LAX92FA374.html
1992, 2f, 1 mile of Buchanan, Accident could have been prevented (INSTRUCTORS INTENTIONALLY OPERATING THE AIRPLANE WITH A KNOWN DEFICIENCY).
Data Source: NTSB AVIATION ACCIDENT/INCIDENT DATABASE Report Number: LAX92FA374 Local Date: 09/02/1992 Local Time: 1441 PDT State: CA City: CONCORD Airport Name: BUCHANAN FIELD Airport Id: CCR Event Type: ACCIDENT Injury Severity: FATAL Report Status: FINAL Mid Air Collision: NO
Category of Operation: GENERAL AVIATION Aircraft Type: AIRPLANE Aircraft Damage: DESTROYED Phase of Flight: 520 TAKEOFF Aircraft Make/Model: PIPER PA-23-160 Operator Doing Business As: Operator Name: CHAVOSSY, LOUIS Operator Code: Operator: Owner Name: CHAVOSSY, LOUIS
THE AIRCRAFT COLLIDED WITH A BRIDGE WHILE TRYING TO RETURN TO THE AIRPORT AFTER REPORTING AN EMERGENCY DURING THE PREVIOUS TOUCH AND GO LANDING. WITNESSES INDICATED BOTH ENGINES SOUNDED LIKE THEY WERE RUNNING AND BOTH PROPELLERS WERE TURNING. THE LEFT ENGINE PROPELLER WAS FOUND FEATHERED AFTER THE ACCIDENT. INVESTIGATION REVEALED A 1.75 INCH OD PLUG INSTALLED IN THE CRANKSHAFT TO SEPARATE OIL PRESSURE FROM THE PROPELLER GOVERNOR AND THE ENGINE CRANKCASE WAS BLOWN AFT DAMAGING THE NUMBER ONE ROD CONNECTING JOURNAL OIL TRANSFER TUBE. EXAMINATION OF THE PLUG DISCLOSED THAT IT WAS INSTALLED BACKWARDS. THE CFI'S SPOUSE CONFIRMED THE IMPROPER PLUG INSTALLATION AND THAT THE CFI WAS KNOWLEDGEABLE OF THE DISCREPANCY.
Occurrence #: 1 130 AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTION
Phase of Operation: 565 GO-AROUND (VFR)
Findings
Subject - Modifier - Personnel Cause/Factor
1a. 14500(S) - 1222(M) Factor
PROPELLER SYSTEM/ACCESSORIES - RUPTURED
1b. 24111(S) - 3109(M) - 4108(P) Cause
MAINTENANCE, INSTALLATION - IMPROPER - OTHER MAINTENANCE PERSONNEL
2a. 17002(S) - 1178(M) Factor
FLUID, OIL - PRESSURE TOO LOW
2b. 24007(S) - 3114(M) - 4103(P) Cause
OPERATION WITH KNOWN DEFICIENCIES IN EQUIPMENT - INTENTIONAL - PILOT IN COMMAND (CFI)
3b. 22307(S) - 3113(M) - 4001(P) Factor
PROPELLER FEATHERING - INADVERTENT -
Occurrence #: 2 220 IN FLIGHT COLLISION WITH OBJECT
Phase of Operation: 553 DESCENT - UNCONTROLLED
Findings
Subject - Modifier - Personnel Cause/Factor
1a. 20200(S) - 2526(M)
OBJECT - BRIDGE/OVERPASS
1b. 24528(S) - 3122(M) - 4103(P)
PROPER CLIMB RATE - NOT ATTAINED - PILOT IN COMMAND (CFI)
THE IMPROPER INSTALLATION OF THE 1.75 INCH OD PLUG IN THE CRANKSHAFT BY UNKNOWN MAINTENANCE PERSONNEL WHICH RESULTED IN AN INADVERTENT FEATHERING OF THE LEFT ENGINE PROPELLER AND THE CERTIFIED FLIGHT INSTRUCTORS INTENTIONALLY OPERATING THE AIRPLANE WITH A KNOWN DEFICIENCY.
Number of Seats: 5
Aircraft Use: INSTRUCTIONAL
Type of Operation: 14 CFR 91
Domestic/International:
Passenger/Cargo:
Registration Number: 4305Y
Air Carrier Operating Certificates:
Aircraft Fire: ON GROUND
Injuries
Fatal Serious Minor None
Crew 2 0 0 0
Pass 0 0 0 0
Other 0 0 0 0
Invlvd 2 0 0 0
Landing Gear: TRICYCLE-RETRACTABLE
Certificated Maximum Gross Weight: 3800
Engine Make: LYCOMING
Engine Model: O-320-B3B
Number of Engines: 2
Engine Type: RECIPROCATING-CARBURETOR
Basic Weather Conditions: VISUAL METEOROLOGICAL CONDITIONS (VMC) Wind Direction (deg): 300 Wind Speed (knots): 13 Visibility (sm): 40 Visibility RVR (ft): 0 Visibility RVV (sm): 0 Cloud Height Above Ground Level (ft): 20000 Visibility Restrictions: NONE Precipitation Type: NONE Light Condition: DAYLIGHT Departure Airport Id: HWD Departure City: HAYWARD Departure State: CA Destination Airport Id: Destination City: Destination State: Flight Plan Filed: NONE ATC Clearance: NONE VFR Approach/Landing: GO AROUND Event Location: OFF AIRPORT/AIRSTRIP
Certificates: PRIVATE, COMMERCIAL, FLIGHT INSTRUCTOR
Ratings:
Plane: SINGLE ENGINE LAND, MULTIENGINE LAND
Non-Plane: GLIDER
Instrument: AIRPLANE
Had Current BFR:
Months Since Last BFR:
Medical Certificate: CLASS 2
Medical Certificate Validity: NON VALID MEDICAL FOR THIS FLIGHT
Flight Time (Hours)
Total : 800 Last 24 Hrs : 1
Make/Model : 170 Last 30 Days: 0
Instrument : 70 Last 90 Days: 0
Multi-Engine: 170 Rotorcraft : 0