Aviation Accident Summaries

Aviation Accident Summary WPR09FA015

Markleeville, CA, USA

Aircraft #1

N9581C

PIPER PA-28R-201T

Analysis

The pilot was in cruise flight on a southerly heading at 13,700 feet mean sea level (msl), and initiated a 180-degree climbing left turn to 14,500 feet. He reported to air traffic control (ATC) that the engine was “missing badly,” and he was returning to his home airport. One minute later, he reported a complete loss of engine power. The pilot decided that he could not make his home base, and elected to head for an alternate airport with ATC guidance. The pilot indicated to ATC that he did not have the airport in sight and was trying to locate it with his global positioning satellite system (GPS). The last recorded radar position was 2.9 miles southeast of the airport and 6,200 feet above field elevation with the airplane on a northerly track. The airplane collided with trees 1.9 miles northwest of the airport while on a southerly heading. While maneuvering, the pilot overflew suitable, unobstructed places to land. Post accident download of an engine data management system displayed stable conditions initially followed by fluctuations in the fuel flow, as well as fluctuations of all six exhaust gas temperature (EGT) and cylinder head temperature (CHT) indications. Over the next two minutes, the readings smoothed out, and then the fuel flow increased while the EGT and CHT dropped to low values indicative of a loss of power. The engine was inspected and prepared for an engine run in a test cell. After replacing several damaged parts including the fuel pump, the engine started easily and ran smoothly throughout its entire power range with no anomalies discovered. The reasons for the fluctuations to the fuel flow, EGT and CHT were not determined.

Factual Information

HISTORY OF FLIGHT On October 16, 2008, about 1100 Pacific daylight time, a Piper PA-28R-201T, N9581C, collided with trees during a forced landing near Markleeville, California. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot was killed; the airplane sustained substantial damage to the fuselage, empennage, and wings. The cross-country business flight departed Minden, Nevada, about 1010, with a planned destination of Camarillo, California. Visual meteorological conditions prevailed, and no flight plan had been filed. A witness at the Minden airport noticed the airplane follow a taxiway to runway 34. He did not hear any unusual engine sounds, and he did not observe any smoke or fluids leaking from the airplane. The Federal Aviation Administration (FAA) indicated that the pilot was in contact with Oakland Air Route Traffic Control Center (ARTCC). The Safety Board investigator-in-charge (IIC) reviewed the ARTCC transcript, which indicated that the pilot contacted them at 1016:54. He stated that he was 10 miles south of Minden at 12,900 feet, and requested visual flight rules (VFR) flight following to Camarillo. ARTCC assigned a secondary beacon code of 3337, and informed him that they had radar contact at 1017:41. Recorded radar data for a target with the beacon code of 3337 at 1018:02 indicated a mode C reported altitude of 13,700 feet. This position computed to be 10.5 miles at 169 degrees from Minden. At 1020:14, the target was 0.6 mile at 113 degrees from Alpine County Airport, and tracking to the south. The target maintained 13,700 feet until 1023:50, when it began an ascending 180-degree left turn. It reached a maximum mode C altitude of 14,500 feet at 1025:14. At 1025:16, the pilot informed ARTCC that he had an engine problem, and was heading back to Minden. He said that the engine was running, but “missing badly.” The controller pointed out that Alpine County Airport was 11-o’clock at 10 miles, if the pilot needed it. The pilot indicated that he was going to try for Minden, but would head for Alpine if the engine started missing again. At 1026:23, the pilot requested that the controller give him the Alpine airport information again, and reported that he had just lost power completely. At 1026:26, the mode C altitude was 14,200 feet. The controller informed the pilot that Alpine was 11-o’clock at 5 miles. During their conversation, the controller noted that the airport elevation was 5,867 feet, the 4,440-foot runway had a hard surface, and the runways were 17 and 35. The pilot requested the identifier so that he could put it in his global positioning satellite system (GPS). After the pilot indicated that he did not have the airport in sight, the controller indicated that the airport was 11- to 12-o’clock at 4 miles. The last recorded radar contact occurred at 1028:26, at a mode C altitude of 12,100 feet. From this position, Alpine County Airport was 2.9 miles at 321 degrees, and Minden was 18.6 miles at 343 degrees. At 1028:30, the pilot stated that his altitude was 11,800 feet. The controller asked him if he had completely lost his engine, or if it was still running. The pilot said that he had, “pretty much completely lost it.” The controller pointed out that Alpine was 12-o’clock at 2-3 miles, and the pilot indicated that he was still looking for it. At 1029:46, the controller stated that radar contact had been lost, but received an unintelligible response. The controller asked an airline pilot to try to contact the pilot, and see if he had the airport in sight. The airline pilot informed the controller that the pilot had the airport, and would try to do his best to contact flight service once on the ground as requested by the controller. A witness about 2 miles from the Alpine airport was driving east on Diamond Valley Road, and saw an airplane flying low. He saw the airplane disappear from sight around a low hill to his right. The witness turned right to go to work, and as he passed the hill where he last saw the airplane, he noticed something white about 100 yards off the road. He went to investigate, and saw the inverted wreckage of the airplane. Witnesses about 1 mile west of the accident site observed a single-engine airplane fly in a northerly direction over a hill to the east of their position. It circled clockwise with the right wing down, and then headed in a southerly direction toward Indian Creek Reservoir, which was between the accident site and Alpine County Airport. They thought that the airplane had power, and that its landing gear was not down. The airplane disappeared from their view. PERSONNEL INFORMATION A review of FAA airman records revealed that the 53-year-old pilot held a private pilot certificate with a rating for airplane single-engine land. He had a third-class medical certificate issued on December 8, 2007. It had no limitations or waivers. An examination of the pilot's logbook indicated an estimated total flight time of 252 hours. He logged 17.5 hours in the last 90 days, and 12.8 hours in the last 30 days. He had an estimated 183 hours in this make and model, and completed a biennial flight review on March 3, 2008. AIRCRAFT INFORMATION The airplane was a Piper PA-28R-201T, serial number 28R-7803267. A review of the airplane’s logbooks revealed that the airplane had a total airframe time of 3,151 hours at the last annual inspection on August 1, 2008. The airplane experienced a nose landing gear collapse on landing on May 10, 2008. The engine was a Teledyne Continental Motors (TCM) TSIO-360FB, serial number 299720-R. Total time recorded on the engine at the last annual inspection was 1,381 hours. Victor Engines overhauled the engine following the nose gear collapse, and time since major overhaul was 4 hours at the annual. Fueling records at Soar Minden established that the airplane was last fueled on October 9, 2008, with the addition of 55 gallons of 100-octane aviation fuel. This occurred on the same date as the pilot’s last logged flight, which was from Camarillo to Minden. WRECKAGE AND IMPACT INFORMATION The accident site to be 313 degrees at 1.9 miles from Alpine County Airport. The first identified point of contact (FIPC) was a tree with broken limbs and the right aileron balance weight at its base. The debris path was along a magnetic bearing of 180 degrees. The next pieces in the debris field were an outboard section of the right horizontal stabilator and the right wing tip fairing, which contained the green navigation light. Broken tree limbs were scattered throughout the debris field from the FIPC to the main wreckage. About 20 feet further in the debris field was a 12-inch-diameter tree that had the top missing. Aft of the tree and in the direction of the debris field was the middle section of the right horizontal stabilator and a section of right wing skin containing the fuel cap. The airplane came to rest inverted about 208 feet from the FIPC, and the orientation of the fuselage was about 080 degrees. Adjacent to the FIPC’s north border were a 1/4–mile-wide treeless pasture and a straight, paved country road. The straight section of the road and pasture were both over 1,500 feet long. MEDICAL AND PATHOLOGICAL INFORMATION The Alpine County Coroner completed an autopsy, and determined that the cause of death was blunt force trauma. The FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, volatiles, and tested drugs. TESTS AND RESEARCH Investigators examined the wreckage at Plain Parts, Pleasant Grove, California, on October 18, 2008. Airframe The fuel selector valve was in the left tank position. The landing gear was down and locked. The gear handle in the cockpit was below the detent in the down position. The flaps were in the retracted position, and exhibited some trailing edge damage. The aileron cables’ chains separated from the control column. The cable’s clevis pins were attached to the chains. The retrievers cut the cables about 3 feet from the wing root during recover. Both left and right primary cables were connected to the bellcranks. The balance cable remained connected to both bellcranks. The horizontal stabilator push-pull tube was connected to the bottom of the T-bar and the pivot lever. Both cables were attached to the pivot lever. One cable fractured and separated in a broomstraw fashion about 1 foot from the pivot lever. The other was cut during recovery. At the control surface, both horizontal stabilators remained attached to the torque tube and balance weight assembly. The cables had been cut aft of the cabin during recovery. The forward rudder attachment fitting remained connected to the rudder torque tube. The cables had been cut during recovery at the aft end of the fuselage. The cables remained attached to the rudder bellcrank assembly. Three threads were visible on the stabilator trim drum; five threads is the neutral position. The ignition key was in the OFF position, and bent about 90 degrees to the left. Both sides of the split electrical master switch were in the ON position. The electric fuel boost pump switch, which had three positions, was in the low position. The center position was off, up was high boost, and down was low boost. To place the switch in the High position, the pilot has to depress a gate guard; the low position is not guarded. One propeller blade bent about 10 degrees aft at its midpoint, and then bent forward about 20 degrees. This blade twisted toward the low pitch, high rpm position. The other two blades gradually bent aft about 5 degrees, and displayed no striations or gouges. The turbocharger compressor and turbine wheels rotated freely by hand. There was liquid in the electric fuel pump. The throttle at the engine was fully aft. It was connected, but would not move manually until investigators cut the throttle cable. The gascolator bowl was missing, but the screen was in place and clean. Engine Examination The IIC observed examination of the engine at the Teledyne Continental Motors (TCM) factory, Mobile, Alabama, from February 17-18, 2009. The TCM examination report is part of the public docket. TCM personnel removed numerous crush-damaged parts, and installed substitute or repaired parts for an attempted engine run. Substituted parts included a primer line, the fuel pump, a spark plug, and the ignition harness. TCM technicians installed the engine in a test cell, and it started easily. They ran the engine at mid and full throttle positions. It ran smoothly at all settings including rapid throttle accelerations and decelerations. The engine idled at 600 revolutions per minute (rpm), and the magnetos dropped 40 rpm on the left and 30 rpm on the right during a functional check. J.P. Instruments Unit The airplane was equipped with a J.P. Instruments EDM 700/800 (serial number 23947) engine data management unit. Among the engine parameters recorded by this unit were the fuel flow in gallons per hour (gph). It did not have the option installed that would have recorded manifold pressure and engine rpm. It did record exhaust gas temperature (EGT) and cylinder head temperature (CHT) for all six cylinders in degrees Fahrenheit (F). It also recorded the parameters in relation to universal coordinated time (UTC), which the IIC converted to PDT. A plot of the data started about 0959:58. The initial fuel flow was about 4 gph. Over the next 7 minutes, the fuel flow remained relatively steady, while the EGTs and CHTs gradually increased. A large rapid increase in fuel flow occurred at 1007:58, with a corresponding increase in EGT and CHT. The fuel flow was 20-22 gph. The EGTs peaked in the range of 1500-1650 degrees F, and stabilized between 1300-1500 degrees F. The CHTs stabilized between 350-400 degrees. The data lines remained flat and stable for 10 minutes. Then the fuel flow decreased to 15 gph; the EGTs increased slightly, and the CHTs decreased slightly. Fuel flow, EGTs, and CHTs remained flat and stable over the next 5 minutes. About 1023:00, fluctuations began in the fuel flow, as well as all six EGT and CHT indications. All markers initially dropped with the EGT and CHT for cylinders number one and three dropping more than the others. About 1 minute later, the fuel flow increased to 20 gph, and smoothed out for 30 seconds. The EGTs and CHTs also stabilized, but at a slightly lower reading than their initial values. During the next 30 seconds, the fuel flow decreased to 15 gph, where it stayed for about 30 seconds. About 1025:30, it increased again to 22 gph while the EGTs decreased rapidly to less than 500 degrees F. The EGTs remained at this value for the duration of the data. The CHTs began to decrease at the same time as the EGTs, but more gradually to less than 100 degrees. The CHTs remained below that value until the end of the data. At 1026:11, the fuel flow decreased to 14 gph; it remained there until 1028. It fluctuated down, then up, and then gradually decreased and stabilized at 6 gph until the data ended at 1031:40.

Probable Cause and Findings

A loss of engine power for undetermined reasons. Contributing to the accident was the pilot’s failure to choose a suitable landing area.

 

Source: NTSB Aviation Accident Database

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