Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Paradise, California 95969
Thursday, April 2, 1992 19:54 PST
NTSB Narrative Summary Released at Completion of Accident
THE 60 HOUR STUDENT PILOT HAD A TOTAL OF 25 HOURS IN TYPE, ALL OF WHICH WERE DUAL. WITH HIS CURRENT FLIGHT INSTRUCTOR THE STUDENT RETURNED TO THEIR HOME BASE AIRPORT TO PERFORM A PREARRANGED GO-AROUND TO FINALIZE THEIR DUAL PERIOD FOR THE EVENING. AFTER THE APPROACH TO THE RUNWAY, THE INSTRUCTOR CALLED FOR THE GO-AROUND. AFTER THE CLIMB WAS ESTABLISHED AT ABOUT 500 FEET AGL HE CALLED FOR THE COWL FLAPS TO BE OPENED, AND MOMENTS LATER THE ENGINE SUDDENLY AND WITHOUT WARNING QUIT. THE INSTRUCTOR SAID THAT AFTER THE ENGINE QUIT THE STUDENT PULLED THE CONTROL YOKE ALL THE WAY BACK AND THE AIRCRAFT ENTERED A DEEP STALL. THE AIRPLANE HAD BEEN MODIFIED TO ACCOMMODATE AN ENGINE WITH MORE HORSE POWER WHICH REQUIRED THE INSTALLATION OF COWL FLAPS. THE FAA APPROVED STC MODIFICATION DRAWINGS REQUIRED THE PUSH-PULL CONTROL FOR THE COWL FLAPS TO BE LOCATED TO THE LEFT OF THE THROTTLE CONSOLE ON A SEPARATE SWITCH PANEL. THE ACTUAL LOCATION OF THAT CONTROL IN THE ACCIDENT AIRPLANE WAS FOUND TO THE RIGHT OF THE THROTTLE BELOW THE PROPELLER CONTROL AND NEXT TO
NTSB Probable Cause Narrative
THE STUDENT PILOT'S INADVERTENT USE OF THE MIXTURE CONTROL INSTEAD OF THE COWL FLAPS AT A CRITICAL PHASE OF FLIGHT, HIS MISUSE OF THE FLIGHT CONTROLS AFTER THE ENGINE FAILURE AND THE INSTRUCTOR'S INADEQUATE SUPERVISION OF THE STUDENT. CONTRIBUTING FACTORS IN THE ACCIDENT WERE: THE NON STANDARD LOCATION OF THE COWL FLAP PUSH PULL CONTROL, DUE TO AN IMPROPER AIRCRAFT MODIFICATION, THE DARK NIGHT LIGHT CONDITIONS WHICH IMPAIRED THE FLIGHT INSTRUCTORS ABILITY TO MONITOR THE STUDENT COCKPIT CONTROL MANIPULATIONS.
Event Information
| Type of Event | Accident |
| Event Date | 4/2/1992 |
| Event Day of the Week | Thursday |
| Time of Event | 1954 |
| Event Time Zone | Pacific Standard Time |
| Event City | PARADISE |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 95969 |
| Event Date Year | 1992 |
| Event Date Month | 4 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | |
| Event Location Nearest Airport ID | |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 0 |
| Degrees magnetic from airport | 0 |
| Airport Elevation | -- |
| Weather Briefing Completeness | Unknown |
| Investigator's weather source | Pilot |
| Time of the weather observation | 0 |
| Direction of event from weather observation facility (degrees) | 0 |
| Weather Observation Facility ID | |
| Elevation of weather observation facility | 0 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | |
| Lighting Conditions | Night/Dark |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 0 |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 7 |
| Air Temperature at event time (in degrees celsius) | 18 |
| Dew Point at event time (in degress fahrenheit) | -18 |
| Wind Direction (degrees magnetic) | 110 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 0 |
| Wind Velocity Indicator | Calm |
| Wind Gust Indicator | Unknown |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 29 |
| Density Altitude (feet) | 0 |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | 1 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | 1 |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 2177 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Apr 2 1992 12:00AM |
| NTSB Notification Time | 2050 |
| Fiche Number and/or location -used to find docket information | 46950 |
| Date of most recent change to record | Dec 11 2000 2:51PM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N9367Y |
| NTSB Number | LAX92FA161 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Destroyed |
| Aircraft Fire | Ground |
| Aircraft Explosion | Ground |
| Aircraft Manufacturer's Full Name | BEECH |
| Aircraft Model | A33 |
| Aircraft Series Identifier | A33 |
| Aircraft Serial Number | CD-262 |
| Certified Max Gross Weight | 3000 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | Unknown |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 4 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Annual |
| Date of Last Inspection | Aug 23 1991 12:00AM |
| Airframe hours since last inspection | 61 |
| Airframe Hours | 4686 |
| ELT Installed | Yes |
| ELT Activated | Yes |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | DESMET, JEFFREY G. |
| Aircraft Owner Street Address | 1122 ELLIOTT RD. |
| Aircraft Owner City | PARADISE |
| Aircraft Owner State | CA |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 95969 |
| Operator is an individual? | -- |
| Operator Name | DESMET, JEFFREY G. |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | |
| Operator City | |
| Operator State | |
| Operator Country | |
| Operator Zip code | |
| Operator Code | |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | Unknown |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Instructional |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | Yes |
| Departure Airport Code | |
| Departure City | |
| Departure State | |
| Departure Country | |
| Departure Time | 1800 |
| Departure Time Zone | PST |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | |
| Destination City | |
| Destination State | |
| Destination Country | |
| Specific Phase of Flight | Approach |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:30AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 0 |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |