CEN23LA262

NTSB accident investigation · Piper PA23 · Ocean Springs, MS · June 23, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
June 23, 2023, 07:34 local (12:34 UTC)
Place
Ocean Springs, MS · Ocean Springs Middle School - Athletic field
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N4307PPiper PA23
Defining event
Initial climb: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Lycoming Engines, Hartzell Propeller, FAA Jackson FSDO, Piper Aircraft
FAA report
20230623009079A
Case key
192454

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

A total loss of engine power during the initial climb due to fuel starvation for undetermined reasons.

Findings · 4

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.

Performance/control parameters: engine out controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-23-160: 2 casesAll aircraft: 35 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-23-160: 4 casesAll aircraft: 9,295 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Unknown/Not determinedPiper PA-23-160: 2 casesAll aircraft: 497 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedPiper PA-23-160: 1 caseAll 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 was planning on conducting a cross-country flight to have an annual inspection performed on the airplane. Before the departure, the pilot reported there was about 105 gallons of 100 low-lead fuel onboard. Shortly after the takeoff, the pilot reported the left engine sustained a total loss of engine power, without any prior indications. The pilot performed a forced landing and the airplane impacted an unoccupied grass athletic field on the property of a school. The airplane sustained substantial damage to both wings and the fuselage. During the accident sequence, the left-wing main fuel cell (rubber bladder style) was breached and no fuel was observed in the cell. The left-wing auxiliary fuel cell (rubber bladder style), was cut open during the recovery to facilitate fuel removal and no recoverable fuel was found. Therefore, it is unknown how much fuel was in the left-wing fuel tanks. During the recovery of the airplane from the accident site, about 45 gallons of fuel was recovered from the right-wing fuel tanks. During the postaccident examination of the left engine, no fuel was observed in any of the fuel hoses forward of the firewall, the engine-driven fuel pump, or the carburetor. All visible damage on the left propeller was consistent with impact forces caused by impact into a soft surface, with the propeller rotating at low or no power. The investigation identified no preimpact mechanical malfunctions or failures with the airframe, the left engine, or the left propeller that would have precluded normal operation. Based on the available evidence, it is likely the left engine sustained a total loss of engine power due to fuel starvation for undetermined reasons.

Factual narrative

On June 23, 2023, about 0734 central daylight time, a Piper PA-23-160 airplane, N4307P, sustained substantial damage when it was involved in an accident near Ocean Springs, Mississippi. The pilot was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot was planning to fly the airplane cross-country to the Transylvania Community Airport (3NR3), Brevard, North Carolina, to have an annual inspection performed. Before the departure at the Ocean Springs Airport (5R2), Ocean Springs, Mississippi, the pilot reported there were about 105 gallons of 100 low-lead fuel onboard for the cross-country flight. The pilot reported that, shortly after taking off from runway 36, the left engine sustained a total loss of engine power without any prior indication. The pilot performed a forced landing northwest of runway 36; the airplane impacted an unoccupied grass athletic field on the property of a school. During the forced landing, the airplane traveled through a fence and came to rest nose down on the athletic field. The pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to both wings and the fuselage. At the accident site, the left throttle control was found in the closed position, the left propeller control was found near the full forward (increase) position, and the left mixture control was found about halfway between the rich and the lean positions. During the accident sequence, the left-wing main fuel cell (rubber bladder style) was breached. The left-wing fuel auxiliary fuel cell (rubber bladder style), was cut open during the recovery to facilitate fuel removal and no recoverable fuel was found. An impact mark that had penetrated the grass into the dirt, near the left engine, was observed containing blue liquid. During the recovery of the airplane from the accident site, about 45 gallons of fuel was recovered from the airplane. Examination of the airframe confirmed flight control continuity. Both fuel selector levers were in the forward position (for the main fuel cells). The crossfeed lever was in the off position. Both primer plungers were found stowed and locked. No fuel was observed in the left-wing auxiliary fuel cell, which had been cut open. No fuel was observed in the left-wing main fuel cell, which had been breached. The left-wing fuel strainer bowl sump drain was actuated and about 1 cup of blue liquid was drained from the strainer bowl. The liquid was consistent in both color and odor with 100 low-lead fuel. The liquid was collected in a glass jar and tested with water finding paste, which showed negative results. Both fuel bladder finger screens and the wing fuel vent system for the left side of the airplane were found free from blockage. The left-wing fuel line was found free from blockage. The left-wing airframe fuel pump was field tested with electric power and operated with no abnormalities noted. Fuel was notobserved in any of the left-engine fuel hoses forward of the firewall. The crankshaft was manually rotated and continuity of the crankshaft to the rear gears and to the valvetrain was confirmed. Thumb compression and suction were observed for all four cylinders. The interior of the cylinders was observed using a lighted borescope and no anomalies were noted. The engine-driven fuel pump remained attached to the left engine. The pump was removed from the engine. The pump was partially disassembled and no damage to the rubber diaphragms or internal check valves was noted. The fuel pump plunger was found installed inverted and fell out when the fuel pump was removed. No fuel drained from the pump when it was tilted. The carburetor remained attached to the left engine and no damage was noted. The throttle, mixture, and carburetor heat cables remained attached to their respective actuator arms. All four bolts for the body of the carburetor were found finger loose, but were safety wired. The carburetor was disassembled and no abnormalities were noted. No fuel was observed in the carburetor float bowl. The carburetor fuel inlet screen was unobstructed. The left propeller remained attached to the engine crankshaft flange with all six propeller mounting studs secure and lockwired. There were no indications of oil leaks originating from the propeller or the mounting flange. The propeller exhibited damage, bending aft, and chordwise/rotational abrasion on the camber side near the tips. There were no preimpact mechanical malfunctions or failures found with the airframe, the left engine, or the left propeller that would have precluded normal operation. A review of the airplane’s maintenance records for the left engine, the left propeller, the right engine, and the right propeller, showed the most recent annual inspection was on June 3, 2021, 24 months before the accident. An annual inspection is required per 14 CFR Part 91.409 Inspections (a), for an aircraft to be airworthy. The left engine had accumulated 1,048.95 hours of time-in-service since the most recent engine overhaul in July 1995, more than 28 years before the date of the accident. Lycoming Engines Service Instruction Number 1009BE, Time Between Overhaul (TBO) Schedules, was released on April 24, 2000. This document states in part: All engine models are to be overhauled within twelve (12) calendar years of the date they first entered service or of last overhaul. This calendar year time period TBO is to mitigate engine deterioration that occurs with age, including corrosion of metallic components and degradation of non-metallic components such as gaskets, seals, flexible hoses and fuel pump diaphragms. Compliance with Lycoming Engines Service Instruction Number 1009BE is not mandated by the Federal Aviation Administration for 14 CFR Part 91 operations. A review of the pilot’s logbook showed that his most recent flight review was on September 30, 2014. Per 14 CFR Part 61.56 (c), a flight review wasrequired within the 24 months preceding the accident to act as a pilot-in-command of an aircraft.

Aircraft

Registration
N4307P
Reported as
Piper PA23 (160)
Category
Airplane
Serial number
23-1808
Built
1959
Airframe hours
5,101.45
Engines
Lycoming Engines O-320-B3B, 180 horsepower, reciprocatingLycoming Engines O-320-B3B, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 3, 2021 · 9.45 hours before
Destination
3NR3 · Brevard, NC
Equipment
Electronic flight bag or handheld device, Auto-pilot, ADS-B, Stall warning system

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
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 2, With waivers/limitations
Last flight review
September 30, 2014
Seat
Left
Restraint
Lap only
Flight hours
928 total · 433 in this make and model · 919 as pilot in command · 12 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 73 °F
Altimeter
29.92 inHg
Observed at
KBIX, 8 nm away
METAR
KBIX 231155Z AUTO 34005KT 10SM CLR 24/23 A2992 RMK AO2 SLPNO 70101 T02380229 10241 20230 52012

FAA reports on this event · 1

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