.

The cockpit controls and instrument panel sustained extensive impact damage and a majority of the navigation instrumentation was destroyed. The navigation and communication radios, and associated wiring harnesses, were heavily damaged and displaced from the installed positions. The emergency hydraulic pump handle was observed in the full aft (extended) position. The mixture controls, throttles and propeller controls were observed in the full forward position. The right fuel control valve was selected to the right main fuel tank. The left fuel control valve was selected to the left main fuel tank position. The fuel cross feed was in the "off" position and both engine primers were in and locked.

The right wing separated from the fuselage near the wing root. The wing was resting, leading edge down, against the fuselage. Extensive impact related leading edge deformation was noted to the entire span of the wing assembly. The landing gear remained attached to the assembly and was in the down position. The aileron and wing flap were found attached to their respective mounting points on the wing assembly. The right engine mounting system, engine and propeller assembly were attached to the wing and sustained extensive impact related damage. The propeller assembly and forward section of the engine were partially buried in the soft mud, adjacent to the airplane wreckage.

The inboard section of the left wing remained partially attached to the fuselage. The aileron was still attached to the wing section. The outboard section of the wing, from the engine nacelle outboard, had separated from the main wing assembly and was located within the confines of the debris field. The flap assembly separated from the inboard section of wing and was located behind the wing. The landing gear remained attached to the wing section and sustained extensive impact related damage. Extensive aft crushing and leading edge damage was noted to the entire assembly.

Minimal damage was noted to the empennage and associated control surfaces. All fixed and movable control surfaces remained attached in their respective positions and the control cables were present.

All aircraft components were located in the immediate area of the main wreckage.

Medical and pathological information

An autopsy on the first pilot was conducted by the Ada County Coroner's Office on July 16. According to the autopsy report, the first pilot's cause of death was attributed to blunt force trauma. The manner of death was listed as accidental.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma C

Aircraft

Registration
N4439P
Reported as
Piper PA-23-160
Category
Airplane
Serial number
23-1956
Engines
Lycoming O-320 B, 160 horsepower, reciprocatingLycoming O-320 B, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Jack L. Knudsen
Airworthiness certificate
Standard, Normal
Departed
BOI · Boise, ID
Destination
ONO · Ontario, OR
Airport
ONO · Ontario Muni

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
70
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
6,000 total
Role
Student pilot
Age
45
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
May 25, 2004
Seat
Left
Toxicology
Performed
Flight hours
750 total · 4 in this make and model · 680 as pilot in command · 24 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 36 °F
Altimeter
30.00 inHg
Observed at
KONO, 2 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.

Other investigations on N4439P · 1

Matched to the same aircraft by N-number and date.