Milton, FL, USA
N5157T
Cessna R182
During a checkout flight by a certified flight instructor (CFI) with the operator in the accident airplane the day before, an excessive (200 rpm) decrease was noted when checking the right magneto. Maintenance cleaned the spark plugs, performed an engine run-up, and returned the airplane to service. The pilot passed the check out flight and was provided the airplane. The CFI reportedly advised the pilot that if there was any maintenance problem to have the airplane worked on and the maintenance cost would be deducted. The day before the accident the pilot flew the airplane to Milton, Florida, and landed uneventfully where the airplane remained overnight. No maintenance was performed or requested, and no fuel was purchased. The pilot and three passengers boarded the airplane for a local flight and three witnesses, one of whom is an A & P mechanic, reported hearing the pilot having trouble starting the engine. The engine ran rough after starting, and the airplane was taxied to the approach end of runway 36 where the pilot performed an engine run-up. Several witnesses including the A & P mechanic reported hearing a discrepancy during the magneto check. The pilot was heard increasing the engine rpm while at the engine run-up area. During the takeoff roll one witness reported that the engine was, "making sounds as if it was not developing power." Several witnesses noted the airplane did not become airborne until approximately 3/4 down the 3,700 foot-long runway, or approximately 2,828 feet down the runway. Conservative takeoff distances for ground roll and distance to clear a 50 foot obstacle per the airplane "Information Manual" were 910 and 1,745 feet, respectively. The airplane began climbing to an estimated height of 100 feet, and the landing gear was noted to retract. One witness reported the airplane flew over her position and the engine was heard to be running rough. A pilot who was flying in the area at the time observed the airplane turn onto the downwind leg, stall, then pitch straight down. The airplane crashed in the side yard of a residence located approximately .30 nautical mile and 303 degrees from the departure end of runway 36. Examination of the flight controls and power section of the engine revealed no evidence of preimpact failure or malfunction. The ignition harness was impact damaged which precluded testing. Examination of the heat damaged magneto revealed the left capacitor was shorted to ground consistent with heat damage, while the right capacitor was functional. Heat damaged components were replaced, the magneto was placed on a test bench and operated with no discrepancies noted. Examination of the impact and heat damaged carburetor revealed the accelerator pump piston seal was badly worn exposing most of the sealing spring; the worn seal would reportedly not result in increased fuel flow. The as found setting of the economizer would result in a leaner fuel/air ratio. Rust was noted in the drain cavity below the float bowl, on the inner portion of the carburetor bowl drain plug, and a small amount of debris was noted in the main bowl chamber. Documents provided by the operator indicate a discrepancy related to excessive rpm decrease during a magneto check on August 27, 2004. The spark plugs were removed, cleaned, rotated, and reinstalled.
HISTORY OF FLIGHT On September 23, 2004, about 1006 central daylight time, a Cessna R182, N5157T, registered to PropCo, Inc., operated by MC Aviation, Inc., experienced an in-flight loss of control and crashed in a residential area located .30 nautical mile west-northwest from the departure end of runway 36 at Peter Prince Field Airport, Milton, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 local, personal flight from Peter Prince Field Airport. The airplane was destroyed by impact and a postcrash fire and the commercial-rated pilot and three passengers were fatally injured. The flight originated about 5 minutes earlier from Peter Prince Field Airport. An acquaintance of the pilot reported the purpose of the flight was to survey damage to the church in which he and the passengers were members of, to survey damage to the homes of church members, and to survey the area in general as a result of Hurricane Ivan to see where assistance from the church was needed. One witness reported seeing four adults board the airplane and three separate witnesses reported hearing the pilot have a difficult time starting the engine, then after it was started, all three reported hearing the engine running "rough." One of the witnesses is a FAA certificated airframe and powerplant (A & P) mechanic. The airplane was observed taxiing to the approach end of runway 36 and one of the three witnesses reported, "During the run up his mag check sounded like it had excessive drop. He increased rpm's and held it there." The witness who is an A & P mechanic reported, "They taxied to the run-up area and in my opinion had an unsatisfactory pre-flight run-up/test. Evidently they chose to take off with the poorly running engine." The third witness reported, "...Got to the runway to do a run up. [Magneto] check sounded rough...." The airplane was taxied onto the 3,700 foot long runway and began the takeoff roll but one of the witnesses reported the engine was, "making sounds as if it was not developing power." The A & P mechanic and one other witness reported the airplane became airborne when it was approximately 3/4 down the runway. The A & P mechanic stated, "The aircraft used 3/4 of the runway trying to get airborne and never developed full power. I would estimate they achieved 100 feet of altitude...." One witness reported seeing the landing gear retract after the airplane became airborne, while another witness reported hearing a rough running engine when the airplane flew overhead her position. A pilot-rated witness who was airborne at the time of the accident reported seeing the flight depart from runway 36. The pilot-rated witness further reported that, "after he had turned downwind the airplane appeared to stall, then pitch straight down." He discontinued his approach, circled the crash site, observed fire, and advised FAA air traffic control of the accident. PERSONNEL INFORMATION The pilot was the holder of a commercial pilot certificate with airplane single engine land, airplane multi-engine land, and instrument airplane ratings. His commercial pilot certificate was first issued on January 27, 1999. The certificate issued on that date had airplane single engine land and instrument airplane ratings. He was issued a first class medical certificate on March 23, 2004, with the restriction, "must wear corrective lenses." A review of copies of his pilot logbooks that contained entries from his first flight on December 14, 1996, to the last entry dated March 7, 2002, revealed no logged flights in the accident make and model airplane. He logged a total time of 2,046.6 hours, 519.1 hours in airplane single engine land airplanes, and 1,482.4 in airplane multi-engine land airplanes. He also logged 647.6 hours as pilot-in-command, and 1,357.8 hours as second-in-command. Further review of his pilot logbook revealed the remarks section of an entry dated January 5, 2001, indicating "Hired at Continental [Express] Part 121." From that date (January 5, 2001), to the last entry in the logbook (March 7, 2002), he logged only 1 flight in a general aviation airplane. That flight occurred on August 3, 2001, the duration was 1.0 hour, and the remarks section for that entry indicates, "Aircraft [check] out PA28-161." According to FAA records, the right front seat occupant was not a certificated pilot. AIRCRAFT INFORMATION The airplane was manufactured in 1981 by Cessna Aircraft Company as model R182, and was designated serial number R18201826. It was certificated in the normal category and was equipped with a Textron Lycoming O-540-J3C5D engine rated at 235 horsepower when operated at 2,400 rpm. The airplane was also equipped with a McCauley B3D32C407-B constant speed propeller. Review of the airplane maintenance records revealed the airplane was last inspected in accordance with a 100-Hour inspection on August 16, 2004. At that time the airplane had accumulated 3,150.0 hours total time. The airplane had accumulated 40.3 hours since the inspection at the time of the accident. Further review of the maintenance records revealed the engine was overhauled by Don George, Inc., in November 1992, and installed in the airplane following overhaul on December 11, 1992. The engine was removed from the airplane due to a propeller strike, disassembled and inspected in October 1993. The engine was reinstalled in the airplane on October 27, 1993, and remained installed until removed postaccident. On August 16, 2004, an entry in the engine logbook indicates in part, "all cylinders were removed and overhauled by John Jewel Aircraft CRS JUJR300L, due to exhaust flange erosion." At the time of the accident the engine had accumulated 920 hours since major overhaul, and approximately 40 hours since the overhauled cylinders were installed. METEOROLOGICAL INFORMATION A surface observation weather report taken at the Pensacola Regional Airport (KPNS), Pensacola, Florida, on the day of the accident at 0953, or approximately 13 minutes before the accident indicates the wind was from 080 degrees at 9 knots, clear skies existed, the temperature and dew point were 24 and 18 degrees Celsius, respectively, and the altimeter setting was 30.14 inHg. The accident site was located approximately 14 nautical miles and 045 degrees from KPNS. AIRPORT INFORMATION The Peter Prince Airport is equipped with one asphalt runway designated 36/18, which is 3,700 feet in length by 75 feet wide. The airport elevation is 82 feet, and the airport is equipped with a common traffic advisory frequency (CTAF)/UNICOM of 122.975 mHz, that is not recorded. WRECKAGE AND IMPACT INFORMATION The airplane crashed in the sideyard of a house located at 7732 Erudition Avenue, Milton, Florida. The accident site was located at 30 degrees 38.721 minutes North latitude and 086 degrees 59.911 minutes West longitude, or approximately .30 nautical mile and 303 degrees magnetic from the departure end of runway 36. The accident site was located .61 statute mile and 333 degrees from the center of the airport. Examination of the accident site revealed the wreckage was upright on a magnetic heading of 035 degrees magnetic near a lake. The engine assembly was beneath ground level with only the outer 10 inches of one propeller blade visible. The "backbone" of the engine was at an angle of approximately 40 degrees with respect to the nearly level ground. The smell of 100 low lead fuel was noted in the ground while digging the earth away from the engine. Fire damage to grass was noted surrounding the left wing, fuselage, empennage, aft portion of the right wing, and at the right wingtip resting location. Examination of the airplane revealed the fuselage was consumed by the postcrash fire from the instrument panel aft to approximately 6 inches forward of the leading edge of the horizontal stabilizer, and fire damage was noted to both wings. Fire damage was also noted to both horizontal stabilizers, the vertical stabilizer, the left elevator, and to a portion of the rudder. Slight paint discoloration was noted on the inboard leading edge and inboard upper skin of the right elevator. All components necessary to sustain flight remained attached to the airplane or were in close proximity to the main wreckage. Bulging of the upper wing skins of both wings consistent with hydraulic deformation was noted in the areas where the fuel tank was installed. Flight control continuity was confirmed for pitch and yaw. Examination of the aileron flight control system revealed both primary flight control cables were fractured near each wing root area; the cables were fractured in tension overload. The aileron balance cable was continuous from the left aileron bellcrank to the right aileron bellcrank. The propeller remained secured to the engine which remained secured to the airframe. One propeller blade was separated from the propeller hub but was found in the engine impact crater. The flaps were retraced based on the examination of the flap actuator, and the landing gear was retracted. Examination of the fuel system revealed the outlet screens of the left and right fuel tanks were free of obstructions. The fuel line from the left fuel tank to the fuel selector was compromised in several locations due to fire, and the fuel line from the right fuel tank was noted going down the aft door post but was not connected in the wing root area due to an excessive gap at the right wing root. The crossover vent line was free of obstructions. The fuel selector was free of obstructions. No obstructions were noted in any fuel line from the fuel selector valve to carburetor inlet fitting. The fuel strainer screen was clean. Vented fuel caps were installed on both fuel tanks. The auxiliary fuel pump was removed for further examination. Examination of the cockpit revealed the mixture, throttle, and carburetor heat controls were full-in. The propeller control was near full-in, and was bent down. The fuel selector handle was bent; the fuel selector was found positioned between the "both" and "right" positions. The primer was in and locked, and the cowl flap selector was in the full open position. The magneto switch was on the "right" magneto position, and the landing gear selector was in the "up" position. The needle of the tachometer was separated from the shaft but when first viewed, the pointer was indicating approximately 2,450 rpm; the recording time was 0378.2 The fuel quantity gauge, amp meter, oil pressure and temperature, and the cylinder head temperature gauges were unreadable. A "Pilot's Operating Handbook" for model R182 was found in the co-pilot's seat back pocket, and a laminated checklist was found in the wreckage. The engine was examined by a representative of the engine manufacturer with FAA oversight. The examination revealed crankshaft, camshaft, and valve train continuity. Suction and compression was noted at each cylinder during rotation of the engine by hand. The single-drive dual magneto (magneto) and carburetor were separated from the engine but recovered from the impact crater. The magneto was rotated by hand and spark was noted at all ignition leads which were cut very close of the cap. The ignition harness was impact damaged which precluded bench testing. Examination of the top spark plugs revealed all exhibited "low service life condition" with the No. 4 exhibiting dark discoloration consistent with a rich condition, and was wet with oil. Examination of the bottom plugs revealed the plug from the No. 1 cylinder could not be removed; the remainder of the plugs also exhibited a "low service life condition" with the Nos. 2 and 4 wet with oil. The No. 5 plug exhibited coloration consistent with a lean fuel/air ratio. Impact and heat damage was noted to the engine driven fuel pump. Disassembly of it revealed no evidence of preimpact failure or malfunction; no fuel was found inside. Examination of both mufflers revealed both flame cones were intact with no internal restriction noted. The oil suction screen was clean. The carburetor, magneto, propeller, and propeller governor were removed for further examination. MEDICAL AND PATHOLOGICAL INFORMATION Postmortem examinations of the pilot and passengers were performed by the District 1 Medical Examiner's Office. The cause of death for all was listed as multiple blunt force injuries. Toxicological analysis of specimens of the pilot was performed by the FAA Toxicology and Accident Research Laboratory (CAMI), and the University of Florida Diagnostic Referral Laboratories (University of Florida), located in Gainesville, Florida. The results of analysis of specimens by CAMI was negative for carbon monoxide, cyanide, and volatiles. Acetaminophen (11.88 ug/ml) was detected in urine, and unquantified amounts of ephedrine, and pseudoephedrine were detected in blood and urine. Additionally, an unquantified amount of phenylpropanolamine was detected in urine. The results of analysis by the University of Florida was negative in blood and urine for volatiles, negative in blood for the "Comprehensive Drug Screen", and cyanide. The result was positive in urine for ephedrine/pseudoephedrine, and phenylpropanolamine, and the carboxyhemoglobin level was 4 percent saturation. Toxicological analysis of specimens of the passengers was performed by University of Florida. The results of analysis of specimens of the right front seat passenger was negative in blood and urine for volatiles, and the "Comprehensive Drug Screen." The results was negative for cyanide in blood, and the carboxyhemoglobin level was 5 percent saturation. The results of analysis of specimens of the left rear seat passenger was negative in bile and blood for volatiles, and the "Comprehensive Drug Screen." The results was negative for cyanide in blood, and the carboxyhemoglobin level was 3 percent saturation. The results of analysis of specimens of the right rear seat passenger was negative in blood and bile for volatiles, and negative in blood for cyanide. Citalopram was detected in blood and bile. The carboxyhemoglobin level was 3 percent saturation. TESTS AND RESEARCH Examination of the auxiliary fuel pump was performed by the NTSB Materials Laboratory, located in Washington, D.C. The examination revealed blue colored material approximately 1/4 inch in diameter was noted in the inlet port of the fuel pump housing, and also covering a hole that connects the internal bushing area with the outlet port cavity. The blue colored material was consistent with the bushing material which is reportedly made of Turcite A. Rotational damage was noted to the seal face and ring face which are adjacent to the rotor. The pump vanes were all in good condition with no obvious damage. Following removal of the vanes, blue colored material (bushing material consistent with Turcite A) was noted to have flowed beyond the ring into the vane slots. There was no failure of fuel pump components. Examination of the propeller and propeller governor was performed by a representative of the propeller manufacturer with FAA oversight. The examination revealed the propeller was rotating at impact but the exact amount of power at impact could not be determined. The butt end of the No. 2 propeller blade exhibited an impact mark related to spring coil marks. The location of the mark on the butt end of the blade correlated to a blade angle of approximately 18.2 degrees. The low pitch blade angle is 16.0 degrees. No evidence of preimpact failure or malfunction was noted to any components of the propeller. The propeller governor was placed on a test bench and the pressure relief setting was at 329 psi (specification is 290 + or - 20 psi). The representative of the propeller manufacturer reported the issue of the relief valve pressure being out of specification, "...would not cause any aircraft systems related problem since single-engine constant speed propellers never operate at pressure relief setting." The pump capacity, leakage rate, and control head setting were within limits. The maximum rpm was at 2,459 (specification is 2,275 + - 10 rpm). The representative of the propeller manufacturer re
The pilots operation of the airplane with known deficiencies in the equipment based on witness statements describing an excessive rpm drop and rough running engine after starting, during the engine run-up, and after becoming airborne, his failure to abort the takeoff after an excessive takeoff roll, and his failure to maintain airspeed resulting in an inadvertent stall, uncontrolled descent, and in-flight collision with terrain. A factor in the accident was the loss of engine power due to undetermined reasons.
Source: NTSB Aviation Accident Database
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