NTSB Factual Report

HISTORY OF FLIGHT

On June 3, 2001, about 1936 Pacific daylight time, a Piper PA-28-181, N8253W, became missing in the vicinity of Lytle Creek, California, on a flight from Perris, California, to La Verne, California. The airplane departed Perris Valley Airport at 1910 en route to Brackett Field in La Verne. Air Desert Pacific operated the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91, and rented it to the pilot for a personal flight. The operator reported that the airplane was overdue on June 6. The San Bernardino County Sheriff’s Aero Bureau discovered the wreckage on September 21, 2008. The airplane sustained substantial damage, and the private pilot was killed. Visual meteorological conditions prevailed, and no flight plan had been filed.

The flight originated from Brackett Field on the day of the accident. The operator reported that a dispatcher released the airplane to the pilot about 1500. The pilot told the dispatcher that he would be going to Perris Valley to skydive, and return later that night. He said if he were unable to land at Brackett, he would probably land at Cable Airport in Upland, California.

The Air Force Rescue Coordination Center (AFRCC) initiated mission number 01M1200A, and the Civil Air Patrol (CAP) organized a search. A CAP officer provided the following information.

Witnesses from the skydiving business reported that they observed the pilot board the airplane, and depart from Perris about 1915. March Air Force Base air traffic control reported that a pilot checked in, identified his airplane as N8253W, and requested flight following. The controller assigned the airplane a discrete beacon code of 0146, and followed the airplane through March airspace. Southern California Terminal Radar Approach Control (SCT TRACON) could not accommodate the pilot with flight following, so March controllers instructed the pilot to squawk 1200, proceed VFR, and try to establish contact with SCT.

About 5 minutes later, N8253W established contact with SCT, and they assigned a discrete beacon code of 0274.

A review of recorded radar data illustrated that the airplane track proceeded along a northerly heading over San Bernardino, and then turned toward the west. SCT informed the pilot that they would be losing radar contact soon, and advised the pilot to proceed VFR. The pilot responded that he was 17 to 18 miles from Brackett. No further transmissions were received from the pilot.

The corrected mode C reported altitude remained steady at 2,500 feet mean sea level (msl) until the target initiated a climb to 2,900 feet about 1 1/2 minutes prior to loss of radar contact.

The beacon code remained on 0274 until the last secondary beacon target at 34 degrees 11 minutes 42 seconds north latitude and 117 degrees 26 minutes 43 seconds west longitude. This location was in the mouth of a canyon that leads to Lytle Creek. This target displayed a corrected mode C reported altitude of 2,900 feet at 1931:47.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed that the 24 year old pilot held a private pilot certificate with a rating for airplane single-engine land. He had a third-class medical certificate issued on October 6, 1999. It had no limitations or waivers.

No personal flight records were located for the pilot. The Safety Board investigator-in-charge (IIC) obtained flight time information from the FAA Airman's Record Branch in Oklahoma, City, Oklahoma. On the pilot's application for a private pilot certificate dated April 18, 2000, the pilot indicated a total time of 50.6 hours.

AIRCRAFT INFORMATION

The airplane was a Piper PA-28-181, serial number 28-8190015. A review of the airplane's logbooks revealed that the airplane had an annual inspection on April 21, 2001. It had a total airframe time of 4,818 hours at the last 100-hour inspection dated May 30, 2001. The tachometer read 4,832 at the accident scene.

The engine was a Textron Lycoming O-360-A4M, serial number L-28490-36A. Total time recorded on the engine at the last 100-hour inspection was 4,818 hours, and time since major overhaul was 2,617 hours.

METEOROLOGICAL CONDITIONS

A routine aviation weather report (METAR) was issued for Brackett Field at 1847 PDT. It reported: skies overcast at 2,500 feet; wind 240 degrees at 7 knots; visibility 7 statute miles; and altimeter 29.80 inches of mercury.

A METAR was issued for Brackett Field at 1947 PDT. It reported: skies overcast at 2,400 feet; wind 250 degrees at 8 knots; visibility 7 statute miles; and altimeter 29.78 inches of mercury.

A METAR was issued for the airport at Riverside, California, at 1953 PDT. It reported: scattered clouds at 4,400 feet; wind 290 degrees at 9 knots; visibility 10 statute miles; temperature 64 degrees Fahrenheit; dew point 54 degrees; and altimeter 29.75 inches of mercury.

A METAR was issued for the airport at Ontario, California, at 1953 PDT. It stated: skies broken at 2,800 feet and 4,500 feet; wind 250 degrees at 8 knots; visibility 10 statute miles; temperature 63 degrees Fahrenheit; dew point 55 degrees; and altimeter 29.76 inches of mercury.

According to a Safety Board Sun/Moon position computer program, sunset occurred at 1953 on the day of the accident.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest on a steep slope near the top southern side of a box canyon that was the middle fork of Lytle Creek. The middle fork canyon is generally oriented east/west. The orientation of the fuselage was about 180 degrees. The approximate global positioning satellite (GPS) estimated elevation of the accident site was 5,600 feet.

The IIC flew over the site in a helicopter. The engine was canted to the left and slightly nose down. The propeller sheared off. The fuselage was on its right side between a boulder and a tree. The right wing was folded under the fuselage. The left wing separated, and was several hundred feet below the main wreckage. It was in a drainage that started above the main wreckage.

MEDICAL AND PATHOLOGICAL INFORMATION

The San Bernardino County Coroner located several bone fragments. A toxicological test could not be conducted.

TESTS AND RESEARCH

Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on October 8, 2008.

Engine

The front of the engine sustained the most mechanical damage. The ring gear fractured and separated around its circumference; the fracture surface was jagged.

The intake and exhaust tubes exhibited mechanical crush damage at the front of the engine. The number two intake tube and numbers one and two exhaust tubes had ductile bending. The front exhaust tubes were displaced aft, and bent at the cylinder attachment points. The number three exhaust tube was crushed at its connection point to the muffler.

Investigators removed the engine. They slung it from a hoist, and removed the spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were circular, wet and oily; the gaps were similar. A runny mixture of black and clear fluids drained from the cylinders upon removal of the lower spark plugs. Several leads on the ignition harness were crushed and torn.

A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head.

The crankshaft was manually rotated with a wrench on the fractured propeller flange. 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. Thumb compression was obtained on all cylinders in firing order.

The magnetos were manually rotated. The right magneto produced spark for all cylinders; the left magneto did not spark. A follow-up test on a magneto test unit produced spark at all posts.

The oil filter contained no debris. The oil cooler remained attached with its lines connected, but it sustained mechanical crush damage.

The fuel pump's rubber diaphragm was unbroken. Air could be heard moving when manually operating the operating arm.

The carburetor’s mounting pad remained attached to the engine along with the throttle valve, which moved freely over 90-degrees of motion when manually operated. The bottom of the carburetor separated; the fracture surface was rough and jagged with a matte appearance. The bottom was hanging by the throttle cable. The finger screen in the carburetor was clean. The bowl was dry, and contained a spider and a spider web. The accelerator pump moved up and down, and squirted a fluid out when first manually operated.

Propeller

The propeller separated between the flange and the front of the case. The crankshaft was bent and oval shaped. The fracture surface on the crankshaft was along a 45-degree angle around half of the circumference, and the rest of the fracture surface was a jagged shear lip.

The outboard half of one blade fractured and separated along a rough, jagged, and V-shaped angular fracture surface. There were gouges and scrapes on the cambered side. The leading edge had gouges and angular chordwise striations. It bent forward about 90 degrees.

The leading edge tip of the second blade separated along a jagged and angular plane. It twisted 90 degrees toward the low pitch, high rpm position. The leading edge had gouges and chordwise striations.

Airframe

The bottom of the fuselage under the cockpit area exhibited upward crush damage, and the skin was ripped open. Te airframe structure sustained mechanical damage and was deformed. The cockpit entry door was open, but the door’s inner and outer latches were in the locked position as was the latch mechanism. The baggage door separated along the hinge skin; the airframe buckled upward in the front baggage area.

The right wing folded underneath the fuselage. The aileron and flap remained attached to the wing, which exhibited leading edge aft crush damage on the inboard third of the wing and along several feet of the wing tip.

The left wing sustained more damage than the right wing. It separated at the wing root along a jagged and angular plane. It exhibited aft crush damage to the spar along its entire length except for the area containing the fuel tank. The wing surfaces, flap, and aileron were all buckled, torn, and deformed.

About 1 foot of the left horizontal stabilizer exhibited several inches of aft crush damage; the right one was unremarkable. The rudder showed slight buckling below the white navigation light.

Control continuity was established for all flight controls. The rudder and elevator components were continuous from the control surface to the cockpit controls. The aileron chain was broken; the turnbuckle was intact, and the cable ends remained attached to each end of the chain. The right aileron cables maintained continuity from the chain end to the control surface, and were cut during recovery. The left aileron bellcrank separated from the airframe. The cables and operating arm remained attached to the bellcrank. The operating arm rod was bent and the rod end separated about 6 threads from the jam nut. One cable separated about 1 foot from the bellcrank in a broomstraw fashion. The other cable sawtoothed through the lower wing skin.

The pilot's handles on the rams horn control yoke fractured and separated on the horizontal portion with an irregular fracture surface.

The pilot's lap belt was not fastened. The pilot's shoulder harness was in its stowed position along the side of the cabin above the left side windows.

The fuel selector valve was in the right main position.

The flap handle was in the up position, and the flaps were in the retracted position. The Piper investigator measured four threads on the elevator trim, and noted that five threads represented the neutral position.

The master switch was a split type, and both were ON. The magneto switch was between the left and right positions. The fuel pump and pitot heat switches were OFF. The anticollision and landing light switches were ON. Only the last two digits of the transponder could be read; they were 00. The cockpit switch for the emergency locater transmitter (ELT) was in the armed position. The switch on the ELT was in the OFF position.

Portable Global Positioning System Satellite (GPS) Examination

The coroner's investigator found a portable GPS unit at the wreckage site. The Safety Board’s Vehicle Recorder’s Division examined the unit. It was badly corroded, but the memory contained 17 data tracks.

Track log 16 began at a GPS recorded time of 6:25:27 PM on June 3, 2001, at coordinates just southwest of Brackett Field. It ended at the approximate coordinates for Perris Valley Airport at 7:07:20 PM.

Track log 17 began from the approximate coordinates for Perris Valley at a GPS time of 10:10:30 PM. At 10:31:48, the unit indicated an altitude of 3,022 feet at 34 degrees 11.752 minutes north latitude 117 degrees 26.793 minutes longitude on a 320 degree true course. The recorded data indicated that the course varied from 294 to 330 degrees over the next few minutes. The altitude indicated a continuous climb. Over the last recorded minute, the course changed toward the south. The last recorded data was at 10:36:01 PM at 34 degrees 14.471 minutes north latitude 117 degrees 32.359 minutes west longitude. The altitude was 5,739 feet, speed was 106 miles per hour, and course 186 degrees.

NTSB Probable Cause

The pilot's inadequate decision to fly into an area of rising terrain.