NTSB Factual Report

HISTORY OF FLIGHT

On November 21, 2014, about 1000 Pacific standard time, a Piper Aircraft PA-24-250 Comanche, N7428P, collided with a tree while on approach to the Garberville Airport, Garberville, California. The private pilot, the sole occupant, was fatally injured; the airplane sustained substantial damage. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. The personal flight originated from Cameron Airpark, Cameron Park, California, with a planned destination of Garberville. Unknown meteorological conditions prevailed, and no flight plan had been filed.

The purpose of the flight was for the pilot to make the routine 155-nautical-mile (nm) cross-country trip to Garberville, where he would stay for a week duration and serve as the communities' Emergency Room (ER) doctor and the hospital's Medical Director. The pilot would make this trip about once per month and would telephone hospital staff to pick him up after he landed.

There were numerous witnesses who observed the airplane maneuvering toward the airport at a very low altitude just below the cloud layer. Most witnesses estimated the airplane was about 100-200 feet above the tree tops. One witness, located on a hill about 1.5 nm southwest of the airport, stated that the airplane was lower than normal and the engine did not sound as if it was producing full power (quieter than normal). Witnesses closer to the accident site noted that the airplane was not emitting any noise. The witness who was the closest to the impact stated that he heard a loud sound of a tree crashing and ran outside his house. He observed the airplane rotate about a tree and cartwheel into the river below.

PERSONNEL INFORMATION

A review of the airmen records maintained by the Federal Aviation Administration (FAA) disclosed that the pilot, age 59, held a private pilot certificate with airplane single-engine land and instrument ratings. The pilot's most recent FAA third-class medical certificate was issued on February 20, 2014 with no limitations.

The pilot's personal flight records were not recovered. On his last application for a medical certificate, the pilot reported a total flight time of 2,115 hours, of which 45 were accumulated in the 6 months prior.

The pilot worked as a doctor in the Garberville community for one week a month as part of a rural medicine program. During his stay, he would live in a house furnished for the rotating doctor staff that was located across from the hospital. Almost every month he would fly his airplane into the Garberville airport between 1000 and 1100 and only had to drive two trips in about five years due to inclement weather.

A friend of the pilot reported that she had flown into Garberville with him in the accident airplane. She stated he would fly into any type of weather and when the clouds occluded the airport, the pilot would circle over the area until it would clear up or he would find a hole in the clouds and drop under the layer. When flying into Garberville, he would usually use a handheld Global Positioning System (GPS) unit.

AIRCRAFT INFORMATION

The Piper Aircraft PA-24-250 Comanche, serial number (s/n) 24-2616, was manufactured in 1961 and purchased by the pilot in 2012. The low-wing airplane was equipped with four seats, retractable tricycle landing gear, and traditional flight control surfaces. The airplane was equipped with a Lycoming O-540-A1D5, s/n L-5661-40, and, according to the manufacturer, is rated at 250 shaft horse power (SHP). The tachometer at the accident indicated that the airplane had a total time in service of 4,932.86 hours.

Maintenance information was recovered from the pilot's preferred maintenance facility and from his paperwork. The most recent annual inspection of the airframe and engine was recorded as being performed in December 2013, at a total time of 4,832.7 hours. The most recent airframe maintenance recorded was for servicing and repair of the landing gear in September 2013. The most recent engine maintenance recorded was the pilot record of his changing the oil on June 28, 2014 at 4,893.1 hours.

No records could be found of the pilot's fueling history and therefore it could not be established as to when the pilot last refueled or the quantity of fuel onboard at the time of the accident.

A friend of the pilot recalled that sometimes when they were flying together the engine would temporarily quit. The pilot would usually fly one fuel tank completely dry and then switch the fuel tanks when the engine began sputtering. He had had prior problems with the fuel pump and according to the maintenance records, the pump was removed and replaced in September 2012.

METEOROLOGICAL INFORMATION

A routine aviation weather report (METAR) was generated by an Automated Surface Observation System (ASOS) in Fortuna, California, located about 35 miles from Garberville on a heading of about 330 degrees. The 0955 METAR from that station included wind from 120 degrees at 15 knots; a scattered layer of clouds at 3,600 and 4,200; a broken layer of clouds at 5,000; with 9 miles visibility. It recorded the temperature at 52 degrees Fahrenheit; dew point 50 degrees Fahrenheit and an altimeter setting of 30.03 inHg.

Witnesses in Garberville reported that there was a low cloud layer at the time of the accident and there was a light rain drizzle.

COMMUNICATIONS

No records were located of the pilot, or a pilot using the airplane's registration number, contacting any Air Traffic Control tower, or Common Traffic Advisory Frequency, during the duration of the flight.

AIRPORT INFORMATION

The Airport/ Facility Directory (AFD), indicated that the Garberville Airport (O16) runway 36 was about 2,780 feet long and 75 feet wide. The runway surface was composed of asphalt. The airport elevation was 550 feet msl. The uncontrolled airport did not have any published instrument approaches. In the remarks section of the AFD was a note "25 ft. trees, 200 ft. from runway, 70 ft. right of centerline." There was 100LL avgas available at all times.

WRECKAGE AND IMPACT

The accident site was located in the South Fork Eel River about 2,260 feet south of the approach end of runway 36 at Garberville. The airplane came to rest in the water, partially resting on a gravel/sand embankment. The left wing was separated and entangled in vegetation/debris on the south side of the river. Following the accident, the water level quickly rose, nearly submerging the entire airframe. The first identified point of contact consisted of a tree that contained a large gouge on its south-facing trunk. That gouge was located about 60 to 70 feet above ground level (agl), and about 20 feet below the top of the tree. Numerous branches, and several pieces of airplane debris, were located immediately beneath the tree, consistent with the left wing colliding with the trees prior to descending into the river. A complete pictorial of the wreckage location and surrounding terrain is contained in the public docket for this accident.

MEDICAL AND PATHOLOGICAL INFORMATION

The County of Humboldt Coroner completed an autopsy of the pilot. The FAA Civil Aeromedical Institute (CAMI) performed toxicological screenings on the pilot. According to CAMI's report (#201400266001) the toxicological findings were negative for carbon monoxide and tested drugs.

TESTS AND RESEARCH

The airplane was examined both after being removed from the river and staged at the airport and then at a later date at a recovery facility. A detailed analysis of the engine and fuel system control continuity was not possible due to the extent of the damage sustained during the collision and the water submersion.

Airframe

The right wing was separated for recovery purposes and contained crush damage to the leading edge. The fuel tank on the outboard right wing was found full of fluid consistent with the odor and appearance of avgas. The right flap remained attached and was physically in the retracted position. About six feet outboard from the wing root, the right wing exhibited aft crush damage, and debris was embedded in the wrinkled skin. The wing tip was absent. The left wing was carried downstream and the fuel tanks were breached.

The rudder and vertical stabilizer remained intact. The right horizontal stabilizer sustained crush damage to the tip. The left horizontal stabilizer and attached elevator were creased in a slight downward V-shape. The left horizontal stabilizer tip was absent.

The nose gear appeared retracted and the right main landing gear remained retracted in the wheel well. The landing gear position knob in the cockpit was in the down and locked selection.

Engine

The engine remained attached to the airframe and mounts, with buckling observed on the firewall. An external visual examination of the engine revealed no evidence of pre impact catastrophic mechanical malfunction or fire. Damage was noted on the No. 1 rocker box cover, where crush deformation was observed.

Investigators removed the upper spark plugs of all cylinders and three lower (the lower Nos. 4 and 6 were not able to be removed due to oil filling the cylinders and potential leakage). According to the Champion Aviation Check-A-Plug AV-27 Chart, the spark plug signatures corresponded to normal engine operation although numerous plugs were coated with oil.

Mechanical continuity was established throughout the rotating group, valve train, and accessory section during hand rotation of the crankshaft. "Thumb" compression was observed in proper order on four of the six cylinders. A subsequent borescope examination of cylinders Nos. 3 and 5, the cylinders that did not yield thumb compressions, revealed post impact foreign debris had been trapped under the valve seats. Additionally, the combustion chamber of each cylinder was examined through the spark plug holes utilizing a lighted borescope. The combustion chambers remained mechanically undamaged, and there was no evidence of foreign object ingestion (pre-impact) or detonation. The valves were intact and undamaged. There was no evidence of valve to piston face contact observed.

The three-bladed constant speed propeller remained attached at the crankshaft flange. The spinner was attached to the propeller and crushed aft. The propeller blades remained attached to the propeller hub. One of the three propeller blades was bent aft about 80 degrees near the blade root. The remaining blades were undamaged, consistent with the engine producing little if any power at the time of impact. The propeller governor was securely attached at the mounting pad with the pitch control rod securely attached at the control arm. The governor was removed for examination. The drive was intact and free to rotate by hand.

Fuel System

The cockpit fuel selector handle was positioned on the left main (30 gal) tank. The fuel selector valve could not be accessed due to the damage sustained to the cockpit. The right outboard tank (15 gal right aux) was full with a fluid consistent with smell and appearance of avgas; the right inboard fuel tank was filled with silt and mud. The gascolator had been submerged in river water. Disassembly of the bowl revealed that there were several ounces of fluid consistent with smell an appearance of avgas. Some water and mud residue was also found in the bowl. The filter screen was found free of contamination.

Investigators removed the fuel line from the electric fuel pump to the gascolator, and a fluid consistent with smell and appearance of avgas dribbled out of the line. The line from the mechanical pump to the carburetor contained a similar liquid. The carburetor sustained crush damage and was broken open, having come loose from the engine. The carburetor bowl was breeched and empty. The carburetor heat and throttle cables remained attached to their respective arms on the carburetor and continuity to the cockpit could not be established due to the compromised airframe. The mixture cable was detached from the intact mixture-arm on the carburetor; the hardware could not be located. According to Lycoming, the carburetor is not equipped with a spring-loaded mixture arm. Therefore the arm would stay positioned wherever the linkage became detached, but would be able to vibrate into any position.

There was no evidence of any pre-impact mechanical malfunctions or failures found during the examination.

NTSB Probable Cause

A loss of engine power for reasons that could not be determined due to extensive damage sustained during the collision and postaccident water immersion.