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. To start the left engine, he used the cross feed, then switched to the left auxiliary 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 who reported 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 it back about 1200 after washing.
A check of 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 an FAA inspector. He stated that the purpose of the flight was to demonstrate the airplane to the passenger, who had recently obtained his flight instructor certificate with a single-engine rating and was interested in possibly obtaining a multiengine instructor rating. The flight instructor 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. He reported opening each fuel tank and looking inside, estimating 25 gallons of fuel in each of the two main tanks. The passenger arrived about 2000, and they reviewed paperwork related to renting the airplane. They entered the airplane with the flight instructor in the left front seat and the passenger 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 about procedures 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 because the hydraulic pump was mounted on the left engine. Since he could not raise the gear, he was unable to maintain airspeed and altitude. The airplane banked left and descended to ground impact.
The passenger was also interviewed by an FAA inspector. He reported meeting the flight instructor at Blue Diamond's office about 2000. After reviewing paperwork, they proceeded to the airplane. He asked if the flight instructor had completed a preflight inspection, and the instructor replied affirmatively. After boarding, the flight instructor stated he would be pilot-in-command. The passenger reported the instructor started the engines and taxied to runway 26L. He noted the instructor had difficulty maintaining the taxiway centerline, and that during taxi, the controller notified the instructor that the airplane's navigation lights were not turned on, requiring several attempts to locate the correct switch.
The passenger reported that before departure, the flight instructor performed only a magneto check and 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 full left aileron position and was trying to make left rudder inputs. The passenger yelled 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 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 and 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. His commercial certificate had the limitation: airplane multiengine VFR only. He held a flight instructor certificate with airplane single- and multiengine land ratings. His most recent first-class medical certificate was issued on February 12, 2007, with the limitation that he possess glasses for near and intermediate vision. He reported 12,000 hours total flight time, 5,000 hours multiengine, and 500 hours in the accident make and model.
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 rating. His most recent second-class medical certificate was issued on September 5, 2007, with no limitations. He reported 482 hours total flight time, 31 hours multiengine, and zero hours in the accident make and model.
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 February 9, 2007, at a total airframe time of 4,181 hours. The most recent 100-hour inspection was completed on August 1, 2007, at a total airframe time of 4,367 hours. The right tachometer was removed during this inspection and a zero-time tachometer installed; the removed tachometer read 4,367 hours. At the time of the 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 1,045.0 hours.
The owner's handbook for the airplane states: If an engine failure occurs during the takeoff 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.
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, 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; altimeter 29.93 inches of Mercury. According to the U.S. Naval Observatory, sunset occurred in La Verne at 1923, and the end of civil twilight was at 1949.
Wreckage and Impact Information
Examination of the accident site and airplane wreckage by a Safety Board investigator and representatives from the FAA, the engine manufacturer, and the airplane manufacturer revealed that the first indication of impact was broken branches beneath a pine tree about 150 feet from the main wreckage. Red glass fragments consistent with the left wing navigation light were found near the tree. Ground scars were noted between the tree impact and main wreckage. The impact line was about 210 degrees, and the elevation of the main wreckage was approximately 967 feet.
The nose section was crushed, the right wing was displaced upward and aft, and the left wing attach points were separated, with the wing rotated to an inverted position. There was thermal damage to the right engine accessories and nacelle area. All engine controls (mixtures, throttles, propellers) were found in the full forward position. The landing gear was extended. The left and right flap actuators were found consistent with a flap setting of 10 to 12 degrees.
The airplane was equipped with four fuel tanks: two 36-gallon inboard main tanks and two 18-gallon outboard auxiliary tanks. The left auxiliary tank filler cap was loose and could be removed by hand; no fuel was noted in the left auxiliary tank. The left main tank filler cap was secure; no fuel was noted in the left main tank. The right auxiliary tank filler cap was loose; no fuel was noted. The right main tank filler cap was secure; about 10 gallons of fuel were removed from the right main tank prior to transport.
The left fuel selector valve in the nacelle and cockpit was positioned on the main tank. The firewall shutoff valve, adjacent to the fuel filter in the nacelle, was about halfway toward the off position, possibly due to cable pull during impact. The fuel filter contained no fuel but contaminants were noted in the gascolator; the filter was not blocked. The right fuel selector valve was positioned on the main tank, and the firewall shutoff valve was open. The right fuel filter also contained no fuel but contaminants; the filter was not blocked.
The left engine remained attached to the airframe and came to rest inverted. Visual examination revealed no evidence of pre-impact catastrophic mechanical malfunction or fire. The crankshaft rotated freely, thumb compression was noted on all cylinders, the valve train operated properly, and mechanical continuity was established. The magnetos produced spark at all plug leads during hand rotation. The left propeller blades were bent aft: blade L1 bent about 15-20 degrees, and blade L2 bent about 80 degrees near midspan, with nicks and scratches.
The right engine remained attached, sustained minor impact damage, and had thermal damage to accessories and nacelle due to a post-impact fire. The crankshaft rotated freely, thumb compression was noted, valve train operated properly, mechanical continuity was established. The magnetos incurred substantial thermal damage and could not be functionally tested. No evidence of pre-impact mechanical anomalies was noted. The right propeller blades were bent aft: blade R1 bent about 10-15 degrees on the outboard third, blade R2 bent about 30 degrees near midspan; both exhibited nicks, dents, and scratches.