NTSB Factual Report

HISTORY OF FLIGHT

On August 8, 2005, at 1258 Pacific daylight time, a Piper PA-28-235, N8540W, veered off the runway during landing and impacted terrain at Big Bear City, California. The airplane was operated by the pilot-owner under the provisions of 14 CFR Part 91. The private pilot and one passenger were fatally injured, and the other passenger was seriously injured; the airplane was destroyed. Visual meteorological conditions prevailed, and a flight plan had not been filed. The flight originated at Henderson Field, Las Vegas, Nevada, about 1130.

Witnesses reported to the National Transportation Safety Board investigator that they observed the airplane make a normal landing approach to runway 08 and flare. The engine suddenly went to full power, the nose pitched up, and then the airplane abruptly turned to the right. It then rolled to the right and impacted the ground inverted at the south edge of the airport boundary.

Emergency crews located the airplane in a large drainage ditch. The plane was inverted and there was no fire.

Statements were taken from eight witnesses. Two of the witnesses interviewed were located at the west end of the airport and had a view of the approach end of runway 08; however, the departure half of the runway is blocked from view by a hangar. They observed the accident airplane make an uneventful approach to landing (from the west), disappear behind the hangar, and then they heard a loud crash. Within a few seconds after hearing the crash, an airplane crossed by them in the opposite direction about 100 feet over the runway heading west. None of the other witnesses recall observing another aircraft in the vicinity at the time of the accident. The Big Bear office personnel who respond to the airport UNICOM radio transmissions did not recall hearing any aircraft announce its arrival nor an aircraft announce its departure during the time surrounding the accident.

Radar data files obtained from the Federal Aviation Administration (FAA) when plotted depict a track originating at Henderson, Nevada, at 1142 PDT, identified with a transponder code of 1200, and arriving in the vicinity of Big Bear Airport at 1250 PDT. The radar track ends over the north shore of Big Bear Lake at 8,000 feet mean sea level (msl), approximately 1.5 miles west of the airport. At 1303, about 5 minutes after the accident, a radar target is identified about 2 miles to the northeast of the airport at 6,900 feet, climbing at 85 knots ground speed, and is identified with a transponder code of 1200. The target travels in a northwest then westerly direction around the north side of Delmar Mountain.

The elevation of Big Bear Airport is 6,748 feet msl, the runways available are 08 and 26, and the traffic pattern is prescribed to be flown on the south side of the runway. The approximate ground distance an airplane would cover performing a downwind departure would be 5.5 miles before the airplane left the vicinity of the airport to the east. Distance measurements are based on the Big Bear Airport arrival-departure pilot guide and the Los Angeles Sectional Chart. The floor of long-range radar coverage in the Big Bear area is limited between 7,300 feet msl in the east, 8,300 feet msl to the west, and 8,500 feet msl directly over the runway. The airport pattern altitude is 7,948 feet msl and is beneath the floor of radar coverage. Terrain usually masks targets below these altitudes.

PERSONNEL INFORMATION

A review of the FAA airman records revealed that the pilot held a private pilot certificate issued on February 11, 1988, with a rating for airplane single engine land.

The pilot held a third-class medical certificate that was issued on August 2, 2004. It had the limitation that the pilot must wear corrective lenses.

An examination of the pilot's logbook indicated that he had accumulated a total flight time of 534.1 hours, with 475.3 of those hours as pilot-in-command. His latest flight review was dated February 22, 2004. Since April 2002 the pilot logged 39.2 hours in the accident airplane, and the last logbook entry was a 1.5-hour flight dated August 5, 2005.

AIRCRAFT INFORMATION

The airplane was a single engine, low wing airplane with fixed landing gear, manufactured by Piper as a PA-28-235, serial number 28-10041. The engine was a Lycoming O-540-B2B5, serial number L-6580-40, rated for 235 horsepower at 2,575 rpm. A review of the airplane's logbook revealed a total tachometer time of 3,159 hours, and 1,959 hours since major overhaul (SMOH). The last annual inspection was dated June 12, 2005.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located on the south side of the airport along the airport boundary fence and in the drainage ditch that runs along the fence. The drainage ditch was about 20 yards wide,10 feet deep, and runs in the east-west direction. The ditch was populated with shrubs, grass, and some small pine trees. The airplane rested inverted along a bearing of 220 degrees and the nose was up against the south side of the drainage ditch. The wreckage coordinates were 34 degrees 15.753 minutes north latitude by 116 degrees 51.493 minutes west longitude. To ease the examination, the wreckage was moved 15 yards to the north onto the asphalt apron. The wreckage was examined on scene by the Safety Board investigator and a technical representative from the Piper Aircraft Company.

Three ground scar areas were identified on the asphalt apron just prior to the ditch. The center scar area consisted of two parallel linear gouges in the asphalt; a shallow gouge measuring 1 foot 4 inches in length, followed by a deeper gouge measuring 2 feet 3 inches in length. The two gouges were parallel and separated by 2 feet 1 inch. On a bearing of 180, and perpendicular to the parallel gouges, was a deep, approximately 2-foot-long, gouge in the asphalt. On a bearing of 030 degrees, and 17 feet away, was a linear paint streak with a distinct point of origin. On a bearing of 210 degrees, and 17 feet away, was a wedge like area of stained wet asphalt with a distinct origin point. The parallel asphalt gouges were approximately 14 yards from the main wreckage.

The left wing separated at the wing root spar. The spar fracture surfaces were all similar with a matte gray color, granular surface, and 45-degree shear lips. The flap had separated from its upper and lower hinge points, and laid next to the wing. The aileron was present on its hinge and the control balance weight was present. The outboard 5 feet of wing tip leading edge exhibited aft and downward crushing. There was an 8-inch flat indentation along the leading edge forward of the fuel cap. The wing tip fuel tank was ruptured and the red position light was present.

The right wing was present and attached to the fuselage. The fiberglass wing tip fuel tank was separated and found against the fence on the far side of the drainage ditch. The remaining wing tip area exhibited a 2 foot 3 inch long, 30-degree inboard to outboard crush. The flap was present on its hinges in a 25-degree down position. The aileron and control balance weight was present on its hinge. Fuel was observed in the main wing tank.

The fuselage and empennage was pulled away from the left side of the aft wing spar line. The fuselage exhibited some oil canning of the skin. The horizontal stabilator was present on the tail. The underside of the right side of the stabilator exhibited a witness mark at the root and 45-degree skin buckling was evident along its span. The right side appeared undamaged. The stabilator balance weight was present. The trim tab position was oriented at about 15 degrees up. Four and a half threads were exposed on the stabilator trim jackscrew. The vertical stabilizer was rotated aft approximately 30 degrees about the base of vertical spar. The bottom 5 inches of the rudder was buckled in "z" pattern. The top of the rudder exhibited damage to the rotating beacon and dislocation of the rudder balance weight.

The cockpit instrument panel was destroyed. The ignition switch was in the "both" position with the key broken off; the fuel pump switch was "on"; the engine tachometer read 0 rpm and 3,177.18 hours; the directional gyro read 060 and the bug was set at 350; the altimeter was set at 30.30 inHg and read 620 feet. The fuel valve was observed in the left tip-tank position. The emergency locator transmitter (ELT) switch was in the "off" position. The ELT external antenna was not present and the antenna base appeared weathered with reddish corrosion on it. The cockpit control column tee bar assembly separated at the cross tube weld, the aileron chain was broken and off the sprocket, the primary aileron control cables were attached to the chain ends and ran aft to the left and right sides of the fuselage. The left side primary aileron cable end was broom strawed, and the separated cable was attached to the left aileron bell crank along with the balance cable. The right side cable was continuous to the right aileron bell crank. The right aileron balance cable was attached to the bell crank with the opposite end of the cable exhibiting a broom strawed appearance. The stabilator cables were continuous from the cockpit tee bar to the horizontal stabilator tube assembly. The rudder cables were attached to the cockpit rudder torque tube assembly and were continuous to the rudder bell crank. The flap handle in the cockpit was in the second notch, which corresponds to 25 degrees flaps down, and the connecting cables were continuous to the flap torque tube assembly.

The engine and engine compartment was rotated to the airplane's right about 25 degrees. The nose wheel was rotated forward into the engine compartment. The carburetor was separated from the engine and fractured vertically through the bowl. The carburetor float was not present with the carburetor debris. Engine control continuity from the cockpit to the engine was not established due to the severity of damage to the carburetor. The exhaust manifold exhibited areas of ductile bending. The top spark plugs, Champion REM40Es, were removed and examined. Cylinder 2, 4, and 6 spark plugs were oil soaked, and cylinder 1, 3, and 5 spark plugs were gray in color. The spark plugs exhibited no indications of mechanical damage. The vacuum pump was removed and the engine was rotated using the vacuum pump accessory drive. The engine rotated producing thumb compression on all six cylinders in firing order. The propeller was separated from the crank flange and was located next to the fence on the far side of the ditch. The propeller was a McCauley fixed pitch prop and had chordwise striations along both tips and leading edge gouging. Both tips were curled and twisted along the blade span.

MEDICAL AND PATHOLICIAL INFORMATION

The San Bernardino County Sheriff-Coroner completed the autopsy on the pilot. The FAA Forensic Toxicology Research Team performed toxicological testing of specimens from the pilot. The results of the analysis were negative for carbon monoxide, cyanide, ethanol, or tested drugs.

ADDITIONAL INFORMATION

Cross-Control Stall

Cross-Control Stalls are discussed in the FAA-H-8083-Airplane Flying Handbook, chapter 4 - Slow flight, stalls, and spins.

"This type of stall occurs with the controls crossed - aileron pressure applied in one direction and rudder pressure in the opposite direction."

"The addition of inside rudder pressure will cause the speed of the outer wing to increase, therefore, creating greater lift on that wing. To keep that wing from rising and to maintain a constant angle of bank, opposite aileron pressure needs to be applied. The added inside rudder pressure will also cause the nose to lower in relation to the horizon. Consequently, additional back-elevator pressure would be required to maintain a constant-pitch attitude. The resulting condition is a turn with rudder applied in one direction, aileron in the opposite direction, and excessive back-elevator pressure-a pronounced cross-control condition.

Since the airplane is in a skidding turn during the cross-control condition, the wing on the outside of the turn speeds up and produces more lift than the inside wing; thus, the airplane starts to increase its bank. The down aileron on the inside of the turn helps drag that wing back, slowing it up and decreasing its lift, which requires more aileron application. This further causes the airplane to roll. The roll may be so fast that it is possible the bank will be vertical or past vertical before it can be stopped." "The nose may pitch down, the inside wing may suddenly drop, and the airplane may continue to roll to an inverted position."

Wreckage release

The wreckage was released by the Safety Board on April 4, 2006.

NTSB Probable Cause

The pilot's failure to maintain aircraft control and adequate airspeed while executing an evasive maneuver during an aborted landing, which resulted in a cross-controlled accelerated stall and impact with terrain. Contributing to the accident was the probable presence of another aircraft on the runway traveling in the opposite direction.