# NTSB SEA95LA088: Piper PA-28-236, N2101X, Tacoma, WA, April 21, 1995 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 21, 1995, 13:25 local (20:25 UTC) - Place: Tacoma, WA - Coordinates: 47.14912, -122.700469 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.1491&lon=-122.7005&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report January 29, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 42142 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA95LA088 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/42142/pdf - Page: https://openairdocs.org/ntsb/SEA95LA088 ## Probable cause FUEL STARVATION DUE TO AN UNLOCKED MIXTURE CONTROL THAT HAD NOT BEEN PROPERLY RIGGED. A FACTOR WAS THE DITCH IN THE EMERGENCY LANDING AREA. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, takeoff - initial climb - mixture control - unlocked (cause) - maintenance,adjustment - improper, company maintenance personnel (cause) - fluid,fuel - starvation (cause) - Forced landing, emergency landing after takeoff - On ground/water encounter with terrain/water, emergency landing after takeoff - terrain condition - ditch (contributing factor) ## Analysis BOTH PILOTS STATED THAT AT ABOUT 200 FT AGL AFTER TAKEOFF THEY EXPERIENCED A LOSS OF POWER. THE INSTRUCTOR ASSUMED COMMAND OF THE AIRCRAFT, MANIPULATED THE THROTTLE TO CONFIRM THE POWER LOSS, THEN MADE A FORCED LANDING. AFTER THE ACCIDENT THE ENGINE WAS RUN SATISFACTORILY IN A TEST CELL AT THE FACTORY. AN FAA INSPECTOR NOTED THAT THE MIXTURE CONTROL LEVER WAS AFT OF ITS LOCKING MECHANISM, WHILE THE MIXTURE CONTROL ON THE FUEL INJECTION SYSTEM SERVO BODY WAS FULL RICH. THE MIXTURE CONTROL CABLE HAD BEEN REPLACED BY THE OPERATOR. ACCORDING TO THE PILOT OPERATING HANDBOOK FOR THE AIRCRAFT, THE PURPOSE OF THE LOCKING MECHANISM IS TO PREVENT ACTIVATION OF THE MIXTURE CONTROL INSTEAD OF THE PROPELLER PITCH CONTROL. ## Factual narrative On April 21, 1995, approximately 1325 Pacific daylight time, a Piper PA-28-236, N2101X, sustained substantial damage when it collided with terrain during a forced landing after a loss of power after takeoff at Tacoma Narrows Airport, Tacoma, Washington. The flight instructor and his private-rated instrument student were uninjured. Visual meteorological conditions prevailed for the flight, for which an instrument flight plan had been filed. There was no fire and the ELT actuated but did not assist in locating the accident site. The two crewmembers stated that power was lost about 200 feet above the runway just after takeoff. The flight instructor assumed control of the aircraft after a sudden loss of power. He stated that he moved the throttle forward and aft to confirm the loss of power, and set up for an emergency landing slightly west of the runway. The aircraft rolled into a ditch during the emergency landing, where the landing gear separated and the aircraft was substantially damaged. The instrument student noted that the ignition was turned off and the fuel tanks were "closed" after the aircraft stopped moving. The instructor noted that the master switch was also turned off. The engine was removed and shipped to the manufacturer for testing under the oversight of FAA inspectors. After some difficulties attributed to the test cell, the engine was started and run to full power for fifteen minutes, cooled, restarted and run to full power for an additional ten minutes. In the opinion of those conducting the tests, the engine ran successfully on the TCM test cell and was capable of operating at rated power. An FAA inspector who inspected the aircraft after the accident noted that the cockpit mixture control lever was rigged so that it was aft of its locking mechanism when the mixture control arm on the fuel injection servo body was against its maximum enrichment stop. The Pilot Operating Handbook for the aircraft states that the purpose of the lock is "to prevent activation of the mixture control instead of the [propeller] pitch control." The FAA inspector noted that the mixture control cable had been replaced by the operator. ## Aircraft - Registration: [N2101X](https://openairdocs.org/deregistered/N2101X-2011-05-14), registration cancelled 2011-05-14, S/N 28-7921009, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA-28-236 - Registry model: [Piper PA-28-201T](https://openairdocs.org/model/piper-pa-28-201t) (registry code 7102819) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7921009 - Airframe hours: 3800 - Engines: CONTINENTAL TSIO-360FB 200 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Pavco - Registered owner: Elihn B. Skinner - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 8, 1995, 5 hours before - Flight plan: IFR - Airport: TIW, Tacoma Narrows Airport, runway 17, 5,002 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: right; flight hours: 3,750 total, 200 in this make and model, 3,650 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 64 °F ## 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 19950421044649A](https://openairdocs.org/incident/19950421044649A), Apr 21, 1995: Piper PA28236, Tacoma, WA, Substantial damage. Lost power on climbout. Landed off airport and struck a ditch. Bogus mixture control lacked full rich stop. 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.