NTSB Factual Report

HISTORY OF FLIGHT

On December 10, 2009, approximately 1430 Pacific standard time, a Piper PA-38-112, N2463K, impacted terrain in a nearly vertical attitude following a loss of control while maneuvering near Ojai, California. The flight instructor and the student pilot were both killed. The airplane was registered to, and being operated by, Aviation Pacific, Inc., under the provisions of 14 Code of Federal Regulations Part 91. No flight plan had been filed for the local pre-solo instructional flight. The airplane had departed Camarillo, California, 37 minutes before the accident. Visual meteorological conditions (VMC) prevailed in the vicinity of the accident site.

The accident airplane was cleared for takeoff from the Camarillo airport at 1353. Soon after takeoff, radio contact was established with Naval Air Station Point Mugu for flight following. After initial radio contact, there were no additional communications from the accident airplane.

The first radar contact with the airplane was at 1358, at 1,800 feet mean sea level (msl), as it headed northwest from the Camarillo Airport. The radar data indicated that the airplane maneuvered in the area of Lake Casitas to east of Ojai, for the next 22 to 24 minutes. At approximately 1425, and at 3,500 feet msl, the airplane began a descent at approximately 660 feet per minute. The accident airplane descended below radar coverage at 1427:30, at an altitude of 2,000 feet. The first 911 call, reporting the accident, was received between 1429 and 1430.

A witness, standing on the playground of Mira Monte Elementary School (240 degrees for 2,000 feet from the accident site), said the airplane approached her position in the school yard at a very low altitude. She thought it was a sailplane, because she did not hear any engine noise. She estimated the airplane was approximately 1/2 mile from the school yard when she heard noises she described as "trying to start the engine." The witness said she then heard the engine running as the airplane made a right turn towards the northeast and rising terrain. After it turned, she could again no longer hear any engine sounds. She said she lost sight of it shortly before it struck the ground.

PERSONNEL INFORMATION

The flight instructor, age 51, held a second-class Federal Aviation Administration (FAA) medical certificate, which was issued on May 20, 2008. He held a commercial pilot certificate and a flight instructor certificate, with ratings in single engine airplane, multiengine airplane, and instrument airplane. His total flight experience was estimated at 1,700 hours by the flight school. The pilot's flight logbook was not available for examination.

The student pilot, age 19, had a first-class FAA medical certificate, which was issued on November 2, 2009. He had accumulated approximately 15 hours of flight experience. The accident flight was in preparation for his first solo flight.

AIRCRAFT INFORMATION

The airplane was a single-engine, propeller-driven, two seat airplane, with dual flight controls, which was manufactured by Piper in 1979. Its maximum takeoff gross weight was 1,670 pounds; its basic empty weight was 1,144 pounds. It was powered by a Lycoming O-235-L2C reciprocating, direct drive, air-cooled, normally aspirated engine, which had a maximum takeoff rating of 118 horsepower at sea level.

A review of the maintenance records indicated that the last annual inspection was performed on January 11, 2009; the last 100-hour inspection was performed on November 27, 2009. The airframe had 4,257 hours on it at the time of the accident. The airplane had two fuel tanks for a total capacity of 32 gallons, of which 30 was usable. Fuel records indicate that at approximately 0938 on the morning of the accident, the airplane was topped off with fuel. Ramp personnel at the Camarillo Airport stated that the flight instructor flew for 1 hour with a student on the morning of the accident. The refueler estimated that when the flight instructor departed for his second flight of the day, he had "around 25 gallons" of fuel onboard.

METEOROLOGICAL INFORMATION

At 1455, the weather conditions at Camarillo Airport (77 feet elevation), Camarillo, located 145 degrees for 18 nautical miles (nm) from the accident site, were as follows: wind 220 degrees at 8 knots; visibility 10 statute miles; cloud condition, overcast at 6,500 feet; temperature 57 degrees Fahrenheit; dew point 43 degrees Fahrenheit; altimeter setting 30.01 inches of Mercury.

Temperature and dew point measurements closer to the accident site were obtained from the APRSWXNET, citizen-operated weather stations. Quality Assurance is done on this data, but it must be noted these are citizen operated, not National Weather Service observations.

1. Location, 1.6 nm at 205 degrees from the accident site, elevation 896 feet:

Temperature 57 degrees F., dew point 37 degrees F. at 1433.

2. Location, 9.9 nm at 102 degrees from the accident site, elevation 663 feet:

Temperature 57 degrees F., dew point 34 degrees F. at 1429.

3. Location, 7.4 nm at 33 degree from the accident site, elevation 3,400 feet:

Temperature 51 degrees F., dew point 38 degrees F. at 1421.

A carburetor icing chart was used with the closest temperatures: temperature 57 degree Fahrenheit, with a dew point of 37 degrees Fahrenheit. The plotted data point was in the zone of "Serious Icing at Glide Power."

WRECKAGE AND IMPACT INFORMATION

The airplane was found on an asphalt road (elevation 828 feet), on the residential grounds of the Krotona Institute of Theosophy, Ojai. Forty to sixty-foot trees lined the road. The airplane was resting on its nose and the leading edges of its wings. The nose was crushed aft, and the engine was displaced into the cabin. The empennage was bent over in a scorpion like manner. No ground scar was evident, and the airplane came to rest oriented north. All of the airplane's major components were accounted for at the accident site.

The forward cockpit section sustained extensive ground impact damage; the instrument panel was fragmented and found in several sections. Most of the flight instruments, engine instruments, and avionics were destroyed. The left wing leading edge skin exhibited aft and upwards crushing along its entire span. Both the aileron and flap surfaces remained attached to the wing, but sustained impact damage. The right wing exhibited aft crushing of the leading edge skins along most of its span. Both the aileron and flap surfaces sustained impact damage but both remained attached to the wing. Both wing fuel tanks were compromised.

The empennage, vertical stabilizer and horizontal stabilizer, along with their respective flight control surfaces were minimally damaged. The propeller blades exhibited few striations and little mechanical damage; the propeller spinner was crushed aft. The engine case exhibited several cracks, but remained intact. The carburetor was broken in half and its base remained connected to the bottom of the engine.

No evidence of any pre-impact mechanical discrepancies were found with the airplane's airframe or engine that would have prevented normal operation. There was no fire.

MEDICAL AND PATHOLOGICAL INFORMATION

The Ventura County, Medical Examiner-Coroner, performed autopsies on both pilots on December 11, 2009. The cause of death determined for both of the occupants was multiple blunt traumas.

The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the flight instructor and student pilot. According to CAMI's report on the flight instructor, his blood was tested for carbon monoxide, cyanide and drugs, with negative results. His vitreous was tested for volatiles; no ethanol was detected.

The student pilot's blood was tested for carbon monoxide and cyanide, with negative results. His vitreous was tested for ethanol and his urine was tested for drugs, with negative results.

TESTS AND RESEARCH

Two students from Aviation Pacific flight school were interviewed by an FAA inspector. They both stated that they had flown with the flight instructor many times. Both students stated that while practicing emergency maneuvers [Engine Power Loss in Flight] the flight instructor never had them use carburetor heat because the rpm would remain in the "green arc." In the manufacturer's Pilot Operating Handbook (POH) for the accident airplane under emergency procedures, Engine Power Loss in Flight, it states that carburetor heat shall be on.

NTSB Probable Cause

Airspeed was not maintained, which resulted in a loss of control and the airplane entering into a stall/spin to the ground. Contributing to the accident was a loss of engine power due to carburetor icing.