Date & Time:
Nov 29, 1987 at 1843 LT
Type of aircraft:
Piper PA-46 (Malibu/Meridian/Mirage/Matrix/M-Class)
Operator:
Registration:
N4369V
Flight Phase:
Landing (descent or approach)
Flight Type:
Training
Survivors:
Yes
Schedule:
Carslbad - Long Beach
MSN:
46-8408076
YOM:
1984
Country:
United States of America
Region:
North America
Crew on board:
2
Crew fatalities:
1
Pax on board:
0
Pax fatalities:
0
Other fatalities:
0
Total fatalities:
1
Captain / Total hours on type:
237
Circumstances:
During the return flight to San Jose and subsequent descent and approach to the Long Beach Airport, the two pilots experienced, in succession, a failure of the turbocharger system, loss of an alternator, loss of engine oil pressure, an unsafe landing gear indication, and an in-flight fire followed by the loss of engine power during a night time circling approach to an unfamiliar airport in visual meteorological conditions. The aircraft crashed onto the southbound lanes of the San Diego freeway at Long Beach after making a flyby of the tower to confirm the landing gear position. The investigation revealed an improperly installed turbocharger, a cracked manifold exhaust, a burned main power lead, a separated cylinder, and a low fluid level in the hydraulic reservoir. Two years prior to this accident, the instructor pilot made an unintentional gear up landing in another aircraft. One year prior to this accident the FAA revoked the mechanic's inspection authorization.
Probable cause:
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
Pilot's failure to land the aircraft after experiencing the pilot's Faulty decision was his previous experience with a gear up landing a Couple of years before.
Findings
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: cruise - normal
Findings
1. Exhaust system, turbocharger - failure, partial
2. (f) exhaust system, turbocharger - disengaged
3. (f) engine installation, mounting bolt - separation
4. (c) maintenance, installation - improper - company maintenance personnel
5. (f) maintenance, inspection - poor - company maintenance personnel
----------
Occurrence #2: airframe/component/system failure/malfunction
Phase of operation: descent - emergency
Findings
6. (f) electrical system, electric wiring - burned
7. Electrical system, alternator - disabled
8. (c) hydraulic system, accumulator - low level
9. Landing gear, gear indicating system - false indication
10. (c) low pass - intentional - pilot in command (cfi)
11. (f) anxiety/apprehension - pilot in command (cfi)
----------
Occurrence #3: fire
Phase of operation: go-around (vfr)
Findings
12. (c) engine assembly, cylinder - fatigue
13. Engine assembly, cylinder - separation
14. Go-around - performed - pilot in command (cfi)
15. (f) judgment - poor - pilot in command (cfi)
----------
Occurrence #4: loss of engine power (total) - mech failure/malf
Phase of operation: approach - vfr pattern - base leg/base to final
Findings
16. (f) fluid, oil - starvation
----------
Occurrence #5: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
17. Light condition - night
18. (c) stall/mush - encountered - pilot in command (cfi)
Pilot's failure to land the aircraft after experiencing the pilot's Faulty decision was his previous experience with a gear up landing a Couple of years before.
Findings
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: cruise - normal
Findings
1. Exhaust system, turbocharger - failure, partial
2. (f) exhaust system, turbocharger - disengaged
3. (f) engine installation, mounting bolt - separation
4. (c) maintenance, installation - improper - company maintenance personnel
5. (f) maintenance, inspection - poor - company maintenance personnel
----------
Occurrence #2: airframe/component/system failure/malfunction
Phase of operation: descent - emergency
Findings
6. (f) electrical system, electric wiring - burned
7. Electrical system, alternator - disabled
8. (c) hydraulic system, accumulator - low level
9. Landing gear, gear indicating system - false indication
10. (c) low pass - intentional - pilot in command (cfi)
11. (f) anxiety/apprehension - pilot in command (cfi)
----------
Occurrence #3: fire
Phase of operation: go-around (vfr)
Findings
12. (c) engine assembly, cylinder - fatigue
13. Engine assembly, cylinder - separation
14. Go-around - performed - pilot in command (cfi)
15. (f) judgment - poor - pilot in command (cfi)
----------
Occurrence #4: loss of engine power (total) - mech failure/malf
Phase of operation: approach - vfr pattern - base leg/base to final
Findings
16. (f) fluid, oil - starvation
----------
Occurrence #5: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
17. Light condition - night
18. (c) stall/mush - encountered - pilot in command (cfi)
Final Report:
N4369V.pdf91.09 KB
