# NTSB ATL96FA010: Piper PA-23-250, N250HP, Isbela Segunda, PR, October 31, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 31, 1995, 15:00 local (19:00 UTC) - Place: Isbela Segunda, PR - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report July 3, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 3635 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL96FA010 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3635/pdf - Page: https://openairdocs.org/ntsb/ATL96FA010 ## Probable cause the pilot's failure to maintain control of the aircraft resulting in a stall. A factor was the mechanic's failure to properly maintain the forward baggage door locking mechanism. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - door,cargo/baggage - open (contributing factor) - maintenance,inspection - inadequate, company maintenance personnel (contributing factor) - aircraft control - not maintained, pilot in command (cause) - stall - inadvertent, pilot in command - In flight collision with terrain/water, descent - uncontrolled ## Analysis The aircraft was on a VFR maintenance test flight. After takeoff, about 200 feet MSL, witnesses noticed the forward baggage door open. The pilot reduced power and began maneuvering. The aircraft stalled, banked left, and dove into the ocean. A witness stated that he heard the power increase prior to the aircraft entering the water. A discrepancy on the locking mechanism of the forward baggage door had been written up on 8/31/95, and no corrective action had been noted. Examination of the wreckage revealed improper maintenance of the forward baggage door locking mechanism and lock attach points. ## Factual narrative HISTORY OF FLIGHT On October 31, 1995, at 1500 atlantic standard time, a Piper PA- 23-250, N250HP, was substantially damaged following a collision with water near Isbela Segunda, Puerto Rico. The airline transport pilot and three passengers were fatally injured in the accident. The aircraft was being operated under the provisions of 14 CFR Part 91 by Isla Nena Air Service, Incorporated, of Vieques, Puerto Rico. Visual meteorological conditions existed at the time of the accident, and no flight plan had been filed for the local, maintenance test flight. The flight departed Vieques Airport at an undetermined time. The aircraft owner stated that the aircraft had not been flown in several months, and that the mechanic had been working on the aircraft prior to the flight. A witness stated that during a steep crosswind departure at about 200 feet MSL (mean sea level) the aircraft's forward baggage door, located on the nose, had opened. He heard the power being reduced, and observed the aircraft begin to buffet. The witness added that the aircraft had "entered a stall." Power was added and the aircraft dove into the water with the left wing low, about 200 feet off the shore line, and sunk in about 15 feet of water. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with airplane single engine, multiengine land, and instrument airplane ratings. He held a first class medical certificate with no waivers/limitations, issued in October of 1994. The pilot's flight experience was obtained from the Aviation Office of American Inc. Pilot Experience Form, dated October 16, 1995. Additional personnel information may be obtained in this report on Page 3 under section titled First Pilot Information. AIRCRAFT INFORMATION The Piper Aztec, PA-23-250, is a six place, multiengine, retractable tricycle landing gear airplane. The aircraft had a normal airworthiness certificate. General maintenance and repair was performed on the aircraft prior to the flight. The maintenance logs were not completed before the flight to reflect corrective actions taken, or to indicate approval for return to service. According to the FAA Program Tracking & Reporting SubSystem, N250HP had been subject to three ramp checks since March 9, 1995, and the aircraft operator had been advised five times of maintenance problems found during the inspections. In addition, Isla Nena Air Service, Inc. had been issued a condition notice on N250HP by the FAA on December 23, 1994 as a result of unspecified unsafe aircraft maintenance conditions. On August 31, 1995, in the aircraft discrepancy column of the aircraft maintenance and flight log, it had been recorded that the "front baggage door locking pin, not engaging." the maintenance log did not indicate that any corrective action had been taken. METEOROLOGICAL INFORMATION The weather at the time of the accident was reported by a station 45 nautical miles away as visual meteorological conditions. Additional meteorological information may be obtained in this report on page 3 under the section titled Weather Information. WRECKAGE AND IMPACT INFORMATION The wreckage was located 200 feet off shore in 15 feet of water. The aircraft was recovered and placed on a roadway of a military installation for examination. The forward baggage door was found open and had sustained minor damage due to impact. A piece of sheet metal was found swiveled across the handle and held in place by a screw and a washer. The front latch assembly was found loose and not secured. The area of the door where the front latch is normally secured was broken away from the door. There were three places in the area of the front latch, that had improper repairs where cracking was observed. The cracks in the metal surrounding the front latch attach point had corrosion, and the metal appeared to have been bent in both directions. The aft door latch assembly was rusted, and the metal surrounding the attach point was fractured. The fractures appeared old, and there was corrosion in the cracked area. The horizontal stabilator, vertical stabilizer, and rudder, were still attached to the fuselage. One stabilator control cable appeared cut, and the other showed evidence of tensile overload. One rudder control cable appeared cut and the other showed evidence of tensile overload. The left wing displayed signs of impact damage. The wing was bent upward, outboard of the nacelle, and the aileron, flap, engine cowling, wing tip, and landing gear had detached. Control continuity was established into the cabin area, and the control stops were in place. The aileron control rod had separated at the bellcrank eye bolt and was not recovered. The left propeller exhibited "S" bending, and the internal pitch change mechanism was broken. The engine examination of the left engine revealed continuity of the engine drive train,and compression in all cylinders. The distributer diaphragm was torn; fuel was present in the fuel injector. The right wing had evidence of impact damage, and was bent upward. The engine cowling, and landing gear had separated and were recovered. The aileron, flap, and wing tip had separated and were not recovered. Control continuity was established into the cabin area, and the control stops were in place. The right propeller exhibited "S" bending. The engine examination of the right engine revealed continuity of the engine drive train, and compression in all cylinders. Aluminum particles were found in the oil pressure screen, the p-lead wire was loose and worn, the left magneto filter condenser shielding was pulled away, and the alternate air box was severely worn. The distributer diaphragm was torn; fuel was not found in the system. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of Miguel Patrick Rodriguez was performed by Dr. Yocasta Brugal of the Instituto de Ciencias Forenses, San Juan, Puerto Rico. A toxicological examination of Miguel Patrick Rodriguez was performed by Lcda. Marie C. Lopez Balaez. The examination was negative for ethanol or drugs. ADDITIONAL INFORMATION The aircraft wreckage was released to Jorge D. Perez, Co-owner of the aircraft, on November 4, 1995. ## Aircraft - Registration: [N250HP](https://openairdocs.org/deregistered/N250HP-1997-02-18), registration cancelled 1997-02-18, S/N 272969 (OpenAirDocs) - Reported make and model: PIPER PA-23-250 - Registry model: [Piper PA-23-250](https://openairdocs.org/model/piper-pa-23-250) (registry code 7102308) (OpenAirDocs) - Category: Airplane - Serial number: 27-2969 - Airframe hours: 4912 - Engines: LYCOMING IO-540-SER 250 horsepower reciprocating - Damage: Substantial damage - Flight: Part 91 - Registered owner: Isla Nena Air Service, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 11, 1995 - Departed: VQS, VIEQUES, PR - Airport: VQS, Vieques, runway 9, 2,500 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 5,270 total, 5,187 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 40° at 15 knots, gusting 22 - Visibility: 3 statute miles - Lowest ceiling: 2,500 ft broken - Temperature: 79 °F, dew point 73 °F - Altimeter: 29.00 inHg - Observed at: JNR, 45 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19951031041599A](https://openairdocs.org/incident/19951031041599A), Oct 31, 1995: Piper PA23250, Isla De Vieques, Puerto Rico, Substantial damage, 4 fatal. On climbout nose baggage door opened. Reduced power. Stalled. Rolled. Dived into ocean. Test flight from storage. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.