Aviation Accident Summaries

Aviation Accident Summary ERA13FA055

Jackson, MS, USA

Aircraft #1

N717RL

PIPER PA-32-300

Analysis

Before the accident flight, the airplane had sat in its hangar for the previous 2 months with its fuel tanks half full under varying temperature conditions. The pilot had planned on flying to a safety seminar that began at 1630, so he had the airplane pulled out of its hangar, and its main fuel tanks were topped off from a fuel truck. After his arrival at the airport shortly before 1700, the pilot performed a preflight inspection. The manager of the hangar facility described the pilot's preflight inspection as "real quick." A lineman observed the pilot in a position to reach the fuel strainer valve, but he did not see the pilot sumping the main fuel tanks. When the lineman drove by the airplane, he saw a puddle about 1 foot in diameter on the tarmac beneath the fuel strainer, but he did not note anything under either main fuel tank drain. The lineman also noted that the airplane had an underinflated tire, but, due to other duties, he could not warn the pilot before he taxied the airplane away. About 2 minutes after takeoff, the pilot reported an "engine problem" to air traffic control and turned the airplane back toward the airport. The airplane subsequently descended at a steep angle, consistent with a stall, into a house located in a populated area. The airplane impacted the roof, came to rest upside down, and was subsequently mostly consumed in a postcrash fire. Postaccident examination of the airplane revealed evidence indicating that the airplane was not under power at the time of the accident; the fuel-injected engine was charred and the propeller did not exhibit torsional bending or leading edge damage that would have been present if it had been under power. No preexisting mechanical anomalies were found that would have precluded normal engine operation. However, when the fuel flow divider was opened, water was found in it, which likely resulted in the loss of engine power. Water typically enters fuel tanks via three sources: leakage, normally through a fuel cap; contaminated fuel sources; and fuel tank condensation. The fuel cap was likely not the source of water since the airplane was stored in a hangar. Contaminated fuel from the fuel truck was also not the likely source of water since the truck was reportedly sumped daily. Further, on the day of the accident, five airplanes received fuel from the same truck before the accident airplane with no reports of any performance anomalies, and a clean fuel sample was taken from the truck about 20 minutes after the accident. It is more likely that condensation occurred in the half-filled fuel tanks during the previous 2 months that the airplane was sitting in the hangar under varying temperature conditions. Regardless, the pilot had an opportunity to eliminate the condensation during the preflight inspection. However, as noted previously, not enough evidence existed to determine whether the pilot actually drained each main tank to ensure that all of the water was removed. It is likely that the pilot either did not sufficiently drain the main fuel tanks or that he was relying on draining the main fuel tanks through the fuel strainer and fuel lines and did not sufficiently drain them all. Given witness statements indicating that the pilot was in a hurry and his oversight of the underinflated tire, it is likely that the pilot's preflight inspection was inadequate, which resulted in his failure to notice the fuel tank condensation.

Factual Information

HISTORY OF FLIGHTOn November 13, 2012, about 1715 central standard time, a Piper PA-32-300, N717RL, was substantially damaged when it impacted a house in Jackson, Mississippi. The airline transport pilot (ATP) and the two pilot-rated passengers were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, from Hawkins Field (HKS), Jackson, Mississippi, to John Bell Williams Airport (JVW), Raymond, Mississippi. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the owner of the company to which the airplane was registered, and who was also a student pilot of the ATP, the ATP and he were going to fly to JVW to attend a Federal Aviation Administration (FAA) safety seminar. The owner was subsequently unable to go, but advised the ATP that the airplane needed to be flown since it hadn't flown since Labor Day [September 3rd]. The owner was unaware that the other two pilots were onboard. Announcements for the safety seminar indicated that it was scheduled to begin at 1630. According to the manager and a lineman at a local fixed base operator (FBO), the airplane was pulled out of its hangar and the main fuel tanks were topped off prior to the arrival of the ATP and the passengers, shortly before 1700. Both indicated that the ATP's preflight inspection was much quicker than normal. The lineman, while subsequently refueling another airplane, only looked at the accident airplane periodically, but did see the ATP walking around it with the two passengers following him, and also saw him in the position required to activate the fuel strainer lever in the interior, right side of the cabin. The lineman later drove by the airplane and noticed a puddle, an estimated 1 foot in diameter, on the tarmac below the fuel strainer. The lineman also stated that the airplane's right tire was low, but that the airplane started and departed before he could inform the ATP. He further observed that the ATP was in the front left seat, and that the younger passenger was in the front right seat. The lineman advised the FBO manager of the underinflated tire, who then watched the airplane during the run-up, and also the takeoff in case assistance was needed. The manager noted that the engine run-up was much quicker than he was accustomed to seeing. He then saw the airplane taxi onto runway 16, and heard an "abrupt" addition of power for takeoff. The airplane subsequently lifted off in the vicinity of taxiway Bravo, with the engine sounding "normal, real strong." An audition of tower communications revealed that, at 1708, the pilot called for taxi. The tower controller approved taxi to either runway 16 or 34, pilot's discretion, and the ATP chose runway 16. At 1712, a pilot requested and was cleared for takeoff, and was advised to then turn right, on course. At 1713, the airplane was cleared to contact Jackson Departure Control. A combined FAA radar depiction with voice overlay first revealed the airplane when it was just south of the departure end of runway 16 at an altitude of 500 feet. At 1713:50, while the airplane was passing through about 700 feet, a pilot contacted departure control. The controller requested that the pilot "ident" and he provided the local altimeter setting. The pilot did not respond. At 1714:05, the airplane reached 1,000 feet, followed by a descent to 900 feet. At 1714:15, a pilot stated "we got an engine problem, we're turning back toward Hawkins." The controller responded, "requiring any assistance, you can turn left or right direct Hawkins," and the pilot replied, "we're headed back, we'll try to make it." The controller then stated, "understand you're declaring an emergency," but there were no further transmissions from the airplane. Radar indicated a right, descending turn, with the last contact at 500 feet. PERSONNEL INFORMATIONThe ATP, age 65, held an airline transport pilot certificate with airplane single engine land, airplane multiengine land, and rotorcraft-helicopter ratings. He also had commercial privileges for airplane single engine sea, glider, and lighter-than-air balloon aircraft. In addition, he held type ratings for four helicopter types and a Lear 45. He was also a certificated flight instructor, ground instructor, and mechanic. The pilot's latest FAA second class medical certificate was dated August 14, 2012. According to the ATP's logbook, he had accumulated 17,775 total flight hours, with 2,664 hours in single engine land airplanes, 2,804 hours in multiengine land airplanes, and 9 hours in the 30 days prior to the accident. On an insurance application for the accident airplane dated March 30, 2012, the ATP indicated 294 hours in make and model. Logbook entries indicated that subsequent to that date, he had an additional 28 hours in make and model. Logbook entries also indicated 142 hours in the accident airplane, with the last flight in that airplane prior to the accident flight occurring on September 3, 2012. AIRCRAFT INFORMATIONThe airplane, manufactured in 1972, was powered by a Lycoming TIO-540-series engine. The airplane's latest annual inspection occurred on March 2, 2012, at 4,385 total airframe hours, and 751 hours since engine overhaul. Based on the ATP's logbook, the airplane flew an estimated 28 additional hours before the accident. According to the owner, the airplane had been sitting in its hangar with the fuel tanks half full. A fuel log and the FBO lineman indicated that just prior to the flight, the ATP requested that the main fuel tanks be topped off with fuel, which resulted in 28.4 gallons being pumped. METEOROLOGICAL INFORMATIONThe HKS Tower observation, at 1715, included clear skies, wind from 010 degrees true at 3 knots, visibility 10 statute miles, temperature 11 degrees C, dew point -2 degrees C, altimeter setting 30.33 inches Hg. AIRPORT INFORMATIONThe airplane, manufactured in 1972, was powered by a Lycoming TIO-540-series engine. The airplane's latest annual inspection occurred on March 2, 2012, at 4,385 total airframe hours, and 751 hours since engine overhaul. Based on the ATP's logbook, the airplane flew an estimated 28 additional hours before the accident. According to the owner, the airplane had been sitting in its hangar with the fuel tanks half full. A fuel log and the FBO lineman indicated that just prior to the flight, the ATP requested that the main fuel tanks be topped off with fuel, which resulted in 28.4 gallons being pumped. WRECKAGE AND IMPACT INFORMATIONThe majority of the airplane came to rest upside down in a house located in a populated area about 185 degrees true, 0.8 nautical miles south of the departure end of runway 16, in the vicinity of 32 degrees, 18.93 minutes north latitude, 090 degrees, 13.28 minutes west longitude. Tree damage indicated an approximately 60-degree descent, heading 310 degrees magnetic. Except for the left wing, which was lying in the yard next door, the airplane was mostly consumed in a postcrash fire, inside the house. All flight control surfaces were accounted for at the scene. Fire damage precluded flight control continuity beyond cable separation points. The airplane's instrument panel was completely destroyed; however, charred remnants from a hand-held GPS receiver were recovered and forwarded to the NTSB Recorders Laboratory for a data recovery attempt which was not successful. Engine power control positions could not be determined, and the fuel tank selector position at the time of impact could also not be ascertained. The fuel tank selector was examined at the NTSB Materials Laboratory; however, no witness marks or other identifying features were found to note what tank position the fuel selector was in. The Lycoming IO-540-series engine was also charred, with all accessories exhibiting thermal damage. The engine was removed from its upside-down position, and placed on a flatbed trailer for further examination. The propeller, which had one blade tip burned off, did not exhibit torsional bending or leading edge damage. Propeller rotation confirmed crankshaft continuity to the back of the engine as well as valve movement. Top spark plugs were removed, and cylinder compression was confirmed; however, as compressions were tested, dirty water, consistent with fire suppression water mixed with engine fluids, was ejected from the spark plug holes. When the fuel flow divider (spider) was opened, water (noted visually and by taste) was found in the lower part that was clear with the exception of a small amount of white particulate matter. ADDITIONAL INFORMATION- Fuel System – From the Cherokee Six 300 flight manual, "Standard fuel capacity…is 84 gallons, all of which is useable except for approximately one pint in each of the four tanks. The two main inboard tanks…hold 25 gallons each…the tip tanks hold 17 gallons each. The fuel selector control is located below the center of the instrument panel on the sloping face of the control tunnel…When using less than the standard 84 gallon capacity of the tanks, fuel should be distributed equally between each side, filling the tip tanks first." The fuel system should be drained daily prior to first flight and after refueling to avoid the accumulation of water or sediment. Each fuel tank is equipped with an individual quick drain located at the lower inboard rear corner of each tank. The fuel strainer and a system quick drain valve are located in the fuselage at the lowest point of the fuel system. It is important that the fuel system be drained in the following manner: 1. Drain each tank through its individual quick drain located at the lower inboard rear corner of the tank, making sure that enough fuel has been drained to ensure that all water and sediment is removed. 2. Place a container under the fuel sump drain outlet, which is located under the fuselage. 3. Drain the fuel strainer by pressing down on the lever located on the right-hand side of the cabin below the forward edge of the rear seat. The fuel selector must be positioned in the following sequence: off position, left tip, left main, right main, and right tip while draining the strainer to ensure that the fuel lines between each tank outlet and each strainer are drained as well as the strainer. When the fuel tanks are full, it will take approximately 11 seconds to drain all the fuel in one of the lines between a tip tank and the fuel selector, and approximately 6 seconds to drain all the fuel in one of the lines from a main tank to the fuel strainer. When the tanks are less than full, it will take a few seconds longer. 4. Examine the contents of the container placed under the fuel sump drain outlet for water and sediment and dispose of the contents. - Fuel Quality - According to the manager of the FBO, the fuel truck was sumped daily. A fuel sample was taken from the truck after the accident by FBO personnel within 20 minutes of the accident, examined, and found to contain no water, debris or other anomalies. It was not retained by authorities prior to NTSB visit to HKS, but remained with the FBO and was not subsequently tested. According to the FBO fueling log, on the date of the accident, the airplane received 28.4 gallons of fuel from the FBO's fuel truck. The log also indicated that five airplanes had been fueled before the accident airplane, receiving a total of 279.1 gallons from the fuel truck, and after the fuel sample was taken subsequent to the accident, one additional airplane was fueled, receiving a total of 44.9 gallons from the fuel truck. There were no reports received of fuel quality issues with any of the other fueled airplanes. - Drain Test - An exemplar PA-32-260 (according to the Piper representative to the investigation, the fuel system is the same for the -260 as the -300) was utilized to attempt a comparison with the approximately 1-foot the fuel stain seen on the ramp after the preflight inspection. After an initial 1-2 second initial draining of the fuel from the exemplar airplane, there was about a 1-foot stain on the asphalt underneath it. Due to the amount of fuel to be drained, subsequent attempts were drained into a calibrated beaker with stopwatch timings for each attempt, and the fuel was then returned to the airplane. For 6 seconds of draining, the quantity averaged about 130 ml per draining, and for 12 seconds of draining, the quantity averaged about 260 ml per draining. Pour tests were then made utilizing water, resulting initially in about a 1 ½-foot puddle for each 130 ml pour, and about a 2-foot puddle for each 260 ml pour. After about 10 minutes, the puddles had expanded significantly more, but in irregular shapes. Noted, however, was because of possible differences, such as slope and surface roughness between the test and the prevailing conditions at HKS, an exact comparison could not be made. MEDICAL AND PATHOLOGICAL INFORMATIONAutopsies were conducted on all occupants at the Mississippi State Medical Examiner's Office, Jackson Mississippi, where cause of death was determined to be "inhalation of products of combustion, aircraft crash." The Medical Examiner also confirmed that the occupant of the left front seat was the ATP. Toxicological testing was subsequently performed by the FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, where it was determined that all three occupants had elevated levels of carbon monoxide in their blood. The ATP had no evidence of drugs in his system.

Probable Cause and Findings

The pilot's inadequate preflight inspection, which resulted in his failure to note the water in the fuel tank due to condensation, which subsequently shut down the engine in flight. Contributing to the accident was the pilot's self-induced pressure to expedite the departure.

 

Source: NTSB Aviation Accident Database

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