N4267R
PIPER PA-32
The 14 Code of Federal Regulations Part 135 airline operated a fleet of single-engine airplanes that shuttled passengers between two islands located about 10 minutes' flying time apart. The flight was carrying six passengers and was being conducted in visual meteorological conditions at dawn. After a normal start, taxi-out, and engine run-up, the airplane departed using the full length of the 8,000-ft-long runway. About 4 minutes after takeoff, the pilot radioed the air traffic control tower that he wanted to "come back in for an immediate landing"; the airplane landed uneventfully on the departure runway about 3 minutes later. The airplane exited the runway at the first taxiway, situated about 3,150 ft past the runway threshold, and the pilot subsequently conducted an engine run-up. The pilot returned to the runway and initiated an intersection takeoff using the 5,550 ft of remaining runway. About 45 seconds after the pilot began the takeoff, the airplane experienced a partial loss of engine power, so he began a second turnback. During the turnback, the airplane stalled at low altitude and impacted airport property near the end of a runway parallel to the departure runway. A postimpact fire ensued; one passenger did not exit the airplane and died. The pilot did not recall making the first turnback, and the investigation was unable to determine the reason for the first turnback. One passenger reported that the pilot was using his mobile telephone at an inappropriate time during the beginning of the flight, and two other passengers reported that the cabin door became unlatched at some point during the flight. Neither passenger reported that any door problems occurred after the second takeoff. Although there was no evidence to support the passengers' allegations regarding the telephone or the cabin door events, an airline representative suggested that the first turnback was conducted due to the door coming open and that the subsequent engine run-up was conducted to conceal the actual reason for the turnback. The representative added that the second turnback may have been due to the pilot's distraction and loss of situational awareness as he attempted to relatch the door that might have become unlatched again. Postaccident on-site wreckage examination and test runs and examination of the engine did not reveal any preimpact mechanical deficiencies that could be directly linked to the power loss. Although anomalies with the engine-driven fuel pump and one magneto were detected during their respective examinations, the units performed satisfactorily during bench testing. However, there were a sufficient number of undetermined details regarding the preimpact configuration and condition of the airframe and the engine to preclude a determination of the preaccident functionality and airworthiness of the airplane. Those details included the magneto-to-engine timing, the internal timing of the right magneto, the fuel selector valve takeoff setting, and the fuel quantity in the selected tank. Review of airplane performance data indicated that the 5,550 ft of runway beyond the taxiway intersection was more than sufficient for the takeoff. The performance data showed a rapid roll into a sustained bank angle during the turnback, which did not support the airline's scenario that the airplane veered off course due to the pilot's loss of situational awareness. The investigation was unable to determine the initiation altitude of the turnback or whether there was sufficient altitude for the safe execution of such a maneuver. However, deductions of the airplane location, altitude, and heading based on the ground scar information indicated that a safe landing would not have been possible from the point in the flightpath where the airplane stalled. Neither the airline nor the airplane manufacturer provided any specific guidance to pilots regarding minimum safe turnback altitudes. The pilot's decision to conduct an intersection takeoff, instead of a full-runway-length takeoff, left 3,150 ft less runway. Although he did not state it explicitly, the apparent reason that the pilot opted for the intersection takeoff was for schedule expediency, by obviating the need for the extra few minutes required to taxi back for a full-runway-length takeoff. Based on the accident flightpath, the additional 3,150 ft of runway likely would have been sufficient to enable a straight-ahead landing after the power loss rather than a turnback. By foregoing the taxi-back, the pilot reduced his margin of safety by decreasing his options in the event of an engine anomaly or power loss. Review of aerial imagery revealed that, beyond the airport's northeast boundaries, there were very few locations suitable for an emergency landing following a low-altitude power loss, which likely contributed to the pilot's decision to attempt to return to the airport. Although the airline published the preferred flight tracks between the two airports that it primarily served, it did not provide any guidance regarding preferred flightpaths or emergency landing sites following an engine failure at low altitude.
HISTORY OF FLIGHT On November 19, 2012, about 0618 local time (2018 November 18 Universal Coordinated Time), a Piper PA-32-300, N4267R, was destroyed when it impacted airport terrain during an attempted turnback immediately after takeoff from Francisco C. Ada/Saipan International Airport (PGSN), Obyan, Saipan, Northern Mariana Islands, a United States territory. One passenger sustained fatal injuries, the pilot and four passengers sustained serious injuries, and one passenger sustained minor injuries. The on-demand charter flight was operated by Star Marianas Air, Inc. (SMA), under the provisions of Title 14 Code of Federal Regulations Part 135. Dawn visual meteorological conditions prevailed, and no Federal Aviation Administration (FAA) flight plan was filed for the flight. According to a representative of the airline, the airline typically shuttled tourists between Saipan and Tinian, an island about 10 minutes' flying time south of Saipan. The passengers on the accident flight included five Chinese nationals and one Filipino national, and the flight was destined for Tinian. According to information from the FAA and Serco, the PGSN air traffic control tower (ATCT) service provider, the pilot first contacted the ATCT at 0604, requesting taxi clearance. The flight was instructed to taxi to the end of runway 7, and was cleared for takeoff about 4 minutes later. About 4 minutes after takeoff, the pilot radioed the ATCT that he wanted to "come back in for an immediate landing if possible." About 3 minutes later, the airplane landed uneventfully on runway 7, and exited the runway at taxiway B. The pilot briefly ran up the engine, and about 3 minutes after landing, informed the ATCT that he was ready for an intersection departure from runway 7. About 45 seconds after that, the airplane was observed turning back to the left, and some garbled radio transmissions were received from the airplane. Shortly thereafter, the airplane impacted airport property near the northeast end of runway 6, a smaller parallel runway situated northwest of runway 7. The bulk of the airplane came to rest at the treeline northwest of runway 6, and a post-accident fire began. The pilot and most passengers exited or were helped from the airplane, but the female passenger seated in the front right seat remained in the airplane, and was fatally injured. About 2 days after the accident, the wreckage was examined on scene by personnel from the FAA, and was then recovered to a secure location. PERSONNEL INFORMATION Pilot Experience and Medical Information FAA and airline information indicated that the pilot held a commercial pilot certificate, with an instrument airplane rating. The pilot began flying for SMA in January 2012. The airline initially qualified the pilot for "PIC" (pilot-in-command) authority in the PA-32-300 on January 11, 2012, and for flight instructor/check airman authority in the airplane on February 3, 2012. His most recent flight review was completed in January 2012, and his most recent FAA first-class medical certificate was issued in August 2012. The pilot had a total flight experience of about 1,238 hours, including about 674 hours in the accident airplane make and model. Airline records indicated that the pilot had flown about 54 hours in October 2012, and about 31 hours in November, the month of the accident. According to the airline's records, the pilot was on duty from 0200 to 0500 on November 15, and did not have another duty period until 1900 on November 17. He was then on duty for 11 hours, had a rest period of 12 hours and 40 minutes, and then went back on duty at 1840 the evening before the accident. At the time of the accident, the pilot had been on duty for almost 12 hours. The FAA Civil Aeromedical Institute conducted forensic toxicology examinations on "blood, serum" specimens from the pilot, and reported that no carbon monoxide, ethanol, or any screened drugs were detected. Pilot Flight Recollections A brief telephone interview was conducted with the accident pilot about 2 weeks after the accident. The pilot remembered most of the accident flight, including events leading up to it, but he had no recollection of the takeoff and return just prior to the accident takeoff. According to the pilot, the flight/load manifest was satisfactory, and he did not note any defects during his preflight inspection, taxi-out, or engine runup. The initial takeoff and climbout was normal, but when the airplane reached an altitude of about 400 to 500 feet above ground level (agl), he noticed a "significant change" in engine sound and power. He observed that the manifold pressure and rpm gauges did not indicate full takeoff power, but stated that the engine gauges in the airline's fleet are "never accurate." He did not observe any unusual instrument indications, but his sense was that the engine's power and sound was less than that normally experienced for the indicated power settings. Upon sensing the power loss, the pilot immediately pushed the throttle, propeller, and mixture controls full forward, but the power continued to decrease. The pilot then turned on the electric fuel boost pump, and switched the fuel selector valve from the left to the right tank. The pilot stated that because he had conducted an intersection takeoff, he did not believe that there was enough runway remaining to land on, and he was therefore faced with the choice of putting the airplane in the ocean ahead, or attempting a turnback for landing on the airport property. He decided to attempt a turnback, and was cognizant of the decreasing power, airspeed, and altitude, as well as the danger of stalling. Initially the pilot intended to land on runway 24, but he overflew that, and then decided to try to land on the ramp. He said that he maintained a bank angle of about 35 to 45 degrees in the turn, but when the airplane was about 15-20 feet above the ground, the airplane suddenly "dropped to the ground." That was the last item he recalled about the accident sequence. When asked about the air turnback, landing, and runup that he had conducted just prior to the accident takeoff, the pilot recalled such an event, but he could not recall whether that event was the night before, or 2 weeks prior to, the accident flight. Regarding that event, the pilot recalled that on departing Saipan, he experienced a "slight power loss" of about 100 rpm, but was able to climb to 1,500 feet on the right downwind traffic pattern leg, and therefore, elected to return to the departure runway. He "landed long," but otherwise normally. He exited the runway, leaned the mixture to "clean the plugs," conducted an engine runup, and determined that the airplane was "fine." The pilot then departed uneventfully, and landed successfully at Tinian, where he informed maintenance or company personnel about the engine event. When informed during a telephone interview with NTSB and FAA personnel that the ATCT records indicated that he had conducted a successful air turnback just prior to the accident, again the pilot had no specific recollection of that event. The pilot did not reconcile his lack of recollection of a previous turnback with his recollection that he had conducted an intersection takeoff during the accident flight. AIRCRAFT INFORMATION General Information The airplane was manufactured in 1969, and was equipped with a Lycoming IO-540 series engine. It was an all-metal low-wing monoplane design with fixed, tricycle-style landing gear. The airplane seated seven persons in a 2-3-2 arrangement from front to back. The cabin was equipped with two entrance doors, one on the front right side (for pilot and co-pilot/front seat passenger), and one at the left rear for the other five passengers. The airplane had two baggage compartments, one forward and one aft. Flap positions include retracted (up/0 degrees), 10, 25, and 40 degrees, and were selected by moving the flap handle to one of the corresponding pre-select notches. The flaps were spring-loaded to the retracted position. Fuel System and Usage Procedures The airplane was equipped with four individually-selectable fuel tanks; left tip/aux, left main, right main, and right tip/aux. Total fuel capacity was 84 gallons. The four-position wing flaps were manually actuated via a cockpit handle and torque tube arrangement. The manufacturer's Owner's Handbook (OH) specified that for takeoff, the fuel selector valve should be set to the "fullest main tank." The OH specified that once in cruise, "in order to keep the airplane in best lateral trim...the fuel should be used alternately from each tip tank" until the tip tank quantities were "nearly exhausted." At that point the OH specified switching to the main tanks. Maintenance Information According to the maintenance records, the airplane had accumulated a total time (TT) in service of about 6,805 hours at the time of the accident. An overhauled engine was installed in July 2012, when the airplane had a TT of about 6,290 hours. The airline maintained the airplane on a progressive, cyclic inspection program which included four elements or segments, designated as "AAIP-1" through "AAIP-4." The most recent completed inspection cycle was the AAIP-1, which was completed on November 17, 2012, at an airframe TT of about 6,799 hours, and an engine time since overhaul of about 516 hours. METEOROLOGICAL INFORMATION The PGSN 0554 automated weather observation included winds from 060 degrees at 10 knots, visibility 10 miles, scattered clouds at 2,000 feet, broken cloud layer at 5,000 feet, overcast cloud layer at 11,000 feet, temperature 27 degrees C, dew point 23 degrees C, altimeter setting of 29.91 inches of mercury. COMMUNICATIONS PGSN was equipped with an ATCT that was operating at the time of the accident, and was operated and staffed under contract to the FAA by Serco Management Services, Inc. A transcript of the communications between the ATCT and the accident airplane was prepared and provided by Serco. According to the transcript, the pilot first contacted the ATCT at 0604:32, and advised that he was at the "commuter ramp" with the terminal information, and was ready to taxi. The controller cleared the airplane to taxi to the "end" of runway 7 via taxiway B and runway 6. The pilot acknowledged "full length," and was advised to expect a 2-minute delay for wake turbulence separation. At 0608:27, the flight was cleared for takeoff and an "early right turnout," which the pilot read back correctly. At 0612:08, the pilot radioed "Saipan tower, uh" but did not continue. At 0612:35, the pilot radioed that he wanted to come back for an "immediate landing if possible," and after a brief discussion about his position, was cleared to land on runway 7. When asked if he required emergency assistance, the pilot replied "negative." After the airplane landed, at 0614:28, the controller instructed the pilot to exit the runway at taxiway B, and remarked that this was the "second time it happened to you in less than two weeks, huh?" to which the pilot responded in the affirmative, and stated that he "just want[ed] to make sure everything's good to go." At 0614:54, the pilot told the controller that he just wanted to do a "quick run-up," and the controller told him to do so on taxiway B, and to advise when ready for departure. At 0616:17, the pilot advised the controller that he was ready for an intersection departure, and was cleared a few second later. At 0617:17, the pilot radioed "six seven romeo would like" but he did not complete that request. At 0617:27, in response to observing the airplane turning and descending, the controller cleared the airplane to land, and a partial, unintelligible response was received from the airplane. Shortly after that, the controller initiated the accident response procedures. AIRPORT INFORMATION PGSN was equipped with two parallel runways, designated as 6/24 and 7/25. Runway 7/25, which was the primary runway and the one used for the two departures, measured 8,700 by 200 feet. Taxiway B, which was perpendicular to the two runways, was located about 3,150 feet beyond the threshold of runway 7. A runway 7 intersection departure from taxiway B would have about 5,550 feet of available runway. The specified traffic pattern direction for runway 7 was left-hand. Runway 6/24 was a designated portion of the pavement that paralleled the full length of runway 7/25. Runway 6/24 measured 7,000 by 100 feet, and the threshold of runway 24 was directly abeam that of runway 25. The centerline of runway 6/24 was offset about 750 feet northwest of that of runway 7/25. The shoreline to the northeast of the airport was oriented approximately perpendicular to the runways, and was situated approximately 2,600 feet beyond the end of runway 7. The shoreline to the southwest of the airport was also oriented approximately perpendicular to the runways, and was situated approximately 4,300 feet prior to the runway 7 threshold. The airport elevation was listed as 211 feet above mean sea level. Review of commercially-available aerial imagery revealed that beyond the northeast airport boundaries, most of the vicinity was either ocean or heavily-vegetated terrain, with very few roads or open fields. WRECKAGE AND IMPACT INFORMATION According to information provided by FAA inspectors who responded to the accident site, the main wreckage came to rest at the junction of the grassy area adjoining runway 6 and the parallel treeline situated about 290 feet northwest of the centerline or runway 6/24. The main wreckage was located about 1,050 feet from the runway 7/25 centerline, and about 700 feet before the departure ends of runways 6 and 7. The main wreckage consisted of the majority of the airplane, excluding the left wing, some cockpit/cabin transparencies, some miscellaneous airplane components, and some luggage. The evidence was consistent with the left wing striking the ground first, while the airplane was in a left turn. The ground scars and debris path were oriented to the northwest, and curved about 15 degrees to the left. The first ground scar was located in the grass about 35 feet from the northwest side of runway 6. The left wing was located about 108 feet beyond the first impact point; the wing was fracture-separated from the airplane at the root, and was lying inverted. The left main landing gear was fracture-separated from the wing; it was found about 10 feet beyond the left wing. The main wreckage was about 114 feet beyond the left wing, and a passenger suitcase was located between the left wing and main wreckage. The airplane came to rest upright against and parallel to the tree line, oriented on a heading of approximately 240 degrees. The cockpit and cabin contents were fire damaged or consumed by fire, as was the outboard half of the right wing. The aft fuselage and empennage were essentially intact. Pitch and rudder control continuity was established from the cockpit area to the respective aft control surfaces. The pitch trim tab was set so that its trailing edge was about 1/2 inch below the stabilator trailing edge. The right wing flap was found in the retracted position, but the left flap was fracture-separated from its actuation linkage and therefore not fixed in any position. Photographs taken several hours after the accident, and subsequent to recovery of the front-right seat passenger, depict the cockpit flap handle to appear to be in the flaps-retracted position. The investigation was unable to determine if the flap handle was disturbed during or subsequent to the accident. The ignition key remained in the ignition and its orientation appeared consistent with it being in the "BOTH" position, but fire damage precluded positive determination. The fuel selector handle appeared to be set to a right side tank, but visual inspection did not permit determination of whether it was set to right main tank, or the right tip tank. The engine control quadrant was fire- and impact-damaged, but the three levers appeared to be near their full-forward positions. The engine was displaced aft and nose-down, but the engine was relatively undamaged. There was no evidence of any catastrophic internal
A partial loss of engine power shortly after takeoff for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal operation and the pilot’s failure to maintain airplane control during the unsuccessful attempt to return for landing on the airport. Contributing to the accident was the pilot’s decision to conduct his second takeoff using less than the full runway length available and the airline’s lack of guidance regarding how to respond to engine failures at low altitudes.
Source: NTSB Aviation Accident Database
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