NTSB Factual Report

HISTORY OF FLIGHT

On July 3, 1994, at 1603 Pacific daylight time, a Piper PA-28-181, N4321N, collided with level terrain approximately 1/2 mile south-southeast of the Lake Tahoe Airport, South Lake Tahoe, California. The aircraft was operated by Inbound Aviation of San Jose, California, and rented by the pilot for a personal cross- country flight. Visual meteorological conditions prevailed during the personal flight. The airplane was destroyed by impact forces and postimpact ground fire. The private pilot and two passengers were fatally injured. The flight was originating at the time of the accident.

According to the Federal Aviation Administration (FAA) coordinator, at 1518 the pilot received a preflight weather briefing from the Reno Flight Service Station. Thereafter, the pilot filed a VFR flight plan to San Jose, California.

Airport personnel reported to the National Transportation Safety Board that prior to the pilot's takeoff the airplane's two fuel tanks were filled to the level of the 17-gallon filler neck indicator tabs. Also, the pilot indicated to a line service person that he was unfamiliar with the airport.

At 1553, the pilot contacted the Lake Tahoe ground controller and requested a clearance to taxi for takeoff. The controller reported that he issued the pilot the requested clearance. Also, the controller provided the pilot with wind and temperature information, and advised the pilot to check the density altitude.

At 1601, the pilot contacted the Lake Tahoe local controller and requested a clearance to take off. The controller reported that he issued the pilot the requested clearance. During an interview with the Safety Board, the controller reported that he observed the accident airplane taxi onto the beginning of runway 18. However, before beginning its takeoff roll, the airplane remained stationary on the runway for between 15 and 20 seconds. Thereafter, the airplane began its takeoff roll, and nothing unusual was noted. The controller further indicated that the airplane became airborne after rolling between 2,500 and 3,000 feet.

In a written statement, the controller reported that after the aircraft took off, he heard the pilot broadcast that he was "in an emergency situation" and then he observed the airplane "in an extreme right wing up/nose-down attitude. The aircraft disappeared behind trees approximately 200 yards east of the runway and burst into flames upon impact." The FAA reported that an emergency locator transmitter (ELT) signal was briefly heard at 1603.

Several witnesses reported to the Safety Board that they observed the airplane during its initial climb. None of the witnesses reported hearing any sound from the airplane other than what they described as a normal-sounding engine under power. The witnesses reported that while the airplane was climbing its pitch attitude decreased and increased several times. The airplane gained a maximum altitude of 200 feet. One of the witnesses described the nose-up pitch as being "at a steep angle," and the airplane was flying slowly. Another of the witnesses reported "the nose attitude came up to approximately 25 degrees."

All of the witnesses reported observing the airplane commence a left bank turn prior to it reaching the south end of the runway. One of the witnesses described the steepness of the turn as being like a "wingover." In general, the witnesses indicated to the Safety Board that during the turn the airplane's bank angle increased while its nose pitch attitude decreased, and the airplane descended into terrain while in a left bank. All of the witnesses reported that within seconds after they lost sight of the airplane they observed a plume of smoke emanating from a location subsequently determined to be the crash site.

PERSONNEL INFORMATION

General Experience

The Safety Board reviewed airman certification records maintained by the FAA, flight training records in the pilot's personal logbook, and interviewed the certified flight instructor (CFI) who checked out the pilot in the accident airplane. The following facts were noted:

In March of 1990, the pilot was issued a Student Pilot Certificate after having received a total of 20 dual flight instruction hours in gliders. The Student Pilot Certificate expired in March, 1992.

In November of 1991, the pilot commenced flight training using Cessna 172 airplanes in Prescott, Arizona. After flying for 25 solo hours and 50 dual instruction hours, the pilot graduated from an FAA-approved Private Pilot certification course on December 8, 1992.

The next date on which evidence was found indicating the pilot flew an airplane was March 30, 1994. The pilot's flight record logbook indicates that on this date he flew the accident airplane for 1.4 hours. The "REMARKS AND ENDORSEMENTS" column in the pilot's logbook was signed by a CFI. The flight time was listed as "DUAL RECEIVED."

The pilot's logbook indicates that he next flew the following day, and again on May 7, 1994. The flights lasted for 0.9 and 0.8 hours, respectively, and were flown in the accident airplane.

The flights were logged as "PILOT IN COMMAND (INCL. SOLO)." The pilot's next logged flight occurred on June 10, 1994. On that date, he made two flights, both in a Cessna 172, for a duration of 0.6 and 0.8 hours, respectively. The next recorded flight, which was the last flight listed in the pilot's logbook, took place on June 24, 1994. The logbook record indicates on this date the pilot received a dual instruction flight lesson in a multiengine Beech airplane for 1.2 hours.

High-Density Altitude Airport Checkout

The CFI who checked out the pilot in the accident airplane reported to the Safety Board that his checkout flight did not include a high-density altitude airport checkout. Accordingly, the pilot was not authorized to fly to Lake Tahoe, which was considered to be a high-density altitude airport.

The operator provided the Safety Board with a copy of the flying club's "By Laws/General Rules" agreement form. The form was dated March 29, 1994, and it bore the pilot's signature. In pertinent part, rule number five stated: "I will not land or takeoff from an airport with a field elevation over 4000' MSL prior to receiving a high-altitude checkout."

AIRPLANE INFORMATION

The airplane inspection times and hours listed in this report were based upon data provided by the operator.

The airplane's weight and balance data, takeoff performance charts, and most of the Piper flight manual were found in the remains of the burned wreckage.

The FAA-certificated maximum gross weight for the airplane in the normal category was 2,550 pounds. The Safety Board estimated that on the accident flight the airplane's gross weight was approximately 2,409 pounds. (See attached weight computation data.)

METEOROLOGICAL INFORMATION

At 1603 Pacific daylight time, the Lake Tahoe weather was reported, in pertinent part, as follows: Scattered clouds at 7,000 feet above ground level; visibility 50 miles; temperature 77 degrees Fahrenheit; wind from 260 degrees at 12 knots; and altimeter 30.09 inches Hg. Based upon these atmospheric conditions, the Safety Board calculated that the density altitude was approximately 8,570 feet.

AIRPORT INFORMATION

The elevation at the approach end of Lake Tahoe Airport, runway 18, was about 6,250 feet mean sea level (msl). The elevation at the departure end of the runway was about 6,264 feet msl. Runway 18 was 8,544 feet long.

In pertinent part, the following remark was printed in the U.S. Government Flight Information Publication entitled "Airport/Facility Directory":

"Normal dep Rwy 18 is a wide left downwind dep, left crosswind turn should not be made until reaching the south arpt boundary and 7500'. If sufficient altitude is not reached after tkf for crosswind turn to a downwind departure with safety approximately 1.5 miles south is a golf course where you may circle to gain altitude. . . ."

WRECKAGE AND IMPACT INFORMATION

Based upon an examination of the accident site, airplane wreckage, and from witness statements the airplane was found to have crashed into a meadow approximately 900 feet east of the runway, and 1,100 feet northeast of the departure end of runway 18. The crash site was located approximately 38 degrees, 53.10 minutes north latitude, by 119 degrees, 59.64 minutes west longitude. (See the accident site airport map.)

An examination was performed of the initial point of impact (IPI) ground scar and the fragmented airframe structure. Red-colored (left wing tip) navigation light lens fragments were found imbedded in the ground at the IPI (see photographs). About 15 feet east, portions of the airplane's left side pilot window, the outside air temperature gauge, and the compass were found along with portions of the front windscreen. The main wreckage was found between 50 and 80 feet farther east and was destroyed by fire. (See the wreckage diagram for additional information.) All of the airplane's major structural components including the wings, flaps, and all flight control surfaces were found at the accident site. No evidence was found of any preimpact component part separation. The continuity of the aileron cable control system was established between the ailerons and the control column chain/sprocket assembly. The stabilator, antiservo tab and rudder were all found attached at their respective hinges. During the wreckage examination, the left wing was found separated from its fuselage attachment points. The wing was moved from the main wreckage site and was relocated to the area where the IPI crater was found. The wing tip was positioned into the IPI crater and the crush line in the wing's leading edge was documented (see Photograph No. 9). As noted in the photograph, the deformation in the wing's leading edge matched the impact crater when the wing was held in a position consistent with the airplane being in a left 80-degree bank and 30-degree pitch-down (nose-low) attitude.

MEDICAL AND PATHOLOGICAL INFORMATION

On July 5, 1994, an autopsy was performed by the El Dorado County Sheriff/Coroner's Office, 300 Fairlane Avenue, Placerville, California. Results of the FAA toxicology tests on the pilot were negative for ethanol and all screened drugs.

TESTS AND RESEARCH

On July 5, 1994, the propeller and engine assembly were examined at the Lake Tahoe Airport. At the Safety Board's request, an FAA airworthiness inspector participated in the examination along with a Lycoming Engine factory technical representative. The following observations were noted:

The propeller was found attached to the engine's crankshaft. Its mounting flange was found crushed in an aft direction. Chordwise scratch marks were observed over the majority of the blade's cambered surface. No leading edge nicks were noted. The outboard foot-long portion of one blade was observed bent forward; the second blade was not observed to be bent.

During a 720-degree rotation of the crankshaft, the valve and gear train continuity was verified. Thumb compression was felt following removal of all upper spark plugs, and about 2 quarts of oil exited from the case. The oil suction screen was observed free of foreign and metallic material, and it was covered with oil.

The throttle and mixture control cables were observed connected to the carburetor. The carburetor bowl was opened. The venturi was observed seated and the throttle plate rotated. The fuel inlet screen was found clean. The vacuum pump drive coupling was found intact.

In conclusion, the FAA inspector and the Lycoming engine participants opined that all engine damage appeared related to postimpact events. No evidence was found of any preimpact malfunctions.

ADDITIONAL INFORMATION

The entire airplane wreckage was verbally released to the operator's assigned insurance adjuster on July 5, 1994. No parts were retained.

NTSB Probable Cause

the pilot's failure to maintain adequate airspeed during initial climb under high-density altitude weather conditions and a resultant inadvertent stall/spin. Factors which contributed to the accident were the pilot's overconfidence in his personal ability, and his lack of experience flying the airplane.