Tuesday, August 9, 2016

Piper PA-28-161 Warrior II, N8441B, operated by Golden State Flying Club: Fatal accident occurred September 03, 2015 near Gillespie Field Airport (KSEE), California

Robert C. Sarrisin and Jeffrey Michael Johnson


The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; San Diego, California
Piper Aircraft; Vero Beach, Florida
Lycoming Engines; Williamsport, Pennsylvania 

Aviation Accident Final Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Data Summary - National Transportation Safety Board:  https://app.ntsb.gov/pdf

Registered Owner: Volar Corp 

http://registry.faa.gov/N8441B



NTSB Identification: WPR15FA256 
14 CFR Part 91: General Aviation
Accident occurred Thursday, September 03, 2015 in Santee, CA
Probable Cause Approval Date: 09/26/2017
Aircraft: PIPER PA28, registration: N8441B
Injuries: 2 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The flight instructor and student pilot were conducting touch-and-go takeoffs and landings in the airport traffic pattern. While on the upwind leg of the traffic pattern following the second takeoff, the airplane entered a steep left turn and impacted a residential area; a postimpact fire ensued. One witness reported that he heard the airplane's engine "shut off," and stated that it sounded as though the engine was "trying to restart."

Investigators could not determine who was manipulating the flight controls at the time of the accident.

Examination of the airframe and flight controls revealed no mechanical anomalies that would have precluded normal operation.

The engine examination revealed no internal mechanical anomalies that would have precluded normal operation. The left magneto was not located. A teardown of the right magneto revealed that the internal components had been improperly assembled; the distributor gear electrode was not seated properly, and the distributor drive gear was stuck inside the magneto. Given the improper assembly of the right magneto it is likely that the magneto had failed to operate properly, which subsequently resulted in a rough running engine and a partial loss of engine power. It is likely that the flight instructor and student were distracted by the partial loss of engine power, and during the turn toward the open field, lost aircraft control and stalled the airplane, and subsequently hit flat terrain.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilots' failure to maintain airplane control following a partial loss of engine power after takeoff, which resulted in an aerodynamic stall. Contributing to the accident was the partial loss of engine power due to a failure of the right magneto.



HISTORY OF FLIGHT

On September 3, 2015, about 0917 Pacific daylight time, a Piper PA-28-161 airplane, N8441B, impacted a residential area in Santee, California, shortly after takeoff from Gillespie Field Airport (SEE), San Diego/El Cajon, California. The flight instructor and student pilot were fatally injured, and the airplane was substantially damaged. The instructional flight was operated by Golden State Flying Club, El Cajon, California, under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan had been filed for the local flight.

According to the Federal Aviation Administration (FAA), air traffic tower personnel at SEE reported that the airplane had been conducting touch-and-go takeoffs and landings on runway 27R. The controller stated that after completion of the second touch-and-go, he expected that the airplane would turn right onto the crosswind leg of the traffic pattern. However, the airplane turned left and descended rapidly toward terrain west of the field. There were no mayday calls received from the accident airplane.

A witness in a vehicle watched the airplane take off and follow a normal climb path. Then he saw the left-wing dip, which initially he thought was a normal traffic pattern turn. He realized that the left wing continued to dip "more severely than normal," and the left bank increased as the airplane flew toward an open field at the west end of the runway. As the airplane continued in a tight left turn, it lost altitude "very quickly," and subsequently impacted the ground.

A witness located near the accident site reported that he heard the airplane's engine "shut off," and stated that it sounded as if the engine was "trying to restart." The airplane then impacted three vehicles, and came to rest inverted in a driveway; a postaccident fire ensued.

PERSONNEL INFORMATION

AIRCRAFT INFORMATION

According to the engine logbooks, the engine was overhauled by Ly-Con Rebuilding company in Visalia, California, and installed on the accident airplane June 25, 2014. At that time, new Slick Champion Aerospace magnetos were installed. A review of the flight schools squawk sheets revealed no identified issues with the magnetos.




WRECKAGE AND IMPACT INFORMATION

The entirety of the airplane was located at the accident site; and sustained thermal damage during a postcrash fire. The left wing had separated from the airplane, and came to rest on top of the right wing.

The fuselage and cockpit area sustained ground impact damage. The flap handle was in between the zero detent and the 10° detent. The ignition switch was found with the key broken inside and the switch was positioned to the "left mag." The fuel selector was positioned to the right fuel tank position. The left-wing fuel tank was breached, but contained 13 gallons of blue-colored liquid consistent with 100-LL aviation fuel. About 23 gallons of fuel was retrieved from the right wing.

The engine remained attached to its mount; the mount was separated from the firewall. The engine assembly came to rest adjacent to the airplane. Several of the rear case accessories separated from their respective mounting pads. The left magneto separated from its mounting pad and was not located.

The propeller remained attached to the engine crankshaft with the spinner exhibiting aft crush damage. One blade was bent forward and the other blade was bent aft. Both propeller blades had minor leading edge and chordwise damage, and remained intact.

MEDICAL AND PATHOLOGICAL INFORMATION

Flight Instructor

The County of San Diego, Office of the Medical Examiner, San Diego, California, performed the autopsy of the flight instructor. The cause of death was reported as multiple blunt force injuries, with a contributing cause of traumatic asphyxia. The manner of death was listed as an accident.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma performed toxicology testing on submitted specimens from the pilot. The test results yielded negative findings for carbon monoxide, cyanide, ethanol, and drugs of abuse.

Student Pilot

The County of San Diego, Office of the Medical Examiner performed the autopsy of the student pilot. The cause of death was reported as blunt force head injuries. The manner of death was listed as an accident.

The FAA's Bioaeronautical Sciences Research Laboratory performed toxicology testing on submitted specimens from the student pilot. The test results yielded negative findings for carbon monoxide, cyanide, and ethanol. The results for tested drugs of abuse were positive for the following:

Anhydroecgonine Methyl Ester detected in urine
Anhydroecgonine Methyl Ester not detected in blood
0.101 (ug/ml, ug/g) Benzoylecgonine detected in urine
Benzoylecgonine not detected in blood
Ecgonine Methyl Ester detected in urine
Ecgonine Methyl Ester detected in blood
2.047 (ug/ml, ug/g) Phentermine detected in urine
0.1 (ug/ml, ug/g) Phentermine detected in blood (lliac)
0.099 (ug/ml, ug/g) Phentermine detected in serum

According to the FAA, Benzoylecgonine is the predominate metabolite of cocaine, and is used as an indicator of cocaine use. Anhydroecgonine methyl ester is a unique pyrolysis product that is formed when cocaine is smoked, and is a possible indicator of "crack cocaine" use. Ecognine methyl ester is an inactive minor metabolite of cocaine. Phentermine is a schedule IV, short-term use, prescription appetite suppressant. The FAA reported that phentermine is not an acceptable medication for use while performing airman duties.

The toxicological findings indicated that although the student had used cocaine hours to a few days before the accident, there was no parent (active) drug detected.

TEST AND RESEARCH INFORMATION

The examination of the airframe revealed no preimpact failures were noted with any flight control surface or flight control system components.

The engine was manually rotated using a drive tool at the vacuum pump drive.

The engine rotated freely, and compression was produced in all four cylinders, which also established valve and gear train continuity. The right magneto (non-impulse coupled magneto) remained attached to the engine at its mounting pad. The magneto was removed and visually examined. During manual rotation of the magneto drive, internal friction was detected and audible grinding was heard.


Further examination of the right magneto revealed no obvious signs of damage. Maintenance personnel were not able to manually rotate the magneto; however, the top gear rotated freely. When the magneto was opened, the distributor gear electrode was not seated properly, and the distributor drive gear was stuck inside the magneto. Once disassembled, the cam follower appeared to be in good condition and the points appeared to be brand new. The rotor drive lower ball bearing was frozen; however, the upper bearing rotated freely with no binding. There was rust present in the rotor drive, but it could not be determined whether it was present before the accident or formed after the accident. The internal components were all in good condition and each individual test of the capacitor, electrodes, and coil were within manufacturer specifications; and the components were in good condition.

NTSB Identification: WPR15FA256
14 CFR Part 91: General Aviation
Accident occurred Thursday, September 03, 2015 in Santee, CA
Aircraft: PIPER PA28, registration: N8441B
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On September 3, 2015, about 0915 Pacific daylight time, a single-engine Piper PA28-161 airplane, N8441B, struck the roof of a house, and came to rest inverted in a driveway in a residential area in Santee, California. Golden State Flying Club, El Cajon, California, operated the airplane as an instructional flight under the provisions of 14 Code of Federal Regulations Part 91. The flight instructor and student pilot were fatally injured. The airplane sustained substantial damage during the accident sequence, and was also involved in a post-crash fire. Visual meteorological conditions prevailed for the local area traffic pattern flight, and no flight plan had been filed. The airplane had just departed from Gillespie Field Airport (SEE), San Diego/El Cajon, California, runway 27R; the accident site was located about a ½ mile from the airport.

According to the Federal Aviation Administration (FAA), tower personnel reported that the airplane had been conducting touch-and-go takeoffs and landings on runway 27R. After completing the second touch-and-go landing, tower personnel stated that the airplane was on the upwind, when they observed the airplane make a left turn and descend rapidly toward the terrain west of the field. There were no mayday calls made by the pilot.

Witnesses located at the accident site reported that the engine quit, and it appeared that the pilots were trying to restart the engine when the left wing struck the roof of a house. The airplane then struck three vehicles, and came to rest inverted in a driveway abut a palm tree.

A National Transportation Safety Board (NTSB) investigator responded to the accident site along with the FAA, and a Piper Aircraft air safety investigator. The entire airplane came to rest at the accident site; the left wing had separated from the airplane, but had come to rest on top of the right wing. The engine and engine mount remained attached to each other, but had separated from the airframe, and came to rest adjacent to the nose of the airplane. The airplane was recovered with an inspection scheduled for a later date.
August 9, 2016 (El Cajon) — The Federal Aviation Administration has approved a request from Gillespie Field Airport Manager Marc Baskel to permanently raise the minimum altitude for air traffic over Gillespie Field from 1,188 feet to 1,388 feet.

“This determination was made with respect to the safe and efficient use of navigable airspace by aircraft and with respect to the safety of persons and property on the ground,” says Tim Hester, airport planner with the FAA in a letter to Baskel dated July 22, 2016.

The change comes after years of complaints by neighbors who contend flight school students flying low over homes pose dangers to residents, also causing noise annoyance. 

 At least twice in recent years, planes from Gillespie have crashed into adjacent neighborhoods, including a fatal crash into a Santee home in 2015 that killed a flight school pilot and student.

“I am hoping this will provide some relief,” says Sue Strom, founder of Advocates for Safe Airport Policy, or ASAP.

Strom indicates that a staffer for Supervisor Dianne Jacob’s office has indicated the change will take effect on September 15th and that Jacob is ”very excited about this.”

A similar request to the FAA a decade ago was reportedly denied.

Source:   http://www.eastcountymagazine.org

Piper PA-28-161 Warrior II, N8441B, Golden State Flying Club: Fatal accident occurred September 03, 2015 near Gillespie Field Airport (KSEE), California





http://registry.faa.gov/N8441B

FAA Flight Standards District Office:  FAA San Diego FSDO-09

NTSB Identification: WPR15FA256
14 CFR Part 91: General Aviation
Accident occurred Thursday, September 03, 2015 in Santee, CA
Aircraft: PIPER PA28, registration: N8441B
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On September 3, 2015, about 0915 Pacific daylight time, a single-engine Piper PA28-161 airplane, N8441B, struck the roof of a house, and came to rest inverted in a driveway in a residential area in Santee, California. Golden State Flying Club, El Cajon, California, operated the airplane as an instructional flight under the provisions of 14 Code of Federal Regulations Part 91. The flight instructor and student pilot were fatally injured. The airplane sustained substantial damage during the accident sequence, and was also involved in a post-crash fire. Visual meteorological conditions prevailed for the local area traffic pattern flight, and no flight plan had been filed. The airplane had just departed from Gillespie Field Airport (SEE), San Diego/El Cajon, California, runway 27R; the accident site was located about a ½ mile from the airport.

According to the Federal Aviation Administration (FAA), tower personnel reported that the airplane had been conducting touch-and-go takeoffs and landings on runway 27R. After completing the second touch-and-go landing, tower personnel stated that the airplane was on the upwind, when they observed the airplane make a left turn and descend rapidly toward the terrain west of the field. There were no mayday calls made by the pilot.

Witnesses located at the accident site reported that the engine quit, and it appeared that the pilots were trying to restart the engine when the left wing struck the roof of a house. The airplane then struck three vehicles, and came to rest inverted in a driveway abut a palm tree.

A National Transportation Safety Board (NTSB) investigator responded to the accident site along with the FAA, and a Piper Aircraft air safety investigator. The entire airplane came to rest at the accident site; the left wing had separated from the airplane, but had come to rest on top of the right wing. The engine and engine mount remained attached to each other, but had separated from the airframe, and came to rest adjacent to the nose of the airplane. The airplane was recovered with an inspection scheduled for a later date.

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