# NTSB SEA92FA147: Piper PA-24-260, N9323P, Woods Cross, UT, July 9, 1992

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: July 9, 1992, 10:30 local (16:30 UTC)
- Place: Woods Cross, UT
- Coordinates: 40.889476, -111.929069 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=40.8895&lon=-111.9291&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 4 fatal
- Status: Completed, report September 28, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 41585
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA92FA147
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/41585/pdf
- Page: https://openairdocs.org/ntsb/SEA92FA147

## Probable cause

PILOT FACTOR IN THAT HE FAILED TO ATTAIN AND MAINTAIN SUFFICIENT FLYING SPEED. FACTORS TO THE ACCIDENT WERE: CYLINDER OVER TEMPERATURE, IMPROPER USE OF THE MIXTURE AND PROCEDURES/DIRECTIVES WERE NOT FOLLOWED.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of control - in flight, takeoff
  - engine assembly,cylinder - overtemperature (contributing factor)
  - mixture - improper use of, pilot in command (contributing factor)
  - airspeed - not maintained, pilot in command (cause)
  - procedures/directives - not followed, pilot in command (contributing factor)
- In flight collision with terrain/water, descent - uncontrolled
  - terrain condition - ground

## Analysis

DURING THE TAKE OFF GROUND RUN, WITNESSES REPORTED THAT THE ENG SOUNDED NORMAL, HOWEVER, THE AIRPLANE REMAINED ON THE RWY FOR AN UNUSUAL LENGTH OF TIME. WHEN THE AIRPLANE FINALLY LIFTED OFF NEAR THE END OF THE RWY, THE ANGLE OF ATTACK INCREASED ABOVE NORMAL. THE AIRPLANE CONTINUED TO CLIMB IN THIS ATTITUDE, WITH THE WINGS WAGGING UP AND DOWN. THE AIRPLANE ATTAINED AN ALT OF APPROX 100 200 FT WHEN THE RT WING AND NOSE DROPPED TOWARD THE GROUND. THE AIRPLANE COLLIDED WITH THE GROUND APPROX ONE HALF MILE NORTH OF THE ARPT IN A NOSE DOWN, RT WING LOW ATTITUDE. A POST CRASH FIRE IGNITED AND CONSUMED THE AIRPLANE. DURING A POST CRASH ENG TEARDOWN, IT WAS FOUND THAT THE NUMBER SIX CYLINDER COULD NOT HOLD COMPRESSION. FURTHER TEARDOWN REVEALED A SECTION OF THE CYLINDER AROUND THE EXHAUST SEAL WAS MISSING. METALLURGICAL EXAMINATION REVEALED THAT THE DAMAGE MOST LIKELY OCCURRED AS A RESULT OF EXTREMELY LEAN OPERATIONS WHICH LEAD TO DETONATION. THE PLT HAD RECENTLY PURCHASED THE AIRPLANE, WHICH WAS EQUIPPED WITH A TURBO CHARGER, AND WAS TAUGHT TO LEAN THE MIXTURE FOR TAKE OFF. THE OPERATORS MANUAL STATES FOR TAKE OFF TO HAVE THE MIXTURE FULL RICH.

## Aircraft

- Registration: [N9323P](https://openairdocs.org/deregistered/N9323P-1992-09-30), registration cancelled 1992-09-30, S/N 244820 (OpenAirDocs)
- Reported make and model: PIPER PA-24-260
- Registry model: [Piper PA-24-260](https://openairdocs.org/model/piper-pa-24-260) (registry code 7102406) (OpenAirDocs)
- Category: Airplane
- Serial number: 24-4820
- Airframe hours: 2128
- Engines: LYCOMING IO-540-R1A5 260 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Personal, Part 91
- Operator: Helmut Fischer
- Registered owner: Fessele, Elsa
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, April 1, 1992, 17 hours before
- Destination: GCN, GRAND CANYON, AZ
- Flight plan: VFR
- Airport: BTF, Skypark, runway 34, 4,700 × 70 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 43; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: unknown, unknown; seat: left; toxicology performed; flight hours: 400 total, 15 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 300° at 7 knots
- Visibility: 50 statute miles
- Lowest ceiling: none
- Temperature: 75 °F, dew point 48 °F
- Altimeter: 30.00 inHg
- Observed at: SLC, 4 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 19920709024629A](https://openairdocs.org/incident/19920709024629A), Jul 9, 1992: Piper PA24260, Bountiful, UT, Destroyed, 4 fatal. Losing power on climbout stalled and dived to ground. NR6 cylilnder cracked. Valves tulipped. Damage from detonation

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.

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