CHI96FA052

NTSB accident investigation · Piper PA-23-250 · Steuben, WI · December 12, 1995

Accident · Serious injuriesField investigationFinal report
Date
December 11, 1995, 18:20 local (Dec 12, 1995, 00:20 UTC)
Place
Steuben, WI
Injuries
3 serious, 1 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N54791Piper PA-23-250
Weather
Instrument (IMC) · Night/dark
Status
Completed · report March 21, 1996
Report
Approved by Office Director
FAA report
19951211040329A
Case key
10064

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

failure of the pilot to select alternate air. Darkness and snowy weather conditions were related factors.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherCruise
Weather condition - snowFactor
Loss of engine power(total) - nonmechanicalCruise
All engines
Induction air control,alternate air/door
Miscellaneous equipment - not selectedPilot in commandCause
Forced landingEmergency descent/landing
In flight collision with objectEmergency descent/landing
Light condition - dark nightFactor
Object - tree(s)
In flight collision with terrain/waterEmergency descent/landing

Analysis

According to a rear seat passenger, the airplane was flying through heavy snow, when both engines lost power. The loss of power occurred as the airplane was flying in instrument conditions at night. Subsequently, the airplane descended and was destroyed, when it collided with trees. During an examination of the airplane on December 13, 1995, ice was found in the air induction system of both engines. No other airplane or engine malfunction was found during the examination. The pilot's operating handbook stated that alternate air should be placed in the full 'on' position prior to entering known or expected icing conditions.

Factual narrative

On December 11, 1995, at 1820 central standard time (cst), a Piper PA-23-250, N54791 was destroyed when it collided with trees and terrain. The pilot reported a loss of power on both engines to Chicago Center, prior to impact. Instrument meteorological conditions prevailed at the time of the accident. The personal 14 CFR Part 91 flight was operating on a IFR flight plan. The pilot and two passengers sustained serious injuries. One passenger received minor injuries. The flight departed from Wausau, Wisconsin en route to Tulsa, Oklahoma at 1740 cst.

The 400 foot wreckage path followed a magnetic heading of 160 degrees. All airplane components were found along the wreckage path. Due to the weather forecast for six inches of snow the evening of December 12, 1995, the airplane wreckage and cockpit were documented, and then moved from the accident location to a unheated airplane hanger. Photographs 1-4 show the wreckage as documented on December 12, 1995.

During the airplane inspection on December 13, 1995, ice was found in the air induction system of both engines. No other airplane or engine malfunction was found on December 13, 1995.

Photographs 5-8 show the air box, air filter box and air filter as removed from the right engine on December 13, 1995. Numerous pieces of ice were found in the right air box, beyond the air filter. Photographs 9 and ten show the fuel control unit and air filter for the left engine as photographed on December 13, 1995. All four impact tubes in the left fuel control unit were completely covered with ice. With the impact tubes blocked by ice, the diaphragm in the fuel control unit would not supply any fuel to the left engine's cylinders.

Both alternate air controls were found in the off position as documented on December 12, 1995, at the accident site. Both left and right air valves were found in the filtered air position on December 13, 1995. Both alternate air cockpit controls could be moved on December 13, 1995.

In a personal interview with the investigator in charge (IIC) a rear seat passenger said the airplane was flying through heavy snow, prior to the loss of power on both engines. The passenger also said that it was a very short time period between the loss of power on the left engine and the loss of power on the right engine.

The pilot's operating handbook was reviewed by the IIC and states that "On the control pedestal are two manual alternate air controls which may be used by the pilot to select alternate air if the automatic feature should fail. These should be placed in the FULL "ON" position prior to entering known or expected icing conditions."

Aircraft

Registration
N54791
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-7554092
Airframe hours
6,639
Engine
Lycoming IO-540-C4B5, 250 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Robert G. Timm
Registered owner
Spirt Of St. Louis Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 9, 1995 · 86 hours before
Departed
AUW · Wausau, WI
Destination
TUL · Tulsa, OK
Flight plan
IFR

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
49
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
10,000 total · 250 in this make and model

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
60° at 8 knots
Visibility
10 statute miles
Lowest ceiling
10,000 ft overcast
Temperature
3 °F, dew point -0 °F
Altimeter
30.00 inHg
Observed at
DBQ, 55 nm away

Docket · 12

The files NTSB released with the investigation on June 28, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.2 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.