N4080P

HISTORY OF FLIGHT

On April 15, 2008, about 2041 Pacific daylight time, a Piper PA-23-160, N4080P, impacted terrain in Bonelli Regional Park, San Dimas, California, following a loss of control during initial climb after takeoff from runway 26L at Brackett Field Airport, La Verne, California. The flight instructor and the pilot rated passenger sustained serious injuries, and the airplane sustained substantial damage. The airplane was registered to Blue Diamond Aviation, La Verne, and was being operated by the pilot under Title 14 Code of Federal Regulations Part 91. Night visual meteorological conditions prevailed, and no flight plan was filed for the local instructional flight that was originating when the accident occurred.

According to the owner of Blue Diamond Aviation, the flight was not authorized, and she had no knowledge that the flight instructor was planning to take the airplane. The owner reported that the airplane had been down for annual inspection since February 26, 2008, and the mechanic had not completed the work. The owner further reported that there was an aircraft status board in the office on the wall behind the front desk; the board showed the airplane was down for maintenance.

The mechanic reported that on April 11, 2008, he attempted to drain fuel from the airplane's left main fuel tank, was unable to do so, and then determined that the left main tank was empty. Between 1900 and 2000 on April 11, he taxied the airplane to a tie down area. In order to start the left engine, he used the cross feed, then he switched to the left aux tank, which contained about 10 gallons of fuel.

A student of Blue Diamond Aviation reported that on April 13, 2008, he and the flight instructor taxied the airplane from the tie down area to a parking spot in front of the Blue Diamond office.

On April 14, 2008, the owner noted the airplane was parked in front of the office. She called the mechanic and he reported that the annual inspection was not completed. As the airplane was very dirty, the owner told the mechanic the airplane needed to be washed as soon as possible. On April 15, 2008, a Blue Diamond flight instructor (not the accident pilot) taxied the airplane to the wash rack about 1030, and taxied the airplane back to Blue Diamond about 1200 after it was washed.

A check of the fuel records for Brackett Field from April 13 to 15 showed no fuel pumped into the accident airplane.

The accident flight instructor was interviewed by a Federal Aviation Administration (FAA) inspector and reported the following information. The purpose of the flight was for the flight instructor to demonstrate the airplane to the passenger. The passenger had recently obtained his flight instructor certificate with a single engine airplane rating and was interested in possibly obtaining his multiengine instructor rating in the accident airplane. The flight instructor stated that he arrived at the airport about 1800 and found the airplane parked in front of the office. He conducted a short preflight inspection using a checklist located in the airplane. In response to a specific question from the FAA inspector, the flight instructor reported that he opened each fuel tank and looked inside estimating 25 gallons of fuel in each of the two main fuel tanks. The passenger arrived about 2000, and they went into the office and reviewed paperwork related to renting the airplane. They then entered the airplane, with the flight instructor sitting in the left front seat and the passenger sitting in the right front seat.

The flight instructor reported that the taxi to runway 26L and the run-up checks were normal. During the takeoff roll, the airplane accelerated normally. Immediately after lifting off at 75 miles per hour, the left engine stopped running and the propeller stopped turning. When asked by the FAA inspector what procedures he used to address the engine failure, the flight instructor stated that he had all engine controls full forward and was using right aileron and left rudder to maintain directional control. He reported that he was unable to raise the landing gear as the hydraulic pump was mounted on the left engine. Since he could not raise the landing gear, he was unable to maintain airspeed and altitude. The airplane banked left and descended to ground impact.

The passenger was interviewed by a Federal Aviation Administration (FAA) inspector and reported the following information. He met the flight instructor at Blue Diamond's office about 2000. After reviewing some paperwork, they proceeded to the airplane. He asked the flight instructor if he had completed a pre-flight inspection of the airplane, to which the flight instructor replied in the affirmative. After they boarded the airplane, the flight instructor stated that he would be the pilot-in-command. The passenger reported that the flight instructor started the engines and proceeded to taxi to runway 26L. He noted that the flight instructor had difficulty maintaining the taxiway centerline, but he was not sure of the reason. He also noted that during the taxi, the controller notified the flight instructor that the airplane's navigation lights were not turned on, and it took the flight instructor several tries before he located the correct switch.

The passenger reported that before departure, the flight instructor did a magneto check only and performed no other checks. During the takeoff roll, the airplane "fishtailed" from right to left. The passenger yelled at the flight instructor to "Kill It" several times during the takeoff roll. The flight instructor continued the takeoff, lifting off at the red line airspeed [72 miles per hour] on the airspeed indicator. According to the passenger, the flight instructor held the control wheel in the full left aileron position and was trying to make left rudder inputs. The passenger yelled at the flight instructor to add right rudder and at the same time, the flight instructor added left rudder trim. As the passenger was readjusting the rudder trim to the right, the airplane hit the ground.

Air traffic control personnel in the Brackett Field Air Traffic Control Tower observed the accident and reported that after takeoff, the airplane entered an "erratic left turn" and crashed into the side of a hill.

The crash site was about 0.7 miles on a 230-degree heading from Brackett Field. The area was an open grass covered field adjacent to a heavily populated RV park. Several persons from the park helped the flight instructor and passenger exit the airplane. Additionally, they used fire extinguishers to extinguish a fire that erupted in the area of the right engine.

PERSONNEL INFORMATION

The flight instructor, age 57, held a commercial pilot certificate with airplane single and multiengine land ratings and an instrument airplane rating. The commercial certificate had the limitation: airplane multiengine VFR only. He held a flight instructor certificate with airplane single and multiengine land ratings. The flight instructor's most recent first-class medical certificate was issued on February 12, 2007, with the limitation: holder shall possess glasses for near and intermediate vision. The flight instructor reported that he had accumulated 12,000 hours total flight time of which 5,000 hours were multiengine airplane flight time with 500 hours in the accident make and model airplane.

The passenger, age 28, held a commercial pilot certificate with airplane single and multiengine land ratings and an instrument airplane rating. He held a flight instructor certificate with an airplane single engine land rating. The passenger's most recent second-class medical certificate was issued on September 5, 2007, with no limitations. The passenger reported that he had accumulated 482 hours total flight time of which 31 hours were multiengine airplane flight time with zero hours in the accident make and model airplane.

AIRCRAFT INFORMATION

The twin-engine, low-wing airplane was manufactured in 1959. It was powered by two Lycoming O-320-B1A 160-horsepower engines equipped with two bladed Hartzell constant-speed propellers.

Logbook entries indicated the most recent annual inspection was completed on 02/09/07, at a total airframe time of 4,181 hours. The most recent 100-hour inspection was completed on 08/01/07, at a total airframe time of 4,367 hours. The right tachometer was removed during this inspection and a 0 time tachometer installed; the removed tachometer read 4,367 hours.

According to the engine logbooks, at the time of the most recent 100-hour inspection, the right engine had accumulated 590 hours since major overhaul (SMOH), and the left engine had accumulated 1,532 hours SMOH.

The time on the right and left tachometers at the accident site were 223.1 and 1,836.1 hours, respectively. The hour meter reading was 1045.0 hours.

Regarding engine failures, the owner's handbook for the airplane states, in part: If an engine failure occurs during the take-off run, the power on the good engine should be cut and the airplane stopped straight ahead. If it occurs after leaving the ground, but with sufficient landing area ahead, a landing should be effected immediately.

According to the performance charts in the owner's handbook, the takeoff distance for the airplane at a standard altitude of 1,000 feet and a temperature of 60 degrees Fahrenheit (16 degrees Celsius {C}) ranges from 400 feet at a gross weight of 2,900 pounds to 1,400 feet at a gross weight of 3,800 pounds.

METEOROLOGICAL INFORMATION

At 2047, Brackett Field reported wind from 200 degrees at 10 knots; 3,000 foot overcast; and 10 miles visibility. The altimeter was 29.97 inches of Mercury.

At 2053, Ontario International Airport, located about 10 nautical miles east of the accident site, reported wind from 250 degrees at 12 knots; visibility 8 miles; few clouds at 6,000 feet; temperature 13 degrees C; dew point 8 degrees C; and altimeter 29.93 inches of Mercury.

According to the ...