Palo Alto Airport
Aircraft Accident/Incident Report

Palo Alto, California 95112
Sunday, January 2, 2005 13:37 PST

NTSB Narrative Summary Released at Completion of Accident

The airplane landed long and overran the runway, colliding with a berm and marshy terrain about 300 yards beyond the runway end. The first leg of the flight originated at Mammoth Lakes, California, destined for Palo Alto. En route at 18,000 feet over the Sierra Nevada Mountains, the pilot observed erratic high oil temperature and low oil pressure readings and diverted to Modesto to have the engine checked. No mechanics were available at the airport and the pilot subsequently departed for Palo Alto, after adding oil to the engine for the 65-mile remaining trip, heading west. En route to Palo Alto, and in actual IFR conditions, the pilot experienced erratic operation of both GPS navigation systems (one failed after losing a lock on the satellites), which troubled the pilot since she had had a very bad prior experience with losing the navigation systems in actual IFR and icing conditions in a non-radar environment. Shortly after that, the oil pressure and oil temperature indications became erratic again, with the oil temperature flickering near the upper limit and the oil pressure flickering near the lower limit. The pilot said she pushed the reset buttons and cycled the circuit breakers and the audible alarms for the oil temperature and pressure sounded. In addition, the ice warning system activated, alerting the pilot to select the deice functions, and after turning them on, the pilot observed clear ice breaking off the wings. Then the fuel gages started to give erratic indications, cycling to near empty and back again. The pilot told the TRACON controller she needed to land as soon as possible and the controller suggested two nearby airports, one with an 11,000-foot-long runway; however, since the original destination was only 8 minutes further on, the pilot elected to continue to Palo Alto. As she approached the airport, the oil temperature continued to fluctuate and the associated warning horn sounded. She continued to reset (silence) the horn as she approached the airport. The pilot was given the winds at Palo Alto (120 degrees at 8 knots) and since she was concerned with losing the engine over a populated city area, she requested runway 31 in order to make a straight-in approach. The pilot was cleared to land on the 2,500-foot-long runway 31. The pilot said she realized she was high on the approach but did not think about a go-around because of the concern with the potential for an engine failure. The airplane landed about halfway down the runway and could not stop before overrunning the runway and colliding with a berm and marshy terrain about 300 yards beyond the runway end. The aircraft is equipped with an integrated engine parameter instrument and warning system (EMIS), which is a precision measurement and display system containing both analog and digital displays of engine related parameters with alarms for parameter exceedances. In normal operation mode, the Enhanced Digital Indicator (EDI) posts a digital enhancement of the selected analog indicators. The automatic exceedance warning mode has the highest priority. When an exceedance is detected, the EDI will automatically select that indicator and display the readings on the LCD. The peak exceedance value of the indicator will flash in the display and be recorded in non volatile memory for future extraction. The EDI was powered up and placed into exceedance review mode. While in exceedance review mode, the EDI reported the following exceedances: 1) Oil Temperature (OT) recorded three events with a peak exceedance of 278 with an average exceedance of 278 for 11 seconds; 2) Oil Pressure (OP) recorded one event with a peak exceedance of 0 (zero) with an average exceedance of 0 for 81 seconds; 3) Manifold Pressure (MP) recorded nine events with a peak exceedance of 42.0 with an average exceedance of 42.0 for 2 seconds; 4) Turbine Inlet Temperature (T.I.T.) recorded one event of 43 seconds at an average exceedance of 1750. The Cylinder Head Temperature (CHT), Fuel Flow (FF), and Propeller rpm (rpm) indicators did not report any exceedances. A functional test of the EMIS system, to include all probes, analog gages, and associated wiring, was conducted, with no anomalies found. The electrical connection of the temperature probe was forcibly manipulated in an attempt to make the indicator fluctuate. All attempts to duplicate a fluctuating oil temperature indication failed. A detailed examination of the engine found no evidence of a malfunction with the lubricating system or evidence of lubrication related damage to the core engine.

NTSB Probable Cause Narrative

the pilot's misjudged distance and speed on final approach, which led to a long landing and a runway overrun. Also causal was the pilot's inadequate in-flight decision to continue flight with indications of apparent serious system anomalies, failure to divert to a more suitable destination alternate, and failure to perform a go-around when an overshoot became obvious. Factors in the accident were the short runway at Palo Alto and the pressure placed on the pilot by the apparent indications of multiple system failures and the potential for a catastrophic engine failure. The cause of the erratic engine instrument indications was not resolved.

Event Information

Type of Event Accident
Event Date 1/2/2005
Event Day of the Week Sunday
Time of Event 1337
Event Time Zone Pacific Standard Time
Event City Palo Alto
Event State CALIFORNIA
Event Country --
Zipcode of the event site 95112
Event Date Year 2005
Event Date Month 1
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 372740N
Event Location Longitude 1220654W
Event Location Airport Palo Alto
Event Location Nearest Airport ID PAO
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1338 Pacific Standard Time
Direction of event from weather observation facility (degrees) 120
Weather Observation Facility ID PAO
Elevation of weather observation facility 5
Distance of event from weather observation facility (units?) 1
Time Zone of the weather observation PST
Lighting Conditions Day
Lowest Ceiling Height 4000
Lowest Non-Ceiling Height 800
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 6
Air Temperature at event time (in degrees celsius) 9
Dew Point at event time (in degress fahrenheit) 7
Wind Direction (degrees magnetic) 120
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 8
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.85
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Minor
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor 1
Injury Total None 3
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 19548
NTSB Notification Source FAA
NTSB Notification Date Jan 2 2005 12:00AM
NTSB Notification Time 1405
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Apr 25 2006 11:00AM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office WP-SJC-FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N4165P
NTSB Number LAX05FA058
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Piper
Aircraft Model PA-46-350P
Aircraft Series Identifier --
Aircraft Serial Number 4636263
Certified Max Gross Weight 4358
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 6
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Jul 1 2004 12:00AM
Airframe hours since last inspection 45
Airframe Hours 484
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Bjorg A. Sky
Aircraft Owner Street Address --
Aircraft Owner City Palo Alto
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 94306
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
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? --
Certified for Part 133 or 137 Operation --
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) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code MOD
Departure City Modesto
Departure State CA
Departure Country USA
Departure Time 1300
Departure Time Zone PST
Destination Same as Local Flt crash at destination city
Destination Airport Code PAO
Destination City Palo Alto
Destination State CA
Destination Country USA
Specific Phase of Flight Landing
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Jan 24 2006 4:47PM
User who most recently changed record COOS
Since inspection or accident Time of Accident
Event Location Runway Number and Location 31
Runway Length 2443
Runway Width 70
Sight Seeing flight No
Air Medical Flight No
Medical Flight --