# NTSB CEN12LA401: Piper PA-23, N3170P, Baltic, OH, June 28, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 28, 2012, 09:20 local (13:20 UTC) - Place: Baltic, OH - Coordinates: 40.439552, -81.700576 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.4396&lon=-81.7006&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report November 26, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards District Office - ADs cited in the narratives: [AD 92-13-04](https://openairdocs.org/ad/92-13-04) (OpenAirDocs) - NTSB case key (mKey): 84115 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12LA401 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84115/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84115 - Page: https://openairdocs.org/ntsb/CEN12LA401 ## Probable cause Loss of engine power due to fuel starvation as a result of particulate contaminant on the carburetor screens. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [Piper PA-23, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102302), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Maintenance/inspections: scheduled maint checks](https://openairdocs.org/ntsb-findings/01010520): Aircraft › Aircraft handling/service · Inadequate inspection; cases with it: [Piper PA-23, 1 case](https://openairdocs.org/ntsb-findings/01010520/cases.md?model=7102302), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/01010520/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-23, 3 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=7102302), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Knowledge: knowledge of procedures](https://openairdocs.org/ntsb-findings/02032010): Personnel issues › Experience/knowledge · Pilot; cases with it: [Piper PA-23, 1 case](https://openairdocs.org/ntsb-findings/02032010/cases.md?model=7102302), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/02032010/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel; cases with it: [Piper PA-23, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7102302), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-23, 3 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102302), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-23, 5 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102302), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis Shortly after takeoff, the left engine lost power so the pilot diverted to an alternate airport for landing. After the left engine was secured, the airplane was not maintaining altitude so the pilot selected an off-airport site short of the alternate airport to land. While approaching the off-airport site, the right engine lost power, and the airplane was substantially damaged during the forced landing. An examination of the fuel system revealed an extensive amount of corrosion consistent with the continued presence of water over an extended period. Both engine carburetor screens were occluded with particle contaminants, which likely resulted in the loss of power in both engines. The pilot reported that before the flight, he conducted a normal preflight inspection, had 54 gallons of fuel added to both main fuel tanks, and sumped one fuel sump cup full of fuel out of each main tank. Neither the previous owner nor the accident pilot was aware of an airworthiness directive (AD) requiring a special fuel sumping procedure before every flight. The AD also specifies that the procedure should be incorporated into the owner handbook and pilot’s operating manual. The required documentation advising pilots of this preflight procedure was not in the airplane. ## Factual narrative On June 28, 2012, approximately 0920 eastern daylight time, a Piper PA-23, N3170P, was substantially damaged during a forced landing to a field near Baltic, Ohio. The pilot and passenger were seriously injured. The personal flight was being conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91 without a flight plan. Visual meteorological conditions prevailed at the time of the accident. The cross-country flight departed Akron-Canton Regional Airport (KCAK), Akron, Ohio, approximately 0900 and was en route to Mallory Airport (WV12), South Charleston, West Virginia. The pilot stated that about 10 minutes after departure, the left engine began to surge and subsequently lost power. He feathered the propeller, secured the engine, and elected to divert to the Richard Downing Airport (I40) near Coshocton, Ohio. The pilot was unable to maintain altitude and elected to perform an off-airport landing to a field. While approaching that field, the right engine lost power. During the emergency approach and landing, the airplane impacted the tops of trees prior to impacting the ground. Both wings were bent and the fuselage was wrinkled during the accident sequence. During recovery, both main and auxiliary fuel tanks were drained. An investigator from the National Transportation Safety Board and two inspectors from the Federal Aviation Administration (FAA) examined the airplane, both engines, and related systems. A sample of fuel, drained from the left wing, contained small particles. Examination of the left engine fuel system revealed metal, dirt, and paint chip contamination in the fuel bowl. In addition, the fuel bowl was pitted and corroded. The fuel screen in the left engine carburetor was 100 percent occluded with contamination similar to what was found in the fuel bowl. Additional contamination was found in the left carburetor bowl. The left engine driven fuel pump was pitted and corroded, and the left engine electric fuel pump screen was occluded. The magnet in the bottom of the pump contained corroded metal fragments. Examination of the right engine fuel system revealed contamination in the fuel bowl, consistent with the contamination found in the left fuel system. The strainer bowl housing was corroded and pitted. The fuel screen in the right engine carburetor was 90 percent occluded with contamination similar to what was found in the fuel bowl. Contamination was also found in the right carburetor bowl and the right engine electric fuel pump. The fuel pump housing exhibited pitting and corrosion. No additional anomalies consistent with a loss of engine power were observed. In November 1988, Piper Aircraft issued Service Bulletin (SB) 827A, in order to address the loss of engine power due to water and sediment accumulation in the fuel system. This service bulletin required the pilot to sump both the main and auxiliary fuel tanks if the dual fuel drain kit had not been installed on the airplane. This was accomplished byselecting both main and auxiliary fuel tanks with the cockpit selector valve. In addition, the pilot was to select a cross feed setting and conduct one additional sump of the system. On August 21, 1992, the FAA issued Airworthiness Directive (AD) 92-13-04, requiring compliance with Piper SB 827A. This AD required that the SB with the sumping procedures be added to the Owner Handbook and Pilots Operating Manual for the airplanes affected by the AD, and that the procedures be complied with if the dual fuel drain kit had not been installed. An examination of the maintenance records revealed that the last annual inspection had been completed on October 1, 2010; under the provisions of 14 CFR Part 43 Appendix D. The logbook entry stated that AD 92-13-04 had been complied with and was to be accomplished prior to each preflight. However, SB 827A was not located in the airplane paperwork, Owner Handbook, or Pilots Operating Manual during the accident investigation. The pilot reported that prior to the flight, he conducted a normal preflight inspection, had 54 gallons of fuel added to both main fuel tanks, and sumped one fuel sump cup full of fuel out of each main tank. The pilot consulted with the previous owner who confirmed that there was only one fuel sump on each wing. The previous owner did not advise of any special procedures required for sumping the fuel. The pilot acknowledged that he was not aware of SB 827A or AD 92-13-04, which required the special fuel sumping procedure. He stated that when he sumped the fuel, he did not notice any contamination in the fuel. ## Aircraft - Registration: [N3170P](https://openairdocs.org/deregistered/N3170P-2018-01-03), registration cancelled 2018-01-03, S/N 23-1105, built 1957 (OpenAirDocs) - Reported make and model: PIPER PA-23 - Registry model: [Piper PA-23](https://openairdocs.org/model/piper-pa-23) (registry code 7102302) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 23-1105 - Airframe hours: 5042 - Engines: LYCOMING O-320-A 160 horsepower reciprocating; LYCOMING 0-320-A 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Last inspection: Annual, October 1, 2010, 37 hours before - Departed: KCAK, Akron, OH - Destination: WV12, SouthCharleston, WV ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: serious; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review January 22, 2011; seat: left; flight hours: 1,086 total, 27 in this make and model, 1,002 as pilot in command, 7 in the last 90 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 55 °F - Altimeter: 29.88 inHg - Observed at: KBJJ, 20 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 20120628015969A](https://openairdocs.org/incident/20120628015969A), Jun 28, 2012: Piper PA-23, Baltic, OH, Destroyed. Aircraft was purchased a week prior (approx 6-21-2012) to date of accident (6-28-2012) by mike mallory. Mr. Mallory hired [privacy data omitted] and [privacy… ## Docket (4 files) The files NTSB released with the investigation on September 14, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84115. 4.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374378&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Telephone Conversation with the Pilot (item 2, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375772&FileExtension=.PDF&FileName=Record%20of%20Telephone%20Conversation%20with%20the%20Pilot-Master.PDF - Piper SB 0827A (item 3, .PDF, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375763&FileExtension=.PDF&FileName=Piper%20SB%200827A-Master.PDF - AD 92-13-04 (item 4, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375774&FileExtension=.PDF&FileName=AD%2092-13-04-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.