CEN19LA129

NTSB accident investigation · Piper PA 23 · Sulphur Spring, TX · April 27, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
April 27, 2019, 09:45 local (14:45 UTC)
Place
Sulphur Spring, TX
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N233PPiper PA 23
Defining event
Enroute-cruise: Fuel contamination
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Piper Aircraft Company, FAA FSDO
FAA report
20190427010939A
Case key
99329

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 inadequate preflight inspection, during which he failed to detect the water contamination in the left fuel, which resulted in a partial loss of power in the left engine. Contributing to the accident was the total loss of power in the right engine for undetermined reasons.

Findings · 5

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid conditionPiper PA-23: 3 casesAll aircraft: 1,695 casesProbable cause
Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Inadequate inspectionPiper PA-23: 1 caseAll aircraft: 195 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Unknown/Not determinedPiper PA-23: 3 casesAll aircraft: 497 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotPiper PA-23: 3 casesAll aircraft: 551 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedPiper PA-23: 4 casesAll aircraft: 2,247 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 pilot of a twin-engine airplane was in cruise flight when the left engine lost partial power. He turned on the boost pumps, checked the fuel quantity and engine gauges, verified fuel tank selection, and added throttle. However, the left engine continued to lose power. The pilot reported that, without warning, the right engine lost total power and would not restart. The right propeller went to the feathered position. The pilot initiated a forced landing to a field. During the descent, the left engine lost total power but the propeller continued to rotate, and the left engine was unresponsive to throttle input. During the forced landing, the airplane sustained substantial damage to the left and right wings and the fuselage. Examination of the right engine found the magneto timing at 12.5º (data plate specifies 25º). Otherwise, no preimpact abnormalities were noted during the right engine examination that would have precluded normal operations. The investigation was not able to determine why the right propeller was stopped in the feathered position. Examination of the left engine found the magneto timing at 23º. The bolts that secured the upper and lower halves of the carburetor were found loose. When the carburetor was opened, the inside of the bowl was dry, and the gasket appeared worn, consistent with rubbing between the two carburetor halves. The top set of spark plugs displayed heavy carbon coating consistent with the left engine running at a rich fuel setting. During a test run, the left engine would not produce rated power and ran rich. When the mixture was leaned, the left engine ran smooth and ran normally. The carburetor was bench tested and operated as expected. The carburetor was disassembled, and evidence of water staining was present. A fuel sample collected from the left side fuel tank appeared divided with the top part blue, consistent with 100 LL avgas, and the lower portion of the liquid was clear with brown sediment visible at the intersection of the two liquids. The fuel strainer bowl revealed rust colored liquid and sediment in the bowl. The fuel strainer screen contained numerous small flakes of an unidentified contaminant. A sample of fuel drained from the left-wing tank tested positive for water when tested with water-finding paste. The loss of power on the left engine is likely due to water contamination.

Factual narrative

On April 27, 2019, about 0945 central daylight time, a Piper PA-23 airplane, N233P, was substantially damaged when it was involved in an accident near Sulphur Springs Municipal Airport (SLR), Sulphur Springs, Texas. The pilot was not injured. The flight was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that before departure from Mount Pleasant Regional Airport (OSA), the airplane’s main fuel tanks were “topped off.” The pilot added that as he passed over SLR, he noticed a slight drop in rpm on the left engine. He increased the left engine manifold pressure to "full," but the engine speed continued to decrease. He observed a small amount of black smoke coming from left engine and checked that the fuel primer was still locked. The airspeed was decreasing, so he decided to turn back to SLR. He turned on the boost pumps, then checked the fuel quantity, verified the fuel selector was set to the main tanks, and checked the engine gauges. The left engine tachometer showed only 2,000 rpm, with full throttle. The airplane was about 3,000 ft mean sea level (msl) and descended 100 to 200 ft per minute while the airspeed decreased. The pilot stated that, "with no warning, the right engine died." He attempted to restart it, but the right engine would not restart, and the propeller went to the feathered position. The airplane was not able to maintain altitude or airspeed, so the pilot located a field to perform a forced landing. As he descended to the field, the left engine lost power. The pilot stated that the “left engine continued to windmill but was not responsive to throttle changes.” After the forced landing and the airplane came to rest, the pilot turned off the fuel pumps, fuel, avionics, and the master switch. During the forced landing, the airplane sustained substantial damage to the left and right wings and the fuselage. After the airplane was recovered, an examination was conducted on the engines and airframe. About 45 gallons of fuel was recovered from the airplane’s main fuel tanks. The left-wing main fuel tank appeared intact, and fluid was observed in the fuel cell when viewed from the filler opening. A sample of fuel collected from the left side fuel tank appeared divided with the top part blue, consistent with 100 LL avgas, and the lower portion of the liquid was clear with brown sediment visible at the intersection of the two liquids. The fuel strainer bowl contained rust colored liquid and sediment. The fuel strainer screen contained numerous small flakes of an unidentified material. A sample of fuel drained from the left tank tested positive for water when tested with Kolor-Kut water finding paste. A fuel sample taken from the right-wing tank appeared blue; consistent with 100 LL avgas. The fuel strainer bowl and screen were absent debris/contaminants. Examination of the right engine found the magneto timing at 12.5º (data plate specifies 25º). Otherwise no preimpact abnormalities werenoted during the engine examination. The right engine’s two-bladed propeller was found in the feathered position. Both blades appeared straight absent bending. Examination of the left engine found the magneto timing at 23º (data plate specifies 25º). The bolts that secured the upper and lower halves of the carburetor were found loose. When the carburetor was opened, the inside of the bowl was dry, and the gasket appeared worn, consistent with rubbing between the two carburetor halves. The top set of spark plugs displayed heavy carbon coating consistent with the engine running at a rich fuel setting. A non-original equipment manufacturer air induction system was observed and appeared free of any blockages. The left engine’s two-bladed propeller was not in the feathered position. Both blades showed signs of polishing with slight S-bending of the blades. The left engine was mounted on a test stand, the bent propeller was replaced with the propeller from the right engine. An engine test run was completed and noted that the left engine would not produce rated power and ran rich. The fuel mixture control was leaned, and the left engine smoothed out and ran normally. The carburetor was bench tested and operated as expected. The carburetor was disassembled, and evidence of water staining was present.

Aircraft

Registration
N233P
Reported as
Piper PA 23 (Undesignat)
Category
Airplane
Serial number
23-604
Built
1956
Airframe hours
3,823.2
Engines
Lycoming O-320-B3B, 160 hp, reciprocatingLycoming O-320-B3B, 160 hp, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 8, 2019
Departed
OSA · Mount Pleasant, TX
Destination
OSA · Mount Pleasant, TX
Equipment
Auto-pilot, ADS-B, Electronic multifunction display

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
47
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
June 4, 2018
Seat
Left
Restraint
Lap only
Flight hours
398 total · 35 in this make and model · 286 as pilot in command · 16 in the last 90 days · 11 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 59 °F
Altimeter
29.94 inHg
Observed at
KSLR, 2 nm away

Docket · 10

The files NTSB released with the investigation on September 22, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.1 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.