NTSB Factual Report

1.1 HISTORY OF FLIGHT

On February 28, 2005, about 1905 Pacific standard time, a Piper PA-28-181, N2954P, impacted mountainous terrain near Yucaipa, California. M.I. Air Corporation was operating the airplane under the provisions of 14 CFR Part 91. The commercial certified flight instructor (CFI), the private pilot undergoing instruction (PUI), and the private pilot rated passenger sustained fatal injuries; the airplane was destroyed. The local instructional night flight departed Redlands Municipal Airport, Redlands, California, at 1846. Visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 34 degrees 02.258 minutes north latitude and 116 degrees 59.249 minutes west longitude, at an elevation of 4,160 feet.

The operator reported that the purpose of the flight was for the PUI to obtain night Visual Flight Rules (VFR) pilot-in-command time. The flight was scheduled to fly in the local area and to make night landings at Redlands Municipal Airport and other local airports.

Friends of the pilot reported they heard the airplane fly over the PUI's residence about 1900. The witness said he could see the strobe lights of the airplane, but could not see the airplane registration number due to the low clouds that were in the area.

The airplane was reported missing on March 1, 2005, at 0800, when personnel at M.I. Air Corporation came to work and discovered the airplane had not returned. San Bernardino County Sheriff's Department Aero Bureau personnel located the wreckage at about 1400 in mountainous terrain about 9.0 nautical miles (nm) southeast of Redlands Municipal Airport.

1.2 PERSONNEL INFORMATION

1.2.1 Pilot Under Instruction

A review of Federal Aviation Administration (FAA) airman records revealed that the PUI held a private pilot certificate with an airplane single engine land rating.

The PUI held a third-class medical certificate that was issued on November 8, 2004. It had the limitations that the pilot must wear corrective lenses.

An examination of the PUI logbook indicated a total logged flight time of 95 hours. He logged 78 hours in the last 90 days, and 33 hours in the last 30 days. He had an estimated 13 hours in the accident make and model. He completed a private pilot examination on January 25, 2005.

The accident flight was the PUI's first night VFR flight as pilot-in-command. The PUI had logged 3.5 hours of dual instruction received during night conditions.

1.2.2 Certified Flight Instructor

A review of the FAA airman records revealed that the CFI held a commercial pilot certificate with ratings for airplane single and multiengine land, and instrument airplane. The CFI also held a certified flight instructor certificate with ratings for airplane single engine land and instrument airplane.

The CFI held a first-class medical certificate that was issued on August 2, 2004. It had no limitations or waivers.

An examination of the CFI pilot's logbook indicated an estimated total flight time of 435 hours. He logged 54 hours in the last 90 days and 23 hours in the last 30 days. He had an estimated 31 hours in this make and model. He completed a certified flight instructor, instrument airplane examination, on February 1, 2005. He had a total of 22 flight hours logged during night conditions.

The CFI had been employed by M.I. Air Corporation since February 10, 2005. According to the CFI's logbook, since beginning his employment, he logged 2.8 hours of night flight time in the local area prior to the accident.

According to the CFI's application for employment with M.I. Air Corporation dated January 26, and February 10, 2005, he worked as a pilot for Mesa Airlines from October 2004 to December 2004, based out of Phoenix, Arizona. He was a student pilot with San Juan College located in Phoenix, Arizona, which is a training facility for Mesa Airlines, from April 2004 until October 2004. No prior pilot work experience was reported.

1.3 AIRCRAFT INFORMATION

The airplane was a Piper PA 28-181, serial number 28-7990587. A review of the airplane's logbooks revealed a total airframe time of 10,796.4 hours at the last 100-hour inspection. The logbooks had an entry for an annual inspection dated July 5, 2004. The tachometer read 4,516.7 at the last inspection. The tachometer read 4,578.5 at the accident scene; the Hobbs hour meter read 1,271.9 at the accident scene.

The engine was a Textron Lycoming O-360-A4M engine, serial number L-23888-36A. Total time on the engine at the last 100-hour inspection was 4,516.7 hours.

Fueling records at M.I. Air Corporation established that the airplane was last fueled on February 27, 2005, with the addition of 8.22 gallons of 100LL octane aviation fuel. Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure.

1.4 METEOROLOGICAL CONDITIONS

The closest official weather observation station was March Air Reserve Base (RIV), Riverside, California, which was located 16 nautical miles (nm) southwest of the accident site. The elevation of the weather observation station was 1,535 feet mean sea level (msl). An aviation routine weather report (METAR) for RIV was issued at 1853. It stated: winds from 310 degrees at 6 knots; visibility 10 miles; skies few clouds at 3,500 feet, a scattered cloud layer at 20,000; temperature 55 degrees Fahrenheit; dew point 48 degrees Fahrenheit; altimeter 30.10 inHg.

According to the National Transportation Safety Board Sun and Moon program for the geographic coordinates and altitude of Yucaipa, sunset occurred at 1744, and nautical twilight ended at 1809. At the time of accident, the moon was 80 percent illuminated.

1.5 COMMUNICATIONS

The investigation did not uncover any communications between the accident aircraft and any airport traffic control tower (ATCT), Terminal Radar Approach Control (TRACON), Air Route Traffic Control Center (ARTCC) Center, or any other facility at the time of the accident.

1.6 WRECKAGE AND IMPACT INFORMATION

Investigators from the Safety Board, the FAA, and Piper, a party to the investigation, examined the wreckage at the accident scene.

The wreckage site was at the 4,168-foot level, on the southeastern slope of a box canyon, about 100 feet below the ridgeline.

The terrain consisted of a ridgeline radiating westward from Pisgah Peak (1.8 nm to the east), in the San Bernardino National Forest. The wreckage site overlooked Wildwood Canyon to the south. The slope, at an estimated 60-degree incline, consisted of primarily decomposed granite and shale covered by loose topsoil.

The first identified point of contact (FIPC) was a ground scar. The debris path was along a magnetic bearing of 280 degrees. A Bendix/King antenna and pieces of painted fiberglass were located in the initial impact crater. The outboard section of the left horizontal stabilizer was found along the north edge of the impact crater. The main wreckage came to rest right side up 60 feet upslope from the FIPC with the nose of the airplane oriented downslope.

1.6.1 Wings

The left wing separated from the fuselage and came to rest upside down and perpendicular with the fuselage. The leading edge was facing aft in relationship to the fuselage, and was bent in half near wing station 106.19. The aileron cables remained continuous along the length of the wing. The fuselage wing root skin exhibited cable rip from the aileron cables. The aileron surface remained attached to the wing at the outboard and middle hinge. The flap surface remained attached to the wing. The fuel tank sustained ground impact damage and had ruptured. The main landing gear assembly was broken and separated from the wing.

The right wing remained partially attached but sustained ground impact damage. The wing leading edge from the root to about midspan exhibited severe aft crushing. The fuel tank had ruptured. The outboard section of the leading edge exhibited minor impact damage. Both the aileron and flap surfaces remained attached to the wing. The aileron cables remained attached at the bellcrank assembly. The main landing gear assembly had broken and separated from the wing.

1.6.2 Empennage

The empennage was partially intact; however, it had partially separated from the cabin section aft of the rear seats in the area of the baggage compartment. The partial separation allowed the cabin area to be offset to the left in relationship to the empennage. The orientation of the tail empennage was 150 degrees. The cabin fuselage was oriented 125 degrees. The left side of the rear empennage forward of the rear bulkhead had caved inwards, and the horizontal surface had skewed forward on the left side in relationship to its normal position.

The tail section sustained damage but remained attached to the empennage. The vertical surfaces in the area of the rear attach fitting sustained minor impact damage. The rudder surface remained attached to the vertical surface. The rudder was mostly undamaged. The rudder control cables remained attached at the rudder bellcrank assembly.

The left outboard side of the horizontal stabilator surface separated at butt line (BL) 53.12 and was located a few feet downslope of the main wreckage. The leading edge of the separated section was crushed aft. The outboard end of the trim tab and the horizontal rib at BL 53.12 exhibited impact damage. The horizontal stabilizer surface control cables remained attached to the stabilator tube assembly.

1.6.3 Fuselage

The fuselage and forward cockpit section sustained ground impact damage. The cabin had partially separated from the empennage section on the right side aft of the rear seats in the baggage compartment area. The cabin area was offset to the left in relationship to the empennage. The cabin and forward cockpit floor area was crushed upwards and aft. The lower right side of the forward cockpit exhibited extensive ground impact damage and had separated from the roof section.

1.7 MEDICAL AND PATHOLOGICAL INFORMATION

The San Bernardino County Coroner completed an autopsy of the PUI and the CFI. The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the PUI and the CFI.

With regard to the PUI, the results of analysis of the specimens were negative for tested drugs. The report contained the following positive results: 21 (mg/dL, mg/hg) ethanol detected in the muscle. No ethanol was detected in the brain.

With regard to the CFI, the results of analysis of the specimens were negative for ethanol and tested drugs.

1.8 TESTS AND RESEARCH

Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on March 9, 2005. FAA, Piper, and Lycoming were parties to the investigation.

1.9 Engine Data

The engine remained attached to the airframe by the engine mount. According to the Lycoming representative, the engine sustained moderate impact energy damage at the forward bottom area encompassing the exhaust system, carburetor, and airbox. The engine mount was bent. Visual examination of the engine revealed no evidence of preimpact catastrophic mechanical malfunction or fire.

The two-bladed fixed pitch propeller remained attached at the crankshaft flange. The impact damaged spinner was attached to the propeller. The propeller blades remained attached to the propeller hub. After removal of the propeller to facilitate the engine examination, investigators noted that one propeller blade had curled aft about midspan. The second blade was bent sharply aft about midspan. Both propeller blades displayed leading edge gouging, torsional twisting, and chordwise striations across the cambered surface.

The carburetor was displaced from the engine; the portion that remained attached at the mounting pad was secure. According to the Lycoming representative, the fracture signature was consistent with overload due to absorption of impact energy. The throttle control rod was secure at the control arm of the carburetor. The mixture control rod attached to the control arm was displaced from the carburetor.

The airbox and air filter were displaced and crushed. The induction system and air filter exhibited no evidence of obstruction to the flow of air to the engine.

The fuel pump was attached to the engine at the mounting pad. The fuel lines remained secure at their respective fittings. The fuel pump was removed for examination. Fluid consistent with the appearance and odor of aviation fuel was found within the internal cavities of the fuel pump. The fuel pump remained free of internal mechanical malfunction and obstruction to flow.

Investigators removed the top spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.

There was no oil residue observed in the exhaust system gas path. Investigators observed significant ductile bending of the exhaust system components.

Investigators manually rotated the magnetos, and both magnetos produced spark at all posts.

The oil suction screen was clean and open. The oil filter was secure at the mount and not removed.

The vacuum pump was removed to facilitate manual rotation of the crankshaft, via the use of a drive coupling tool. The crankshaft rotated freely and the valves moved approximately the same amount of lift in firing order. The fuel pump plunger moved up and down, and the gears in the accessory case turned freely. Investigators obtained thumb compression on all cylinders in firing order.

1.10 Emergency Locator Transmitter

The Emergency Locator Transmitter (ELT), attached to the aircraft, model ELT-200, part number 453-0198, serial number E03551, was manufactured by Artex Aircraft Supplies, Inc. (Artex). The ELT did not transmit after the accident. After removing the ELT from the aircraft, the IIC activated the unit by turning the switch to the ON position. He observed a blinking indicator light and the unit transmitted an emergency signal.

The Seattle Manufacturing Inspection District Office (MIDO) Aviation Safety Inspector (ASI) and Artex examined the ELT on April 11, 2005. The ELT was physically moved through a motion designed to activate the G-switch. The ELT failed to transmit a signal. Next, the ELT switch was placed in the ON position. Although the switch's red indicator light blinked, the ELT failed to transmit a signal.

The unit was disassembled and inspected. The interior of the unit and circuit board showed no physical damage. The G-switch and Crystal were inspected and found to be the correct part numbers. They were configured and installed in conformance with current approved engineering drawings. According to the manufacturer, the Crystal did not function due to an open circuit, and the G-switch did not function because of a "stuck" metal contact ball. According to the manufacturer, the metal ball contact element wears a groove in the barrel due to vibration, and the metal particles eventually jam the ball in place. The battery was tested and had an acceptable output.

On April 20, 2005, the MIDO ASI obtained further information from Artex, which indicated that this model ELT has a history of failures based on the contact ball in the G-switch sticking due to wear. The length of time before this occurs varies with the amount of vibration the ELT is subjected to.

ADDITIONAL INFORMATION

The IIC released the wreckage to the owner's representative on July 21, 2005.

NTSB Probable Cause

The failure of the private pilot and the flight instructor to maintain adequate terrain clearance while flying in unfamiliar mountainous terrain in dark night conditions.