# NTSB CHI93LA184: Piper PA-23-160, N3333P, Ely, MN, May 27, 1993 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: May 27, 1993, 13:20 local (18:20 UTC) - Place: Ely, MN - Coordinates: 47.900753, -91.849716 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.9008&lon=-91.8497&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report August 17, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 9212 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI93LA184 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/9212/pdf - Page: https://openairdocs.org/ntsb/CHI93LA184 ## Probable cause the pilot's decision to continue flight with a known deficiency in the airplane's hydraulic system. Factors associated with the accident are the loss of power in the left engine due to fuel contamination, and a leak in the hydraulic system. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, cruise - 1 engine - fluid,fuel - contamination (contributing factor) - In flight collision with terrain/water, descent - emergency - hydraulic system - leak (contributing factor) - operation with known deficiencies in equipment - continued, pilot in command (cause) ## Analysis THE PILOT REPORTED THE LEFT ENGINE LOST POWER WHILE THE FLIGHT WAS CRUISING AT 7,000' MSL. HE SAID HE FEATHERED THE LEFT PROP, BUT CONTINUED TO LOSE ALTITUDE. HE WAS UNABLE TO MAINTAIN ALTITUDE, AND MADE A FORCED LANDING INTO TREE TOPS. THE PILOT REPORTED THAT THE AIRPLANE'S MAIN LANDING GEAR HAD KEPT 'SAGGING' THROUGHOUT THE FLIGHT, AND HE WAS REQUIRED TO PLACE THE MAIN GEAR SELECTOR IN THE 'UP' POSITION EVERY 3 TO 5 MINUTES. HE SAID THE GEAR PROBLEM WAS APPARENTLY CAUSED BY A SLOW LEAK IN THE HYDRAULIC SYSTEM, AND THAT IT HAD BEEN SCHEDULED FOR REPAIR. HE WROTE IN HIS REPORT TO THE NTSB: 'IN RETROSPECT, I BELIEVE THIS SEEMINGLY MINOR PROBLEM MAY HAVE BEEN OF CRITICAL SIGNIFICANCE IN CAUSING THIS PROBLEM...I MAY HAVE BEEN ABLE TO RECOGNIZE THIS AS THE SOURCE OF DRAG...AND AVOID THE CRASH-LANDING.' AN EXAMINATION OF THE LEFT ENGINE AFTER THE ACCIDENT DISCLOSED WATER AND DEBRIS IN THE FUEL SYSTEM AND BLACKENED SPARK PLUGS. ## Factual narrative On May 27, 1993, about 1320 central daylight time, a Piper PA-23-160 airplane, N3333P, operated by Crystal Shamrock, Inc., sustained substantial damage when it collided with trees approximately four miles north of Ely, Minnesota. The commercial pilot and the sole passenger aboard were seriously injured. The flight departed Hallock, Minnesota about 1100, with an intended destination of Cook County Airport, Grand Marias, Minnesota. Instrument meteorological conditions prevailed for 14 CFR Part 91 flight, and an instrument flight plan was filed. The pilot reported a relatively slow loss of power from the left engine while in cruise at 7,000' MSL. He said the power loss developed over several seconds. The pilot wrote in his report to the NTSB that he feathered the left engine and made a diversion to Ely, Minnesota. He was unable to maintain altitude, and complained of excessive drag from an unknown source on the airplane. He wrote that it became apparent that the airplane would not reach Ely due to his inability to maintain altitude, and he elected to make a forced landing into the tree tops. During the flight, the pilot said the main landing gear kept creeping down and he had to keep "snugging" it up by putting the gear handle in the up position. Once the left engine ceased to run, he said he used the emergency hydraulic hand pump to accomplish the same task. According to the pilot's written statement, he was aware of the sagging gear problem prior to the flight, and that it was necessary for him to bring the gear up every 3 to 5 minutes. He said that the main landing gear system apparently had a slow leak, and it was scheduled for repair soon. He also wrote: "In retrospect, I believe this seemingly minor problem may have been of critical significance in causing this accident. I think given a few more seconds of time, I may have been able to recognize this as the source of drag and eliminate it and avoid the crash-landing." The airplane's left engine was examined in the field by an FAA inspector. His report (appended) notes that all of the left engine spark plugs were very blackened, and that the fuel sample taken between the fuel pump and carburetor was dirty and watery. ## Aircraft - Registration: [N3333P](https://openairdocs.org/deregistered/N3333P-1996-05-21), registration cancelled 1996-05-21, S/N 231284 (OpenAirDocs) - Reported make and model: PIPER PA-23-160 - Registry model: [Piper PA-23-160](https://openairdocs.org/model/piper-pa-23-160) (registry code 7102304) (OpenAirDocs) - Category: Airplane - Serial number: 23-1284 - Airframe hours: 6965 - Engines: LYCOMING O-320-B3B 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Crystal Shamrock, Inc. - Registered owner: Crystal Shamrock, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 26, 1993, 88 hours before - Departed: 03Y, HALLOCK, MN - Destination: CKC, GRAND MARAIS, MN - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: helicopter, airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; flight hours: 2,715 total, 137 in this make and model, 2,466 as pilot in command, 59 in the last 90 days, 39 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 110° at 11 knots - Visibility: 2 statute miles - Lowest ceiling: 900 ft - Temperature: 46 °F, dew point 39 °F - Altimeter: 29.00 inHg - Observed at: ELO, 4 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 19930527015439A](https://openairdocs.org/incident/19930527015439A), May 27, 1993: Piper PA23160, Ely, MN, Substantial damage. Lost power left engine. Feathered but unable hold altitude due sagging landing gear. Water debris in fuel system. 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.