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N454FL accident description

Oregon map... Oregon list
Crash location 45.017500°N, 123.755555°W
Nearest city Grand Ronde, OR
45.060113°N, 123.609277°W
7.7 miles away
Tail number N454FL
Accident date 14 Oct 2004
Aircraft type Piper PA-28-140
Additional details: None

NTSB Factual Report


On October 14, 2004, approximately 1800 Pacific daylight time, a Piper PA-28-140, N454FL, operated by a private pilot, was destroyed after impacting trees and mountainous terrain about 7 miles southwest of Grand Ronde, Oregon. A post-crash fire ensued. The airplane was registered to and operated by Cirrus Aviation, LLC, of McMinnville, Oregon. The private pilot and two passengers on board the airplane were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was being conducted in accordance with 14 CFR Part 91. The local flight departed the McMinnville Municipal Airport (MMV), at 1700.

In an interview with the NTSB investigator-in-charge (IIC), the owner of the fixed base operation where the airplane was rented reported that the pilot and his two passengers were going on a local flight; however, the destination and intent of the flight was not known. The owner stated that the pilot told her that he planned to return at approximately 1900. Subsequent to the pilot's failure to return at the specified time, an alert notification (ALNOT) was issued for the missing aircraft at 2259. Approximately 1400 on October 15, 2004, the aircraft was located in dense forested mountain terrain approximately 7 nautical miles southwest of Grand Ronde, and 2 nautical miles northeast of Saddle Bag Mountain.

A hunter who was in the general vicinity of the crash site on the evening of the accident reported hearing an airplane, then looked up to see a light aircraft approaching [from] a southerly direction toward his position. The hunter stated that he was rather surprised to see a plane in the air [during] the late afternoon hour, and that it made a circle over the area to the northwest in a deliberate manner, as though it was looking for something, "...taking aerial photography or spotting elk." The hunter related, "I was a little concerned about his altitude, which seemed to be rather low for the hilly terrain and timber. [As] the plane was closer I noted the red fuselage with white markings. It looked very slow, almost at stall speed. The tail seemed to be lower than the front. I listened hard for any indication of engine trouble, sputtering, uneven rpms, etc. The engine sounded smooth and powerful. Then it disappeared over the timber to the east." The hunter reported that about 10 to 15 minutes later the [airplane] returned overhead. The hunter stated, "It had a similar low altitude, and was headed east again. It flew over the clear cuts and disappeared over the timber. I found out later that the aircraft I had seen and the aircraft that had crashed were the same aircraft."

On October 15, 2004, representatives from the National Transportation Safety Board, the Federal Aviation Administration, and The New Piper Aircraft visited the accident site to examine the wreckage. That afternoon the aircraft was recovered to a secure location for further investigation, which would be supervised by the IIC.


The 1971 model Piper PA-28-140 airplane, serial number 28-7125249, was a single-engine, low wing, fixed landing gear airplane. The airplane was powered by a four cylinder, air-cooled, normally aspirated Lycoming O-320 engine, rated at 150 horsepower. The airplane was configured to carry a maximum of four occupants.

A review of maintenance records revealed that the last annual inspection was completed on April 21, 2004, with a total airframe time of 3,930 hours. The review of the engine maintenance logs showed that the engine underwent its most recent 100 hour inspection on August 19, 2004, with a tach time of 4034.06 hours, a total time on the engine of 2823.7 hours, and 723.7 hours since its last major overhaul. The last major overhaul on the engine was conducted on April 19, 1997.


The pilot received his private pilot certificate with a single-engine land rating on October 4, 2003. According to the pilot's logbook, the last entry prior to the accident flight revealed that he had accumulated 111.3 total flying hours, with 41.8 hours in make and model.

The pilot held a third class medical certificate with no restrictions, dated October 4, 2002.


At 1753, the weather reporting facility at the McMinnville Municipal Airport, located 32 nautical miles northeast of the accident site, reported wind 040 degrees at 7 knots, visibility 10 statute miles, sky clear, temperature 24 degrees C, dew point 12 degrees C, and an altimeter setting of 30.03 inches of Mercury.


Examination of the accident site by the NTSB IIC and representatives from the Federal Aviation Administration, Lycoming Engines, and The New Piper Aircraft revealed that the aircraft came down through a tall stand of mature trees on a magnetic heading of approximately 350 degrees, with a wreckage distribution path of 124 feet measured along a magnetic heading of 352 degrees. The beginning of the wreckage path began at tree approximately 80 feet high, with the wreckage located within 30 feet of the tree. The wreckage came to rest inverted in dense, wooded, mountainous terrain on an upslope of approximately 40 to 50 degrees and lying perpendicular to the slope. A Global Positioning System (GPS) recorded the accident location at 45 degrees 00.965 minutes North latitude, 123 degrees 44.820 minutes West longitude, at an elevation of 2,350 feet. All major components of the airplane were accounted for in the main wreckage area. A post-accident fire consumed the cockpit, fuselage, both inboard wing sections, and a portion of the empennage.

The left wing was separated from the fuselage at its wing root and located in the main wreckage area. The wing was destroyed and exhibited thermal damage and sooting. The wing came to rest oriented upslope at approximately a 45 degree angle resting against a tree, which was impaled into the wing's leading edge about 5 feet inboard of the wing root. The wing's flap remained attached to the wing at all of its attach points. The position of the flap prior to impact could not be determined due to impact damage. The left aileron was separated from the left wing and found under the tail section of the airplane. The wing's fuel tank had been breached. The lower half of the right main landing gear was broken and separated from the wheel well.

The right wing was separated from the fuselage and located inverted and perpendicular to the wreckage distribution path. The wing's carrythrough spar was bent and twisted to a point outboard from the wing root for about 7 feet. The aileron remained attached to the wing at the two outboard attach points, and the flap remained attached to the wing at its two inboard attach points. The position of the flap prior to impact could not be determined due to impact damage. The wing exhibited thermal damage and sooting, and its fuel tank was breached. The right main landing gear was broken and separated from the wheel well.

The aircraft's empennage was found laying on the left side of the vertical stabilizer, with the right side of the stabilator pointing upslope at an angle estimated at 45 degrees. The rudder, vertical stabilizer and stabilator remained attached to the empennage at all attach points. All components of the empennage exhibited thermal damage and sooting. The stabilator trim setting was observed at 9 threads, which equates to a slight nose up attitude.

The engine came to rest in an inverted position but still attached to the engine mount. A detailed examination of the engine was conducted after the aircraft had been recovered from the accident site to a secure location.

The cockpit and cabin areas were destroyed and consumed by fire. The only instrument which was identifiable was the airspeed indicator, which indicated 50 knots. All other cockpit instruments were destroyed.

No evidence of an in-flight mechanical and/or flight control malfunction was found that would have rendered the airplane uncontrollable prior to the impact. Control continuity to all control surfaces was established on site during the initial examination of the wreckage.


The autopsy was performed on the pilot by the Lincoln Country Medical Examiner's Office, Clackamas, Oregon, on October 17, 2004. The FAA Civil Aeromedical Institute (CAMI) Forensic Toxicological and Accident Research Center at Oklahoma City, Oklahoma, examined the specimens taken by the medical examiner. The toxicological findings were negative.


On October 28, 2004, under the supervision of the NTSB IIC, an examination of the engine was conducted at the facilities of HLM Air Services Inc., Independence, Oregon. The examination revealed that the engine remained attached to the engine mount and sustained thermal damage as a result of the effects of the post impact ground fire. The engine accessories had been destroyed, rendering them unsuitable for testing. A visual examination of the engine revealed no evidence of pre-impact catastrophic mechanical malfunction or fire.

The bottom spark plugs were removed and examined. The electrodes remained mechanically undamaged, and according to the Champion Spark Plugs "Check-A-Plug" chart AV-27, the spark plug electrodes displayed coloration consistent with normal operation. The oil soaking of the spark plugs was attributed to the engine positioning at the mishap site and post recovery.

The crankshaft was free and easy to rotate in both directions. Thumb compression was observed in proper order on all four cylinders. The complete valve train was observed to operate in proper order. Normal lift action was observed at each rocker assembly. Clean, uncontaminated oil was observed at all four rocker box areas. Mechanical continuity was established throughout the rotating group, valve train and accessory section during hand rotation of the crankshaft. The accessory gears, including the crankshaft gear, bolt and dowel were intact and remained undamaged by a pre-impact malfunction. There was no oil residue observed in the exhaust system gas path. There was no significant ductile bending of the exhaust system components.

The left magneto remained secure at the mounting pad. The magneto had been subjected to thermal effect damage as a result of the post impact ground fire. The magneto sustained varying degrees of damage that rendered the unit inoperative and therefore, could not be functionally tested. Magneto to engine timing could not be ascertained. The right magneto had been displaced from the mounting pad. The magneto had been subjected to thermal effect damage as a result of the post impact ground fire. The magneto sustained varying degrees of damage that rendered the unit inoperative and therefore, could not be functionally tested. Magneto to engine timing could not be ascertained. The ignition harness had sustained varying degrees of damage by thermal energy and was not tested. The ignition harness was attached at the spark plugs.

The oil cooler and oil filter were destroyed by impact and fire. There was no evidence of pre-mishap metal contamination observed at the oil suction screen or rocker box areas when opened for examination.

The carburetor was displaced from the engine and the portion that remained attached at the mounting pad was secure. The fuel bowl and float assemblies were destroyed. The throttle remained secure at the control arm of the carburetor. The mixture control was destroyed. The fuel pump was partially consumed and destroyed resulting from the thermal effects of the post impact ground fire. The fuel pump mounting flange remained attached at the mounting pad. The two mounting bolts remained in place and properly safety wired.

The two bladed fixed pitch propeller remained attached at the crankshaft flange. The spinner was crushed aft and remained attached to the propeller. The propeller blades remained attached to the propeller hub. The propeller blades displayed leading edge gouging, torsional twisting, chordwise striations across the cambered surface and trailing edge “S” Bending. The signatures were consistent with the absorption of rotational forces applied at the crankshaft at the time of impact.

The aircraft wreckage was released to the owner's representative on October 28, 2004. No components were retained.

NTSB Probable Cause

The pilot's failure to maintain clearance from high terrain while maneuvering. A factor contributing to the accident was the high terrain.

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