RENO, NV, USA
N69645
Piper PA28R-180
The pilot said that the landing gear down lights did not come on and he executed a go-around so the air traffic control tower personnel could visually check the gear's position. The tower personnel confirmed that the gear appeared down. On crosswind, the aircraft descended and struck a fence. The pilot said the engine began sputtering when he initiated the climb. Witnesses, including another pilot in the traffic pattern, reported seeing the aircraft in a nose high attitude with the wings oscillating before the aircraft entered a stall and descended behind buildings. The pilot was in the left seat for the flight. A Statement of Demonstrated Ability was issued on March 17, 1987, for a right arm amputation from the shoulder down on the basis of a special medical flight test in a non-complex Piper PA28-180. The FAA inspector who conducted the flight test issued a student pilot certificate with several limitations, which were not transferred to his subsequent temporary and permanent pilot certificates as required by pertinent FAA Orders. The certificated flight instructor (CFI) who flew with the pilot just before this flight noted that he had many difficulties in controlling the aircraft and working the trim, adjusting the power settings, operating the gear controls, talking on the radio, and moving the flap control handle. In any of those operations, the pilot had to hold the yoke with his knees and reach across his body. The CFI said the pilot needed more work and did not endorse him for high performance aircraft. Post-accident examination of the aircraft revealed no evidence of failure or malfunction with the flight controls or engine. Fuel system continuity was established. A measured 2.5 gallons were drained from the left wing tank and 1.5 gallons from the right wing tank (unusable fuel in each tank is 1-gallon). A screw that attaches to the bus was found to be missing from the landing gear indicator circuit breaker. The system had been worked on by a maintenance facility just before the flight. Prior to the 4.5-hour accident flight, the pilot had logged 3 hours in high performance aircraft with a CFI. Most of the aircraft controls, normal and emergency, are on the pilot's right side. The pilot wore no prosthetic device during the accident flight. None of the passengers were rated pilots.
On September 12, 1997, at 1350 hours Pacific daylight time, a Piper PA28R-180, N69645, descended into a fence while on a right crosswind in the traffic pattern at the Reno, Nevada, airport. The aircraft sustained substantial damage and the pilot/owner and three passengers suffered serious injuries. There was no fire, nor were there any ground injuries. Visual meteorological conditions prevailed and no flight plan was filed. The personal flight departed from the Ogden, Utah, airport at 0908, and was terminating at the time of the accident. The pilot reported that after completing the normal approach checklist for initial approach into Reno he noticed that the landing gear down indication lights did not come on. He also stated that he did not feel or hear the gear come down. He then relayed that information to Reno Air Traffic Control Tower (ATCT) and they suggested that he execute a flyby so they could visually check the landing gear position. The tower confirmed that the gear did appear to be down. After passing the tower, the pilot reported that he noticed that the airspeed was decreasing so he "dropped the nose a little bit to establish climb." He then added full throttle with no response. The pilot said that he heard the engine sputtering and realized that a "crash was imminent" so he reduced the throttle, turned off the fuel shutoff valve, and pulled the prop back. He asked his front seat passenger to push in all the circuit breakers for him. The aircraft impacted a cyclone fence surrounding the tennis court at a middle school. A Federal Aviation Administration (FAA) inspector from the Reno, Nevada, Flight Standards District Office arrived at the accident site at 1430. He conducted an examination of the airplane and spoke to several witnesses to the accident, including a pilot who was in the traffic pattern behind the accident aircraft. The pilot/witness stated that he saw the accident aircraft just after it made a low pass by the tower and reported that "the nose of the aircraft rose to a normal climb attitude, but the aircraft was already going so slow that it just mushed and started to wobble as it approached stall speed. The aircraft settled to within about 20 feet of the ground, then leveled off and began to stabilize." He further reported that after the aircraft initiated a right turn at 100 feet agl, the aircraft entered a full stall at a very high sink rate and disappeared behind the buildings and trees. All statements from ground witness and ATCT personnel corroborate the nose high attitude of the airplane, slow speed, and "fluttering wings." The FAA inspector further reported that neither he nor any fire department personnel observed any fuel spill around the aircraft. A measured 2.5 gallons of fuel were drained from the left wing tank and 1.5 gallons were drained from the right wing tank. The unusable fuel in each tank is 1 gallon. He noted that the flaps were full down at 40 degrees. The FAA inspector also reported that three circuit breakers were found electrically open at the accident site. The breakers were identified as the generator field, fuel pump, and landing gear indication. The Safety Board conducted an examination of the airframe and powerplant following recovery of the aircraft. Continuity was established for all flight and engine controls. The engine rotated with compression developed in each cylinder. Mechanical continuity was established to the accessory gears and valve train. The right and left magnetos produced spark at all four plug leads during hand rotation. The fuel injection servo and induction systems were examined and observed to be free of obstruction. The throttle and mixture controls were found attached to the servo, and continuity to the cockpit was established. All engine compartment fuel lines were found to be in place and secured. The fuel servo fuel inlet screen was found in place and free of contamination. The fuel pump was found attached to the engine and was observed to function by hand rotation of the crankshaft. Examination of the spark plugs did not reveal any damage to the electrodes or any evidence of fouling. The spark plugs showed normal color, wear patterns, and electrode gaps according to the Champion Check-a-Plug Chart. The right and left main landing gear separated from the wings, with fractures of the rear bearing housings. Both the actuating cylinders were found in the extended position. The down limit switch and the squat switch were functionally tested using an Ohm meter and were found to function normally. The nose gear assembly was also separated by impact. Its down limit switch was functionally tested with an Ohm meter and found to function normally. External power was applied to the landing gear hydraulic pump. The pump motor was found to function in either direction when power was applied. During the examination of the electrical circuit breaker panel, the landing gear indication breaker was found to be missing the screw that attaches it to the buss bar assembly. Visual inspection of the landing gear down in-transit and gear unsafe light bulbs did not reveal any stretched or broken filaments. In a written statement from the pilot, he noted that the aircraft had experienced "landing gear indication problems" in the recent past that had received maintenance attention. He stated that the landing gear indicator lights had worked for four or five flights since the maintenance; this was the first flight since then that they had not functioned. Review of maintenance work orders from Great Western Aviation, Ogden, Utah, disclosed that the aircraft was worked on in August 1997 for several discrepancies. The work orders are appended to this report. Discrepancy items 6 through 12 on the work order concern intermittent operation of several landing gear indications. Corrective actions listed included the removal and replacement of the switches for gear down proximity, throttle position, and oleo squat. In addition to the landing gear system work, an electric pitch trim system was installed. PERSONNEL INFORMATION A certified copy of the pilot's Blue Ribbon Airman file was obtained from the Airmen Certification Branch of the Federal Aviation Administration and is appended to this file. The pilot, seated in the left seat at the time of the accident, holds a private pilot certificate with an airplane single engine land rating. Due to an amputation of his right arm from the shoulder down, the pilot also holds a Statement of Demonstrated Ability (SODA), which was issued on March 17, 1987. The FAA Guide for Aviation Medical Examiners was consulted and the relevant portions are appended to this report. According to that guide, the FAA issues a SODA to pilots who have certain static defects that will not progressively worsen. The extent of the functional loss that has been cleared by the FAA is stated on the face of the SODA, and if the medical examiner finds the condition has become worse, a medical certificate should not be issued even if the applicant is otherwise qualified. The SODA cannot be used in lieu of a medical certificate; it should be attached to the pilot's medical certificate. The pilot completed a special medical flight test with an FAA inspector on April 2, 1987, in a Piper PA28-180, a non-complex aircraft. The FAA Inspector's Handbook 8700.1 was consulted and copies of the relevant portions are appended to this file. According to that guide, in the section pertaining to conducting a medical flight test, it is stated that an inspector must "determine if the applicant can perform the appropriate pilot functions for the type of medical test being conducted, as follows...observe an applicant with a deformity or absence of the extremities demonstrate the following in an aircraft: (a) the ability to reach and operate effectively all controls which would normally require the use of that extremity (or those extremities); note any unusual body position the applicant may use to compensate for the defect and what effect that position has on the applicant's field of vision; (b) the ability to satisfactorily perform emergency procedures relative to flight, such as recovery from stalls, and engine out procedures (multiengine aircraft)." It further states that "operating limitations required by physical deficiencies may restrict holders to certain aircraft types, special equipment or control arrangements, or special operating conditions. One of the listed examples is "LIMITED TO AIRCRAFT WITH ALL CONTROLS BELOW SHOULDER LEVEL," for an airman who is unable to use the upper extremities, possibly because of the loss of an arm. The guide also states that limitations should be as general as possible to eliminate the necessity of additional special medical tests when the pilot desires to fly additional aircraft types for which he or she is physically competent. The FAA inspector who conducted the medical flight test issued the pilot a student pilot certificate with the following limitations on his certificate: push to talk with boom mike required; knee clipboard required; and toe brakes required. The pilot completed a private pilot practical flight test with a designated pilot examiner on November 26, 1988. The FAA inspector's handbook states that "if a student pilot passes both the flight test and the medical test, the inspector must place all appropriate operational limitations on the Temporary Airman Certificate." It further states that "any operating limitation may be deleted or amended only on the basis of an additional special medical test, or upon qualification by the pilot for an appropriate medical certificate without waiver or exemption." The temporary and permanent pilot certificates issued to the pilot following the flight test did not bear any limitations. Furthermore, an Airman Records Correction Notice from the Airmen Certification Branch, AAC-260, dated February 27, 1989, stated that private pilot application was returned for the following reason: "our records read 'Push to talk with boom mike required, knee clipboard required, toe brakes required.' Please verify if the airman passed a special medical flight test for this." No additional special medical flight test was conducted, nor were any changes made to the pilot's certificate following the noted discrepancy. The certified flight instructor (CFI) who flew with the pilot just before the accident reported that he "noted the difficulties Mr. Howell faced due to his impairment. For example, to trim the aircraft, adjust the power settings or move the flaps, he had to hold the yoke with his knees and reach across his body to make any adjustments. This is difficult to do with one arm and still keep pitch attitude. He told me the aircraft would have electric trim installed the first of September. The aircraft was not equipped with an intercom system, so he had the microphone mounted on the left window post next to his head. This required releasing the yoke every time he had to communicate on the radio." The CFI further reported that the pilot's landings were "very rusty" and that they were working on improving them. The CFI reported that he heard about the accident on September 14, 1997, and at that time he had no "prior knowledge of the flight and had not given Mr. Howell any endorsements." He reported that it was his understanding that he would fly with the pilot for approximately 7 more hours, and when he felt the pilot was ready, he would endorse his logbook for both a High Performance checkout and a Biennial Flight Review. The pertinent provisions of 14 CFR 61.31 of the Federal Aviation Regulations pertaining to operation of high performance airplanes states: "A person holding a private or commercial pilot certificate may not act as pilot in command of an airplane that has more than 200 horsepower, or that has a retractable landing gear, flaps, and a controllable propeller, unless he has received flight instruction from an authorized flight instructor who has certified in his logbook that he is competent to pilot an airplane that has more than 200 horsepower, or that has a retractable landing gear, flaps, and a controllable propeller, as the case may be." Prior to the accident flight, the pilot had logged approximately 3 hours in high performance aircraft, all in the accident aircraft, with the certified flight instructor. The accident flight was approximately 4 1/2 hours. The pilot reported to the FAA inspector that he had misplaced his pilot logbook. Most of the aircraft controls, normal and emergency, are on the right side from the perspective of a pilot sitting in the (left side) pilot's seat. The pilot wore no prosthetic device during the accident flight. None of the passengers were rated pilots.
The pilot's failure to maintain an adequate airspeed during a go-around, which resulted in an inadvertent stall/mush. Factors in the accident were: the pilot's lack of qualification in the aircraft; the FAA pilot certification system's failure to transfer the medical limitations imposed on the pilot to his private pilot certificate; the pilot's inadequate preflight and in-flight fuel planning/decisions that caused the aircraft to arrive with a critically low fuel state, which resulted in a momentary loss of power due to an unporting of the fuel tank supply pickup at a critical time in the go-around; and, the maintenance facilities' failure to properly connect the landing gear indicator circuit breaker to the bus pane.
Source: NTSB Aviation Accident Database
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