CEN12FA628

NTSB accident investigation · Piper PA-23-250 · Bullard, TX · September 12, 2012

Accident · FatalField investigationFinal report
Date
September 12, 2012, 14:55 local (19:55 UTC)
Place
Bullard, TX
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N4842PPiper PA-23-250
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report January 13, 2014
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Piper Aircraft Company
FAA report
20120912025339A
Case key
85019

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's maneuver, which exceeded the airplane's structural limit and resulted in an in-flight breakup.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

AircraftAircraft › Aircraft oper/perf/capability · Not specifiedPiper PA-23-250: 1 caseAll aircraft: 63 casesProbable cause
Wing structureAircraft › Aircraft structures · Capability exceededPiper PA-23-250: 1 caseAll aircraft: 48 casesProbable cause
ActionPersonnel issues › Action/decision · PilotPiper PA-23-250: 1 caseAll aircraft: 111 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane was en route to its destination when it was observed to make several turns before it pitched nose up, climbed, rolled to the right, and then headed toward the ground nose first. Several witnesses observed airplane components floating down after the airplane. All witnesses reported hearing loud engine noises throughout the event. Impact signatures were consistent with a nose down attitude with a near vertical descent angle. Distribution of the airplane wreckage supported the observation by eyewitnesses of an inflight breakup. An examination found that both wings failed in overload with positive wing loading. In addition, there was no evidence of flight control over travel or flutter. It could not be determined whether the pilot intended to perform the abnormal maneuver or if it was the result of a physiological issue.

Factual narrative

The twin-engine, low wing, six seat, retractable landing gear airplane was manufactured in 1961 with the serial number 27-413. It was powered by two 250-horsepower Lycoming O-540-A1D5 engines driving metal, two-blade, constant speed, Hartzell HC-A2VK-2 propellers. The airplane's last annual inspection was conducted on August 31, 2012, at a total airframe time of 6,076.35 hours. The left engine's starter cable was replaced on the day of the accident. There was no record of any other recent maintenance performed on the airplane. On September 12, 2012, about 1455 central daylight time, a Piper PA-23-250 airplane, N4842P, impacted terrain following an in-flight break-up near Bullard, Texas. The commercial pilot was fatally injured and the airplane was substantially damaged. The airplane was registered to X Aviation LLC, Houston, Texas, and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight. The flight originated from the David Wayne Hooks Memorial Airport (KDWH), Houston, Texas, about 1355, and was en route to the Tyler Pounds Regional Airport (KTYR), Tyler, Texas. According to eyewitness statements, the airplane approached Lake Palestine, near Bullard, while flying several thousand feet above the ground. The airplane was observed to make several turns, pitched nose up, and climbed. The airplane then rolled to the right and headed toward the ground nose first. Several witnesses observed airplane components floating down after the airplane. All witnesses reported hearing loud engine noises throughout the event. An autopsy was performed on the pilot by Forensic Medical Management Services of Texas as authorized by the Justice of the Peace, Precinct 2, Smith County, Texas. The cause of death was blunt force injuries and the manner of death was ruled an accident. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens provided were negative for ethanol and drugs. At 1453, an automated weather reporting facility at KTYR reported wind from 130 degrees at 11 knots, 10 miles visibility, few clouds at 5,000 feet, temperature 90 degrees Fahrenheit (F), dew point 64 degrees F, and a barometric pressure of 30.03 inches of mercury. The pilot, age 51, held a commercial pilot certificate for airplane single engine land, multi-engine land, and instrument airplane. He was previously issued a flight instructor certificate for airplane single engine which expired on August 31, 1983. On April 5, 2012, the pilot was issued a first class special authorization, interim issuance medical certificate due to hyperthyroidism. A review of the pilot's log book revealed that the pilot had accumulated a total of 937.7 hours, 39.4 hours of multiengine time, and 24.4 hours in the make and model of the accident airplane. He obtained his multiengine land ratingon April 28, 2012. A layout of the airplane's wings and fuselage was conducted. Both wings displayed near symmetric damage and deformation with signatures that both wings failed in overload with positive wing loading. Examination of the empennage did not reveal any signatures of over travel or flutter. The accident site was located on a road near a wooded, residential area. Damage to trees surrounding the accident site was consistent with a steep descent angle. Airplane components were located in several directions from the accident site at distances up to one-half mile. The largest concentration was within a 40 yard radius of the main wreckage, however wing components were scattered to the north and east of the accident site. Ground impact signatures consisted of two impact craters, one for left engine and one for the fuselage. The main wreckage consisted of the fuselage, empennage, rudder, elevators, both engines, and portions of both wings. The odor of fuel was detected at the accident site. The left wing was fragmented outboard of the left engine. The left flap was found at the accident site along with a portion of the left aileron. The left wing tip was found near a lake shore about 175 yards north of the accident site and the inboard portion of the aileron located about 500 yards north of the accident site. The right wing was fragmented outboard of the right engine. The right flap was found 40 yards east of the accident site along with the right aileron. A large section of the right wing was recovered from a lake about 175 yards north of the accident site, with the right wing tip was located 380 yard east of the accident site. Both engines remained attached to the wing mounts. The left engine was fractured in multiple places. The left propeller fractured at the first crankshaft web. One blade displayed leading edge polishing, deep nicks, gouges, and chordwise scratches. The opposite blade had leading edge polishing and chordwise scratches from the blade root to near mid span where it was displayed aft. The right engine's crankcase was fractured in multiple locations. The right propeller hub remained attached to the engine and one blade had fractured from the hub. Both blades displayed curling, leading edges nicks and gouges, and chordwise scratches. Flight control continuity was established from the flight controls to the rudder and elevators, and to the aileron bellcranks. The cockpit section was fragmented, torn, and displaced. The left engine's tachometer displayed 1,650 rpm with a Hobbs time of 315.4 hours and the right engine's tachometer displayed 1,450 rpm with a Hobbs time of 313.8 hours. Most of the other cockpit instruments were unreadable or destroyed.

Aircraft

Registration
N4842P
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-413
Airframe hours
6,085
Engines
Lycoming O-540 SERIES, 250 horsepower, reciprocatingLycoming O-540 SERIES, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 31, 2012 · 9 hours before
Departed
KDWH · Houston, TX
Destination
KTYR · Tyler, TX
Flight plan
Unknown

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
51
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
April 27, 2012
Seat
Left
Toxicology
Performed
Flight hours
938 total · 24 in this make and model · 792 as pilot in command · 45 in the last 90 days · 14 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 64 °F
Altimeter
30.03 inHg
Observed at
KTYR, 15 nm away

Docket · 11

The files NTSB released with the investigation on November 18, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.9 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.