Pilot Debrief

PIPER PA 28R-180 near Lake Elsinore, CA — 2014-07-06

Final reportWPR14FA282
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Date
2014-07-06
Location
Lake Elsinore, CA, USA
Aircraft
PIPER PA 28R-180
Registration
N3723T
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Maneuvering

Probable cause

The pilot's failure to maintain airplane control when the landing gear unintentionally extended while maneuvering at low altitude and airspeed, which increased the airplane’s drag and decreased its ability to climb over the rising terrain.

NTSB narrative

A video made by a witness located in a restaurant parking lot near the top of a ridge initially shows the airplane wings level at a low altitude with a steady engine rpm and the landing gear in the retracted position. The airplane then makes about a 45-degree, left turn. The airplane subsequently levels off, flying in the direction toward the ridgeline with the landing gear in the extended position. The airplane continues at a low altitude toward the rising terrain, and then the video ends. Shortly thereafter, witnesses reported seeing smoke in the area where the airplane had disappeared from their sight. The wreckage was found about 0.32 mile southwest of the restaurant parking lot, and the airplane had impacted trees on the rising terrain. Postaccident examination of the airframe and engine revealed no malfunctions or failures that would have precluded normal operation. This airplane was equipped with a back-up landing gear extension system, which incorporates a pressure-sensing device to automatically lower the landing gear at airspeeds between about 85 and 105 mph depending upon the power setting and regardless of the position of the gear handle in the cockpit. The system can be overridden by manually holding the emergency gear lever in the raised position. About 16 years before the accident, the manufacturer issued a mandatory two-part service bulletin requiring that either (1) the back-up landing gear extension system be removed from the airplane or (2) that the owner and operator review and understand the information about the system in the airplane flight manual and Pilot's Operating Handbook, including its operation and limitations. The mechanic who conducted the airplane's most recent annual inspection reported that the airplane's back-up landing gear extension system was still operational and that it had not been disabled. The pilot was maneuvering at a low level in an area with no suitable terrain for landing; therefore, it is likely that he did not intentionally lower the landing gear. During the steep turn, the airspeed likely decreased enough for the back-up landing gear system to engage and extend the gear. With the increased drag of the landing gear and low airspeed, the airplane did not have sufficient power or altitude to clear the rising terrain and subsequently collided with trees.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have avoided low altitude maneuvering near rising terrain.

NTSB coding

Evidence available

  • Video
  • Photos
  • 17 docket documents
View NTSB final reportView NTSB docket

Docket documents17

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