Aviation Accident Summaries

Aviation Accident Summary LAX05FA255

San Luis Obispo, CA, USA

Aircraft #1

N4401X

Piper PA-28-151

Analysis

While on the crosswind leg during initial climb, the pilot cruised into upsloping terrain about 0.9 miles from the runway. The pilot's day began when he departed his residence about 0700. Thereafter, he commuted to work, which involved flying a borrowed airplane to a neighboring city. Upon completing work, the pilot was dropped off at the airport. The pilot intended either to fly home or to the location where his next day's work was to be performed. He was due to report to work the following morning at 0730. It was a dark night, and an overcast ceiling existed at 800 feet above the ground. No moon or stars were visible from the airport. A hill was located about 1 mile northeast of the airport. The pilot departed using runway 11, made a left crosswind turn, and impacted the hill while climbing in controlled flight. Fire department personnel responding to the accident site said that the clouds were nearly at ground level and that the forward (horizontal) visibility was between 1/4- and 1/2-mile. The pilot had received his private pilot certificate the preceding month, at a total flight time of 69.6 hours, including 3.5 hours at night.

Factual Information

HISTORY OF FLIGHT On August 1, 2005, about 2153 Pacific daylight time, a Piper PA-28-151, N4401X, impacted upsloping hilly terrain about 1 mile northeast of the San Luis County Regional Airport (SBP), San Luis Obispo, California. The non-instrument rated private pilot had borrowed the privately owned and operated airplane for his business related cross-country flight. Instrument meteorological conditions (IMC) prevailed in the vicinity of the accident site. No flight plan had been filed. The airplane was destroyed during the impact sequence and post impact ground fire, and the pilot was fatally injured. The flight was performed under the provisions of 14 CFR Part 91, and it originated from San Luis Obispo about 2150. Work associates of the pilot reported to the National Transportation Safety Board investigator that on August 1, the pilot had departed his residence by 0700, and he drove to work in Selma, California. After completing work in Selma, the pilot drove to Fresno where he boarded the accident airplane and flew to his next job site, which was located near San Luis Obispo. After completing work at that site, the pilot was dropped off at SBP. The associates reported that the pilot's next work site was located in San Jose, California, where he was expected by 0730 the following morning. The associates indicated that upon departure from SBP, the pilot would have either flown to his Fresno home airport, or he would have flown to San Jose to position himself for the following day's work. Customarily, the pilot would have notified either his family or other work associates of his plans, but on this occasion no communications were received. Several witnesses, who were located in the vicinity of SBP, reported observing some or all of the airplane's final flight. In pertinent part, one of the witnesses reported that he is a private pilot and was getting ready to depart the airport in his truck. He heard the sound of the airplane's engine and observed its flashing beacon and strobe lights. The witness further indicated that the airplane departed using runway 11 and then made a left crosswind turn toward Islay Hill. At the moment of impact, a bright flash was noted emanating through the overcast layer of clouds. PERSONNEL INFORMATION The pilot was issued a private pilot certificate in July 2005. On the date of his application for the certificate, June 21, 2005, the pilot reported that his total flight time was 69.6 hours. Also, his total pilot-in-command time was 20.2 hours, and his total nighttime flight experience (dual) was 3.5 hours. The pilot's personal flight record logbook was not located. It reportedly had been on board the airplane. Based upon information provided by the airplane's owner and acquaintances of the pilot, the Safety Board investigator estimated that the pilot's total flight time was about 77 hours. AIRCRAFT INFORMATION The airplane was maintained on an annual and 100-hour inspection basis. No airplane or engine logbooks were located during the investigation. The airplane's owner reported that he believed they had been on board the airplane and were consumed by fire. The owner provided the Safety Board investigator with copies of maintenance invoices that indicated work was performed on the airplane during the preceding year. On February 21, 2005, the airplane had received an annual inspection, at a total airplane time of 5,225.8 hours. On May 17, 2005, the airplane received a 100-hour inspection. The last maintenance invoice was dated July 12, 2005. On this date the record indicates that the airplane's engine oil was changed. Thereafter, the engine was run up and no oil leaks were noted. According to a Major Repair and Alteration Form 337, on May 28, 2004, a Garmin GNS 430 global positioning satellite receiver was installed in the airplane. The airplane was placarded with the following statement: "GPS Limited to VFR use only." On October 26, 2004, on another Form 337, the "VFR use only" placard was removed. METEOROLOGICAL INFORMATION About the time of the accident, witnesses located in the San Luis Obispo area reported observing a hillside fire about 1 mile northeast of SBP. According to a California Department of Forestry fire captain, who is also a current airplane pilot, upon responding to the accident site he noted that the clouds were nearly at ground level. The captain stated that the forward (horizontal) visibility was between 1/4- and 1/2-mile. According to witnesses at and near SBP, about the time of the accident no moon or stars were visible, and the wind was calm. They described the area surrounding the airport as being dark, and there was an overcast sky condition. The closest official aviation weather observation station to the accident site was located at the San Luis Obispo Airport, elevation 212 feet mean sea level (msl). At 2156, the airport's automated surface observing system (ASOS) reported the following weather conditions: Wind from 120 degrees at 3 knots; 10 miles (ground level) visibility; an overcast ceiling at 800 feet above the ground; and temperature/dew point of 14/12 degrees Celsius, respectively. COMMUNICATIONS A search of nearby Federal Aviation Administration (FAA) facilities did not reveal evidence that any ground-to-air communications or services had been provided to the pilot. AIRPORT AND GROUND FACILITIES The airport's control tower was closed at the time of the accident pilot's takeoff on runway 11. The runway is 5,300 feet long by 150 feet wide. WRECKAGE AND IMPACT INFORMATION The accident site in located on Islay Hill, about 35 degrees 14.7 minutes north latitude by 120 degrees 37.3 minutes west longitude. The estimated elevation of the accident site on the south-southwest side of the hill is about 740 feet msl. The site is approximately 40 feet below the top of the hill, and on about 20-degree upsloping terrain. The principal axis of wreckage distribution is in a north-northeasterly direction. The distance and magnetic bearing from the departure end of runway 11 to the impact site is about 0.9 nautical miles and 026 degrees, magnetic. According to fire department personnel, the fire area appeared symmetrically located on the left and right side of the airplane, and it had the appearance of being fuel-fed. The fire had melted airframe structure into the dirt. Approximately 1/8-acre of native vegetation had been burned, and fire had consumed the airplane. MEDICAL AND PATHOLOGICAL INFORMATION The San Luis Obispo County Sheriff-Coroner's office performed a postmortem examination of the pilot. Also, the county's contract laboratory performed toxicology tests. No evidence of ethyl alcohol or screened drugs was detected. FAA Forensic Toxicology Research Team at the Civil Aeromedical Institute also performed toxicology tests. No evidence of ethyl alcohol or screened drugs was detected. TESTS AND RESEARCH The wreckage was initially examined on scene by the FAA coordinator. The Safety Board investigator performed a follow-up examination of recovered portions of the airplane wreckage while in storage at the recovery facility. The airplane's flight control cables were found attached to the aileron bellcrank assemblies and to the empennage. The opposite ends of the cables exhibited either broomstraw separation signatures or were not located in the fire-damaged and melted structure. All of the flight control surfaces and/or attachment points were found impact-damaged and destroyed. The entire fuselage and most of the airframe including the wings and the entire cockpit were similarly destroyed or melted. The entry door handle to the cockpit was found in the closed position. The propeller was not recovered; it was not located. The fire-damaged engine was separated from the airframe. The crankshaft could not be rotated by hand. No evidence of preimpact damage was noted. Under the Safety Board investigator's supervision, a visual examination of the partially disassembled engine was performed by the Lycoming Engine participant, who indicated the following: The top spark plugs exhibited normal wear signatures. All of the accessories were found destroyed, and none could be functionally examined. The participant opined that the cylinders and the valve and gear train did not exhibit evidence of any preimpact mechanical malfunction. See the Lycoming Engine participant's report for specific details of the partial engine teardown examination. ADDITIONAL INFORMATION All of the recovered airplane wreckage was released to Aircraft Recovery Services, Littlerock, California, on August 5, 2005. No parts or records were retained.

Probable Cause and Findings

The pilot's continued flight into instrument meteorological conditions, and his failure to maintain clearance from the rising hilly terrain. Contributing factors were the pilot's inexperience regarding flying during the dark, nighttime condition, and the low ceiling.

 

Source: NTSB Aviation Accident Database

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