Roanoke, TX, USA
N4567J
PIPER PA-28R-180
The pilot, who had purchased the airplane about 2 months earlier, and the flight instructor departed on an instructional flight. Two witnesses reported that the airplane's engine did not sound right during the takeoff and the ground roll was longer than normal. Just beyond the runway, the airplane turned slightly left and then impacted the top of several trees. Both wings separated and remained lodged in the treetops; first responders noted fuel running from the wings. The emergency locater transmitter (ELT) was in found in the off position. Examination of the engine revealed water and contaminants in the fuel system, especially in the injection servo and fuel pump, which would have resulted in the rough-running engine and loss of engine power. A review of the airplane's maintenance records did not reveal any entries since the pilot had purchased the airplane. The airplane's last maintenance entry was at the annual inspection, which was about the time the airplane was purchased. The entry stated "found water in tanks - sumped tanks, cleaned flow divider, fuel screens and lines." The log also had the entry that stated "c/w FAR 91.207 ELT insp by installing new batteries, due March 2017." The airport manager had witnessed the same pilot depart in the accident airplane about a month earlier; however, the airplane's engine did not sound right, and the pilot returned to the airport. A review of the pilot's logbook revealed an entry "aborted X-country, lost engine power, so landed" on that date. About 2 weeks later, an e-mail from the pilot to family members stated that a clogged fuel injection system was found after the aborted flight. Two days after that, the pilot's logbook reflected 1.1 flight hours with a note that stated "test flight, perfect." On that same date, the pilot wrote a check to a maintenance company at the airport on which the airplane's registration number and "Maint" were written in the memo field. It is likely that either at the annual inspection and/or 2 weeks before the accident, maintenance personnel did not appropriately address the fuel contamination issues that persisted at the time of the accident. The airplane was not equipped with shoulder belts. During the impact sequence, the pilot likely rotated about his lap belt, braced himself with his arms and fractured his shoulders, but his head struck the instrument panel, resulting in his fatal skull injury. The flight instructor similarly rotated forward about his lap belt; his chest and abdomen struck the instrument panel resulting in his fatal injuries. Had the airplane been equipped with single or double shoulder restraints, the pilots' injuries likely would have been less severe and they might have survived.
HISTORY OF FLIGHT On September 22, 2012, about 1330 central daylight time, a Piper PA-28R-180 airplane, N4567J, impacted trees and terrain approximately 800 feet south of the Northwest Regional Airport (F52), Roanoke, Texas. The commercial rated pilot and certificated flight instructor (CFI) were fatally injured and the airplane sustained substantial damage. The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions prevailed and no flight plan was filed. The flight was originating at the time of the accident. Witnesses reported that the airplane departed runway 17; however, the takeoff roll was noticeably longer than airplanes typically perform, with an unusual engine sound. The airplane was observed to start a slight left turn, before it descended towards a stand of trees and disappeared out of sight. The airplane impacted the top of several trees before coming to rest in a grove of trees just beyond the end of the runway. The airport manager reported that about 2-3 weeks prior to the accident flight, he saw accident the airplane depart the airport. He thought the engine was running rough, the airplane's nose was high, and thought the pilot was going to stall the airplane at a low altitude. He added that the airplane circled around and lined up for a landing, but before reaching the runway the engine revved up and the pilot conducted a go-around; however, again the engine started to sound rough and the pilot made a left turn. The manager added that the airplane circled back to the runway at low attitude and he wasn't sure the airplane would make it back to the runway. The airplane barely made the runway and bounced on landing. The manager told the pilot that he wanted the airplane looked at, and that the pilot to receive some additional instruction before any further flights from the airport. PERSONNEL INFORMATION The airplane owner and pilot in the left seat held a commercial pilot certificate for airplane, single-engine land; airplane–instrument. A second-class Federal Aviation Administration, (FAA) medical certificate was issued on March 12, 2010, with the restriction, "must wear corrective lenses". On the pilot's last medical certificate application he reported 450 total flight hours with 10 hours in the last six months. A review of the pilot's flight log revealed that he had a total of 476.6 flight hours. The entry on August 4, 2012 was annotated as, "new airplane checkout satisfactory". An entry on August 17, 2012, for 0.3 hours, was annotated as, "aborted X-country, lost engine power, so landed". The entry on August 30, 2012, was for 1.1 hours and was annotated as, "Test flight. Perfect". The flight instructor in the right seat, held airline transport pilot certificates for airplane, single and multi-engine land; airplane-instrument. He also held flight instructor ratings for airplane single engine and instrument airplane. A second-class Federal Aviation Administration medical certificate was issued on March 26, 2012. The instructor's logbook was not provided; however, the instructor reported on his last medical certificate he had accumulated 9,000 total flight hours with 190 hours in the last six months. AIRCRAFT INFORMATION The accident airplane was a Piper PA-28R-180, which is an all-metal, four-seat, low-wing airplane with retractable landing gear and controllable pitch propeller which was manufactured in 1968. The airplane was powered by a 180 horsepower Lycoming IO-360-B1E engine, driving a constant speed, two-bladed metal, controllable pitch propeller. According to FAA records the pilot purchased the airplane in July, 2012. The airplane's front occupant's seats were equipped with lap belts, but not shoulder harnesses. According to maintenance records, the airplane's most recent annual inspection was completed July 10, 2012, with an airframe total time of 7,048.11 hours and tachometer time of 5,124.11 hours, with 100.11 hours since major overhaul on the engine. The review of the engine maintenance records revealed an entry annotated during the last annual inspection which read; "replaced fuel line between engine driven pump and servo, found water in fuel, flushed flow divider, screens and lines". The entry annotated in the airframe log read; "found water in tanks – sumped tanks, cleaned flow divider, fuel screens and lines". The log also had the entry; "c/w FAR 91.207 ELT insp by installing new batteries, due March 2017" The July 10, 2012 annual was the last entry in the maintenance records; there were no entries past the July 10th, date. The family of the pilot provided email excerpts and a fuel log for the airplane. The excerpt dated August 28, is quoted as; "was clogged fuel injection system. One fuel line was almost completely plugged. Will test fly tomorrow." The family also provided a bank cancel check, made out to Richmond [Aviation] for $200 on August 30, 2012, which had the annotation, " N4567J Maint", in the check's memo section. METEOROLOGICAL INFORMATION At 1353, the automated weather observation facility located at Fort Worth Alliance Airport (KAFW), located about 7 miles southwest of the accident location, recorded wind calm, visibility 10 miles, clear of clouds, temperature 92 degrees Fahrenheit (F), dew point 46 F, and a barometric pressure of 30.06 inches of mercury. AIRPORT INFORMATION Northwest Regional Airport (52F) is a privately owned airport open to the public and located about 3 miles northwest of Roanoke, Texas. The airport is non-towered and pilots are to use the Common Traffic Advisory Frequency (CTAF). The airport features an asphalt runway, 17-35 which is 3,500-foot long and 40-foot wide. COMMUNICATIONS The pilot was not in contact with air traffic control and there were no reported distress calls from the pilot. WRECKAGE AND IMPACT INFORMATION The Federal Aviation Administration (FAA) and National Transportation Safety Board (NTSB) responded to the accident site. The airplane impacted several trees off the south end of runway 17. Both the left and right wings separated near the wing roots and remained suspended in the trees. The fuselage was located about 60 feet beyond the wings, nestled amongst the base of several trees. The first responders reported that when they arrived at the accident site, fuel was running out of the wings. Both wing's fuel tank receptacles had rust along the filler ports. The fuselage was upright, but tilted to the right and wedged between several trees, with the front of the engine resting at the base of a tree. The fuselage back to the empennage had heavy bending and buckling. The engine and instrument panel were pushed back slightly into the cockpit area. The engine's crankshaft broke just behind the crankshaft flange, but remained in place. The propeller remained bolted to the engine crankshaft flange; only two of the three blades were visible; with one blade bent under the airplane. One blade was absent any leading edge gouges or polishing and appeared unmarked. The remaining blades also appeared unmarked except the outer 4-5 inches near the tip; which appeared twisted. The engine starter, located behind the propeller and crankshaft ring gear, had an only a minor scoring. The empennage exhibited substantial damage to the both sides of the horizontal stabilator; nearly severing the stabilator from the fuselage, the vertical stabilizer and rudder remained attached to the aft section of the fuselage with only minor damage. The stabilator trim tab remained attached via the respective hinge. The airplane's emergency locator transmitter (ELT) was located in empennage section; the unit's activation switch was found in the "off" position. There were no indications that the unit was accessed by first responders. MEDICAL AND PATHOLOGICAL INFORMATION The Tarrant County Medical Examiner's District, Tarrant County, Fort Worth, Texas, Office of the Chief Medical Examiner, conducted autopsies on the flight instructor and pilot. The cause of death for the flight instructor is listed as: blunt trauma of chest and abdomen; the cause of death for the pilot is listed as: basilar skull fracture. The FAA Toxicology Accident Research Library, Oklahoma City, Oklahoma, conducted toxicological testing on both occupants. For the pilot the results were negative for carbon monoxide, cyanide, ethanol, and tested drugs. For the flight instructor the results were negative for carbon monoxide, cyanide, and ethanol. The test was positive for etomidate and ondansetron in blood and urine and for naproxen and salicylate in urine. TEST AND RESEARCH A refueling history for the airplane was provided; the fuel log's first entry was July 28th, in Jacksonville, Florida, with the comments, "test flight after purchase". August 4th and 11th , entries were in Baton Rouge, Louisiana, with the comments: " for ferry of plane" and "topped off plane at NW Regional". The final entry was on September 18th, at 52F, with the comments, "topped off but did not fly". During an interview with the airport manager at 52F, he stated that he thought the accident airplane received gas, about 3-4 days prior to the accident flight; he also added that a number of airplanes received gas between the time the airplane was fueled and the accident flight. He also added that after the accident a sample of fuel was taken; a visual inspection of the sample revealed that it appeared consistent with 100LL aviation fuel and absent water or debris. An examination of the airplane engine was conducted by the NTSB investigator IIC. Continuity was established from the front of the crankshaft to the rear gear drive section of the engine, and through the valve train. The top set of sparkplugs were removed and produced spark when the engine was rotated by hand. Each cylinder produced suction and compression during a thumb test. Both magnetos were removed from the engine and bench tested; each one rotated freely and produced a spark at each terminal. The oil filter was removed and cut open; the filter was free of metal particulates and debris. The engine's fuel flow divider was removed and opened; the divider was dry but contained a small quantity of particles. The engine driven fuel pump valves and pump housing had areas of rust or corrosion throughout the internal sections; residual liquid consistent with fuel and water was found inside the pump. The fuel servo's fuel screen was absent of any contaminates; the fuel servo was then removed from the engine and disassembled. Fluid consistent with water and fuel were found inside the fuel servo. A white particle and other particulates were also found inside the servo; additionally, several components inside the servo also contained white particulates.
The loss of engine power during takeoff due to fuel contamination. Contributing to the accident was maintenance personnel's failure to adequately correct the water contamination effects. Contributing to the severity of the occupants' injuries was the lack of shoulder restraints.
Source: NTSB Aviation Accident Database
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