NTSB Factual Report

HISTORY OF FLIGHT

On August 13, 2010, about 1245 Pacific daylight time, a Piper PA-28R-201, N3463Q, impacted pine trees and terrain in the Tahoe National Forest, near Emigrant Gap, California. Monterey Bay Aviation, Inc., operated the airplane under the provisions of 14 Code of Federal Aviation Regulations Part 91, as a cross-country flight. The certified flight instructor (CFI) and private pilot receiving instruction were fatally injured; the airplane was substantially damaged. Visual meteorological conditions prevailed for the flight that departed Auburn Municipal Airport (AUN), Auburn, California. No flight plan had been filed.

According to the Federal Aviation Administration (FAA), the flight had originally departed Watsonville Municipal Airport (WVI), Watsonville, California, about 1030, with a planned destination of Auburn; an instrument flight rules (IFR) flight plan had been filed for the flight. FAA records revealed that the IFR flight plan had been closed once the flight reached Auburn. According to the FAA, the pilots had gotten refreshments at the airport restaurant and then departed the airport about 1215.

Witnesses located at the Tunnel Mills campsite reported that the accident airplane flew over their campsite between 1230 and 1300, while they were eating lunch. The airplane was low-flying, just above the tree tops on a heading of 120 degrees. Witnesses said the engine was running and sounded normal; no sputtering. After disappearing from their view, they heard two "bangs" followed by silence. Afterward the campers were able to locate the accident site, and reported the accident to the California Highway Patrol (CHP).

PERSONNEL INFORMATION

The purpose of the flight was to provide mountain flying training for the private pilot.

CFI

A review of FAA airman records revealed that the 32-year-old pilot held a flight instructor certificate with ratings for airplane single-engine land and sea, multiengine land, and instrument airplane.

The pilot held a third-class medical certificate issued on July 7, 2008. It had no limitations or waivers. No personal flight records were made available to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC). The NTSB IIC obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma, and the pilot's experience form from the operator. The pilot was hired by Monterey Bay Aviation on December 7, 2004. At that time, the pilot listed his experience as 1,649 total hours. His last flight review at that time was July 2004.

The pilot reported on his medical application dated July 7, 2008, that he had a total time of 2,755 hours with 150 hours logged in the last 6 months. In the days preceding the accident, the flight instructor flew with the private pilot 4 times; once on July 12, 2010, for a total time of 1.1 hours, and three times on August 12, 2010, for a total of 3.5 hours.

Private Pilot Receiving Instruction

A review of FAA airman records revealed that the 21-year-old pilot held a private pilot certificate with ratings for airplane single-engine land, and instrument airplane. The pilot was issued his airplane single-engine land rating on November 27, 2005. On April 25, 2009, he was issued his instrument rating.

The pilot held a first-class medical certificate issued on September 2, 2008. It had no limitations or waivers.

The NTSB IIC reviewed the pilot's logbook; the pilot had an estimated total flight time of 332 hours. During the 4 months before the accident, the pilot had accrued an estimated 19 hours; with 3.5 hours in the accident make and model airplane. In the month preceding the accident, the private pilot flew with the flight instructor 4 times. The first flight was on July 12, 2010; the pilot received a checkout flight with the accident flight instructor. On August 12, 2010, there were a total of 3 flights with the accident flight instructor, where the pilot received instruction in canyon flying and mountain flying.

The pilot reported on his most recent medical application dated September 2, 2008, that he had a total time of 193.9 hours with 32 hours logged in the last 6 months.

AIRCRAFT INFORMATION

The airplane was a Piper PA-28R-201, serial number 28R-7737055. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 8,447.48 hours at the last annual inspection dated March 1, 2010. There were no additional entries in the airframe logbook.

According to the airplane's logbook, the next 100-hour inspection was due at a tachometer time of 8,462.06, and the next 50-hour inspection was due at a tachometer time of 8,412.06.

According to the airframe logbook, on August 1, 1999, the Lycoming IO-360-C1C6, serial number L-17052-51A, engine was removed due to a cracked crankcase. On August 7, 1999, a factory overhauled Lycoming engine IO-360-C1C6, serial number L-22246-51A, was installed on the accident airplane.

METEOROLOGICAL CONDITIONS

The nearest weather reporting station was the Blue Canyon Nyack Airport, Placer, California. The station was 3.9 miles northwest of the accident site. Recorded weather at 1352 reported wind from 310 degrees at 5 knots and clear skies, temperature 23 degrees Celsius, dew point 8 degrees Celsius, altimeter setting 30.07 inches of mercury. The calculated density altitude was 6,582 feet. An hour before the accident, at 1152, reported wind was from 270 degrees at 4 knots and clear skies, temperature 22 degrees Celsius, dew point 9 degrees Celsius, altimeter setting 30.07 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in a remote area of the Sierra Nevada Mountain Range north of the Sawtooth Ridge, in the Tahoe National Forest, 1/2 mile east of a campsite. The wreckage was at an elevation of 4,700 feet, and the main wreckage came to rest on a heading of 114 degrees, in rising mountainous terrain.

The airplane came to rest inverted at the base of 200-foot pine trees adjacent to an old logging road. The flight path of the airplane was easterly toward rising terrain. The entire wreckage came to rest in a linear distribution path of 110 yards. The main wreckage consisted of the fuselage and empennage, the right wing, and a portion of the left wing. The outer portion of the left wing, about 5 feet, separated from the wing and was found about 90 yards west of the main wreckage. The engine, firewall, and propeller assembly came to rest about 20 yards east of the main wreckage.

An impression was identified in a tree that matched the damage of the separated left wing section. The tree impression was used to compute the angle of attack of the airplane at the time of the impact. It was determined that the damage was consistent with the airplane being in a 33-degree nose up attitude, consistent with a climb, while at an 18-degree banking left turn. Another tree strike was observed to the forward fuselage at the left side of the instrument panel. The damage continued through the fuselage, separating the instrument panel, right front seat, the cabin door, forward cabin floor, and right wing.

MEDICAL AND PATHOLOGICAL INFORMATION

It could not be determined who was manipulating the flight controls at the time of the accident.

CFI

The Office of the Sheriff-Coroner – Placer County completed an autopsy on August 16, 2010, as well as toxicological testing of specimens. The coroner listed the cause of death as multiple blunt-force trauma. Analysis of the specimens contained positive finds for the Delta-9 THC, Delta-9 Carboxy THC, Caffeine, Cotinine, Nicotine, and Theobromine compounds.

Delta-9 THC 2.5 ng/mL was detected in femoral blood

Delta-9 Carboxy THC 8.7 ng/mL was detected in femoral blood

Positive results for Caffeine, Cotinine, Nicotine, Theobromine in heart blood

The FAA Bioaeronautical Sciences Research Laboratory CAMI, Oklahoma City, Oklahoma, performed toxicological testing of specimens as well. Analysis of the specimens performed by CAMI contained no findings for carbon monoxide or volatiles. The report contained the following findings for cyanide: 0.57 (ug/ml) Cyanide detected in blood (cavity). The report also contained the following findings for tested drugs:

0.1686 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Lung

0.0432 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Kidney

0.0052 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Blood (Cavity)

0.353 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Urine

0.0575 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Kidney

0.0101 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Blood (Cavity)

0.0051 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Lung.

Private Pilot Receiving Instruction

The Office of the Sheriff-Coroner – Placer County completed an autopsy, on August 16, 2010, as well as toxicological testing of specimens. The coroner listed the cause of death as multiple blunt-force trauma.

The FAA Bioaeronautical Sciences Research Laboratory CAMI, Oklahoma City, Oklahoma, performed toxicological testing of specimens. The analysis of the specimens was negative for carbine monoxide, cyanide, and ethanol. An unspecified amount of Cetirizine, an antihistamine, was detected in urine and blood.

TESTS AND RESEARCH

A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Flight control continuity was established via flight control cables and associated hardware to all primary controls. The front portion of the fuselage separated diagonally across from the left front windshield pillar through the instrument panel, right forward floor board, right front seat and door with hinges and forward structure; the tree impact also penetrated the right wing root area. The instrument panel, T-bar, and rudder pedals remained attached by control cables. The empennage remained intact, all the control cables for the empennage controls were continuous to their respective attach points and the controls were manually manipulated from the cockpit. The stabilator pitch trim drum showed 5 threads upper extension, which the manufacturer's representative reported was consistent with a neutral setting.

Visual examination of the engine revealed that the left side of the engine had sustained impact damage. The rocker push rods had sustained impact damage. The number four cylinder sustained impact damage in the exhaust rocker and valve area. The exhaust and intake systems sustained impact damage. The fuel injector had separated from its mounting bracket. The oil sump had been breached, and the alternator had sustained impact damage.

During the engine examination, the accessories were removed from the rear of the engine. Also removed were the rocker covers, all of the spark plugs, all of the fuel injectors, the flow divider, oil suction screen, fuel inlet screen, and the propeller spinner. According to the Champion Aviation Check-a-Plug chart AV27, the spark plug signatures were consistent with normal operation. The propeller was manually rotated, and thumb suction and compression were obtained in all cylinders except the number two cylinder. Further inspection revealed that the intake valve was wedged open; both rockers and their respective shafts had broken away. The damage was attributed to accident impact forces. The left magneto remained attached and secured to its mounting bracket. The right magneto had separated from its mounting pad. Both magnetos were manually rotated, and spark was observed at all posts. Investigators observed fuel at the flow divider, engine driven fuel pump, and fuel injector. An unmeasured amount of fuel was retained and tested utilizing a water disclosing paste; no water was observed in the fuel. All of the cylinders were inspected using a lighted borescope with no defects noted. The engine starter exhibited rotational scoring on the Bendix housing. According to the manufacturer, there were no pre impact malfunctions that would have precluded it from making power prior to impact.

The 3-bladed metal Hartzell propeller remained attached to the engine. The propeller governor remained attached to its mounting flange, which had been fractured. The mounting flange was removed and inspected with no additional anomalies noted. For identification purposes, the blades were marked A, B, and C. Blade A was bent forward about midspan of the blade. The trailing edge of the blade exhibited chordwise scratching. At the tip of blade A, investigators observed brown transfer discoloration. Blade B exhibited s-bending, and had a gouge near the propeller hub, as well as a brown transfer discoloration at the tip of the blade, and the face of the blade had nicks and gouges, along with chordwise/longitudinal scratching. Blade C, exhibited s-bending; about 7 inches from the propeller hub outward had an indentation on the leading edge of the blade; additionally there were several nicks and gouges along the leading and trailing edge of the blade. A brown transfer discoloration was present at the tip of the propeller blade.

NTSB Probable Cause

The pilots’ failure to maintain sufficient altitude to clear terrain while maneuvering. Contributing to the accident was the flight instructor’s delayed remedial action.