Jean, NV, USA
N9199Z
Piper PA-28-161
!!THIS CASE WAS MODIFIED JANUARY 31, 2006!! The airplane collided with mountainous desert terrain in a box canyon during low altitude flight maneuvering. The pilot, a military helicopter pilot, was checked out in the airplane 4 days prior to the accident. He held approximately 500 hours total flight time and 150 hours flight time in airplanes. He and his passenger arrived at their destination 2 days prior to the accident. After fueling the airplane, they departed for the return flight home. Radar plots ending about 17 miles from the accident site indicated that the airplane maintained an approximate mean sea level (msl) altitude of 3,500 feet (about 100 feet above ground level) as it flew in a southerly direction, with the surrounding terrain rising to 4,400 feet msl at a rate of increase per mile that was about twice the climb capability of the airplane. The wreckage site was located in a canyon, at an elevation of 3,780 feet msl. The top of the ridges behind the accident site rose to 4,400 feet msl. The toxicological report for the pilot was positive for ethanol, but the state of the specimens evaluated made it impossible to determine whether the ethanol was produced post-mortem or was a result of ingestion of alcohol. No mechanical or control anomalies were found with either the airframe or engine during the post-accident examinations.
!!THIS CASE WAS MODIFIED JANUARY 31, 2006!! HISTORY OF FLIGHT On February 16, 2004, about 1430 Pacific standard time, a Piper PA-28-161 single engine airplane, N9199Z, collided with mountainous terrain 9 miles south of Jean, Nevada. Plus One Flyers, Inc., San Diego, California, was operating the privately registered airplane under the provisions of 14 CFR Part 91. The commercial pilot and one passenger sustained fatal injuries; the airplane was destroyed. Visual meteorological conditions prevailed during the cross-country personal flight, and no flight plan had been filed. The airplane departed from the North Las Vegas, Nevada, airport at 1359, and was en route to Montgomery Field, San Diego. Recorded air traffic control (ATC) transmissions from the North Las Vegas ground and tower controls were reviewed. N9199Z contacted North Las Vegas ground control at 1353, and requested a visual flight rules (VFR) departure to the west, with a climb to 4,500 feet mean sea level (msl). N9199Z was cleared to taxi to runway 7. At 1359, N9199Z was cleared for takeoff. The operator completed a Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2). He stated that the pilot reserved the airplane on February 11, 2004. The pilot and passenger departed Montgomery Field on February 14, and arrived at the North Las Vegas airport later that day. On February 16, the pilot and passenger departed North Las Vegas for the return flight to Montgomery Field. The airplane did not arrive. The Federal Aviation Administration issued an alert notice (ALNOT) on February 17, 2004, after a concerned party notified authorities that the pilot did not report to work. Search and rescue personnel concentrated the search for the airplane over an area southwest of Las Vegas, Nevada. ATC radar data indicated that the last target for the airplane was at 1417, at 100 feet above ground level (agl) south of Las Vegas. The radar returns ended approximately 17 miles northwest of the accident site. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a commercial pilot certificate with airplane single engine land, helicopter, and instrument airplane and helicopter ratings. The pilot held a second-class medical certificate that was issued on March 14, 2003. It had no limitations or waivers. No personal flight records were located for the pilot. The aeronautical experience listed in this report was obtained from a review of the medical FAA records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated a total civilian time of 4.6 hours with 2 hours logged in the last 6 months as of March 14, 2003. The pilot reported on FAA Form 2120-0021, Airman Certificate and/or Rating Application, dated March 29, 2002, that his military pilot-in-command time was accrued in T-34 airplanes, and the TH-57 helicopter, a military version of the Bell 206. The pilot's most recent civilian certified flight instructor (CFI) indicated that the pilot had logged approximately 500 hours total time, with about 150 hours in airplanes. The pilot joined Plus One Flyers, Inc., on December 7, 2003. He completed check out flights in a Cessna 172RG, on February 8, 2004, and in N9199Z, the accident airplane, on February 12, 2004, 4 days prior to the accident. The pilot was employed as a helicopter pilot in the military. AIRCRAFT INFORMATION The airplane was a Piper PA 28-161, serial number 2841290. An annual inspection was completed on October 6, 2003. The tachometer read 2,293.0 at the last inspection. Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure. The airplane had a Textron Lycoming O-320 engine, serial number L-17634-39A. At the time of the last annual inspection, the engine accumulated 1,542.0 hours since its last major overhaul. Based on the last entry dated February 13, 2004, the engine had accumulated 1660.8 hours since its last major overhaul. Fueling records from North Las Vegas Airport established that the airplane was last fueled on February 16 with the addition of 22 gallons of 100LL-octane aviation fuel. The fuel tanks were filled "to the tabs." METEOROLOGICAL INFORMATION The closest official weather observation station was Henderson Executive Airport, Henderson, Nevada, which was located 21 nautical miles (nm) northwest of the accident site. The elevation of the weather observation station was 2,492 feet msl. A routine aviation weather report (METAR) for Henderson was issued at 1445. It reported the following conditions: winds from 030 degrees at 6 knots; visibility 20 miles; scattered clouds at 15,000 feet, broken clouds at 25,000 feet; temperature 17 degrees Celsius; dew point -9 degrees Celsius; altimeter setting 30.19 inHg. WRECKAGE AND IMPACT INFORMATION The National Transportation Safety Board investigator-in-charge (IIC) examined the wreckage at the accident scene. The primary wreckage was located at 35 degrees 36.513 minutes north latitude and 115 degrees 17.735 minutes west longitude. The elevation was 3,780 feet mean sea level (msl). The orientation of the fuselage was 130 degrees magnetic. The airplane came to rest in a canyon, which generally ran from northwest to southeast, in mountainous, desert terrain. Entering the canyon from the northwest, the walls sloped moderately upward, and were covered with boulders and desert plants. The main canyon then branched off into smaller canyons. The wreckage was located within one of these smaller canyons. The canyon walls became narrower and steeper in the ascent of a mountain that rose to 4,000 feet. Fire and impact forces destroyed the airplane. The right wing was torn from the fuselage and found inverted over the right elevator. The upper portion of the left wing was inverted and torn from the fuselage. It was located on the left side of the airplane. The entire cockpit area was consumed by fire. The tail section sustained fire damage and the rudder and elevator sections remained attached. The engine, which sustained thermal damage, was displaced from the airframe, and located forward of the main wreckage. The propeller was 5 feet forward of the engine. A portion of the windscreen with an outside air temperature (OAT) gage was located 10 feet forward of the propeller. Examination of the propeller revealed that it had been severed from the engine crankshaft flange. One blade revealed leading edge impact damage, gouging, and twisting of the entire blade with a blade tip loss. The other blade also lost a tip section and was bent aft with a lesser amount of leading edge damage. The emergency locator beacon (ELT) was properly installed, but suffered fire damage to the antenna coaxial cable and melting of the battery pack and transmitter. MEDICAL AND PATHOLOGICAL INFORMATION The Clark County Coroner completed autopsies on the pilot and the passenger. The autopsies concluded that the deaths were the result of injuries sustained in the accident. The autopsy report on the pilot's toxicology results noted findings that were consistent with alcohol ingestion. The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the pilot and passenger. The results of analysis of the specimens were negative for carbon monoxide, cyanide, and tested drugs. The pilot's report contained the following positive results: 94 (mg/dL, mg/hg) ETHANOL detected in Vitreous 55 (mg/dL, mg/hg) ETHANOL detected in Urine 89 (mg/dL, mg/hg) ETHANOL detected in Blood 16 (mg/dL, mg/hg) ACETALDEHYDE detected in Vitreous 3 (mg/dL, mg/hg) ACETALDEHYDE detected in Urine 23 (mg/dL, mg/hg) ACETALDEHYDE detected in Blood It was noted on the report that a portion of the ethanol found may have been the result of ingestion. TESTS AND RESEARCH The FAA, Piper, and Textron Lycoming were parties to the investigation. Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on March 3, 2003. The engine was examined and the top spark plugs were removed. The number 2 and number 4 spark plugs were clean. The number 1 and number 3 spark plugs were oily. None of the spark plugs displayed mechanical deformation. The number 2 and number 4 spark plug electrodes were gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head. Investigators manually rotated the engine. The engine rotated freely and the valves moved approximately the same amount of lift in firing order. After the removal of the accessory case, the gears turned freely. Thumb compression was obtained on all cylinders in firing order. The oil pump would not rotate and was removed from the accessory case. The oil pump casing contained coking, consistent with excessive heat. The gears were not gouged and there was no scoring evident on the oil pump casing. Both magnetos were removed and sustained thermal damage. The left magneto was rotated; the right magneto would not rotate. The vacuum pump was removed and examined. All vacuum pump veins were whole, in position, and moved freely. The oil sump screen was clean and open. All of the airplane control surfaces were accounted for. The airframe manufacturer representative measured the anti-servo trim actuator at three threads. He reported that this corresponded to a nose-down trim position. The flap selector was positioned to the retracted position. The density altitude was calculated by the Safety Board IIC using a standard lapse rate of 2 degrees per 1,000 feet, and the ambient temperature from Henderson. The density altitude was calculated to be 4,420 feet. According to Figure 5-17 of the pilot operating handbook, report number VB-1360, utilizing a maximum gross weight condition, the climb performance at 3,000 feet msl was 460 feet per minute using the best rate of climb speed of 79 knots. The time and distance to climb from 3,000 feet msl to 4,000 feet msl as indicated on Figure 5-19, was about 3 minutes over a distance of 4 nautical miles. A Safety Board topographical mapping program indicated that the terrain elevation increased approximately 800 feet over a horizontal distance of 6,000 feet. Over the last 2,500-foot distance, the elevation increased approximately 500 feet. The Safety Board ATC specialist reviewed recorded radar data from Las Vegas ASR-9. The airplane climbed while on a northwesterly course, which initially nearly paralleled federal airway V23. The radar track then proceeded in a southerly direction on an approximate heading of 170 degrees. The airplane's presumed flight path was overlaid on a topographical map. The last recorded radar returns from 1416:44 until 1417:20, were plotted by the ATC specialist. The initial mode C indicated altitude was 3,800 feet, with surrounding terrain at 3,800 feet. At 1416:53, the plot indicated a mode C altitude of 3,500 feet; the surrounding terrain was about 4,100 feet. At the final plot located about 17 miles north of the accident site, the surrounding terrain elevation increased to 4,400 feet. ADDITIONAL INFORMATION The IIC released the wreckage to the owner's representative.
!!THIS CASE WAS MODIFIED JANUARY 31, 2006!! the pilot's failure to maintain adequate clearance with the rising terrain, while maneuvering at low altitude in a mountainous area.
Source: NTSB Aviation Accident Database
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