CHI98LA011

NTSB accident investigation · Piper PA-23-250 · Charlotte, MI · October 9, 1997

Accident · Minor injuriesLimited investigationFinal report
Date
October 9, 1997, 10:17 local (14:17 UTC)
Place
Charlotte, MI
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N54738Piper PA-23-250
Weather
Visual (VMC) · Day
Status
Completed · report May 21, 1998
Report
Approved by Office Director
FAA report
19971009031169A
Case key
10762

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

improper positioning of the fuel selector by the second pilot, which resulted in fuel starvation; inadequate supervision by the pilot-in-command; and failure of the flight crew to follow the published emergency procedures for loss of engine power.

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.

Loss of engine power(total) - nonmechanicalCruise
All engines
Fuel system,selector/valve - switched off
Fuel tank selector position - improperCopilot/second pilotCause
Fluid,fuel - starvationCause
Supervision - inadequatePilot in commandCause
Forced landingEmergency descent/landing
Emergency procedure - not followedFlightcrewCause
In flight collision with terrain/waterEmergency landing
On ground/water collision with objectEmergency landing
Object - tree(s)Factor

Analysis

The left-seat pilot stated that before takeoff, the fuel selectors for both engines were set to the 'INBOARD' detents. The cowl flap selectors, located forward of the fuel selectors on the same floor mounted console, were both set to the 'OPEN' positions. At approximately 1200-1300 feet AGL, the co-pilot began to transition the aircraft from climb to cruise, and initiated action to close the cowl flaps. Shortly thereafter, both engines lost total power simultaneously. In attempts to restart the engines, the pilot-in-command tried varying the power level positions, adjusting the mixture control, and turning the fuel pumps on and off. He decided to initiate a forced landing in a soybean field. During the subsequent forced landing, the airplane touched down approximately 150 feet from the end of the field. The airplane slid across the bean field, collided with trees, and came to rest. Examination of the cockpit revealed both fuel selectors to be in the middle position, indicating 'OFF.' The cowl flap selectors were both in the full up and aft position, indicating 'OPEN.' Both pilots stated that the cowl flap selectors were set to the 'OPEN' position during takeoff and climb. The co-pilot stated that he moved the cowl flap selectors to the middle, or 'trail' position, shortly before both engines failed. Neither pilot remembered touching the fuel selectors at any time after takeoff.

Factual narrative

On October 9, 1997, at 1017 eastern daylight time (edt), a Piper PA-23-250 Aztec, N54738, operated by an airline transport pilot, lost total engine power on both engines shortly after takeoff from Fitch H. Beach Airport, near Charlotte, Michigan. The airplane was substantially damaged during the subsequent forced landing. Both the pilot-in-command and the pilot-rated passenger received minor injuries. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under 14 CFR Part 91 and no flight plan was on file. The local flight departed Fitch H. Beach Airport at 1010 edt.

The accident flight was being conducted as a pre-purchase demonstration flight. The multi-engine rated left-seat occupant was being shown the airplane, which was under the authority of the Airline Transport Pilot (ATP) certificated right-seat occupant. In their respective statements, both pilots attest to completing a thorough preflight, which included an extensive discussion about the fuel system. According to the left-seat pilot, prior to takeoff the fuel selectors were set to the 'INBOARD' detents, and the pressure crossfeed was set to the 'OFF' position. The cowl flap selectors, located forward of the fuel selectors on the same floor mounted console, were both set to the 'OPEN' positions.

During taxi, takeoff, climb, and cruise, the left-seat pilot was the pilot flying (co-pilot) and the right-seat ATP was the pilot not flying (PIC). According to the PIC, the co-pilot demonstrated a "...good knowledge of the turbo operating characteristics, maintained excellent directional control...and after rotation began a smooth acceleration for blue line." At about 500' above ground level (AGL), the PIC performed a visual scan of the engine instruments. He stated that the "...engine and fuel gauges at that time...were in the green with the tanks indicating full." At approximately 1200-1300 feet AGL, the co-pilot began to transition the aircraft from climb to cruise. At which time, he stated that he closed the cowl flaps. Shortly thereafter, both engines lost total power simultaneously. At this time, the manipulation of the flight controls was transferred to the pilot-in-command. In an attempt to restart the engines, the PIC tried varying the power level positions, adjusting the mixture control, and turning the fuel pumps on and off. In a written statement, the PIC reported that he "...decided to leave both engines wind-milling...while working on engine restart procedures." During the emergency descent, the PIC determined that the airplane would not make the landing site initially chosen due to tree obstruction on the near side of the field. He decided to land prior to the trees, in a soybean field. During the subsequent forced landing, the airplane touched down approximately 150 feet from the end of the field. The airplane slid across the bean field until colliding with trees and coming to rest. The PIC reported that the airplane was configured with the flaps up, landing gear retracted, and propellers unfeathered during the forced landing sequence.

The damage to the airplane prevented the left-seat occupant from exiting the aircraft. The left wing at the leading edge root had penetrated the fuselage, pinning his left leg. The airplane's right wing leading edge, inboard of the engine, impacted a tree approximately 1 foot in diameter. The fuel tanks were inspected and found to have ample fuel in the main tanks. Both the pilots and a fueler indicated to a Federal Aviation Administration (FAA) Inspector that 85 gallons of fuel had been pumped into the Aztec the day of the accident flight. The main fuel lines for both engines were removed at the firewall and were found to be without any fuel. The fuel flow dividers on both engines were inspected and were also found to be without fuel. An examination of the engine revealed no anomalies. The spark plugs were found to be in good condition. Each cylinder was found to have compression, and both engines demonstrated mechanical continuity. Flight control surfaces were examined for control continuity and found to be operational.

An examination of the cockpit revealed both fuel selectors to be in the middle position, indicating 'OFF.' The cowl flap selectors were both in the full up and aft position, indicating 'OPEN.' Both pilots stated that the cowl flap selectors were set to the 'OPEN' position during takeoff and climb. The co-pilot stated that he moved the cowl flap selectors to the middle, or 'trail' position, shortly before both engines failed. Both pilots told the FAA that neither one touched the fuel selectors at any time after takeoff; this included climb, cruise, emergency descent, and after the crash. According to the FAA-approved Piper PA-23-250 checklist, the 'Engine Inoperative Procedures' checklist calls for the fuel selector to be set to the 'OFF' detent. The 'Engine Failure During Flight' checklist calls for the fuel selector to be switched to the other tank.

Aircraft

Registration
N54738
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-7554052
Airframe hours
3,217
Engine
Lycoming TIO-540, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Glenn Douglas Leonard
Registered owner
Bill M. Kelly
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 10, 1997
Departed
07G
Destination
07G
Airport
07G · Fitch H Beach, runway 20, 3,500 × 75 ft, concrete

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
48
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
7,236 total · 55 in this make and model · 6,254 as pilot in command · 15 in the last 90 days · 7 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 6 knots
Visibility
10 statute miles
Lowest ceiling
6,000 ft broken
Temperature
70 °F, dew point 61 °F
Altimeter
30.00 inHg
Observed at
TEW

FAA reports on this event · 1

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