# NTSB WPR14FA282: Piper PA 28R-180, N3723T, Lake Elsinore, CA, July 6, 2014

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: July 6, 2014, 09:20 local (16:20 UTC)
- Place: Lake Elsinore, CA
- Coordinates: 33.650001, -117.397499
- Nearby events: https://openairdocs.org/map.md?lat=33.6500&lon=-117.3975&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering-low-alt flying: Loss of lift](https://openairdocs.org/ntsb-events/500)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report June 18, 2015
- Report: Approved by Office Director
- NTSB office: Western Pacific Region
- Parties: Piper Aircraft, Lycoming Engines, Federal Aviation Administration
- NTSB case key (mKey): 89609
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14FA282
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89609/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89609
- Page: https://openairdocs.org/ntsb/WPR14FA282

## Probable cause

The pilot's failure to maintain airplane control when the landing gear unintentionally extended while maneuvering at low altitude and airspeed, which increased the airplane’s drag and decreased its ability to climb over the rising terrain.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Landing gear system: gear extension and retract sys](https://openairdocs.org/ntsb-findings/01023230): Aircraft › Aircraft systems · Unintentional use/operation (probable cause); cases with it: [Piper PA-28R-180, 2 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md?model=7102809), [All aircraft, 416 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md)
- [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28R-180, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7102809), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)
- [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28R-180, 5 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7102809), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28R-180, 17 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102809), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28R-180, 2 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=7102809), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md)
- [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28R-180, 4 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=7102809), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Maneuvering-low-alt flying: Abrupt maneuver](https://openairdocs.org/ntsb-events/270); cases with it: [Piper PA-28R-180, 1 case](https://openairdocs.org/ntsb-events/270/sequence.md?model=7102809), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md)
- [Maneuvering-low-alt flying: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-28R-180, 3 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102809), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)
- [Maneuvering-low-alt flying: Loss of lift](https://openairdocs.org/ntsb-events/500) (defining event); cases with it: [Piper PA-28R-180, 2 cases](https://openairdocs.org/ntsb-events/500/sequence.md?model=7102809), [All aircraft, 252 cases](https://openairdocs.org/ntsb-events/500/sequence.md)
- [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-180, 19 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102809), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

A video made by a witness located in a restaurant parking lot near the top of a ridge initially shows the airplane wings level at a low altitude with a steady engine rpm and the landing gear in the retracted position. The airplane then makes about a 45-degree, left turn. The airplane subsequently levels off, flying in the direction toward the ridgeline with the landing gear in the extended position. The airplane continues at a low altitude toward the rising terrain, and then the video ends. Shortly thereafter, witnesses reported seeing smoke in the area where the airplane had disappeared from their sight. The wreckage was found about 0.32 mile southwest of the restaurant parking lot, and the airplane had impacted trees on the rising terrain. Postaccident examination of the airframe and engine revealed no malfunctions or failures that would have precluded normal operation. This airplane was equipped with a back-up landing gear extension system, which incorporates a pressure-sensing device to automatically lower the landing gear at airspeeds between about 85 and 105 mph depending upon the power setting and regardless of the position of the gear handle in the cockpit. The system can be overridden by manually holding the emergency gear lever in the raised position. About 16 years before the accident, the manufacturer issued a mandatory two-part service bulletin requiring that either (1) the back-up landing gear extension system be removed from the airplane or (2) that the owner and operator review and understand the information about the system in the airplane flight manual and Pilot's Operating Handbook, including its operation and limitations. The mechanic who conducted the airplane's most recent annual inspection reported that the airplane's back-up landing gear extension system was still operational and that it had not been disabled. The pilot was maneuvering at a low level in an area with no suitable terrain for landing; therefore, it is likely that he did not intentionally lower the landing gear. During the steep turn, the airspeed likely decreased enough for the back-up landing gear system to engage and extend the gear. With the increased drag of the landing gear and low airspeed, the airplane did not have sufficient power or altitude to clear the rising terrain and subsequently collided with trees.

## Factual narrative

The Piper Aircraft Corporation issued a mandatory service bulletin (No. 769) on October 19, 1983 recommending that a landing gear back-up extension override mechanism be installed onto the airplane within the next 100 hours of operation, or at the next scheduled inspection or maintenance, whichever occurs first. This mechanism will override the back-up landing gear extension system without the pilot having to manually hold the emergency gear lever. On March 4, 1988, Piper Aircraft Corporation issued a two part service bulletin (No. 866A) requiring the back-up landing gear extension system to be removed from the airplane or that the owner and operator review and understand the system, how it operates, and its limitations. To remove the back-up gear extend system, Piper provides a back-up landing gear extender removal kit. However, the removal kit can only be used if service bulletin No.769 has already been complied with. If the owner and/or operator chooses to continue to use the system, Piper requires that not only does the owner/operator understand the system, how it operates, and its limitations, but they require a copy of this service bulletin to be attached to the airplane flight manual. Piper also mandates that an entry is made in the airplane logbook indicating compliance with Part II of this service bulletin. The four-seat, low-wing, retractable-gear airplane, serial #28R-30029 was manufactured in 1967. It was powered by a Lycoming IO-360-B1E, 180 horsepower engine and equipped with a Hartzell, constant speed propeller. Review of copies of maintenance logbook records showed an annual inspection was completed May 12, 2014, at a recorded tachometer reading of 4,651.1 hours, and airframe total time of 9,487.1 hours. Due to extensive damage, the tachometer and the Hobbs hour-meter were unable to be identified within the wreckage. This airplane was equipped with a back-up landing gear extension system. This system incorporates a pressure sensing device to automatically lower the landing gear at airspeeds between about 85 MPH and 105 MPH depending upon the power setting, and regardless of the position of the gear handle within the cockpit. The system can be overridden by manually holding the emergency gear lever in the raised position. The mechanic who conducted the airplane's most recent annual inspection reported that the airplane's back-up landing gear extension system was still operational, and that the system had not been disabled. On July 6, 2014, about 0920 Pacific daylight time, a Piper PA-28R-180, N3723T, collided with mountainous terrain near Lake Elsinore, California. The private pilot and two passengers died and the airplane was destroyed. The airplane was registered to, and operated by, the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, and no flight plan was filed. The flight originated from French Valley Airport (F70), Murrieta,California at about 0815. A witness reported that he was standing in the parking lot for a popular cliff side restaurant with about 25 other people. He heard and observed an extremely low flying airplane buzz overhead. The airplane made about a 45 degree banking turn towards the ridgeline when he heard a hydraulic noise ("gggeee"); he observed the landing gear doors open and the landing gear extend. He reported that the gear took about three seconds to lower; it wasn't a sudden drop. The witness also stated that it didn't sound as if the airplane was operating at full power, but at about half power. As the airplane leveled off in a southwesterly direction, it barely cleared the powerlines along the road and proceeded towards the ridge before going out of sight. About five seconds later they observed a plume of smoke. The witness mentioned that it appeared as if the pilot was "showing off." One witness videoed the flyby while standing in the restaurant parking lot. The airplane was seen coming from the southeast with a steady engine RPM, and the landing gear in the retracted position. The pilot made a hard left turn; when the airplane started to level off towards the southwest, the landing gear was in the extended position. The airplane went out of sight flying towards rising terrain with the right wing slightly lower than the left, and the video ends. The provider of the video reported that a few seconds after the video ended he observed a cloud of smoke rise where the airplane had disappeared. An autopsy was performed on the pilot on July 8, 2014, by the Riverside County Sheriff - Coroner Division located in Perris, California. The cause of death was thermal injuries with inhalation of products of combustion. The FAA's Civil Aerospace Medical Institute performed forensic toxicology on specimens from the pilot with negative results for carbon monoxide, ethanol, and tested for drugs. The nearest weather reporting station was located at the March Air Reserve Base (RIV), Riverside, California, about 17 miles north of the accident site. At 0858, the weather was reported as calm wind, clear skies, visibility 10 statute miles, temperature 28 degrees C, dewpoint 7 degrees C, and an altimeter setting of 30.06 inches of mercury. Witnesses reported that the wind was calm the morning of the accident. The pilot, age 49, held a private pilot certificate for airplane single-engine land with an instrument rating issued January 18, 2004, and a third-class airman medical certificate issued April 17, 2014 with no limitations. During his most recent medical examination, he reported he had accumulated 3,400 total flight hours, none of which were within the past six months. A friend of the pilot reported that the pilot purchased the airplane in about 2008 and used it to commute to work for about one or two years. After a change in work, the pilot did not fly the airplane for about five years. During that time, the pilot had the airplane's engine overhauled andairframe completely inspected. After the work, and an annual inspection was completed, the airplane was test flown and broken-in about 5-7 weeks prior to the accident. The pilot had told his friend that, after the maintenance, the airplane had been flying better than ever before. The airplane was recovered and transported to a recovery yard; there were no preimpact mechanical malfunctions or failures with the airframe or engine that would have precluded normal operations. The Engine: Postaccident visual examination of the engine revealed no evidence of catastrophic mechanical failure or malfunction. The engine and fuel system sustained heavy thermal damage throughout. The fuel flow divider was still secured to its mount and the fuel lines were still secured from its fittings to each cylinder's fuel injector. The throttle and mixture controls were still secured to their respective control arms on the fuel servo, and the throttle lever was found against the stop in the full open position. The throttle plate displayed heavy thermal damage and was bent in half. The magnetos were still attached to the aft portion of the engine, but they sustained heavy thermal damage and were unable to be tested. The ignition harness was still secured from its respective magnetos to the spark plugs. The top spark plugs were removed and the electrodes displayed wear consistent with normal operations when compared to the Champion Spark Plugs "Check-A-Plug" chart AV-27. The rocker covers were removed and no thermal damage was noted. The propeller was attempted to be rotated by hand; but it would not rotate. The accessory section sustained heavy thermal damage. Further examination revealed melted aluminum was found covering the accessory gears that connect to the crankshaft, restricting its movement. A borescope was used to examine the inside of the cylinders combustion chambers. The combustion chambers, piston heads, and valves were intact and undamaged. There was no evidence of foreign objects or oil deprivation. Holes were drilled into the crankcase to examine the crankshaft, connecting rods, and camlobes. The crankshaft and the connecting rods were well oiled and displayed no evidence of oil deprivation, contamination, or heat distress. The camshaft was intact and all camlobes appeared to have their normal shape. The wreckage was approximately 560 yards (0.32 miles) southwest of the restaurant parking lot at an elevation of about 2,585 feet. The first identified points of impact were three topped trees near the edge of a ravine. The trees measured between about 3-5 inches in diameter and were topped about mid-height. About 20 feet beyond the trees was the right wing and right wing landing gear at the edge of the ravine. The aileron and flap were partially attached to the wing, which sustained fire damage specifically in the fuel tank area. The main wreckage came to rest at the bottom of the ravine; no impact damage was noted to the ravine wall between the right wingand main wreckage, however, this area was heavily burned and trafficked by emergency personnel. The engine was found inverted and partially covered in dirt and debris. One propeller was visible, and the outboard about 1/3rd of it was bent forward. The other blade was partially underneath the firewall and forward fuselage; it was noted that it was bent aft about midspan. The forward cabin was on top of and slightly to the right of the engine. The forward cabin area was heavily damaged and burned. The instrument panel was unreadable, and the fuel selector was unable to be located. The front two seats and rear bench seat were burned and located within this area. Further to the right was the empennage, which was heavily damaged and burned. The left wing was separated from the fuselage at the wing root and came to rest on top of, and to the left of, the engine. The left wing sustained heavy fire damage specifically in the fuel tank area. The aileron and flap were partially attached to their attachment points. Control continuity was established throughout the airframe. The cables leading to the wings sustained fractures consistent with tension overload, and the empennage control cables had been cut by emergency personnel.

## Aircraft

- Registration: [N3723T](https://openairdocs.org/deregistered/N3723T-2018-02-15), registration cancelled 2018-02-15, S/N 28R-30029, built 1967 (OpenAirDocs)
- Reported make and model: PIPER PA 28R-180
- Registry model: [Piper PA-28R-180](https://openairdocs.org/model/piper-pa-28r-180) (registry code 7102809) (OpenAirDocs)
- Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28R-30029
- Year built: 1967
- Airframe hours: 9487
- Engines: LYCOMING IO360 SER 180 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Personal, Part 91
- Operator: Symiczek Douglas J
- Registered owner: Symiczek Douglas J
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, May 12, 2014
- Departed: F70, Murrieta, CA
- Destination: F70, Murrieta, CA

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 49; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; seat: left; restraint: lap only; toxicology performed; flight hours: 3,400 total

## Weather

- Conditions: Visual (VMC), Day
- Wind: calm
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 82 °F, dew point 45 °F
- Altimeter: 30.05 inHg
- Observed at: RIV, 17 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 20140706013829A](https://openairdocs.org/incident/20140706013829A), Jul 6, 2014: Piper PA-28R-180, Lake Elsnore, CA, Destroyed, 3 fatal. N3723T, a PA-28R-180, departed french valley airport (F70) at approximately 0830 PDT on a local flight with three persons onboard. At approximately 0925 PDT,…

## Docket (17 files)

The files NTSB released with the investigation on June 3, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89609. 10.4 MB in all.

- Record of Conversations - Witness Statements (item 1, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427410&FileExtension=.PDF&FileName=Record%20of%20Conversations%20-%20Witness%20Statements-Master.PDF
- Record of Conversation – Friend of Pilot and Airplane Refueler (item 2, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427415&FileExtension=.PDF&FileName=Record%20of%20Conversation%20%E2%80%93%20Friend%20of%20Pilot%20and%20Airplane%20Refueler-Master.PDF
- Record of Conversation – Mechanic (item 3, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427416&FileExtension=.PDF&FileName=Record%20of%20Conversation%20%E2%80%93%20Mechanic-Master.PDF
- Video of the Airplane’s Flyby Shortly before Impact (item 4, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427411&FileExtension=.PDF&FileName=Video%20of%20the%20Airplane%E2%80%99s%20Flyby%20Shortly%20before%20Impact-Master.PDF
- On Scene Summary (item 5, .PDF, 6 photos, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427412&FileExtension=.PDF&FileName=On%20Scene%20Summary-Master.PDF
- Engine Examination Summary (item 6, .PDF, 8 photos, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427413&FileExtension=.PDF&FileName=Engine%20Examination%20Summary-Master.PDF
- Google Map of the Accident Site (item 7, .PDF, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427414&FileExtension=.PDF&FileName=Google%20Map%20of%20the%20Accident%20Site-Master.PDF
- Service Bulletin No. 769 – Landing Gear Backup Override Mechanism (item 8, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427417&FileExtension=.PDF&FileName=Service%20Bulletin%20No.%20769%20%E2%80%93%20Landing%20Gear%20Backup%20Override%20Mechanism-Master.PDF
- Service Bulletin No. 866A – Removal of Landing Gear Backup Extender (item 9, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427418&FileExtension=.PDF&FileName=Service%20Bulletin%20No.%20866A%20%E2%80%93%20Removal%20of%20Landing%20Gear%20Backup%20Extender-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 523 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427419&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427420&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF
- Toxicological Report (item 12, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427421&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF
- Photo 1 – Top of Ravine (item 13, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427422&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93%20Top%20of%20Ravine-Master.PDF
- Photo 2 – From top of ravine to bottom of ravine (item 14, .PDF, 999 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427423&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20From%20top%20of%20ravine%20to%20bottom%20of%20ravine-Master.PDF
- Photo 3 – Across and Down the Ravine (item 15, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427424&FileExtension=.PDF&FileName=Photo%203%20%E2%80%93%20Across%20and%20Down%20the%20Ravine-Master.PDF
- Photo 4 – Cabin and Left Wing (item 16, .PDF, 990 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427425&FileExtension=.PDF&FileName=Photo%204%20%E2%80%93%20Cabin%20and%20Left%20Wing-Master.PDF
- Photo 5 – Empennage (item 17, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427426&FileExtension=.PDF&FileName=Photo%205%20%E2%80%93%20Empennage-Master.PDF

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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