# NTSB BFO93FA063: Piper PA-28-140, N56430, Edgewater, MD, April 17, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 17, 1993, 15:21 local (19:21 UTC) - Place: Edgewater, MD - Coordinates: 38.900955, -76.539634 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.9010&lon=-76.5396&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report September 12, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 8748 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO93FA063 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8748/pdf - Page: https://openairdocs.org/ntsb/BFO93FA063 ## Probable cause The pilot's improper in-flight planning/decision after selecting the wrong runway for a precautionary landing , which resulted in an inadvertent descent into transmission lines, while attempting to maneuver back to the runway. Factors related to the accident were fatigue failure of the number 4 exhaust valve, and failure of maintenance personnel to comply with service bulletins regarding the inspection and replacement of the valve. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, cruise - normal - engine assembly,valve,exhaust - fatigue (contributing factor) - maintenance,service bulletin/letter - not complied with, other maintenance personnel (contributing factor) - In flight collision with object, maneuvering - turn to landing area (emergency) - weather condition - gusts (contributing factor) - precautionary landing - attempted, pilot in command - weather condition - tailwind (contributing factor) - wrong runway - selected, pilot in command (contributing factor) - in-flight planning/decision - improper, pilot in command (cause) - go-around - initiated, pilot in command - object - wire,transmission - descent - inadvertent, pilot in command ## Analysis The pilot reported to air traffic control that he had only 'partial power'. He received vectors to the closest airport. One witness, a certified flight instructor, saw the airplane and heard the pilot transmit that he would be making a 'partial power landing downwind on runway 12.' The witness reported that the winds were 'stiff' and favoring the opposite runway. The airplane made an approach over runway 12, and then the pilot announced that he was 'going around.' The airplane was then observed to climb, banked steeply to the left, turned back towards the airport, descended, and impacted power lines and a corn field. An examination of the engine revealed that the No. 4 exhaust valve had fractured as a result of fatigue cracking. Service Bulletins recommending the inspection and replacement of the valve were not complied with. ## Factual narrative HISTORY OF FLIGHT On April 17, 1993, at 1521 eastern daylight time, N56430, a Piper PA-28-140, operated by International Aviation, Inc. of Frederick, Maryland, impacted power lines and was destroyed while attempting a precautionary landing near Lee Airport in Edgewater, Maryland. The pilot was fatally injured and the passenger was seriously injured. Visual meteorological conditions prevailed and no flight plan was filed. The personal flight was conducted under 14 CFR 91 and originated from Frederick, Maryland, en route to Ocean City, Maryland. At 1148 on the day of the accident, a gentleman identifying himself as the pilot of N56430 contacted the Leesburg Flight Service Station and requested a weather briefing for Hagerstown, Pennsylvania, and Ocean City, Maryland. According to the father of the pilot, the pilot and a friend had decided to fly to Ocean City, Maryland, for the day. At 1454, the pilot contacted Baltimore Approach Control and reported that he had "... just departed Frederick..." and requested a clearance through the Terminal Control Area at 3,000 feet. Baltimore Approach Control verified that they had the airplane on radar and granted a clearance. At 1515, the pilot contacted Baltimore Approach Control to report "...we have a problem here...we got partial power..." and requested to "...turn it into Baltimore..." The airplane was about 3000 feet mean sea level (msl) and 12 miles south of Baltimore at the time. The pilot also reported "...we have full tanks." Approach Control provided priority handling to the airplane and a vector to the Baltimore Washington International Airport. AT 1516, the pilot asked Baltimore Approach Control if he was closer to Lee Airport. Baltimore Approach Control said "affirmative" and the pilot requested vectors to Lee Airport. The airplane was five miles north of Lee Airport at this time. At 1518, the pilot reported that he had Lee Airport in sight and he was going to "...go ahead and make an approach..." At 1519 the pilot changed frequencies to the common traffic advisory frequency (CTAF) for Lee Airport. A certified flight instructor (CFI) who was at the airport at the time received a phone call from Baltimore Approach Control and was informed about the aircraft. The CFI stated that he utilized a hand-held radio receiver and went outside to see and hear the airplane. He witnessed the accident and said; "The plane entered the airport environment at the approach end of runway 30 and established a left downwind for runway 12. I questioned the pilot's decision...since the winds were a stiff steady 12 to 15 knots at 300 degrees directly favoring runway 30. Just at that time a call came over the multicom frequency that stated; "Lee Traffic, Lance 56430 will be making [an] emergency partial power landing, will be landing downwind on runway 12". I stated to Greg 'well he knows what he is up against.' The plane then turned a tight left base followed by a turn to final approach for runway 12. "The plane...began dissipating the excess altitude. As the plane approached the runway 12 threshold, the pilot recovered from the full slip at 30 feet [above the ground] from the runway surface. As the plane straightened the plane's ground speed increased notably.... As the plane traveled down the runway in flight, its height had reached 5 to 10 feet above the runway surface, never touching [the runway]. It was apparent to me that the plane was going to run off the runway and hit the fence at the departure end of runway 12 after landing.... The plane was located two-thirds to three-quarters down the runway...a call came over the multicom frequency; 'Lance 56430 going around runway 12 at Lee'. With steady power, the plane continued climbing and gained altitude.... We both saw the plane bank left. The bank angle reached approximately 50 to 55 degrees and the plane dropped sharply.... I would have to estimate that the plane was about 200 feet [above the ground] prior to banking." Another witness, who was employed as a police officer and was also a CFI, observed the airplane as it began to go around. He stated that he heard the engine running rough. He saw the airplane turn back toward the airport, descend, impact power lines with its left wing, explode into flames, roll inverted, and impact a corn field located about one quarter mile north of the airport. The accident occurred during the hours of daylight at 38 degrees 56.57 minutes North and 076 degrees 34.13 minutes West. PERSONNEL INFORMATION According to FAA records, the pilot, age 23, was a certificated private pilot with a rating in airplane single engine land. He received his private pilot license on November 28, 1992. He held a current third class medical certificate. According to the pilot's personal logbook, the pilot accumulated about 75 hours of total flight time, including eight hours in type. AIRCRAFT INFORMATION The airplane, a 1973 Piper model PA-28-140, was operated as a lease-back rental airplane by International Aviation, Inc., a fixed-based operator located in Frederick, Maryland. According to maintenance logbooks, the airplane had accumulated about 3,600 hours of total flight time. It received a 100-hour inspection on January 29, 1993, and had accumulated about 89 flight hours since the last inspection to the time of the accident. No discrepancies which would have been related to the accident were recorded in the logbooks. The engine, a Lycoming model O-320-E3D, serial number L30961A27, was originally installed on the accident airplane upon the airplane's delivery from the factory. According to maintenance logbooks, the engine had accumulated about 3,600 hours of total operation, including about 1,600 hours since its last major overhaul. The maintenance logbooks indicate that this overhaul occurred on November 10, 1977, and new exhaust valves, part number 75068, were installed at this time. METEOROLOGICAL INFORMATION The reported surface weather conditions at the Baltimore Washington International Airport about 30 minutes prior to the accident were: "measured ceiling 7,000 feet overcast, visibility 20 miles, temperature 56, dewpoint 33, wind 290 degrees at 16 knots gusting to 22 knots, altimeter 29.84." The Baltimore Washington International Airport is located about 15 miles north of Lee Airport. The reported wind conditions at the Baltimore Washington International Airport were consistent with the observations given by the two CFI ground witnesses at Lee Airport. AERODROME INFORMATION Lee Airport is located about five miles southwest of the city of Annapolis, Maryland. It is uncontrolled and rests at an elevation of 30 feet msl. It has a single asphalt runway which is 2,505 feet in length and 45 feet in width. The runway is oriented 12/30. The approach end of runway 30 is about one-quarter mile from a four-lane state highway. Several restaurants and power lines are located along this highway. The approach end of runway 12, the accident runway, is located near an open field. The airport has a wind sock located near the center of the airport. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the accident site by an FAA inspector on the day of the accident, April 17, 1993. The inspector authorized the removal and security of the wreckage to a hangar prior to the Safety Board's arrival. The wreckage was then examined by the Safety Board on the evening of the accident, and again on the following day. The wreckage was found about one-quarter of a mile southeast of Lee Airport. The airplane came to rest inverted in a plowed filed. A broken power line was found about 150 feet from the accident site. The airplane remained in one piece. The cabin area was crushed and damaged by fire. Both wings and the vertical stabilizer were substantially damaged. The right wing fuel tank was compromised and received ## Aircraft - Registration: [N56430](https://openairdocs.org/deregistered/N56430-1996-03-01), registration cancelled 1996-03-01, S/N 287325629 (OpenAirDocs) - Reported make and model: Piper PA-28-140 - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Category: Airplane - Serial number: 28-7325692 - Airframe hours: 3607 - Engines: Lycoming O-320-E3D 150 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: International Aviation, Inc. - Registered owner: Fellows Plumbing And Heating - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: 100 hour, January 29, 1993, 89 hours before - Departed: FDK, FREDERICK, MD - Destination: N80, OCEAN CITY, MD - Airport: ANP, Lee, runway 12, 2,505 × 45 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 23; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 75 total, 8 in this make and model, 22 as pilot in command, 18 in the last 90 days, 6 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 16 knots, gusting 22 - Visibility: 20 statute miles - Lowest ceiling: 7,000 ft overcast - Temperature: 55 °F - Altimeter: 29.00 inHg - Observed at: BWI, 33 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 19930417009589A](https://openairdocs.org/incident/19930417009589A), Apr 17, 1993: Piper PA28140, Annapolis, MD, Destroyed, 1 fatal. Lost power. Diverted. Tried downwind landing. Missed. Hit wires on go around. Engine had swallowed a valve. 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.