Aviation Accident Summaries

Aviation Accident Summary CEN11FA007

Naperville, IL, USA

Aircraft #1

N3402Q

PIPER PA-32R-300

Analysis

During takeoff, the pilot rotated the airplane beyond the airplane's takeoff ground roll distance and at a speed near the airplane’s stall speed. A witness saw the airplane climb with a nose-up pitch of about 20 degrees. Although the airplane had experienced a partial loss of engine power, as reported by the pilot, it was still able to climb while in a high pitch attitude and corresponding high drag attitude, which is indicative that the airplane had excess horsepower to climb and sustain flight at higher airspeeds and lower angles of attack. However, the pilot continued to attempt to climb rather than to abort the takeoff, exceeded the necessary power requirements, and was unable to sustain the climb; the airplane impacted a building. Postaccident examination of the airplane’s engine revealed a detached fuel servo air inlet coupling that would have perturbed or restricted airflow to the fuel servo, which resulted in the reduced engine power. The examination also revealed a preexisting hole in an exhaust pipe near the fuel servo that would have allowed hot exhaust gases to flow into the fuel servo air inlet, which would also result in reduced engine power. The airplane had undergone an annual inspection performed by the airplane’s owner and two mechanics with inspection authorizations 3 flight hours before the accident flight; the inspection should have identified the detached coupling and the hole in the exhaust pipe.

Factual Information

HISTORY OF FLIGHT On October 6, 2010, about 1204 central daylight time, a Piper PA-32R-300, N3402Q, impacted a building after takeoff from runway 36 at Naper Aero Club Airport (LL10), Naperville, Illinois. The certificated private pilot and a passenger received serious injuries. The airplane sustained substantial damage to the fuselage and wings. Visual meteorological conditions prevailed at the time of the accident. The airplane was registered to Airplane Holding Company and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. An instrument rules flight plan was on file and the flight was destined to Allegheny County Airport, Pittsburgh, Pennsylvania. The flight was originating at the time of the accident. A witness, who was preflighting his airplane at LL10, stated that he saw the airplane during its run-up and thought it unusual that its engine did not sound very loud compared to other higher performance airplane engines. He said he saw the airplane taxi onto runway 36 and without stopping, power was applied for the takeoff. The witness watched the airplane during the takeoff and was surprised to see it use the entire runway and not lift off. He said that it was similar to an airplane that has landed and taxies to the runway end for a turnoff. The witness said he saw the airplane in a slow climb followed by an immediate and moderate bank to the left, which was corrected for to the right. He said that the climb performance was very weak. Another witness, who was located at the southeast corner of the building that was struck by the airplane, stated that the airplane seemed to be very low. The airplane was in a twenty degree nose-high attitude with the wings level. The engine was running but seemed to be struggling. On November 6, 2010, the pilot was interviewed by Federal Aviation Administration (FAA) inspectors from the Dupage Flight Standards District Office, West Chicago, Illinois. During the interview, the pilot stated that the winds were from the west and there was a direct crosswind at the start of the accident takeoff roll. The pilot stated that he believed there was no tailwind for the takeoff roll. When asked if there were any ‘out of the ordinary observations’ prior to, during, and after the takeoff roll of power settings, airspeeds, manifold pressure, and engine speed settings, the pilot said that all appeared normal. The pilot stated that he has performed numerous weight and balance calculations and knew that the airplane’s load was lighter than normal and was in limits. The pilot stated that ‘everything was normal at the mid-point of the runway. I did not hear anything out of the ordinary. I rotated the aircraft at the end of the runway at the stall warning; the aircraft didn’t seem to want to climb. I tried to gain altitude so I could turn the airplane but I couldn’t.’ The pilot was then asked if he had completed a runway performance calculation prior to takeoff. The pilot then responded by saying that he would not answer anymore questions until he had an attorney. According to the pilot’s written statement received on November 10, 2010, the pilot had performed a “normal” preflight and after liftoff, the engine was developing full power. The airplane then impacted a building while maneuvering for an emergency landing. On November 18, 2010, two mechanics that performed the last 100-hour/annual inspection of the airplane were interviewed by the National Transportation Safety Board Investigator-in-Charge (IIC) with a court reporter. On April 15, 2011, the pilot was interviewed by the IIC with a court reporter and his attorney present. During that interview, the pilot stated that for the takeoff, he used a short field technique with the flaps extended to the second setting (25 degrees). He set the manifold pressure to 25 inches of mercury (Hg) while the airplane was stopped, and during the takeoff roll he increased the manifold pressure to 29 inches of Hg. He first realized that there was a problem when the airplane lifted off and did not have any climb power. The liftoff occurred beyond the runway midpoint. He did not remember what the airspeed was at takeoff rotation. The stall warning horn sounded when the airplane was about 5 feet above the runway. He did not retract the flaps. The manifold pressure was about 29 inches of Hg, the mixture was full rich, and the propeller was set for full power. PERSONNEL INFORMATION The pilot, age 66, held a private pilot certificate with airplane single-engine land and instrument airplane ratings. He was issued a third class airman medical certificate on August 26, 2010. On August 30, 1986, the pilot was issued a private pilot certificate and on October 26, 1988, he was issued an instrument airplane rating at a total flight time of 1,179 hours. The pilot had three logbook entries dated September 29, 2010, and in the accident airplane. The first entry was a flight from LL10 to MDW that was 0.5 hours in duration with no remarks. The second entry was from MDW to MDW that was 1.6 hours in duration of which 1.6 hours was dual flight instruction with a remark of an “IPC- endorsement….” The third entry was from MDW to LL10 that was 0.4 hours in duration with no remarks. The total time for the third entry, which was also the last of all the entries in the logbook was 1,141.1 hours. The pilot had no previous FAA record of incidents, accidents, or enforcement actions. The pilot stated that he had been a prior president of the Naper Aero Flying Club, which he said was a type of association that not all of the homeowners at LL10 belong to. He said that he first learned of mechanic A and mechanic B, when they were recommended to him by a previous airport manager for LL10. The pilot stated that the manager had experience with maintenance personnel and had owned a flight school in Schaumberg, Illinois, which was no longer in business. The pilot said that he did not remember the name of the flight school. The pilot said that he had used both mechanics for the past 10 years. Mechanic A and Mechanic B had known each other since the 1990s while at a maintenance training facility at Chicago Midway International Airport, Chicago, Illinois. Mechanic B had been Mechanic A's supervisor while they were employed at an air carrier. Mechanic B stated that he had been employed by Northwest Aviation, Schaumberg, Illinois, which was no longer in business. At the time of their interviews, Mechanic A was employed as an aircraft mechanic at a maintenance facility and Mechanic B was not employed. Mechanic B said that he may have first worked on the airplane since 2006 and it was the first time that he had seen the supplemental type certificate (STC) SE85WE turbocharger installation on this or any other airplane. Both mechanics performed the last 100-hour/annual inspection, which was owner assisted. Mechanic B signed the airplane and engine logbooks annual inspection entries. Mechanic B stated that he worked with Mechanic A on other aircraft including his (Mechanic B's) own. Both mechanics stated that they performed aircraft maintenance that included several private and flying club airplanes at LL10. Mechanic B said that they would get paid for their maintenance work but were not trying to make a profit. Mechanic B said that he has a standard base rate which was dependent upon the aircraft owner's [work] contribution. Mechanic A’s last renewal for (IA) under Part 65.93 was February 23, 2009, the basis of which was 5 aircraft alterations, 2 repairs, and 12 annual inspections. Mechanic B’s last renewal for (IA) under Part 65.93 was February 19, 2009, the basis of which was 13 annual inspections. Two of the annual inspections were on his (Mechanic B) own aircraft. AIRCRAFT INFORMATION The airplane was a 1977 Piper PA-32R-300, serial number 32R-7780310, which was powered by a Lycoming IO-540-K1G5D, serial number L-14210-48A, and engine. The engine was modified by the installation of a Rajay turbonormalized (to maintain sea level pressure of 29.92 inches of Hg) turbocharger system under STC SE85WE. On November 10, 2010, the aircraft logbooks were received from the pilot's attorney following two written requests to the pilot that was dated October 18, 2010, and November 4, 2010. A January 24, 2008, engine logbook entry for the replacement of cylinder numbers 3 and 4 was made by mechanic A at a tachometer time of 3,306.38 hours. Mechanic A signed the next entry dated January 11, 2010, at a tachometer time of 3,333.7 hours for the reinstallation of an overhauled fuel injection flow divider and replacement of 4 valve springs for the number 1 cylinder. There was no separate signed list of airworthiness directives (ADs) that had been complied with for the last annual inspection. The airframe and engine logbook annual inspection entries had cited several ADs but none of those cited AD 2009-02-03. AD 2009-02-03, effective February 9, 2009, was to be performed before further flight, for the installation of a new servo plug gasket to prevent a lean running engine, which could result in a substantial loss of engine power. The airframe and engine 100-hour/annual inspection logbook entries since 2006 were signed by the mechanic B who had also signed the last 100-hour/annual inspection dated September 22, 2010, at a total airframe time, total engine time, and tachometer time of 3,339.85 hours. The engine time since overhaul at this inspection was 1,240.01 hours. The last 100-hour/annual inspection was owner assisted. Engine logbook records from the last annual inspection stated that the compression ratios were: cylinder 1 – 72/80, cylinder 2 – 68/80, cylinder 3 – 77/80, cylinder 4 – 76/80, cylinder 5 – 70/80, cylinder 6 - 76/80. The Piper Cherokee Six Service Manual, part number 753 690, for PA-32-260 PA-32-300, PA-32R-300 airplanes was issued May 1, 1965, and has had 16 revisions with the last dated March 27, 2008. The pilot was asked to provide manuals used in the last annual inspection. The only manual provided was Piper Service Manual 753 690 with a revision date of November 4, 1983. The maintenance manual for the turbocharger system was not provided. Rajay Industries, Inc. had published a maintenance manual for the Turbocharger System with Automatic Control. The manual states that the turbocharger installation should be inspected at the 25, 50, and 100 hour inspections. Areas of inspection include but not limited to: 1. All inlet and compressor discharge ducting for loose clamps or leaks 2. Inspect engine air inlet assemble for cracks, loose clamps, and screws The inspection requirements for 1,000 hour or annual inspections state in part: 1. Remove all turbocharger kit components from the engine. Inspect and repair as necessary. 2. Check operation of the overboost valve. Disconnect actuator cables from wastegate and wire waste gate in full closed position. Operate engine from idle to maximum power. 3. Inspect security, leakage, loose fittings, and visible wear of overboost valve, actuator, controller, hoses, cables, etc. There was no logbook record that the 1,000 hour or annual inspection of the turbocharger system was performed. A Piper PA-32R-300 Pilot’s Operating Handbook (POH) along with an attached Rajay POH supplement, FAA Form 337 for the STC installation, and a “High-Flying Lance” article were recovered from the accident airplane. The POH also contained weight and balance forms with the latest dated February 1, 1993. The empty weight was 2,280.80 lbs and the moment are was 83.85 inches. The maximum gross weight of the airplane was 3,600 lbs. The pilot and passenger weights were about 200 lbs and 160 lbs, respectively. The baggage aboard the airplane consisted of about 45 lbs located between the forward and aft facing passenger seats and about 79.5 lbs of other items located through the cabin that were not part of the airplane weight and balance. The pilot reported that about 90 gallons of 100 low lead (100LL) fuel was aboard at takeoff. According to the POH, the 25 Degree Flaps Takeoff Performance, Takeoff Distance Over 50 feet Barrier was about 1,650 feet. METEOROLOGICAL INFORMATION The Lewis University Airport (LOT) automated weather observing system located about 8 nautical miles southeast of LL10 at an elevation of about 708 feet mean sea level, recorded at: 1205: wind – 270 degrees at 8 knots; visibility – 10 statute miles; sky condition – clear; temperature - 21 degrees Celsius (C), dew point – 5 degree C The pilot stated that at the beginning of the takeoff roll, there was a direct crosswind from the west. AIRPORT INFORMATION Naper Aero Club Airport (LL10) was a nontowered airport that had an elevation of 702 feet mean sea level (MSL). The airport had two runways: runway 18/36 (2,575 feet by 30 feet, asphalt and runway 9/27 (1,750 feet by 70 feet, turf). WRECKAGE AND IMPACT INFORMATION The airplane impacted a building located about 2,000 feet north of the departure end or runway 36 at an estimated height of 40-50 feet. The airplane was in an upright position on the roof of the building. The engine which was attached the firewall along with the forward baggage compartment was separated from the fuselage and was resting inverted. The landing gear was retracted. Examination of the cockpit revealed that the master switch and the fuel pump switch were in the on position. The magneto switch was in the both position. The altimeter setting was about 30.06 inches of Hg and indicated about 810 feet MSL. The directional gyro indicated about 323 degrees. The tachometer indicated 3,342.86 hours. The instrument panel sustained impact damage and the wiring for the pilot intercom system that was exposed was consistent with speaker wire. The parking brake handle was not in the engaged position. The throttle quadrant sustained damage. The cockpit throttle control was full forward, the cockpit propeller control was about 1/4 inch from full forward, and the cockpit mixture control was near the forward position. Throttle quadrant control continuity to the engine was confirmed. Examination of the flight controls confirmed flight control continuity from the control surfaces to the cockpit flight controls. The flaps and cockpit flap control handle were both at the flaps 25 degree positions. The pitch trim was in the neutral position. The airplane fuel tank quantities were approximately full. The fuel selector was on the right tank position and was able to be moved by hand. The movement also confirmed that detents were present. The fuel sump filter contained a liquid consistent with 100LL. The fuel filters in the fuel system were free of blockage. A liquid consistent with 100LL was also present in flow divider, injector nozzles, engine driven fuel pump inlet and within the engine driven fuel pump. The fuel hoses were connected and no leaks were noted. The engine air intake ducts were unobstructed. The fuel servo, a Bendix RSA 10ED1, part number 2524273-11, serial number 58323, examination revealed that the inlet air duct coupling was separated from the servo air inlet. A clamp was present and over the inlet air duct. The clamp was secured onto itself. The duct coupling that attaches to the fuel servo inlet was not attached to the fuel servo or any portion of the clamp. There was no damage to the coupling consistent with it breaking away from the fuel servo and/or clamp during impact. The coupling displayed wear features consistent with preimpact separation. The opposite end of the coupling was attached to the inlet air duct and secured under its clamp. The engine was attached to all of its engine mounts, and the engine frame was attached to the firewall. There was deformation of the right side of the engine frame as viewed from tail to nose of the airplane. The exterior and its accessories were covered with a residue consistent with oil/dirt in an amount indicative of a lack of a recent engine wash. A wire that was wrapped around an upper right side engine oil sump stud and was connected to the cylinder number 1 baffling in place of the engine manufacturer’s approved part. The approved part is a tie rod to re

Probable Cause and Findings

The pilot’s failure to abort the takeoff when he realized the airplane was not attaining sufficient takeoff and climb performance. Contributing to the accident was the airplane’s partial loss of engine power due to an obstruction of the fuel servo air inlet by the intake duct coupling and ingestion of exhaust gases from a preexisting hole in the exhaust pipe. Also contributing to the accident was the improper annual inspection of the airplane by the owner and two mechanics.

 

Source: NTSB Aviation Accident Database

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