DEN05FA045

NTSB accident investigation · Piper PA-31P · Gallup, NM · December 29, 2004

Accident · FatalField investigationFinal report
Date
December 29, 2004, 10:18 local (17:18 UTC)
Place
Gallup, NM
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N573BPiper PA-31P
Weather
Visual (VMC) · Day
Status
Completed · report October 27, 2005
Report
Approved by Office Director
Parties
Federal Aviation Administration, Hartzell Propeller, Inc., Textron Lycoming, The New Piper Aircraft, Inc.
FAA report
20041229033129A
Case key
60790

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

the pilot's failure to maintain minimum controllable airspeed which resulted in the loss of control, and impact with wires, a tree and terrain.

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 powerCruise
Engine shutdown - intentionalPilot in commandFactor
1 engine
Reason for occurrence undeterminedFactor
Engine assembly,valve lifter - unapproved part
Loss of control - in flightManeuvering
Precautionary landing - initiatedPilot in command
Aircraft control - not maintainedPilot in commandCause
Airspeed(vmc) - not maintainedPilot in commandFactor
In flight collision with objectDescent - uncontrolled
Object - wire,transmission
Object - tree(s)
Terrain condition - ground

Analysis

While maneuvering during a precautionary landing with the right engine shutdown, the airplane entered a Vmc roll and an uncontrolled descent, and impacted wires, trees, and terrain. According to air traffic control communications, while en route the pilot experienced a rough running right engine and performed a precautionary shutdown of the engine. The pilot elected to divert to an airport and received vectors from air traffic control for a visual approach. Witnesses who were located at the airport reported the airplane was on a normal downwind for the runway. When the airplane reached the approach end of the runway, the pilot turned to the right which was away from the airport. A witness who was monitoring the UNICOM frequency informed the pilot he was turning away from the airport and the pilot responded, "Busy." The airplane continued the right turn subsequently entered a Vmc roll and a rapid descent toward the terrain. The airplane wreckage was located on hilly, rocky terrain approximately 3 miles south of the airport. The airplane was fragmented and destroyed during the impact sequence and post-impact fire. Examination of the airframe and propellers revealed no anomalies that would have precluded normal operations. Examination of the left engine revealed the forward gearbox was destroyed and mechanical continuity of the rotating components and internal mechanisms was established. Examination of the right engine revealed the forward gearbox was destroyed and mechanical continuity of the rotating components and internal mechanisms was established. The reason for the reported rough running engine was not determined. The lifters installed in both engines during the overhauls were not approved lifters for the accident engines.

Factual narrative

History of flight

On December 29, 2004, at 1018 mountain standard time, a Piper PA-31P (Navajo) twin-engine airplane, N573B, was destroyed when it impacted transmission lines, trees and terrain following a loss of control while maneuvering near Gallup, New Mexico. The commercial pilot, who was the sole occupant, sustained fatal injuries. The airplane was registered to and operated by the pilot. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight. The flight departed Glendale Airport, Glendale, Arizona, at 0917, and was destined for Newton, Kansas.

According to the Glendale Federal Aviation Administration (FAA) control tower, the pilot received an IFR clearance to Newton, Kansas, at 0850. At 0915:16, prior to takeoff, the pilot stated, "...I got an engine that is running pretty hot, I'm gonna pull off here." At 0915:29, the pilot informed the controller he was going to taxi the airplane to the ramp to troubleshoot the problem. At 0915:52, the pilot stated, "I'm gonna make a quick phone call and I'll let you know what I want to do." At 0916:28, the pilot stated, "...once you get a little air movement past it looks like it's gonna be okay, I just do not want to hold too long. At 0917:16, the local controller cleared the pilot for takeoff.

According to the Albuquerque Air Route Traffic Control Center (ARTCC), the pilot reported he was on frequency, at 0928. At 1002:48, the pilot stated, "...I think I'm gonna do a precautionary shutdown of the right engine [I'd] like vectors to the [uh next] landing strip..." At 1703, the controller stated, "...understand [you're] shuttin down the uh right engine." The pilot confirmed the right engine shutdown, and requested vectors to the nearest airport. The controller informed the pilot of two landing locations, GUP and Black Rock Airport, near Zuni, New Mexico, which were approximately the same distance. The pilot chose GUP due to weather considerations. At 1007:38, the controller asked, "The heading is uh, I'm showin zero four zero at fifty two miles, able to make that?" The pilot acknowledged, "no problem..."

At 1013:34, the controller asked the pilot if emergency equipment was needed at GUP, and the pilot stated, "negative." At 1016:10, the controller informed the pilot the winds at GUP were at 170 degrees at 16 knots. At 1017, the pilot was cleared for the visual approach to GUP and shortly thereafter, the pilot was cleared to the GUP UNICOM frequency. No further communications were recorded between the pilot and the ARTCC controller.

Witnesses, who were located at the Gallup Municipal Airport, reported that Albuquerque ARTCC notified Gallup Flying Service, a local fixed based operator, that a Piper Navajo (PA-31P) was inbound with the right engine shut down due to a "rough running, shaking" engine. Shortly thereafter, the witnesses observed the airplane on a "normal downwind for runway 24." One witness communicated with the pilot on the UNICOM frequency, and the pilot indicated "he had things in control." When the airplane was near the approach end of runway 24, the witness observed the airplane turn right and heading away from the airport. The witness then contacted the pilot on the UNICOM frequency and informed him he was turning away from the airport. The pilot responded, "Busy." The witnesses observed the airplane continue the right turn, stall, and enter a rapid descent toward the terrain. One witness stated the airplane "went into a VMC roll to the right...the VMC roll developed fully into a vertical dive and remained so until the airplane impacted the ground." The witness who was monitoring the UNICOM frequency lost sight of the airplane behind a ridge line and then saw smoke.

A witness who lived near the accident site reported he heard something above his house and observed an airplane coming towards him. He heard engines "going on and off again." The airplane was flying straight, then turned sideways and went down. The witness could not tell if either engine was operating.

According to the pilot's friends and relatives, the accident flight engine shutdown was the third or fourth engine shutdown the pilot performed since he purchased the airplane in August 2004.

Personnel information

The pilot held a commercial pilot certificate, issued on April 22, 1989, with single-engine land, multi-engine land, and instrument airplane ratings. The pilot was issued a second-class medical certificate on September 14, 2004, with a limitation for corrective lenses.

According to the pilot's personal logbook, as of the last entry dated December 23, 2004, the pilot had accumulated 935 total flight hours, 849 hours as pilot-in-command, and 470 hours in multi-engine airplanes. The pilot had logged 45 hours in the accident airplane. In the preceding 90 days, the pilot had logged 27 total flight hours, of which 10 hours were in the accident airplane, and in the preceding 30 days, he logged 10 total flight hours, of which 4 hours were in the accident airplane.

On June 9, 2004, the pilot completed an instrument proficiency check, pilot proficiency award program (WINGS Phase II), and a high altitude airplane endorsement at Flight Safety International, Lakeland, Florida. On July 7-16, 2004, the pilot completed 16 hours of instruction in a Piper Navajo simulator at Flight Safety International.

Aircraft information

The accident airplane, N573B, a Piper PA-31P, serial number 31P-7530008, was manufactured by Piper Aircraft Corporation in 1975. The Piper PA-31P is a pressurized twin-engine, low wing, all metal airplane of semimonocoque design. The airplane was powered by two six-cylinder, air cooled, geared propeller reduction, horizontally opposed, turbocharged, fuel injected, internal combustion engines.

The airplane was issued a FAA Standard Airworthiness Certificate on December 23, 1974, and was certificated for normal category operations. The airplane was registered to the pilot on August 28, 2004. A review of the airplane's maintenance records revealed the airframe underwent a recent annual inspection on July 30, 2004, at a total airframe time of 6,773.1 hours, and a Hobbs meter time of 1,270.7 hours. On December 23, 2004, at an hour meter time of 1,319.7, the airframe's air conditioning system was serviced, and an emergency locator transmitter (ELT) check was performed.

The left engine, a Lycoming TIGO-541-E1A (serial number RL-753-62) engine rated at 425 horsepower, underwent a major overhaul and was installed on the airframe on May 3, 2004, at a total time of 2,182 hours, and a Hobbs meter time of 1,198.6 hours. The engine's most recent 100-hour inspection was completed on July 30, 2004, at a total time of 2,256 hours and 74.1 hours since major overhaul.

A mechanic and friend of the pilot reported that during a flight on December 13, 2004, the pilot experienced a violent vibration with the left engine while on final approach to the Glendale Airport. At the time of the event, the left engine had accumulated approximately 120 hours since major overhaul. Examination of the engine revealed the number 4 cylinder exhaust valve cap and keeper were broken, and the exhaust valve was loose. According to the maintenance logbook entry dated December 18, 2004, the mechanic "removed the #4 cylinder assembly on the #1 engine due to lifter failure." Per instructions from the facility that completed the engine overhaul, the mechanic installed a serviceable cylinder assembly and installed new lifters (12) on all six cylinders. The mechanic and pilot test ran the engine and no anomalies were noted.

The left propeller was a three-bladed Hartzell HC-C3YN-2LUF (hub serial number DG663B) single acting, hydraulically operated constant speed model with feathering capability. The propeller was overhauled and installed on the airplane

Aircraft

Registration
N573B
Reported as
Piper PA-31P
Category
Airplane
Serial number
31P-7530008
Airframe hours
6,773.1
Engines
Lycoming TIGO-541-E1A, 425 horsepower, reciprocatingLycoming TIGO-541-E1A, 425 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Ronald L. Patton
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 1, 2004 · 49 hours before
Departed
GEU · Glendale, AZ
Destination
EWK · Newton, KS
Flight plan
IFR
Airport
GUP · Gallup Municipal

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
50
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 1, 2004
Seat
Left
Toxicology
Performed
Flight hours
936 total · 62 in this make and model · 850 as pilot in command · 27 in the last 90 days · 10 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 15 knots, gusting 21
Visibility
10 statute miles
Lowest ceiling
7,500 ft broken
Temperature
48 °F, dew point 37 °F
Altimeter
29.98 inHg
Observed at
GUP, 2 nm away

Docket · 37

The files NTSB released with the investigation on July 25, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 35.4 MB in all.

Email Correspondence from PilotItem 1 · .PDF · 98 KBATC StatementsItem 2 · .PDF · 190 KBWitness StatementsItem 3 · .PDF · 299 KBMechanic StatementItem 4 · .PDF · 69 KBAccident Site DiagramItem 5 · .PDF · 34 KBWeather Reports and RecordsItem 6 · .PDF · 54 KBATC TranscriptsItem 7 · .PDF · 472 KBExcerpts of Airframe Accident ReportItem 8 · .PDF · 186 KBExcerpts of Engine Accident ReportItem 9 · .PDF · 800 KBComponent Exam ReportItem 10 · .PDF · 7.5 MBExcerpt of Pilot LogbookItem 11 · .PDF · 14.6 MBExcerpt of Airframe LogbookItem 12 · .PDF · 838 KBExcerpts of Left Engine LogbookItem 13 · .PDF · 495 KBExcerpts of Left Propeller LogbookItem 14 · .PDF · 254 KBExcerpts of Right Engine LogbookItem 15 · .PDF · 407 KBExcerpts of Right Propeller LogbookItem 16 · .PDF · 161 KBStatement of Party Representatives to NTSB InvestigationItem 17 · .PDF · 59 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 18 · .PDF · 96 KBToxicological ReportItem 19 · .PDF · 73 KBPhoto #1 - View of Accident SiteItem 20 · .PDF · 486 KBPhoto #2 - View of Section of Right WingItem 21 · .PDF · 523 KBPhoto #3 - View of Accident Site (Lycoming)Item 22 · .PDF · 496 KBPhoto #4 - View of Accident SiteItem 23 · .PDF · 493 KBPhoto #5 - View of Accident SiteItem 24 · .PDF · 475 KBPhoto #6 - View of Accident SiteItem 25 · .PDF · 456 KBPhoto # 7 - View of Accident SiteItem 26 · .PDF · 516 KBPhoto # 8 - View of Accident SiteItem 27 · .PDF · 516 KBPhoto # 9 - View of Accident SiteItem 28 · .PDF · 483 KBPhoto #10 - View of Accident SiteItem 29 · .PDF · 520 KBPhot0 #11 - View of Left Engine (Lycoming)Item 30 · .PDF · 525 KBPhoto #12 - View of Left Engine (Lycoming)Item 31 · .PDF · 514 KBPhoto #13 - View of Left Turbocharger Impeller and ShroudItem 32 · .PDF · 454 KBPhoto #14 - View of Left Propeller (Hartzell)Item 33 · .PDF · 486 KBPhoto #15 - View of Fractured Blade (Hartzell)Item 34 · .PDF · 309 KBPhoto #16 - View of Right Engine (Lycoming)Item 35 · .PDF · 513 KBPhoto #17 - View of Left Turbocharger Shroud (Lycoming)Item 36 · .PDF · 493 KBPhoto #18 - View of Left PropellerItem 37 · .PDF · 511 KB

FAA reports on this event · 1

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