NTSB Factual Report

1.1 History of Flight

On January 13, 2006, about 1819 Pacific standard time, a Piper PA-30 (Twin Comanche), N7291Y, impacted terrain 410 feet from the approach end of runway 30 at Visalia Municipal Airport, Visalia, California. The commercial pilot was the registered owner of the airplane and operated it under the provisions of 14 CFR Part 91. The pilot and three passengers sustained fatal injuries; the airplane was destroyed. Night visual meteorological conditions prevailed and no flight plan had been filed. The airplane was landing following a flight from Byron Airport, Byron, California, where the pilot had picked up two child passengers and departed at 1711. The airplane was based at Visalia.

The airplane was reported overdue to the airport manager at 2145 on January 13. He received information that that the airplane's services were terminated by Fresno Approach Control at 1811, approximately 7 miles north of Visalia. At this point, the airport manager checked the emergency frequency for the transmission of an emergency locator transmitter (ELT) but no aural alarm was heard. He then began a ground search for the airplane and located it near the approach end of runway 30 at 2215. Emergency response personnel were then notified.

1.1.1 Witness Information

A witness spoke with investigators the morning following the accident. He was driving parallel to the runway about 1820 on a local road and saw the event. He saw the airplane banking and heard the engines running prior to its impact with the ground. After it impacted, there were no other sounds. The witness described what he saw with his hands and showed the airplane descending, prior to twisting to the left and impacting the ground. The witness noted that it was difficult to see due to the dark lighting conditions. After the accident, the witness drove to the local fire department where he reported the accident and told them that he may have been seeing things due to the darkness. The witness then drove back to the airport fence and noted that there was no immediate fire department response.

The fire department was contacted regarding this report and advised that the city of Visalia was conducting an investigation into the report. They did not make any comments regarding the witness' report to the National Transportation Safety Board investigator.

A pilot that was flying a King Air from Santa Monica Airport heard the accident pilot on the Visalia airport UNICOM. The accident pilot called downwind and the pilot and accident pilot exchanged general light conversation. The accident pilot then called base and no further transmissions were heard. The witness landed about 1830 and thought the transmissions with the accident pilot occurred between 1820 and 1825. After refueling, the witness departed about 1900 and returned about 2215. The witness flew over the accident site twice during the evening and did not see it. The witness further noted that although he did not personally know the accident pilot, he believed that the accident pilot flew at least 3 to 4 times per week for business purposes. Dark lighting conditions existed with clear skies or high cirrus clouds, and light winds favoring runway 30. The witness also noted that the medium intensity approach lighting system was on when the accident airplane was attempting to land.

Another pilot was returning from picking up a student and a coworker. His wife was also in the airplane. The pilot was on downwind and he heard the accident pilot and a King Air pilot on the UNICOM frequency. The King Air pilot told the accident pilot that he had plenty of room to land and to go ahead. The pilot saw the airplane turn onto 1/2-mile final with the King Air pilot about 4 miles out, and everything appeared normal. After that time, the pilot began concentrating on flying the airplane and configuring it for landing. He estimated that he landed about 20 seconds after the airplane crashed.

1.2 Personnel Information

1.2.1 Pilot Information

The pilot held a commercial certificate with ratings for single engine, multiengine, and instrument airplanes. His last medical was obtained on February 1, 2005, and it was a third-class. On the pilot's last medical application, he indicated a total flight time of 5,700 flight hours and 75 hours in the previous 6 months. The pilot completed a flight review on January 5, 2005, in a Cessna 172. No personal flight logbooks were located for the pilot.

1.2.2 Pilot 72-Hour History

According to the pilot's family, during the days leading up to the accident, he was traveling for work. On January 10, the pilot flew commercially to Portland, Oregon, where he performed work functions and then drove to Seattle. On January 11 and 12, the pilot attended meetings and had some extra personal time prior to his return flight to California. On the evening of January 12, the pilot went to dinner with friends in Seattle and then flew commercially to Fresno after his flight was delayed for 1 hour. Upon arriving in the Fresno area, he offered his business partner a ride home and dropped him off at 0030 on January 13. The pilot is then presumed to have driven home and arrived there about 0130 on January 13.

At 1330 on the day of the accident, the pilot made arrangements to pickup the passengers at Byron. At 1650, the pilot and one passenger landed at Byron Airport. They departed with two additional passengers at 1711.

1.3 Aircraft Information

1.3.1 General Aircraft History

The Piper PA-30 airplane (serial number 30-329) was manufactured in 1964. In 1984, it had been modified from its original design to have two counter rotating Textron Lycoming engines, which powered two Hartzell propellers. The installed engines were: Textron Lycoming LIO-320-B1A (right) and a Textron Lycoming IO-320-B1A (left).

The type certificate data sheet (TCDS), identification A1EA, indicated that the airplane was certified with two Lycoming IO-320-B1A engines, and referenced additional certified engine installations in note 5. In note 5 of the TCDS, it stated that the following engines were eligible for installation: left, IO-520-C1A, and right, LIO-520-C1A.

In the maintenance records for the airplane, it was noted that the installation was approved through Federal Aviation Administration (FAA) Form 337, Major Repair and Alteration, dated December 14, 1984. The FAA Form 337 noted that the Piper Counter Rotating Powerplant Conversion Kit was installed per Piper Service Letter 552. Supplement 11 of the PA-30 approved flight manual (AFM) pertained to the installation of a counter rotating power plant on the right side. In the limitations section, the engine model designations were Textron Lycoming LIO-320-B1A (right) and a Textron Lycoming IO-320-B1A (left). The propeller designations were a Hartzell HC-E2YL-2 (left) and a Hartzell HC-E2YL-2BL (right).

1.3.2 Maintenance Information

The last annual inspection was performed on November 3, 2005. At the time of the inspection, the total time on the airframe was 2,981.1 hours. During this inspection it was noted that the ELT was inspected in accordance with FAR 91.207 (D). This FAR requires that the ELT be checked for proper installation, battery corrosion, operation of the controls and crash sensor, and the presence of a sufficient signal radiated from its antenna. At the annual inspection, the left engine had accrued 1,998.2 hours since its last major overhaul. The right engine had accrued 1,959.1 hours since its last major overhaul. The times listed in the engine logbooks were logged incorrectly and an attached letter from the maintenance company explaining these discrepancies is included with the docket material for this accident.

1.3.3 Oil Analysis

The airplane underwent recurring oil analysis for each engine and the testing was completed at Aviation Oil Analysis. The sample dates dated from October 9, 2003, to December 26, 2005. The processing date for the December 26 oil samples was noted as January 9, 2006. The right engine samples were generally unremarkable although on September 19, 2005, the nickel values were noted as abnormal. The following month the same value was noted but the results indicated normal.

The left engine showed no abnormal wear from October 2003 until November 2004. On the March 2005 sample the following codes were noted: engine/oil time unknown (112); aluminum appears slightly high (101); chrome appears slightly high (105); and resample next oil change to check wear trend (170). The next sample date was July 8, 2005, and the following codes were noted: engine time unknown (162); aluminum appears slightly high (101); resample next oil change to check wear trend (170); and see comments below (995). The comment section indicated that no sample date was provided with the submitted oil sample. The next sample was taken on September 15, 2005, and the following codes were noted: aluminum appears high (102) and resample every 25 hours to monitor wear trend (135). The last sample on December 26, 2005, showed the following codes: wear metal high indicating possible piston wear (145); check oil filter for chips (108); and resample 15 to 20 hours to monitor wear trend (158). The last sample was obtained from the oil analysis company and was not with the maintenance logbooks for the airplane.

1.3.3 Installed Equipment

The airplane was equipped with a Garmin 296 personal global positioning system unit. The unit was powered at Garmin International under the supervision of an FAA Kansas City Flight Standards District Office inspector. The unit sustained significant impact damage. It was powered using a 12-volt power source and the data was extracted using a USB PC interface cable. The unit contained 74 waypoints, 2 routes, 82 tracklogs, and 10,000 trackpoints (70 of the trackpoints were recorded on January 13, 2006). The first recording on January 13 was at 1554. The last recorded trackpoint was 25 nautical miles northwest of the Visalia airport. The Garmin representative indicated that the tracklog terminating at this location could be due to two reasons; the user may have turned the unit off at this point or the user at a previous time may have changed the record method for the tracklog from the default of "wrap" to "fill." In the "fill" mode, the unit records trackpoints until the track memory has reached its capacity of 10,000 points. Due to the damage sustained to the unit, the Garmin representative was unable to determine to what track record method the unit was set. The data stored in the unit indicated that the unit was powered on for three flights in October, four flights in November, two flights in December, and two flights in January, which included the first leg of the accident flight.

1.4 Meteorological Information

An FAA Airway Transportation Systems Specialist retrieved an archived data report for the Visalia airport automated weather observation system (AWOS). The report indicated the following for 1820: wind from 170 at 0 knots; visibility 6 miles; sky condition clear; temperature 54 degrees Fahrenheit; dew point 48 degrees Fahrenheit; and altimeter 29.94 inches of Mercury.

1.5 Wreckage and Impact Information

On January 14, the National Transportation Safety Board investigator, two FAA inspectors from the Fresno Flight Standards District Office, and a representative from New Piper, a party to the investigation, responded to the accident scene. The airplane came to rest on a heading of 060 degrees, 410 feet from the end of runway 30. The initial impact point formed two impact craters; the first located approximately 3 feet from the right wing tip and containing the right propeller, and the second located approximately 12 feet from the first. The impact craters were oriented on an approximate heading of 152 degrees. Investigators measured the distance between the right and left engines and noted a distance of about 12 feet.

The wreckage was confined to the general impact area and all control surfaces were accounted for and still attached to the airplane. Vertical aft accordion crushing was evident on the forward engine nacelles and the nose section. The entire forward portion of the fuselage was crushed and pushed aft. The right wing sustained leading edge crush inboard of the right engine in both an upward and aft direction and the light buckling was present over the wing skins. The left wing was crushed upward and aft from the left engine, outboard 4.5 feet to a rivet line where the skin was torn. From this point outboard, the leading edge was bent and the tip was crumpled and bent upward.

Fuel, consistent in color and smell with aviation grade 100 LL, was found in each of the main and outboard fuel tanks.

1.6 Medical and Pathological Information

The Tulare County Sheriff's Office, Coroner Division, completed an autopsy on the pilot and external examinations on the passengers. The FAA's Bioaeronautical Research Laboratory completed toxicological testing on samples from the pilot. The toxicological report was positive for the following:

ATENOLOL detected in Blood

ATENOLOL present in Urine

1.677 (ug/ml, ug/g) DOXYLAMINE detected in Blood

DOXYLAMINE present in Urine

The report was negative for cyanide, volatiles, and all other tested drugs.

The Safety Board Medical Officer reviewed the pilot's medical records obtained by subpoena from a primary care doctor and those records maintained by the FAA Aerospace Medical Certification Division. On the pilot's most recent application for his third-class medical certificate he reported using only Voltaren and Lipitor. The pilot reported no in response to all medical history conditions except for "Military medical discharge," and "Admission to Hospital." In the explanation section it was noted, "Replace both knees."

Review of primary care physician records showed that the pilot had been prescribed atenolol and hydrochlorothiazide/triamterene for the control of high blood pressure. He was also noted to have had a long history of intermittent low back pain that was significantly worsening in March 2005. At that time he was unable to complete an MRI examination of his lower back due to the pain. He was noted to be complaining of difficulty sleeping due to the back pain on four different occasions from September 2004 until March 2005. There was no notation of sleep aids prescribed for the pilot, and, after March 2005, there was no indication in the records of any further treatment of the pilot's pain.

1.7 Survival Aspects

The airplane occupant restraint system did not include shoulder harnesses. The front passengers were wearing their lap belts. The rear passengers sat on GRACO backless booster car seats.

In 1995 the Piper Aircraft Company issued Service Bulletin (SB) 980 outlining the procedures for the installation of an approved shoulder harness restraint system. The SB is mandatory and encourages owners to install the shoulder harness kits to improve airplane safety. Also, two supplemental type certificates (STC) are on file with the FAA for the installation of front seat shoulder harnesses (STC Numbers SA0048WI and SA1689SO). In addition, one STC is on file for the installation of the rear seat shoulder harnesses (STC Number SA00746WI).

The FAA published Seat Belts and Shoulder Harnesses, Smart Protection for Small Airplanes (AM-400-90/2). In the publication it states that seat belts alone will only protect the occupant in very minor impacts and that using shoulder harnesses in small aircraft would reduce injuries by 88 percent and fatalities by 20 percent. The publication also noted that small children should be placed and secured in approved "child safety seat" devices during aircraft operation. The publication goes on to say, "install the child safety seat according to the instructions on the seat, using the airplane safety belt to secure it. When children outgrow the safety seat, they can safely get by using only the airplane seat belt. Larger children can use a shoulder harness if it does not rub on their face or neck when they are seated."

The National Highway Traffic Safety Administration notes that seat belts are not designed for children.

NTSB Probable Cause

the pilot's failure to maintain airspeed during the landing approach, which resulted in a stall and uncontrolled descent. Contributing factors to the accident were the pilot's impairment due to his prolonged use of a highly sedating over-the-counter sleep aid and fatigue due to lack of sleep.