NTSB LAX04FA064 — 2003-12-08 · Placerville, California, United States

Aircraft involved

N14XL Iniziative Industriali Italian Sky Arrow 650 TC Fatal

Probable cause & findings

the pilot's failure to fully remove an accumulation of ice and frost on the wings, which led to an inadvertent stall/mush and collision with the ground. A factor in the accident was the pilot's failure to correctly configure the flaps for takeoff.

Factual narrative

HISTORY OF FLIGHT

On December 8, 2003, about 0655 Pacific standard time, an Iniziative Industrali Sky Arrow 650 TC, N14XL, collided with terrain during takeoff at the Placerville Airport, Placerville, California. The airplane was owned and operated by the private pilot under the provisions of 14 CFR Part 91. The pilot was fatally injured and the airplane was substantially damaged. Visual meteorological conditions prevailed and no flight plan had been filed for the personal cross-country flight that was originating at the same time with an intended destination of Palo Alto, California. The pilot's wife stated that he had called her about 0650 to say that he was preparing to depart for Palo Alto, California. About that time a witness reported seeing a red and white airplane with a pusher propeller taxiing to the runway. About 1100, a pilot arriving into Placerville Airport noticed an airplane off the runway to the south. He reported it to the airport operations manager. The manager located the airplane and notified rescue agencies. No reports of an Emergency Locator Transmitter (ELT) beacon signal were received.

PERSONNEL INFORMATION

The pilot was issued his private pilot certificate on October 1, 1992. His logbook records total single engine flight time of 652 hours and 172 hours in the Sky Arrow. The pilot's last biannual flight review was on March 27, 2002. The pilot obtained his third-class medical on May 22, 2003, with a corrective lens restriction. He regularly commuted on Monday's from Placerville Airport to Palo Alto Airport.

AIRCRAFT INFORMATION

The airplane was a two seat tandem design with a high wing. The power plant was a pusher configuration with the engine mounted above and aft of the cockpit. The engine was an 81 horsepower, Rotax 91A. The airplane and engine logbooks record that the last annual inspection was completed on April 4, 2003, at an aircraft total time of 953.6 hours. The last maintenance performed on the engine was an oil change and tune-up on October 15, 2003, at an engine total time of 1050.7 hours.

METEOROLOGICAL INFORMATION

The closest meteorological recording station was an AWOS-3 (Automated Weather Observation System) located at Auburn, California, which is about 20 miles northwest of Placerville. At 0630, the temperature was recorded as 03 C, the dew point 0 C, and the sky was clear. The Federal Aviation Administration (FAA) inspector who responded to the accident lives 8 miles from the Placerville airport and reported that there was frost on his outdoor furniture that morning. A California Highway Patrol pilot stopped by the Placerville airport around 0510, and noted that the top of the wings of his airplane and others had frost and ice on them. The Placerville Airport Manager noted that there was frost on his truck the morning of the accident.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located approximately 1,450 feet down the length of runway 23 and 140 feet to the south on downhill sloping terrain. The terrain consisted of heavy manzanita brush and scrub oak trees. The Plexiglass canopy of the two place tandem airplane was shattered and an approximate 5-inch diameter oak tree branch was located in the pilot occupiable space. The airplane was oriented with the right wing slightly low and the nose pointing downhill. Approximately 1,250 feet down runway 23, a 21-foot-long ground scar resembling tire tracks was located on a grass shoulder area on the south side off the runway. The track was angled away from the runway and ran in the southwest direction pointing towards the airplane wreckage. The tracks originate about the middle of a grass shoulder area that parallels the runway. Between and forward of two narrow parallel tracks is an elongated and much wider area of disturbed earth that approximates the dimensions of the aircrafts nose. The nose wheel was detached and the fronts of the main landing gear fiberglass wheel fairings were shattered. A 1-inch diameter branch penetrated the leading edge of the left wing inboard of the lift strut mount and was imbedded in the wing. The flaps were fully retracted. The tops of the wings were smooth with no observable paint scratches or blemishes. One blade of the wood-fiberglass composite propeller was split along the length of its span. A 1-foot-long vertical shallow indentation was located on the empennages right lower side below the vertical stabilizer. The fuselage area below the cockpit had cracks and slight crush damage. The cockpit instrument panel was intact. Both ignition switches on the instrument panel were on, the nav light switch was on, and aux fuel pump switch was on. The choke lever was full forward. The carb heat lever was in the off position and the fuel shutoff lever was not engaged. All circuit breakers were in. The flap lever was in the 0 degree position. The ELT was located beneath the passenger seats left side. The remote antenna and remote activation connection were not connected. The ELT switch was in the off position. When the switch was placed in the on position the activation light illuminated. The airport manager observed that there was water on the top of the wing in the form of large drops that would periodically run off the wing on to the ground.

PATHOLOGICAL INFORMATION

The El Dorado County Coroner conducted an autopsy on the pilot. According to the coroner's report, the pilot's cause of the death was asphyxiation attributed to a fracture of the left hyoid bone, laceration, and blunt trauma to the anteria neck. Toxicology test results for ethanol and drugs were negative.

TESTS AND RESEARCH

The airplane wreckage was moved to a storage facility in Pleasant Grove, California, and examined by the National Transportation Safety Board Investigator-in-Charge. Engine The undamaged engine cowling was removed and the engine examined. The 4-cylinder Rotax engine sustained no observable damage. The top spark plugs of each cylinder were removed. All spark plug gaps were similar, gray in color, and had no mechanical damage. The oil dipstick indicated that the oil in the reservoir was below the minimum mark. Five gallons of fuel was observed in the fuel tank. The engine was started and run for approximately 2 minutes. The engine tachometer was not indicating any rpm. The oil pressure warning light was illuminated and the oil pressure gage was reading 1 bar with the needle pointing to the red-green arc interface. The engine was shutdown and 8 ounces of engine oil added to the oil reservoir. The engine was restarted. The oil pressure warning light did not illuminate and the oil pressure gage indicated 2.1 bar, well into the green arc. There was no sign of an engine oil leak. Airplane Performance Calculations The Sky Arrow 650 TC Flight Manual was used to calculate the required takeoff distance of the airplane using an outside air temperature of 32 degrees Fahrenheit and a pressure altitude of 2,500 feet mean sea level. The takeoff roll was calculated as 912 feet and the distance to clear a 50-foot obstacle is 1,556 feet. The normal takeoff flap configuration, as described in the Flight Manual, is the 10-degree setting. The normal takeoff procedure is to accelerate to 45 KIAS, rotate, and retract flaps at 60 KIAS and 200 feet.

ADDITIONAL INFORMATION

The Pilot's Handbook of Aeronautical Knowledge (AC 61-23C) states that frost on the wings can adversely affect performance and control. The airplane entered a stall/mush condition during the takeoff initial climb, descended back to ground impact, veered off the runway, and collided with trees and terrain. A witness saw the airplane taxi to the runway about 0650. The nearest weather reporting station was 20 miles northwest, and at 0630, recorded a temperature of 03 C, the dew point 0 C, with clear sky conditions. A Federal Aviation Administration inspector lives 8 miles from the airport and reported that there was frost on his outdoor furniture that morning. Another pilot stopped by the airport around 0510, and noted that the top of the wings of his airplane and others had frost and ice on them. The first responder to the accident reported that large water droplets covered the tops of the wing. The wreckage was located approximately 1,450 feet down the runway and 140 feet to the south on downhill sloping terrain. Approximately 1,250 feet down the runway, a 21-foot-long ground scar resembling tire tracks was located on a grass shoulder area on the south side off the runway. The track was angled away from the runway and ran in a direction pointing towards the airplane wreckage. The tracks originated about the middle of a grass shoulder area that parallels the runway. Between and forward of two narrow parallel tracks was an elongated and much wider area of disturbed earth that approximated the dimensions of the aircraft's nose. Examination of the wreckage found no evidence of a preimpact malfunction or failure of the control system or power plant. Following recovery of the wreckage, the engine was test run successfully while still installed in the airframe. Using the airplane flight manual the takeoff ground roll under the accident ambient conditions was calculated as 912 feet and the distance to clear a 50-foot obstacle was 1,556 feet. The normal takeoff flap configuration, as described in the Flight Manual, is the 10-degree setting. The flaps were found in the retracted position with the cockpit control in a matching setting. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12

Verbatim from NTSB's published report. Source file NTSB_2003_LAX04FA064.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

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