NTSB Factual Report

HISTORY OF FLIGHT

On March 13, 2005, about 1557 Pacific standard time, a Piper PA-28-140, N9956W, impacted a road's guard rail and crashed onto the downsloping embankment adjacent to the Big Bear Lake, about 1 mile west of the Big Bear City Airport, Big Bear City, California. The accident occurred during the initial climb portion of takeoff. The airplane was substantially damaged. The private pilot was seriously injured, and the three passengers sustained minor injuries. Visual meteorological conditions prevailed. The pilot reported that he was a part owner of the accident airplane, which he was operating under the provisions of 14 CFR Part 91 on a personal flight to the French Valley Airport, Murrieta, California. No flight plan was filed. The flight began about 1555.

Pilot Statement.

The pilot reported to the National Transportation Safety Board investigator that earlier on the accident date, about 0930, he had flown without passengers, and with less fuel in the airplane's fuel tanks, from the Big Bear City Airport to the French Valley Airport (a 43 nautical mile-long direct course). The pilot indicated that he had not experienced any problems with the airplane during the takeoff and climb out from Big Bear, or thereafter during the flight. Later in the morning the pilot made an uneventful flight back to Big Bear. Around 1130, after securing the airplane, the pilot met friends and departed the area.

The pilot further reported that about 1430 he returned to the airport and made preparations for his return flight to French Valley. The pilot added a total of 25.0 gallons of fuel to the airplane's fuel tanks. The pilot informed County of San Bernardino Sheriff's Department personnel that the airplane's fuel tanks contained between 34 and 36 gallons of fuel at departure. Subsequently, he reported to the Safety Board investigator that after adding the 25 gallons, the airplane contained between 32 and 34 gallons of fuel, but most likely 32 gallons.

While the pilot was refueling the airplane, the three passengers unloaded most of the baggage and items not needed for the flight. The items were placed into an automobile that the pilot's wife was using to drive home. According to the pilot, he performed a preflight inspection of his airplane, and no anomalies were noted. The passengers then boarded the airplane.

The pilot started the engine, taxied for takeoff, and performed an engine run-up. Prior to releasing the brakes for the takeoff, the pilot applied full engine throttle, and he leaned the mixture to obtain the "best rpm." Again, no anomalies were noted, and the takeoff roll commenced. In the pilot's completed "Aircraft Accident Report," he made the following (paraphrased) statement regarding the events that followed:

The airplane was held on the runway until obtaining 80 mph, and it was rotated prior to reaching 1/2 way down the runway. The airplane initially climbed at 200 feet per minute, and it was 100 feet above ground level (agl) upon reaching the runway's end. The airplane was 250 feet agl approaching high (power) lines (located 1 mile west of the runway's departure end). During this period, the airplane encountered turbulence. The stall warning flashed. The pilot reported that he maintained 80 mph with the vertical speed indicator registering a zero foot per minute rate of climb.

During an interview with the Safety Board investigator conducted the evening of March 13, 2005, the pilot stated that the maximum altitude that the airplane gained was 6,950 feet mean sea level (msl). The pilot stated he was certain of this altitude because he was watching the altimeter closely. Although he had been "on the controls" earlier during the flight, when the stall light illuminated he "took over the controls, and lowered the airplane's nose." The engine's throttle was full forward, and the engine sounded okay.

The pilot additionally reported that he maintained 80 mph when a downdraft was encountered. The airplane descended 200 feet within seconds. Observing electrical lines ahead, and unable to gain altitude, he opted to descend under the lines to avoid them. The pilot further reported that he intended to clear the causeway (located under the power lines) but the airplane's landing gear struck a guardrail that stopped the airplane's travel.

Passenger Statement.

The passenger seated in the front right seat reported to the Safety Board investigator that he and the pilot listened to the airport's automated weather observing system (AWOS) transmission. Thereafter, while the pilot handled the engine's throttle and brakes, the passenger was allowed to steer the airplane with the rudder pedals, and they taxied toward the runway.

The passenger reported that the pilot had given him permission to perform the takeoff. The passenger stated that, from the start of the takeoff roll, he had his hand on the yoke. The passenger made the following statement regarding the sequence of events that followed:

"He (the pilot) then released the brakes and the plane started to roll down the runway. He (the pilot) told me to rotate when the plane reached a speed of 85 mph. I started to pull back gently on the yoke a little before the plane reached 85 and only the nose wheel rose off the ground. When that happened (the pilot) said, 'not quite yet,' and I lowered it back down. A couple of seconds later the plane reached 85 mph and I rotated out at about midfield. The entire time, (the pilot) was riding the controls with me. After we had cleared the end of the runway (the pilot) took over full control of the plane. He continued to climb at 85 mph and achieved a 200-foot per minute vertical speed. Other than the stall light flickering on for less than a second right after takeoff, everything about the flight was completely normal until the plane hit some very minor turbulence. Our altitude at the time of the turbulence was over 250 feet agl. The stall light came on briefly. It went out right when the plane started to fall. Within a couple of seconds after hitting the turbulence, the plane went from being well over 200 feet above the top of some oncoming power lines, to directly in line with them."

Witness Statement.

A ground-based witness, located 0.1 mile south of the accident site, reported observing the airplane 15 to 20 seconds before the crash. The witness reported to the Safety Board investigator that when he first saw the airplane it was flying in a nose high pitch attitude, and it was flying very slowly. The witness estimated that the airplane's nose was between 10 and 15 degrees above the horizon. The witness indicated that he was so impressed by the airplane's nose high pitch attitude that he remarked to his son, who was with him, "get your nose down." The airplane appeared to be hanging in the sky like a kite. Then, suddenly, the airplane's nose lowered, and the airplane descended until impacting the road's guardrail.

PERSONNEL INFORMATION

Pilot.

The pilot held a private pilot certificate with an airplane single engine land rating. The pilot reported that his total flight time was about 600 hours, and he had flown the PA-28-140 model of airplane about 60 hours. During the preceding 90-day period, he had flown the airplane about 13 hours.

The pilot's last flight review was completed on October 29, 2004. The review was accomplished in the accident airplane.

Passenger/Student Pilot.

The 16-year-old passenger who occupied the front, right seat in the airplane held a student pilot and a third-class aviation medical certificate. The certificate was issued to the student on January 20, 2005.

The passenger reported having logged about 15 hours of dual instruction in a Cessna 172. He had not soloed. The passenger reported that he had no previous flying experience in the Piper Cherokee, model PA-28-140.

AIRPLANE INFORMATION

The airplane was manufactured in 1967. The airplane serial number is 28-23503.

Ownership and Airplane Flight Manual (AFM) Revisions.

The pilot verbally reported to the Safety Board investigator that his name will not appear in the Federal Aviation Administration's (FAA) airplane owner registration files as being a co-owner of the airplane. The pilot indicated that he is a financial partner with another person in the airplane's ownership. The other person is the owner of record according to the FAA.

According to information received from The New Piper Aircraft, Inc., it sends AFM revisions and service letters to the person/company it has recorded in its files as being the airplane owner. If ownership changes, revisions will continue to be sent to the original owner until such time as the new owner notifies Piper to change its records.

Airplane Flight Manual (AFM).

The AFM found in the airplane wreckage was issued to N9956W, serial number 28-23503. The first page in the AFM regarding weight and balance (Section 1) is dated July 25, 1967. Thereafter, on page 10 in Section 1, the airplane is shown to have had two (rear) jump seats installed, for a total of four seats.

In the AFM's limitation section, page 2 of 4, the center of gravity (CG) range in the normal category at 2,150 pounds gross weight is indicated from 90.1 to 94.0 inches aft of datum. The referenced page bears the following statement: "FAA APPROVED 2/14/64 REVISED 12/13/65 Rev. No. 8."

The latest revision (page) included in the AFM is revision number 11, dated December 6, 1966.

FAA Type Certificate Data Sheet & AFM Revisions.

The FAA Type Certificate Data Sheet for the accident model of PA-28-140 airplane in the serial number range from 28-20001 through 28-26946, indicates that the authorized CG range is from 88.4 to 95.9 inches aft of datum, at a maximum 2,150-pound gross weight.

According to the New Piper Aircraft, Inc., the current revision to the AFM for this airplane is revision number 23, dated July 25, 1975.

Pilot's Estimated Airplane Weight and Takeoff Performance.

The pilot verbally reported to the Safety Board investigator that prior to taking off he had performed a weight and balance computation. No physical evidence of the "paperwork" associated with the computation was provided. The pilot indicated that he was familiar with the respective passenger weights, and he relied upon his familiarity with the passengers for his determination of their weights in making his computations. The pilot stated that, during takeoff, "we were probably 100 pounds from being overweight."

The pilot also reported that he was of the opinion the airplane would not be climbing out at a rate much more than 200 feet per minute. At no time during the interview with the pilot did he indicate having referred to the "Take-Off Distance vs. Density Altitude" or the "Rate of Climb vs. Density Altitude" charts in the "Piper Cherokee 140 Owner's Handbook" for ascertaining performance data.

Weight and Balance.

The pilot verbally reported to the Safety Board investigator that the fuel tanks may have contained as much as 34 gallons of fuel, rather than the 32 gallons which he initially reported. However, his best estimate remained at 32 gallons of fuel. The pilot stated that, for certain, the quantity of fuel in the tanks was below the level of the two 18-gallon filler neck indicators in the wing tanks.

The Safety Board investigator unloaded the baggage observed in the airplane. The baggage consisted of charts, seat cushions, headphones, logs, and various miscellaneous objects. The baggage weighed 16 pounds.

The airplane's weight and balance was computed under the following two scenarios: (A) Fuel quantity at 34 gallons, and the maximum reported passenger weight; and (B) Fuel quantity at 32 gallons and the minimum reported passenger weight.

Under scenario (A) the airplane's gross weight and CG was 2,134 pounds and 89.9 inches aft of datum. Under scenario (B) the gross weight was 2,114 pounds and the CG was 89.8 inches aft of datum.

Based upon the above data and by reference to the AFM in the airplane, the airplane was between 16 and 36 pounds beneath its maximum certificated gross weight. Also, the CG was between 0.2 and 0.3 inches forward of the forward CG limit listed in the AFM.

Based upon revision number 12 to the AFM, which was incorporated by a commensurate revision to the FAA's Type Certificate Data Sheet expanding the CG range, the airplane's CG was between 1.4 and 1.5 inches aft of the forward limit.

The airplane's last annual inspection was performed about 6 months before the accident. The mechanic who performed the inspection reported verifying that an AFM was on board the airplane. He opined that it was the owner's responsibility to ensure that the AFM incorporated the latest revision. The last revision in the accident airplane's AFM was number 11. The Safety Board investigator subsequently ascertained that the current revision number was 23.

METEOROLOGICAL INFORMATION

A private pilot, who witnessed the accident, was located in a kayak on the Big Bear Lake. This witness reported that the sky was clear over the lake to the west of the accident site. However, cumulus-like clouds were present in the vicinity of the airport. A westerly wind existed on the lake, and it's estimated speed was 10 knots. Occasionally, the wind increased in speed to about 15 knots, and white caps became visible on the lake.

A student pilot, who witnessed the accident, was located about 0.1 mile south of the crash site. This witness reported that the sky was mostly clear over the lake to the west of the accident site. There may have been high clouds over the airport area. The wind was blowing about 5 knots from the west. This estimate of the wind's speed may vary between 4 and 8 knots. The visibility was not restricted.

The Big Bear City Airport is equipped with an automated weather observing system (AWOS-3). This system automatically reports the airport's altimeter setting, wind direction and speed, temperature, dew point, visibility, cloud/ceiling data, and the density altitude.

At 1600, the Big Bear Airport's AWOS reported weather was as follows: Broken ceiling at 4,400 feet agl; overcast clouds at 5,500 feet agl; visibility 10 miles; temperature/dew point 58/35 degrees Fahrenheit; wind 260 degrees at 7 knots with no gusts; and altimeter 30.01 inches of mercury. The density altitude was also broadcast and was 8,100 feet.

The Safety Board investigator was standing at the Big Bear Airport during the airplane's accident flight. The investigator noted that the sky condition and wind speed appeared as reported by the airport's AWOS.

On March 13, 2005, during the Safety Board investigator's interview with the pilot, he acknowledged having heard the airport's AWOS broadcast prior to taking off. The pilot stated that he recalled hearing that the broadcast density altitude was either 8,100 or 8,200 feet. Additionally, the pilot reported that prior to taking off he had not contacted any flight service station to obtain the weather or to receive a briefing.

AIRPORT COMMUNICATION AND INFORMATION

The Big Bear City Airport is an uncontrolled airport. Airport personnel do not record communications transmitted or received on the published common air traffic frequency.

The airport's elevation is 6,748 feet msl. Runway 26 is 5,850 feet long by 75 feet wide, and it has an asphalt surface.

WRECKAGE AND IMPACT INFORMATION

The approximate global positioning satellite coordinates for the accident site are 34 degrees 15.563 minutes north latitude by 116 degrees 53.059 minutes west longitude. The estimated accident site elevation is 6,760 feet msl. The site is located about 1 mile west (243 degrees, magnetic) from the departure end of Big Bear City Airport's runway 26.

The accident site and airplane wreckage examination revealed the airplane impacted a guardrail located on the western side of a north-south oriented public road, known as the Standfield Cutoff. The guardrail was found broken from its supporting post structure and was displaced in a westerly direction on the side of the road. Power lines, having an estimated height of 45 feet agl, are located over the road.

NTSB Probable Cause

The pilot's failure to maintain adequate airspeed that resulted in an inadvertent stall/mush during initial climb. Contributing factors were the pilot's inadequate preflight preparations and the high density altitude.