NTSB Factual Report

History of Flight

On September 21, 1996, about 1530 hours Pacific daylight time, a Piper PA28-181, N2393W, lost control in-flight and crashed about 1 mile east/northeast of Shadow Mountain Airstrip, Caliente, California. The pilots were conducting a visual flight rules instructional/personal flight. The airplane, registered to a private individual and operated by Burbank Flying Club, Burbank, California, was destroyed by impact and the postimpact fire. Three of the occupants, including the certificated commercial pilot/flight instructor occupying the right front seat and the noncertificated student pilot occupying the left front seat, sustained fatal injuries; one passenger was seriously injured. Visual meteorological conditions prevailed. The flight originated at Burbank Airport at 1435.

The registered owner of the accident airplane told Safety Board investigators in an interview conducted on October 1, 1996, that he leases the airplane to the Burbank Flying Club. About 2 weeks before the accident he scheduled the airplane for an instrument lesson at 1500 on September 21, 1996. When he arrived at Burbank Flying Club he learned that the instructor aboard the airplane erased his name from the schedule and inserted his (the instructor's) name.

Safety Board investigators interviewed several ground witnesses. None of the witness, however, observed the crash. A ground witness reported that he was in his yard, about 100 yards south of Shadow Mountain Airstrip when he observed a predominantly white low wing airplane attempt to land toward the east. The airplane went around and made a right turn to reenter the traffic pattern. The airplane touched down on the second approach, but landed long and was too fast. The airplane lifted off when it was near the end of the runway and began a shallow climb toward the east. The airplane disappeared from his view and never returned. He said that the winds were out of the west about 5 knots gusting to 10 knots, and that he was in his tractor and could not hear any engine sounds. He said that he heard fire engine sounds between 30 and 45 minutes after the airplane departed.

Another ground witness said that between 1525 and 1530 he observed smoke emanating from the accident site while driving east on Weedpatch Highway. At 1526, he saw the surviving passenger in a field. The man told him that he was a passenger in an airplane that had crashed and that people were screaming in the airplane. Moments later, the witness saw fire equipment driving west on the highway.

The passenger told him that the flight departed Burbank airport, and that the student pilot was flying to Shadow Mountain Airstrip to see a film producer. He said that when the flight arrived at the airstrip the pilot tried to land toward the east, but the runway was too short. The pilot executed a go-around and climbed toward the east. Moments later, the airplane turned to the left. The next thing the passenger remembered was that he was lying on the ground and the airplane erupted into flames.

A third witness said that she observed the airplane flying toward the west at a low altitude. She said she knew that her neighbors were expecting a business associate and assumed that the airplane was landing at the Flying "S" Airstrip located north of Weedpatch Highway.

Safety Board investigators interviewed the surviving passenger at the Southwest Regional Office, Gardena, California, on December 5, 1996. The passenger said that he is not a certificated pilot, nor has he taken any flying lessons. He said that the student pilot invited him on the morning of the accident to accompany him to visit his friend at Caliente. The passenger was aware that the student pilot was taking flying lessons, but he was not aware that this was the first flight that the student had flown the airplane. The passenger said that before departing on the accident flight, the student pilot telephoned the friend he was going to visit. The friend told him to fly over his residence and then land at the airport. The friend also told the student pilot that the flight should land toward the west; the student pilot relayed this information to the instructor.

The student pilot flew the airplane while it was en route. When the flight arrived at Caliente, the instructor assumed the controls. The instructor circled the vicinity of the airport and the nearby residences. The instructor then entered the traffic pattern and landed toward the east. The airplane touched down about midfield. When it was evident that the airplane was not going to be able to stop on the runway environment, the instructor initiated a go-around. During the pull-up, a buzzer (the aural stall warning) sounded and the student pilot told his fiance, seated in the left rear seat, "do not worry, everything is under control."

The airplane initially climbed straight out to about 500 feet above the ground and then turned left (north) toward rising terrain. When the airplane flew further into the canyon, the pilot turned the airplane. When the airplane turned between 90 and 110 degrees, the aural stall warning buzzer sounded. The bottom of the airplane then struck some trees and plunged downward. During the descent, the passenger saw the ground through the windscreen.

The passenger said that he may have seen a red light illuminate on the instrument panel before the airplane struck the trees. He said that at the time of the accident, the skies were clear with unlimited visibility; the winds were from the west between 5 and 10 miles per hour.

Crew Information

The pilot-in-command (PIC) held a commercial pilot certificate with airplane ratings for single and multiengine land and instrument. The PIC received the multiengine rating on February 26, 1996. He also held a certified flight instructor's certificate with an airplane single engine rating. The PIC received his last unrestricted first-class medical certificate on June 26, 1996. According to current federal air regulations, a first-class medical certificate is valid for 6 calendar months.

Safety Board investigators did not recover the PIC's flight hours logbook. The flight hours reflected on page 3 of this report were the hours he reported on the application form when he received his multiengine rating. According to the Burbank Flying Club records, the PIC received a check-out in the accident airplane on December 20, 1994. The records also reflect that the PIC signed the Burbank Flying Club Course Rules on June 27, 1994. Course rule number 5 states, "No off airport landings are allowed. No operations permitted on other than asphalt or concrete runways."

The dual student pilot did not hold a medical or student pilot certificate. The Burbank Flying Club president told Safety Board investigators that the dual student had not joined the club. He said that the club rule allows anyone to receive flight instruction for an unspecified period; the person, however, could not solo any airplane until he or she joins the club.

Safety Board investigators did not recover the dual student pilot's flight hours logbook. According to Burbank Flying Clubs records, however, the dual student pilot received his first flight lesson on July 28, 1996. The dual student pilot received two more flight lessons before departing on the accident flight. The dual student pilot's flight records indicate that he received 3.9 instructional hours in Cessna 172 airplanes before departing on the accident flight. The accident flight was the first flight the dual student had flown in the accident airplane make and model.

The flight hours reflected in Supplement E of this report include the accident flight.

Airport Information

Shadow Mountain Airstrip is owned and operated by Shadow Mountain Airstrip Association, Northridge, California, and is not for general public use. It has one east/west dirt surface runway that is about 3,400 feet long by about 30 feet wide. The airstrip does not have any FAA Air Traffic Control or meteorological facilities.

The airstrip manager told Safety Board investigators on October 19, 1996, that he had not been to airstrip in about 2 years. He said that a local resident often grades the landing surface. He also said that once and a while he will grant permission to land at the airport if he feels the pilot has sufficient experience and is aware of the surrounding terrain. The manager said that he did not give the PIC of the accident airplane permission to land at the airstrip and was not aware that the accident occurred.

Safety Board investigators noted that the airstrip contained a windsock. The sock, however, was missing; only torn and tattered remnants were found on the windsock ring.

Wreckage and Impact Information

The crash site is surrounded by high mountainous terrain in a northerly arc from the west to the east. Geometric calculation and the wreckage examination disclosed the airplane struck the ground in a near nose-down vertical attitude with the nose yawed to the right about 15 degrees. The airplane came to rest, inverted, about 92 feet west/southwest of the initial impact point.

The cabin/cockpit area was incinerated. Kern County Sheriff's deputies reported that both front seats were removed by rescue personnel.

All of the airplane's major components and flight controls were found at the impact site.

Right Wing Examination:

The right wing remained attached at its respective wing-to-fuselage attach fittings. The inboard section of the leading edge was bent down about 75 degrees. The right main landing gear remained attached at its respective attach points.

The entire right wing displayed extensive postimpact fire damage. The upper midsection skin was burnt away and the spar displayed extensive twisting and burn damage. The fuel tank area displayed hydraulicing signatures and contained some fuel.

The aileron remained connected to its respective attach points. The inboard section of the aileron was melted. The flaps appeared to be in the retracted position, but moved freely.

Left Wing Examination:

The wing separated from its respective wing-to-fuselage attach fittings and was found lying right-side-up next to the right wing tip. The entire inboard section was incinerated. The wing also displayed extensive hydraulicing signatures. The leading edge outboard panel was bent upward and crushed toward the trailing edge.

The landing gear strut was found adjacent to the wing. The aileron cables remained attached at its respective attach points. The cables separated and the fracture surfaces displayed extensive fraying and necking down signatures.

Empennage Examination

The outboard section of the elevator was melted. The entire empennage was destroyed by the postimpact fire. Only remnants of the spar caps were found. About 80 percent of the stabilator trim tab was found; the skin between the stabilator's leading edge and the trim tab was destroyed by fire.

The elevator trim tab actuator was extended by four threads; the jackscrew was extended about 3/8 inch. According to the The New Piper Aircraft Company representative, this setting corresponds to a near neutral position.

On-Scene Engine and Propeller Examination:

The propeller was found impaled in the initial impact crater and separated from the engine crankshaft. The propeller blades displayed chordwise scuffing, leading edge gouging and "S" twisting signatures.

The upper spark plugs displayed normal operating signatures.

The vacuum pump was removed and a spline tool was inserted in its accessory drive section. The crankshaft could not be rotated due to the postimpact fire damaged accessory section. All of the accessories were destroyed by the postimpact fire and could not be tested. Both magnetos were found attached to the accessory section. The outer body housings of both magnetos were melted.

Medical and Pathological Information

The Kern County Coroner's Office conducted the postmortem and toxicological examinations on both pilots and the deceased passenger. The toxicological examinations on both flight crew members were negative for alcohol and drugs.

Tests and Research

A detailed engine examination was conducted on October 1, 1996, at Aircraft Recovery Service, Compton Airport, Compton, California.

The engine displayed postimpact fire damage.

Continuity of the engine gear and valve train was established. Before the continuity was established, however, investigators were unable to turn the engine crankshaft. The accessory section housing was removed and the crankshaft rotated freely.

During continuity testing of the gear and valve train assembly, no compression was evident in the numbers 1, 2, and 4 cylinders. Minimal thumb compression was noted on number 3 cylinder.

The crankshaft propeller attach fitting displayed torsional overload signatures.

The oil suction feed screen was free of contaminates. The oil pump gears were intact and no evidence of any metal particles was observed. The gears displayed some heat distress signatures.

The through-bolt nut was split apart and displayed heat damage. Two of the threads, however, were still attached.

The numbers 2 and 4 cylinders contained extensive debris and their associated intake and exhaust valves were found in the open position. According to the Lycoming representative, the number 2 and 4 cylinder valve springs were subjected to extreme external temperatures and the valve springs tension was relaxed.

The number 1 piston and piston rings displayed normal signatures. All of the pistons were connected to their respective connecting rods. The connecting rods were connected to their respective crankshaft journals. The piston domes and their associated piston rings displayed normal operating signatures.

The crankshaft displayed external thermal heat transference heat signatures.

Additional Information

The airframe and engine were released to Aircraft Recovery Service, Compton, California, on October 1, 1996. The Safety Board did not retain any airframe or engine components.

NTSB Probable Cause

improper in-flight planning/decision by the flight instructor (CFI) by allowing the airplane to flying into a box canyon area, and his failure to maintain adequate airspeed, which resulted in an inadvertent stall and collision with wooded terrain. The CFI's selection of the wrong runway and the resultant tailwind were related factors.