CEN23FA284

NTSB accident investigation · Piper PA-30 · Sherman, TX · July 8, 2023

Accident · FatalClass 3 · FieldFinal report
Date
July 8, 2023, 09:41 local (14:41 UTC)
Place
Sherman, TX · rural area near road
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N4743MPiper PA-30
Defining event
Approach: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Lycoming Engines, FAA, Flight Standards District Office, Piper Aircraft
FAA report
20230708010969A
Case key
192560

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

On this page

Probable cause

The pilot’s failure to maintain control during a forced landing following a loss of engine power. Contributing was the pilot’s failure to feather the left propeller following the loss of engine power.

Findings · 7

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-30: 28 casesAll aircraft: 9,295 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA-30: 13 casesAll aircraft: 1,391 casesProbable cause
Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationPiper PA-30: 2 casesAll aircraft: 176 casesProbable cause
Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Fatigue/wear/corrosionPiper PA-30: 2 casesAll aircraft: 176 casesProbable cause
Performance/control parameters: engine out controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-30: 2 casesAll aircraft: 35 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementPiper PA-30: 14 casesAll aircraft: 1,695 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 multi-engine airplane was in level flight at 5,000 ft on a north heading toward the destination airport. Onboard data indicated the right engine’s fuel flow fluctuated for about 15 seconds. About 20 seconds later, the left engine fuel flow reduced to zero. The airplane made a slow descent toward the east for about 9 minutes, away from the destination airport. The airplane then turned west back toward the airport and continued a slow descent. About 10 minutes later, the airplane was less than 100 ft above ground level, with a groundspeed of about 61 knots. The airplane turned left about 40° during the last 4 seconds of recorded data and subsequently impacted a field with a nose-down attitude. The airplane sustained substantial damage to the fuselage, empennage, and both wings. Postaccident examination of the airplane revealed the left engine’s fuel selector was in the off position and right engine’s fuel selector valve was in the main tank position. The right fuel selector valve was corroded, which most likely resulted in the right engine fuel flow fluctuations. It is possible that the pilot moved the left engine fuel selector from auxiliary tank to off inadvertently when he intended to move the right engine’s fuel selector from the auxiliary tank to the main tank. The left-engine propeller was not feathered at the accident site, which resulted in additional in-flight drag and a higher minimum controllable airspeed (VMC). During the attempted forced landing, the pilot failed to maintain adequate airspeed, which resulted in a loss of control and a nose-down impact with terrain. The pilot’s toxicology results indicated use of the sedating antihistamine medication diphenhydramine, and he may have experienced associated impairing effects at the time of the accident. More precise interpretation of the diphenhydramine level in cavity blood was not possible. The pilot also had used other drugs that may have had adverse side effects (yohimbine, as well as both tadalafil and tamsulosin), although there was no way to determine whether such side effects were present or significant. The investigation was not able to determine the role the pilot’s medication usage may have played in the accident sequence.

Factual narrative

The airplane is equipped with four integral fuel cells located in the leading-edge sections of the wings. Capacity of the two main fuel cells is 30 gallons each, of which 27 gallons is usable. The auxiliary fuel system consists of two 15-gallon cells (all usable) installed in the wings just outboard of the main fuel cells. The airplane also had wingtip tanks with a capacity of 15 gallons each that are connected to the adjacent auxiliary fuel cells. The left and right engine fuel selector valves enable fuel to be drawn from any of the fuel cells to both engines. The fuel selector valve positions are main, auxiliary, crossfeed, and off. Positioning of the left versus right fuel selectors involves a rotation in the opposite direction (see Figure 1). Figure 1. Diagram of Left and Right Fuel Selector Valves On July 8, 2023, about 0941 central daylight time, a Piper PA-30, N4743M, was substantially damaged when it was involved in an accident near Sherman, Texas. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast (ADS-B) information, the airplane departed Aero Country Airport (T31), McKinney, Texas, at 0902 and proceeded toward Sherman Municipal Airport (SWI), Sherman, Texas, about 5,000 ft mean sea level (msl). At 0919:20, while the airplane was level on a northerly heading toward SWI, onboard data indicated the right engine’s fuel flow fluctuated for about 15 seconds. At 0919:55, the left engine’s fuel flow rapidly dropped to zero and the left engine cylinder head and exhaust gas temperatures decreased. At 0921:55, about 6 miles southeast of SWI, the airplane started an orbit to the right, then began a shallow descent on an easterly heading away from SWI. About 0926, the left engine’s fuel flow rapidly increased, then dropped back to zero for the remainder of the flight. The airplane continued a shallow descent on easterly and northeasterly headings. About 0931 and 13 miles east of SWI, the airplane turned left and continued a shallow descent while on westerly and southwesterly headings. About 0941, the last ADS-B data showed the airplane at 61 knots and less than 100 ft above ground level. The airplane was about 250 ft northeast of the accident site. During the last 4 seconds of recorded data, the airplane turned left about 40°. An autopsy of the pilot was performed by the Southwestern Institute of Forensic Sciences at Dallas Office of the Medical Examiner, Dallas, Texas. The cause of death was blunt force injuries. Toxicological testing by the Federal Aviation Administration (FAA) Forensic Sciences laboratory detected diphenhydramine in urine and at 70 ng/mL in cavity blood. Diphenhydramine is a sedating antihistamine medication widely available over the counter in multiple sleep aids and cold and allergy products. Diphenhydramine can cause cognitive and psychomotor slowing and drowsiness. The FAA states that pilotsshould not fly within 60 hours of using diphenhydramine to allow time for it to be cleared from circulation. Diphenhydramine concentrations in postmortem cavity blood cannot be directly compared to established ranges in living individuals because diphenhydramine has substantial potential for postmortem redistribution and cavity blood has a potential to be diluted or contaminated by other body fluids. Toxicology testing by the FAA also detected tadalafil, yohimbine, tamsulosin, and acetaminophen in cavity blood and urine. Descriptions of these medications and their potential for flying impairment are discussed in the NTSB Medical Factual Report, located in the docket for this investigation. No alcohol was detected in cavity blood. The airplane impacted a field on a southwest heading and came to rest upright about 50 ft beyond the initial impact crater. Both propellers were buried in soft soil near the impact crater and had minimal indications of scoring or rotational energy. All propeller blades were near the low pitch stop (not feathered). The forward fuselage was crushed consistent with a nose-down impact. The landing gear and flaps were in the retracted position. No anomalies were observed with the flight control system. About 9 gallons of fuel were recovered from the left main fuel cell and about 11 gallons from the left auxiliary fuel cell. About 9 gallons were recovered from the right main fuel cell and about 3 gallons from the right auxiliary fuel cell. No fuel was recovered from either wing tip tank. Both electric fuel pump switches were in the on position. The fuel filler caps were not worn or damaged and the rubber sealing surfaces were not cracked. The left fuel selector handle was found in the off position and the right fuel selector handle was found in the main tank position. Fuel sampled from the left fuel selector contained a minimal flake of corrosion and did not illicit a reaction from water finding paste. Fuel sampled from the right fuel selector contained multiple rust flakes and a bead of water and the fuel drained very slowly. The right fuel selector was disassembled, which revealed rust and water that partially blocked the filter elements. The right fuel selector was tested with low air pressure, which revealed partial blockage to the right auxiliary fuel tank port, and air could pass through that port when the handle was selected either to the off or main tank position. The right fuel selector handle was difficult to move and produced a grinding sound when turned. Both engines were examined, which revealed normal crankshaft rotation, with suction and compression obtained from all cylinders. The magnetos of both engines produced sparks at all posts when manually rotated. The left engine servo fuel screen was free of debris. The right engine servo fuel screen contained rust particles but was not blocked.

Aircraft

Registration
N4743M
Reported as
Piper PA-30
Category
Airplane
Serial number
30-1848
Built
1969
Airframe hours
3,641
Engines
Lycoming IO-320-B1A, 160 horsepower, reciprocatingLycoming IO-320-B1A, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 3, 2022 · 24 hours before
Departed
T31 · McKinney, TX
Destination
SWI · Sherman, TX
Equipment
Stall warning system, ADS-B, Auto-pilot, Electronic multifunction display, Electronic primary flight 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
69
Injuries
Fatal
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
December 1, 2022
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
540 total · 376 in this make and model · 317 as pilot in command · 3 in the last 90 days · 0 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 73 °F
Altimeter
29.95 inHg
Observed at
KGYI, 12 nm away
METAR
KGYI 081450Z 21012KT 10SM CLR 28/23 A2995

Docket · 17

The files NTSB released with the investigation on September 5, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.5 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.