Accident Details
Probable Cause and Findings
The partial loss of engine power due to the operator's inadequate engine maintenance relating to excessively rich mixtures (high fuel flow rates) and spark plug/magneto deficiencies. Contributing factors were degraded climb performance resulting from the high density altitude and the airplane loading which exceeded maximum weight and aft center of gravity limits.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On August 17, 1997, at 1744 hours Pacific daylight time, a Piper PA-34-200T, N6654A, operated by the Aero Club, Van Nuys, California, experienced a partial loss of engine power during takeoff from runway 17 at the uncontrolled Kern Valley Airport, Kernville, California. Witnesses reported observing black smoke trailing from the airplane during its initial climb. The pilot reported that the airplane failed to climb or adequately increase airspeed, so he elected to ditch into Isabella Lake, about 1.25 miles south of the airport. The airplane sank in about 20-foot-deep water and was destroyed. The airline transport pilot and three passengers sustained minor injuries. The fourth passenger was seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the flight.
The pilot reported to the Safety Board that on Friday, August 15, he flew the passengers from Van Nuys to Kernville. By prior arrangement, he was to pick up the passengers 2 days later and fly them back to Van Nuys. On August 17, the pilot flew the airplane in solo flight from Van Nuys back to Kernville. The flight lasted about 0.9 hours and was flown at 180 miles per hour (mph) at a cruise altitude of 8,500 feet mean sea level (msl). The pilot reported that he landed at Kernville about 1730.
The passengers were all waiting for the pilot at the airport for their return flight home. The passengers boarded the airplane, and according to the pilot, no instructions were given on how to fasten their seat belts because the "passengers had previously been briefed on seat belt operation . . . ."
The pilot further stated that "after a couple of attempts a hot (engine) start was performed," which was followed by running up the engines "to verify that all were in operating condition." The pilot verbally reported that although he did run-up both engines to 2,000 rpm and tested their magneto rpm drop, which was each between 50 and 100 rpm, he did not cycle the propellers.
The pilot reported he then taxied to the approach end of the runway and tookoff with both mixture controls in the full rich position.
According to the pilot, during the takeoff roll the airplane's acceleration appeared normal, and he rotated at 100 mph. The airplane further accelerated to 120 mph while climbing 100 feet. Then, the engines sounded as though they had reduced their power to half.
The pilot reported that he responded to the situation by retracting the landing gear, and attempting to restore engine power. He verified that both fuel valves were on, the mixture, propeller, and throttle controls were full forward, the auxiliary fuel pump switches were off, and the magneto switches were on. The fuel pressure gauges for both engines indicated "0" pounds of fuel pressure.
The pilot further reported he then moved the left engine's auxiliary fuel pump switch to the "on" and "off" position two times, and the engine developed (more) power. The left engine's fuel pressure gauge then "registered full fuel pressure."
The pilot attempted the same procedure with the right engine, but as soon as he turned the auxiliary fuel pump switch "on" the engine made a distinct sputtering sound, so he switched the pump off.
The pilot maneuvered around a hill, and the airplane continued descending and losing airspeed. The pilot verbally reported that throughout the flight both engines continued operating, and the propellers rotated between 2,400 and 2,450 rpm. The pilot indicated that he elected to ditch in the water rather than to lose control of the airplane.
INJURIES TO PERSONS
The left rear seat passenger was the only seriously injured occupant. This passenger was located in front of the aft baggage compartment. The other five occupants received minor injuries.
PERSONNEL INFORMATION
By letter dated August 27, 1997, the Safety Board requested that the pilot complete the required Aircraft Accident Report Form, No. 6120.1/2, and submit for inspection his personal flight records. On October 20, 1997, through the pilot's counsel, a flight record logbook was submitted.
An examination of the logbook revealed the pilot's flying activities between 1989 and August 1992. No more recent flights were noted. The pilot's counsel indicated that the pilot would search for additional evidence of more recent flight activity, and he would provide the evidence when located.
As of July, 1998, neither additional documentation nor the 6120.1/2 form have been received by the Safety Board. Accordingly, the pilot's recent flying experience and currency pertinent to the accident flight could not be established.
AIRCRAFT INFORMATION
Fuel Pump Switch Design.
The pilot verbally reported that the airplane's auxiliary fuel pump rocker type switches had only two positions. The switches could be set to either the "on" or the "off" position.
The Safety Board's examination of the accident airplane's fuel pump's switches revealed that they were designed with three positions, as follows: "low," "high," and "off." Positioning the switches into the "high" position first required moving a guard cover away from the switches.
Aft Baggage Compartment Tie Down Straps.
During an August 18, 1997, interview with the right front seated passenger, he reported that no one secured the two bags which he observed placed into the aft baggage compartment just behind the rear seats.
According to the airplane's flight manual, the aft baggage compartment was equipped with tie down straps. An examination of the airplane revealed the presence of four bolt-sized holes beneath the carpeted baggage compartment floor. No tie down straps were located. The Piper participant reported that the "bolt holes" appeared to be located where bolts/tie down straps had once been installed. No other device was observed in the baggage compartment area for securing the passenger's luggage.
Weight and Balance Computation.
The pilot reported that he did not compute the airplane's weight and balance prior to taking off from Kernville. He simply performed a visual estimate for the weights of the passengers and their baggage. The pilot stated that he has never used the Airplane Flight Manual which he believed was carried in the airplane.
Weight and Balance Computation.
The Federal Aviation Administration (FAA) certificated maximum gross weight for the airplane is 4,570 pounds. The aft center of gravity (CG) limit at that weight is 94.6 inches.
Based upon weight and balance data provided by The New Piper Aircraft, Inc., the weights of the occupants and their baggage, and the estimated fuel onboard, the Safety Board calculated that upon departure the airplane's gross weight was not less than approximately 4,730 pounds, and its CG was about 95.69 inches aft of datum.
History of Black Smoke.
The Safety Board interviewed the two pilots who had flown together in the airplane immediately prior to the accident pilot's flights. They reported that between approximately July 17 and August 10, 1997, they had taken off from the Van Nuys Airport. During departure, control tower personnel alerted them that black colored smoke was observed trailing from the airplane. The pilots leaned the mixture control(s) and made a low pass by the tower. No further evidence of smoke was reported, and they continued their flight without mishap.
On August 15, 1997, as the accident pilot was departing from Kernville, two of the passengers which had just exited the airplane observed black smoke trailing from the airplane. On August 17, when the accident pilot returned to Kernville to transport the passengers for the return (accident) flight to Van Nuys, one of the passengers informed the pilot of his earlier observations. The passenger reported to the Safety Board that the pilot had similarly observed the black smoke during his previous departure.
On August 21, 1997, the pilot acknowledged to the Safety Board that he had observed the left engine's black smoke during his August 15 flight with the passengers. He stated that the smoke "cleared itself after 5 to 7 seconds on takeoff." The pilot further stated that upon landing back at Van Nuys, he had mentioned the occurrence to the operator.
Two witnesses, located at the Kernville Airport, reported observing black smoke trailing from the airplane during its initial climb on the accident flight. One of the witnesses was an airplane mechanic. This witness also indicated that as the airplane departed it made a noise like an engine was sputtering, and one or both of the engines sounded rough running.
Maintenance.
An examination of the airplane's maintenance records did not reveal evidence of any maintenance performed since the last 100-hour inspection on July 2, 1997. Since that date, the airplane had been operated for about 80 hours.
METEOROLOGICAL INFORMATION
The pilot reported that he did not receive a weather briefing prior to the flight.
Two of the passengers reported that while at the airport, just prior to takeoff, they observed a thermometer which indicated the outside air temperature was between 94 and 96 degrees Fahrenheit. Another passenger estimated that the temperature was between 85 and 90 degrees Fahrenheit. A witness, located adjacent to the airport, estimated that the temperature was between 86 and 90 degrees Fahrenheit.
Based upon this 11-degree maximum temperature range, the Safety Board calculated the approximate density altitude was 4,300 feet, plus or minus 300 feet.
WRECKAGE AND IMPACT INFORMATION
The airplane was examined immediately following its recovery from the lake. The airframe was found mostly intact, and all flight control surfaces remained attached to their hinges. The left wing, the rudder, and the stabilator were found securely attached to the fuselage. The right wing was found attached to the airframe by the aileron control cables.
Except for evidence of water intrusion,...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX97FA292