NTSB Factual Report

HISTORY OF THE FLIGHT

On April 20, 1994, at 1123 hours Pacific daylight time, a Piper PA-32R-301T, N8171G, crashed after takeoff from runway 21 at the Santa Monica Municipal Airport, Santa Monica, California. The airplane was being operated by the pilot as an instrument flight rules (IFR) cross-country flight to Van Nuys, California, when the accident occurred. The airplane was destroyed by the impact sequence and postimpact fire. The certificated commercial pilot, the sole occupant, was fatally injured. Visual meteorological conditions prevailed at the time. The flight originated from Bermuda Dunes, California, and was part of a continuing flight to Van Nuys.

A Federal Aviation Administration (FAA) airworthiness inspector, Van Nuys Flight Standards District Office, reported that the pilot departed the Van Nuys Airport on April 19, 1994, and flew to the Los Angeles International Airport. After picking up passengers, the airplane departed for Bermuda Dunes. On April 20, 1994, the pilot arrived at the Santa Monica Airport and a passenger disembarked at a fixed-based operator's facility. The aircraft then taxied to runway 21 for departure. Following departure, no further communications were received from the pilot.

At 1121:50 hours, continuous data recording (cdr) radar data from the FAA's Southern California Terminal Radar Approach Control (TRACON) Facility at the Los Angeles International Airport indicated that the airplane's radar track began at 200 feet mean sea level (msl). The airplane climbed to a maximum altitude of 400 feet. The radar track ended at 1122:08 hours at 300 feet.

Witnesses reported that the airplane's ground roll and initial climb appeared normal. As the airplane passed over the departure end of runway 21, the engine began to sputter. The airplane was then observed to enter a right turn, reverse course, and descend in a nose-down attitude. The airplane collided with a power pole and electrical wires and came to rest against the back of a private residence garage. No persons on the ground were injured.

The accident occurred during the hours of daylight at latitude 34 degrees, 00.79 minutes north and longitude 118 degrees, 27.54 minutes west.

OTHER DAMAGE

The airplane struck a utility pole and then a residential garage building at the point of rest.

CREW INFORMATION

The pilot held a commercial pilot certificate with airplane single-engine land, multiengine land, and instrument airplane ratings. In addition, the pilot held a flight instructor certificate with an airplane single-engine rating. The most recent first-class medical certificate was issued to the pilot on August 10, 1993 and contained no limitations.

According to the pilot's logbook, his total aeronautical experience consists of about 1,055 hours, of which 24 hours were accrued in the accident aircraft make and model. In the preceding 90 and 30 days prior to the accident, the logbook lists a total of 129 and 35 hours, respectively, flown.

AIRCRAFT INFORMATION

The airplane had accumulated a total time in service of 2,009.3 flight hours. Examination of the maintenance records revealed that the most recent annual inspection was accomplished on March 21, 1994, 24.5 flight hours before the accident.

The engine also had accrued a total time in service of 2,009.3 hours of operation. The maintenance records note that a major overhaul was accomplished on September 11, 1991, 266.1 hours of operation before the accident. An annual inspection was accomplished on the date specified above for the airframe.

The last documented fueling of the aircraft occurred at the Van Nuys Airport on April 19, 1994, with the addition of 60 gallons of 100LL octane aviation fuel. Examination of the maintenance records revealed no unresolved maintenance discrepancies against the airplane prior to departure.

METEOROLOGICAL INFORMATION

The closest official weather observation station is Santa Monica, California, which is located at the departure airport. At 1124 hours, a special surface observation was reporting in part: Sky condition and ceiling, partial obscuration, 1,200 feet overcast; visibility, 3 miles in fog; temperature, 66 degrees F; dew point, 57 degrees F; wind, 100 degrees at 5 knots; altimeter, 29.98 inHg.

AERODROME AND GROUND FACILITIES

The Santa Monica Municipal airport has a published elevation of 172 feet msl. The airport is equipped with a single, hard- surfaced runway on a 030/210 degree magnetic orientation. Runway 21 is 4,987 feet long by 150 feet wide.

WRECKAGE AND IMPACT INFORMATION

National Transportation Safety Board investigators examined the airplane wreckage at the accident site on April 20, 1994. A path of wreckage debris from the initial point of contact with a utility pole to the wreckage point of rest was observed on a magnetic heading of 353 degrees. (All heading/bearings noted in this report are oriented toward magnetic north.) A second examination of the wreckage was conducted on April 29, 1994, after the airplane was recovered.

The first identified impact point was with a utility pole about 35 feet above the ground. About 4 feet of the outboard end of the right wing, including the wing tip, were located at the base of the pole. The airplane came to rest about 70 feet from the pole with the empennage resting against the south wall of a residential garage in about a 60-degree nose-down attitude. At the point of rest, the fuselage was oriented on a 137 degree heading.

The cabin floor and underside of the aft fuselage were crushed in an upward direction. The left wing and inboard section of the right wing remained attached to the fuselage. Fire destroyed the right wing and right side of the fuselage. Arriving fire department personnel reported that fuel was observed dripping out of the right wing and placed a garbage can under the wing to contain the leaking fuel. About 1 gallon of fuel was recovered from the right wing.

The left wing exhibited aft crushing and upward curling of the leading edge from the wing tip inboard about 2 1/2 feet. The leading edge of the left wing exhibited buckling and a small rupture about 4 feet outboard from the fuselage. Slight sooting was observed on the upper surface of the wing at the leading edge. About 16 ounces of blue-colored fuel was recovered from the fuel tank. Extensive sooting was observed on the underside of the wing from the leading edge in an aft direction about 4 feet outboard from the fuselage. The underside of the wing exhibited about a 4-inch puncture about 2 feet aft of the leading edge that penetrated the inboard fuel tank. Small pieces of wood were observed in the hole. The wood pieces and surrounding wing structure did not exhibit any charring, paint blistering, or damage. The under wing sooting extended from the leading edge to the trailing edge of the flap and did not emanate from the puncture.

The empennage remained attached to the fuselage. Fire damage was evident at the base of the vertical stabilizer and on the inboard end of the left horizontal stabilizer. Due to the impact and postimpact fire damage, Safety Board investigators were unable to operate the flight controls by their respective control mechanisms; they were, however, able to establish continuity of the flight control cables to the cabin/cockpit area. The flight control cable chain was engaged with the control column sprocket gear.

The three-bladed propeller assembly separated from the engine crankshaft. It was located about 10 feet south of the main wreckage. All three blades remained attached to the hub. The spinner was crushed aft over the hub. One propeller blade exhibited about a 10-degree aft bend about midspan. The second blade exhibited a slight forward bend about midspan with torsional twisting. The third blade was broken in the hub and rotated with the leading edge forward about 90 degrees. It also exhibited aft bending about midspan and torsional twisting. All of the blades exhibited slight leading edge gouging, slight chordwise scratching, and dirt on the outboard half of each blade.

The engine was crushed aft against the firewall and was twisted about 90 degrees to the left along its longitudinal axis. It sustained impact damage to the front and underside portion of the engine case. The starter ring gear was broken and crushed aft. The gear teeth were crushed into a portion of induction tubing producing rotational gouging marks. Hand rotation of the crankshaft produced 360 degrees of rotation. Gear and valve train continuity was established and thumb compression in each cylinder was noted when the crankshaft was rotated.

The turbocharger received slight impact damage in an aft direction. The pressure relief valve was distorted. Hand rotation of the turbocharger impeller produced 360-degree rotation with slight resistance. The waste gate was found in the fully-closed position.

The fuel servo throttle arm was found in the full-open position. Vegetation was found in the inlet. The inlet screen was free of contaminants and was damp with an odor of fuel. The fuel mixture control rod was destroyed. The fuel control butterfly valve was found in a near full-open position.

The fuel line to the fuel servo was broken at its attach fitting. About 1/2 ounce of blue-colored fuel was retrieved from the fuel line. The fuel selector filter was free of contaminants and contained the presence of fuel. The fuel selector was positioned on the left tank. The engine driven fuel pump was devoid of fuel and the diaphragm was intact. After removal from the engine, it could be rotated by hand. Application of electrical power to the fuel boost pump produced pump action.

The magnetos produced spark at all upper terminals upon hand rotation. The vacuum pump internal block was broken in numerous pieces. The vanes were intact. The sparks plugs exhibited no unusual combustion signatures.

MEDICAL AND PATHOLOGICAL INFORMATION

A post mortem examination of the pilot was conducted by the Los Angeles County Department of Coroner, 1104 N. Mission, Los Angeles, California, 90033, on April 22, 1994. The cause of death for the pilot was attributed by the attesting pathologists to multiple blunt force injuries.

A toxicological examination of the pilot was conducted by the FAA Civil Aeromedical Institute (CAMI) on October 4, 1994. The examination revealed nicotine metabolite in the blood and urine. In addition, 0.034 (ug/ml, ug/g) Benzolyecgonine was detected in urine. CAMI personnel reported that Benzolyecgonine is a metabolite of cocaine and medical literature has shown that the finding of Benzolyecgonine in the urine, and a lack of cocaine in the blood or urine, has no effect on pilot performance.

FIRE ASPECTS

After ground impact, a witness arrived at the accident site and observed fire beginning at the right wing root, next to the engine. Fire progressed up the right side of the fuselage. Fire then progressed along the leading edge of the left wing in an outboard direction from the fuselage. Bystanders began spraying water on the burning aircraft and rescuers. The witness indicated that the source of fire was due to a seepage of fuel along the ground from the right wing.

TESTS AND RESEARCH

On May 17, 1994, Safety Board investigators conducted an examination of the engine's turbocharger at Allied Signal, Torrance, California. The pressure relief valve was distorted and unable to be bench tested. The turbocharger received light impact damage. The turbocharger shaft could be rotated with slight resistance. Asymmetrical rotational scoring was noted on the inner compressor housing. Allied Signal personnel noted several discrepancies with components of the internal center housing. It contained several non-aviation grade commercial components. A drain can attached to the center section outlet oil port contained a loose nut that was heard rattling inside the can. The interior of the can does not contain any fittings for the nut. According to the manufacturer, the discrepancies noted in the interior center housing did not affect the functional capability of the turbocharger. The turbocharger was last overhauled in September, 1991.

ADDITIONAL INFORMATION

WRECKAGE RELEASE

The Safety Board released the wreckage, located at Aero Aviation, Compton, California, to the owner's representatives on May 25, 1994. No parts or components were retained by the Safety Board. The engine turbocharger was retained by FAA airworthiness inspectors.

NTSB Probable Cause

fuel starvation resulting from the failure of the pilot to select a tank containing fuel, and his failure to maintain adequate airspeed while maneuvering for a forced landing which resulted in an inadvertent stall.