# NTSB BFO94FA140: Piper PA-32R-300, N4316X, Roanoke, VA, August 19, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 19, 1994, 15:15 local (19:15 UTC) - Place: Roanoke, VA - Location: 37.2710° N, 79.9414° W: Placed by OpenAirDocs: center of Roanoke, VA, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=37.2710&lon=-79.9414&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed, report April 5, 1995 - Report: Approved by Office Director - ADs cited in the narratives: [AD 77-23-03](https://openairdocs.org/ad/77-23-03), [AD 80-14-02](https://openairdocs.org/ad/80-14-02) (OpenAirDocs) - NTSB case key (mKey): 8857 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO94FA140 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8857/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=8857 - Page: https://openairdocs.org/ntsb/BFO94FA140 ## Probable cause THE DISCONNECTION OF THE THROTTLE CABLE FROM THE THROTTLE ARM ON THE FUEL INJECTOR SERVO. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, takeoff - initial climb - throttle/power lever,linkage - disconnected (cause) - Forced landing, emergency descent/landing - In flight collision with object, maneuvering - turn to landing area (emergency) - object - tree(s) ## Analysis DURING TAKEOFF CLIMB, THE AIRPLANE'S ENGINE LOST POWER. DURING A TURN TO THE EMERGENCY LANDING AREA, THE AIRPLANE STRUCK TREES AND FELL TO THE GROUND. POSTACCIDENT EXAMINATION OF THE AIRFRAME AND FUEL SYSTEM DID NOT REVEAL ANY ANOMALIES. EXAMINATION OF THE ENGINE REVEALED THE THROTTLE CABLE WAS FULL FORWARD (MAXIMUM FUEL FLOW) BUT DISCONNECTED FROM THE THROTTLE ARM ON THE FUEL INJECTOR SERVO. THE THROTTLE ARM WAS IN THE IDLE POSITION. THE HARDWARE CONNECTING THE THROTTLE CABLE ROD END TO THE THROTTLE ARM WAS NOT LOCATED. EXAMINATION OF THE THROTTLE CABLE ROD END AND THROTTLE ARM REVEALED WEAR AROUND THE CIRCUMFERENCE OF THEIR ATTACHMENT HOLES. THE WEAR AROUND THE CIRCUMFERENCE OF THE ATTACHMENT HOLE ON THE THROTTLE ARM WAS CONSISTENT WITH INSTALLATION OF THE ROD END AT A SKEWED ANGLE. THE AIRPLANE RECEIVED AN ANNUAL INSPECTION ABOUT 99 HOURS PRIOR TO THE ACCIDENT. ## Factual narrative HISTORY OF FLIGHT On August 19, 1994, at 1515 eastern daylight time, a Piper PA-32R-300, N4316X, lost engine power shortly after takeoff from the Roanoke Regional Airport, Roanoke, Virginia. The pilot was maneuvering the airplane to make an emergency landing on a golf course when the airplane struck trees on the golf course. The pilot was seriously injured and the two passengers were fatally injured. The airplane was destroyed. The visual flight rules flight had originated from Nassau, Bahamas, landed at the Fort Pierce Airport, Fort Pierce, Florida, and then continued to Roanoke where the airplane was refueled. The flight was destined for Meadville, Pennsylvania, and was operated under 14 CFR Part 91. According to the pilot, shortly after takeoff the airplane's engine started to lose power. He stated that the engine's revolutions per minute slowly declined until the engine was not producing enough power to maintain flight. The pilot stated that when he figured the airplane could not make the airport, he decided to make an emergency landing on a golf course. He stated as he was maneuvering to land on the golf course, he saw trees but thought the airplane had enough altitude and airspeed to fly over them. He stated when he input elevator to get over the trees, the airplane did not respond and started to descend. He stated at that time he turned the airplane to the left in attempt to miss the trees. The airplane struck the trees and continued to the ground. PERSONNEL INFORMATION The pilot held a private pilot certificate with a single engine land rating. According to the pilot's records, at the time of the accident, he had accumulated about 2,259 total flight hours, of which, 867 hours were in the same make and model as the accident airplane. AIRCRAFT INFORMATION According to the airplane's Aircraft and Engine Log books, the airplane and engine received an Annual Inspection on December 12, 1993, at a tachometer time of 3,591.87 hours, 99 hours prior to the accident. The engine's time since major overhaul was 814.8 hours at the annual inspection. Since the annual inspection, the only maintenance logged was an engine oil and filter change on March 15, 1994, at a tachometer time of 3,634 hours. The entry also stated, "...Lyc Engine additive & operational check completed...." At the time of the Annual Inspection, the log books indicated that all Airworthiness Directives (ADs) applicable to the airplane were accomplished. Two AD's applicable to the throttle cable control rod end were visually checked. AD 77-23-03, published in 1977, was accomplished on the accident airplane. AD 80-14-02, published in 1980, could not be verified. AD 80-14-02 requires that the throttle linkage connecting hardware be replaced. This hardware was not recovered at the accident site. (See attached ADs for further information.) The mechanic who accomplished the Annual Inspection and subsequent oil and filter change wrote on the Safety Board's Statement of Witness Form, "[The airplane] Had appropriate AN Hardware installed when last inspected." WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the accident site on August 19 and 20, 1994. Examination of the wreckage revealed the airplane came to rest on a golf course about 1/2 mile west of the approach end of runway 6 at the Roanoke Airport. Examination of the accident site revealed a large broken tree with an airplane seat track lodged in it. The airplane came to rest about 100 feet beyond the broken tree on a magnetic heading of about 300 degrees. The left and right wing were separated from the airplane and came to rest next to the fuselage. Both of the fuel tanks contained fuel and no contaminants were found. Examination of the engine revealed the throttle cable was full forward (maximum fuel flow) but disconnected from the throttle arm on the fuel injector servo. The throttle arm was in the idle position. The hardware connecting the throttle cable rod end to the throttle arm was not located. The engine was removed from the airplane and transported to Lycoming located in Williamsport, Pennsylvania, for further examination and test run. The throttle cable was reconnected to the throttle arm and the engine was tested. The engine started and performed with no anomalies noted. ADDITIONAL INFORMATION The Throttle Control Cable Rod End and the Throttle Arm were removed from the airplane and sent to the Safety Board's Materials Laboratory in Washington, D.C. Examination of the Throttle Control Cable Rod end and Throttle Arm revealed "wear" around the circumference of their attachment holes. (See attached Metallurgist's Factual Report for details.) The Metallurgist's Factual Report states, "Wear around the circumference of the attachment hole on the arm was consistent with installation of the rod end at a skewed angle...." The airplane wreckage was released to Robert P. Porter, Assistant Vise President, AIG Aviation, on August 20, 1994. The engine was retained and released to Mr. Porter on October 6, 1994. ## Aircraft - Registration: [N4316X](https://openairdocs.org/deregistered/N4316X-1998-09-09), registration cancelled 1998-09-09, S/N 32R7680009 (OpenAirDocs) - Reported make and model: PIPER PA-32R-300 - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7680009 - Airframe hours: 3690 - Engines: LYCOMING IO-540-K1A5D 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Kulwicki, Joseph F. - Registered owner: Kulwicki, Joseph F. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 23, 1993, 99 hours before - Departed: ROA - Destination: 26B, MEADVILLE, PA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 2,259 total, 867 in this make and model, 2,165 as pilot in command, 30 in the last 90 days, 22 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 7 knots - Visibility: 15 statute miles - Lowest ceiling: 25,000 ft broken - Temperature: 86 °F, dew point 64 °F - Altimeter: 30.00 inHg - Observed at: ROA, 1 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 19940819022389A](https://openairdocs.org/incident/19940819022389A), Aug 19, 1994: Piper PA32R300, Roanoke, VA, Destroyed, 2 fatal. Lost power on climbout. Struck trees trying land on golf course. Found throttle disconnected. Improperly installed. ## Docket (19 files) The files NTSB released with the investigation on June 4, 1995, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=8857. 2.3 MB in all. - Supplement A - Wreckage Documentation (item 1, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40009990&FileExtension=.PDF&FileName=Supplement%20A%20-%20Wreckage%20Documentation-Master.PDF - Supplement B - Cockpit Documentation (item 2, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40009991&FileExtension=.PDF&FileName=Supplement%20B%20-%20Cockpit%20Documentation-Master.PDF - Supplement S - Aircraft Occupant and Injured Ground Personnel (item 3, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40009992&FileExtension=.PDF&FileName=Supplement%20S%20-%20Aircraft%20Occupant%20and%20Injured%20Ground%20Personnel-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 4, .PDF, 486 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476324&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2-Pilot Statement Given at Accident Site (item 5, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40009994&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2-Pilot%20Statement%20Given%20at%20Accident%20Site-Master.PDF - Metallurgist's Factual Report (item 6, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476325&FileExtension=.PDF&FileName=Metallurgist%27s%20Factual%20Report-Master.PDF - Metallurgist's Figure 1 (item 7, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40009996&FileExtension=.PDF&FileName=Metallurgist%27s%20Figure%201-Master.PDF - Metallurgist's Figure 2 (item 8, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40009997&FileExtension=.PDF&FileName=Metallurgist%27s%20Figure%202-Master.PDF - Metallurgist's Figure 3 (item 9, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40009998&FileExtension=.PDF&FileName=Metallurgist%27s%20Figure%203-Master.PDF - Metallurgist's Figure 4 (item 10, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40009999&FileExtension=.PDF&FileName=Metallurgist%27s%20Figure%204-Master.PDF - Metallurgist's Figure 5 (item 11, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40010000&FileExtension=.PDF&FileName=Metallurgist%27s%20Figure%205-Master.PDF - Statement of Witness - Mechanic (item 12, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476326&FileExtension=.PDF&FileName=Statement%20of%20Witness%20-%20Mechanic-Master.PDF - Lycoming Engine Report (item 13, .PDF, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476327&FileExtension=.PDF&FileName=Lycoming%20Engine%20Report-Master.PDF - Airwothiness Directives and Service Bulletin (item 14, .PDF, 579 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40010003&FileExtension=.PDF&FileName=Airwothiness%20Directives%20and%20Service%20Bulletin-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 15, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476328&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photo 1. View of accident site. The airplane collided with the trees and came to rest as shown. (item 16, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40010005&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20accident%20site.%20%20The%20airplane%20collided%20with%20the%20trees%20and%20came%20to%20rest%20as%20shown.-Master.PDF - Photo 2. Overall view of airplane as it came to rest. (item 17, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40010006&FileExtension=.PDF&FileName=Photo%202.%20%20Overall%20view%20of%20airplane%20as%20it%20came%20to%20rest.-Master.PDF - Photo 3. View of engine at accident site. (item 18, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40010007&FileExtension=.PDF&FileName=Photo%203.%20%20View%20of%20engine%20at%20accident%20site.-Master.PDF - Photo 4. Close up view of the throttle cable (indicated by arrow on left) and the throttle arm on the fuel injector servo (indicated by arrow on right) as found at the accident site. (item 19, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40010008&FileExtension=.PDF&FileName=Photo%204.%20%20Close%20up%20view%20of%20the%20throttle%20cable%20(indicated%20by%20arrow%20on%20left)%20and%20the%20throttle%20arm%20on%20the%20fuel%20injector%20servo%20(indicated%20by%20arrow%20on%20right)%20as%20found%20at%20the%20accident%20site.-Master.PDF 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.