NTSB Factual Report

HISTORY OF FLIGHT

On January 28, 1995, at 1035 Pacific standard time, a Piper PA- 28-180, N9602J, owned and operated by the pilot, experienced a partial loss of engine power during takeoff from runway 08 at the Big Bear City Airport, Big Bear City, California. The airplane collided into mountainous terrain about 0.76 nautical miles southeast of the airport. Visual meteorological conditions prevailed at the time of the personal flight to Parker, Arizona, and no flight plan was filed. The airplane was destroyed. The private pilot and his wife were fatally injured. The family dog survived. The flight was originating at the time of the accident. The estimated takeoff time was around 1032.

Witnesses reported observing the airplane become airborne about midfield, and no unusual engine sounds were detected. Upon passing the over the departure end of the runway, witnesses observed the airplane commence a right turn at an estimated altitude of 250 to 300 feet above ground level. The witnesses further reported that as the airplane continued on the crosswind leg, it gradually descended until finally impacting terrain.

PERSONNEL INFORMATION

Based upon information contained in the pilot's flight record logbook, the pilot initiated flight training in August of 1993. On April 4, 1994, he was issued a private pilot certificate. All flight training was conducted in Cessna 150 airplanes. On April 9, the pilot received a check-out in a Cessna 172, and he flew that model of airplane during the following two months.

On August 6, 1994, the pilot received a check-out in the accident airplane, and he purchased it several days later. The pilot flew the airplane on over 40 occasions during his 6 months of ownership. By the accident date, the pilot had logged 38 hours of flight time in the accident airplane. His total logged flight time was about 113 hours.

During the 6-day period which preceded the accident, it had snowed in the Big Bear area. The pilot did not fly his airplane.

AIRPLANE INFORMATION

The airplane was equipped with an exterior, electric, oil sump heater. The heater was used to preheat the engine oil before starting the engine in periods of cold weather

AIRPORT DEPARTURE PROCEDURES

Terrain rises to the south of the airport. The published airport takeoff and departure procedures for runway 08 were, in part, to execute a 10-degree left turn at the end of the runway, and then to climb out over the Big Bear Lake.

WRECKAGE AND IMPACT INFORMATION

On January 28, 1995, the National Transportation Safety Board examined the airplane wreckage at the accident site. The on-scene examination revealed the presence of numerous felled trees and severed tree limbs on the snow-covered mountainside along a magnetic track of 060 degrees. The airplane was located on its right side at the bottom of a ravine, on a magnetic heading of 130 degrees, and it was partially resting on top of severed branches.

The airplane's right wing was located at ground level, and the left wing was pointed in a near-vertical upward direction. The engine remained attached to the firewall, and it was also on its right side at ground level. All flight control surfaces remained attached to the airframe structure.

The estimated crash site elevation was 7,000 feet mean sea level.

The geographic coordinates for the accident site main wreckage were 34 degrees, 15.20 minutes north latitude, by 116 degrees, 50.74 minutes west longitude.

During the examination of the airplane, the master switch was turned on, and the stall warning light was observed to illuminate. The starter was turned on, and the starter motor engaged. Control cable continuity was established between the aft baggage compartment and the rudder and stabilator assemblies.

The fuel tank caps were found seated on both tank filler necks. The caps were removed and inspected. The rubber sealing cap gaskets were found bearing circular marks which were off-center, with respect to the geometric center of the gaskets. The gaskets did not fit snugly on the base of the caps. The outside diameter of the gaskets contained nicks. The gaskets had a hand-made appearance (see photograph).

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the San Bernardino County Coroner's Office in San Bernardino, California. Toxicology tests were performed by the Federal Aviation Administration, Civil Aeromedical Institute, Oklahoma City, Oklahoma. No drugs or ethanol were detected.

TESTS AND RESEARCH

On January 30, 1995, the airplane wreckage was additionally examined following its recovery to the Long Beach, California, facilities of National Aircraft. All eight spark plugs were removed and visually examined. The Lycoming engine participant opined that they appeared low time and in a serviceable condition.

Fuel was found in the gascolator bowl, in the main fuel inlet line to the carburetor, and inside the carburetor. No evidence of water was observed. The fuel inlet screen was found free of contamination. During hand rotation of the crankshaft, the vacuum pump drive gear was observed to rotate, and the continuity of the valve and gear train was established.

During the examination of the engine compartment, four pieces of pre-cut 2-inch-thick foam rubber material were found. Two of the pieces appeared to match the shape of the opening at the front of the engine cowl. Portions of the foam material bore indentation marks which matched the pattern of several partially crushed cylinder cooling fins. A foam fragment was found wedged against the front of the engine's No. 1 cylinder. A fragment from another piece of foam rubber was found squeezed between cooling fins at the front of the No. 2 cylinder. A 2-inch-thick foam plug was found inside the engine's lower cowl air scoop which routes induction air to the carburetor.

The Safety Board removed the plug from the air scoop and examined it. The foam plug was observed shaped to match the inside dimensions of the air scoop, and fit snugly inside it (see photographs). The edges/sides of all the foam rubber material exhibited an uneven texture and shape, and had the appearance of having been cut by hand to its existing form.

ADDITIONAL INFORMATION

The airplane wreckage was released to the assigned insurance adjuster on January 31, 1995. No parts were retained.

NTSB Probable Cause

the pilot's improper preflight inspection during which he failed to insure removal of the induction air system inlet covers. This action resulted in a partial loss of engine power during initial climb. A factor which contributed to the accident was the pilot's decision to not follow published takeoff procedures which would have permitted flight over lower elevation terrain.