Aviation Accident Summaries

Aviation Accident Summary ERA15FA109

Lakeland, FL, USA

Aircraft #1

N465JA

PIPER PA-23

Analysis

The flight was the seventh lesson for the multiengine student, which likely included a simulated engine failure of the right engine usually performed over or near the destination airport. After takeoff, the flight proceeded north; radar returns were consistent with airwork. The airplane then turned and began flying toward the destination airport at 3,600 ft mean sea level and 105 mph. A witness heard a "pop" sound, and another witness heard an unusual engine sound; these might be consistent with a quick reduction in power on one engine, and, based on radar data, the airplane began to slow about that time, consistent with reduced power from one engine. The airplane then began a right turn, pitched nose down, descended into a building, and was nearly consumed by a postcrash fire. Although the final descent was captured by a security video, the low-resolution image precluded a determination of the state of the airplane at that time. No structure associated with the aft portion of the fuselage was identified in the wreckage. Examination of sections of the fractured structure revealed no evidence of preimpact failure or malfunction. Examination of the fractured left rudder cable revealed extensive postaccident heat damage to the fracture surface that precluded determination of the fracture mode. Examination of the engines and propellers revealed no evidence of preimpact failures or malfunctions; neither propeller was in the feathered position. The rudder with attached trim tab and a flight bag separated from the airplane during the descent came to rest outside the impact area. The separated rudder exhibited evidence of overtravel in both directions that is consistent with loss of cable tension; the reason for the loss of cable tension could not be determined. It also could not be determined how the flight bag became separated from the wreckage. Discrepancies previously noted by Federal Aviation Administration personnel during a ramp inspection of the accident airplane had been repaired before the accident flight. Further, the pilot who flew the accident airplane the day before reported no discrepancies during that flight. Although the toxicological finding in specimens of the pilot-rated student were positive for ethanol, it is likely that it was the result of postmortem production.

Factual Information

HISTORY OF FLIGHTOn January 22, 2015, about 0913 eastern standard time, a Piper PA-23, N465JA, registered to 55XRAY, Inc., and operated by Tailwheels, Etc., descended into a building northwest of the Lakeland Linder Regional Airport (LAL), Lakeland, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 local, instructional flight. The airplane was destroyed and the flight instructor and pilot-rated student were fatally injured. The flight originated about 0847 from LAL. Personnel of the operator reported the purpose of the flight was training for the pilot-rated student, who intended to add a multi-engine rating to his private pilot certificate. The flight, which was the 7th lesson, was scheduled between 0800 and 1000 hours. One typical procedure to perform during the 7th lesson was an engine shutdown (typically the right) and to feather the right propeller. In that scenario, the flight would depart LAL and proceed to the north while climbing to between 3,000 and 4,000 feet mean sea level (msl). The flight would then return and when over LAL, the right engine would be secured and the right propeller would be feathered. Security video from the operator depicted the pilot-rated student walking to the airplane and an employee of the operator reported watching him from the window perform a preflight inspection. The same individual also reported watching the flight instructor inspect the airplane. Another flight instructor with the operator, who was parked on the ramp next to the accident airplane, also observed the pilot-rated student performing a walk around of the accident airplane, noting he added oil to the left engine. The flight instructor who witnessed the preflight inspection reported he did not see anything "out of order" and the pilot-rated student did not ask or mention anything to him as he was standing nearby. Because of the resolution of the security video, seating positions could not be detected. The accident airplane then taxied to another spot on the ramp east of the parked location, and turn to a northeast direction. The airplane remained on that spot for 2 minutes 46 seconds. According to air traffic control (ATC) chronological summary of flight communications and voice communications, a flightcrew member contacted ground control and requested taxi to the active runway with a northbound departure. The controller cleared the flight to taxi to runway 05 via Echo, and about 0847, the local controller cleared the flight for takeoff; portions of the taxi and about 13 seconds of the takeoff were recorded by security video. According to uncorrelated radar data, at 0849:48, an airplane with a transponder code of 1200 appeared about 1.3 nautical miles and 020 degrees from the departure end of runway 05; altitude was not reported. The airplane proceeded in a northerly direction and about 0850:00, the flightcrew were advised by the local controller that frequency change was approved. There was no further communication with the flight crew of the accident airplane. The uncorrelated radar data indicated that the airplane proceeded north of the airport where changes in direction consistent with airwork were performed; altitude was not reported for several of the radar targets. Following the airwork, the airplane flew in a southerly direction towards LAL. Closer review of the radar data revealed at 0911:43, while north of I-4, the airplane was at 3,600 feet msl, while no altitude was reported at the next secondary return observed 5 seconds later, or for the remainder of the 14 secondary returns. A witness who was located approximately 1.8 nautical miles and 032 degrees from the accident site, reported seeing the airplane when it was north of I-4 flying in a southbound direction at what he estimated was 10,000 feet; the sound was what directed his attention. He noticed the airplane was flying level, and heard 2 pops from the engine(s). The second "pop" sound was louder than the first, and he reported that the engine "quit." The airplane continued in a southerly direction until about 0912:29, or just south of I-4, at which time a change to a southwesterly direction was noted. The airplane continued on the southwesterly heading until the last radar target at 0912:57, about 1,443 feet and 047 degrees from the accident site. The witness who was located about 2 miles northeast of the accident site reported that a couple seconds after the second "pop" sound, the airplane "nose-dived" and descended steeply. He heard an explosion and saw large black smoke. He reported seeing puffs of gray or black colored smoke from the engine(s) when he heard the "pop" sound, but also stated that he saw the puffs of smoke from the airplane while it was in a nose-down attitude. Another witness who was driving on Polk Parkway in a southbound direction, about 1,500 feet and 072 degrees from the accident site, with the windows up noticed a light colored airplane "heading to do a stunt" in what he described as a nose-down attitude. At about 400 to 600 feet, he saw something about the size of the front wheel separate from the front of the airplane, or the airplane could have hit a bird; he could not describe the color of the item that he saw separating from the airplane. He did not observe the ground impact because trees obscured his view, and noticed smoke. He pulled off the road and called 911 to report what he had seen. He indicated the weather conditions at the time consisted of sunny conditions, no clouds, and breezy. He confirmed the airplane was not spinning when he saw it, and he did not see any smoke trailing the airplane. The airplane crashed west of his position, and he could not hear any sounds from the engines. Two witnesses who were located on the property where the airplane crashed, or about 2,050 feet and 315 degrees from the accident site location, both reported seeing the airplane. One witness reported hearing the airplane travelling from north to the south, and she heard, "…a very loud/unusual engine sound coming from the plane." She looked to the east-southeast, and witnessed the airplane descending in a vertical direction with the nose, "in a dive position." After a few seconds, she heard an explosion and saw black and gray colored smoke at the tops of the trees. She realized the airplane had crashed and called 911 to report the accident. The other witness reported she was looking to the east, and heard a loud engine noise from an airplane that was travelling from the north to the south. She reported the engine noise got louder as the airplane descended nose first to the ground. She heard an impact and smoke immediately followed. She also called 911 to report the accident. Security cameras captured video depicting the final portion of the airplane's descent and subsequent post-impact fireball. The cameras were located about 0.50 nautical mile and 245 degrees from the accident site. The video was provided to the NTSB for analysis. PERSONNEL INFORMATIONThe flight instructor, age 61, held an airline transport pilot (ATP) certificate with an airplane multi-engine land rating. On the ATP certificate he was type rated in a RA390S, issued November 26, 2011. He held a commercial pilot certificate with an airplane single engine land rating, and also held a flight instructor certificate with airplane single engine, airplane multi-engine, and instrument airplane ratings; the multi-engine rating was issued on June 27, 2014. He held a 2nd class medical certificate with a limitation to wear corrective lenses issued July 16, 2013. According to personnel employed by the operator, the flight instructor was hired approximately 5 years prior to the accident. A review of his pilot logbook, which contained entries from January 1, 2014 through January 21, 2015, revealed he logged a total time of 6,609 hours. Of the total time, about 2,520 hours were in multi-engine aircraft. Between January 1, 2014 and January 21, 2015, he logged about 60 hours in the accident airplane. Since adding a multi-engine rating to his flight instructor certificate in June 2014, he logged 44.4 hours as an instructor in the accident airplane. The pilot-rated student, age 40, held a private pilot certificate with an airplane single engine land, and instrument airplane ratings, and held a second class medical certificate with no limitation issued November 26, 2014. A review of the pilot-rated student's logbook, which contained entries from September 29, 2007 to January 21, 2015, revealed he logged a total time of 333.0 hours. Excluding the accident flight, he logged a total of 6 flights in the accident airplane, accruing a total of 7.6 hours. Of the 6 flights, all were flown with the accident flight instructor. AIRCRAFT INFORMATIONThe airplane was manufactured in 1957 by Piper Aircraft, as model PA-23, and was designated serial number 23-1033. It was powered by two 150 horsepower Lycoming O-320-A1B engines and equipped with Hartzell HC-C2YL-2CUF constant speed propellers installed in accordance with Supplemental Type Certificate (STC) SA00721CH. Maintenance records before 2009 were not available for the airframe, engines, or propellers. Review of the maintenance records revealed the airplane was last inspected in accordance with an annual inspection on December 15, 2014. The airplane total time at that time was reported to be 5,922.1 hours. Although the hour meter was destroyed, the hour meter at the end of the last flight before the accident flight was 5,936.8 hours, or an elapsed time of 14.7 hours since the last annual inspection was performed. On December 8, 2014, or about 7 days before the last annual inspection was completed, personnel of the FAA Flight Standards District Office in Orlando, Florida, conducted a ramp inspection and maintenance records review of the operator's airplanes and facility; the ramp and records inspection included an inspection of 5 airplanes which included the accident airplane. Correspondence between the FAA and the operator dated December 12, 2014, indicated that with respect to the accident airplane, a cracked baffle in the right engine compartment was noted, and fuel appeared to be seeping from the fuel cap inboard right fuel tank. On January 9, 2015, the operator submitted a letter to the FAA indicating that with respect to the accident airplane, the cylinder baffle was repaired and the right fuel cap and surrounding area was cleaned and inspected for leaks but none were found; new gaskets were ordered. A review of the airframe logbook revealed an entry dated December 23, 2014, indicating a new right main fuel cell was installed. The airplane was flown the day before by a pilot-rated student and the accident flight instructor during a training flight. The pilot-rated student reported that after departure from Lakeland, they performed airwork consisting of steep turns, slow flight, power-on and power-off stalls, several simulated engine out and velocity minimum control air (Vmca) demonstrations. They also performed a simulated single engine ILS approach to runway 9 at LAL. She reported that the airplane "flew flawlessly", and indicated she is a commercial pilot, flight instructor, and airframe and powerplant mechanic with inspection authorization. The flight duration was reported to be 0.9 hour. METEOROLOGICAL INFORMATIONA surface observation weather report taken at LAL at 0850, or approximately 23 minutes before the accident indicated the wind was from 080 degrees at 3 knots, the visibility was 7 statute miles, and scattered clouds existed at 12,000 feet. The temperature and dew point were 18 and 17 degrees Celsius, respectively, and the altimeter setting was 30.20 inches of mercury. The accident site was located about 2 nautical miles and 326 degrees from the center of LAL. AIRPORT INFORMATIONThe airplane was manufactured in 1957 by Piper Aircraft, as model PA-23, and was designated serial number 23-1033. It was powered by two 150 horsepower Lycoming O-320-A1B engines and equipped with Hartzell HC-C2YL-2CUF constant speed propellers installed in accordance with Supplemental Type Certificate (STC) SA00721CH. Maintenance records before 2009 were not available for the airframe, engines, or propellers. Review of the maintenance records revealed the airplane was last inspected in accordance with an annual inspection on December 15, 2014. The airplane total time at that time was reported to be 5,922.1 hours. Although the hour meter was destroyed, the hour meter at the end of the last flight before the accident flight was 5,936.8 hours, or an elapsed time of 14.7 hours since the last annual inspection was performed. On December 8, 2014, or about 7 days before the last annual inspection was completed, personnel of the FAA Flight Standards District Office in Orlando, Florida, conducted a ramp inspection and maintenance records review of the operator's airplanes and facility; the ramp and records inspection included an inspection of 5 airplanes which included the accident airplane. Correspondence between the FAA and the operator dated December 12, 2014, indicated that with respect to the accident airplane, a cracked baffle in the right engine compartment was noted, and fuel appeared to be seeping from the fuel cap inboard right fuel tank. On January 9, 2015, the operator submitted a letter to the FAA indicating that with respect to the accident airplane, the cylinder baffle was repaired and the right fuel cap and surrounding area was cleaned and inspected for leaks but none were found; new gaskets were ordered. A review of the airframe logbook revealed an entry dated December 23, 2014, indicating a new right main fuel cell was installed. The airplane was flown the day before by a pilot-rated student and the accident flight instructor during a training flight. The pilot-rated student reported that after departure from Lakeland, they performed airwork consisting of steep turns, slow flight, power-on and power-off stalls, several simulated engine out and velocity minimum control air (Vmca) demonstrations. They also performed a simulated single engine ILS approach to runway 9 at LAL. She reported that the airplane "flew flawlessly", and indicated she is a commercial pilot, flight instructor, and airframe and powerplant mechanic with inspection authorization. The flight duration was reported to be 0.9 hour. WRECKAGE AND IMPACT INFORMATIONExamination of the accident site revealed the airplane crashed into a concrete building, and the building and the contents of it were destroyed. The accident site was located approximately 2.4 nautical miles and 326 degrees magnetic from the center of LAL. According to personnel of the Lakeland Police Department, a black colored bag containing a study guide for the accident airplane, a pilot logbook, and over the counter pain relief medication was found near the accident site. The bag was associated with the pilot-rated student, and was removed from the site and secured before NTSB arrival. The bag was located approximately 459 feet and 13 degrees from the crash site. Examination of the bag revealed evidence of wear in several areas, but no evidence of fire was noted on the bag exterior or interior items. Law enforcement personnel also performed aerial and ground searches of the outlying area and no other aircraft parts were identified. Further examination of the area surrounding the accident site revealed a piece of rudder with rudder trim tab attached was located approximately 138 feet and 7 degrees from the accident site. Examination of the part revealed no evidence of fire; evidence of over travel of the upper hinge was noted on both sides of the rudder. The upper hinge remained attached and a portion of the vertical stabilizer aft spar remained attached to the hinge (45 degree shear lips of the fracture surfaces were noted). The leading edge from the upper hinge below was displaced to the left approximately 60 degrees. The full span of the trim tab remained attached, but the piano wire was extended about 1 inch at the bottom and several of the hinges were not secured. The lower portion of the forward spar was torn (45 degree shear lips), and the aft spar was fractured at the lower end of the trim tab (also 45 de

Probable Cause and Findings

An in-flight loss of control for reasons that could not be determined during postaccident investigation; the loss of control likely occurred during a simulated loss of power in the right engine during an instructional flight.

 

Source: NTSB Aviation Accident Database

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