# NTSB DEN05FA045: Piper PA-31P, N573B, Gallup, NM, December 29, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 29, 2004, 10:18 local (17:18 UTC) - Place: Gallup, NM - Coordinates: 35.474998, -108.747222 - Nearby events: https://openairdocs.org/map.md?lat=35.4750&lon=-108.7472&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - 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. - NTSB case key (mKey): 60790 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN05FA045 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60790/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60790 - Page: https://openairdocs.org/ntsb/DEN05FA045 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, cruise - engine shutdown - intentional, pilot in command (contributing factor) - 1 engine - reason for occurrence undetermined (contributing factor) - engine assembly,valve lifter - unapproved part - Loss of control - in flight, maneuvering - precautionary landing - initiated, pilot in command - aircraft control - not maintained, pilot in command (cause) - airspeed(vmc) - not maintained, pilot in command (contributing factor) - In flight collision with object, descent - 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](https://openairdocs.org/deregistered/N573B-2006-08-09), registration cancelled 2006-08-09, S/N 31P-7530008, built 1974 (OpenAirDocs) - Reported make and model: Piper PA-31P - Registry model: [Piper PA-31P](https://openairdocs.org/model/piper-pa-31p) (registry code 7103120) (OpenAirDocs) - Registry engine: [Lycoming TIGO-541SER](https://openairdocs.org/engine/lycoming-tigo-541ser) (registry code 41539, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 31P-7530008 - Airframe hours: 6773.1 - Engines: Lycoming TIGO-541-E1A 425 horsepower reciprocating; Lycoming 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; 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 ## 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 20041229033129A](https://openairdocs.org/incident/20041229033129A), Dec 29, 2004: Piper PA31P, Gallup, NM, Destroyed, 1 fatal. (-23) On December 29, 2004 at 1030 MST, a Piper PA-31P, N573B registered to the pilot [privacy data omitted] crashed 1 1/2 miles south of runway 24 while… ## Docket (37 files) The files NTSB released with the investigation on July 25, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60790. 35.4 MB in all. - Email Correspondence from Pilot (item 1, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234900&FileExtension=.PDF&FileName=Email%20Correspondence%20from%20Pilot-Master.PDF - ATC Statements (item 2, .PDF, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409390&FileExtension=.PDF&FileName=ATC%20Statements-Redacted.PDF - Witness Statements (item 3, .PDF, 299 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409391&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Mechanic Statement (item 4, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234903&FileExtension=.PDF&FileName=Mechanic%20Statement-Master.PDF - Accident Site Diagram (item 5, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234904&FileExtension=.PDF&FileName=Accident%20Site%20Diagram-Master.PDF - Weather Reports and Records (item 6, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234905&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - ATC Transcripts (item 7, .PDF, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409392&FileExtension=.PDF&FileName=ATC%20Transcripts-Redacted.PDF - Excerpts of Airframe Accident Report (item 8, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234907&FileExtension=.PDF&FileName=Excerpts%20of%20Airframe%20Accident%20Report-Master.PDF - Excerpts of Engine Accident Report (item 9, .PDF, 800 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234909&FileExtension=.PDF&FileName=Excerpts%20of%20Engine%20Accident%20Report-Master.PDF - Component Exam Report (item 10, .PDF, 7.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409393&FileExtension=.PDF&FileName=Component%20Exam%20Report-Redacted.PDF - Excerpt of Pilot Logbook (item 11, .PDF, 14.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409394&FileExtension=.PDF&FileName=Excerpt%20of%20Pilot%20Logbook-Redacted.PDF - Excerpt of Airframe Logbook (item 12, .PDF, 838 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409396&FileExtension=.PDF&FileName=Excerpt%20of%20Airframe%20Logbook-Redacted.PDF - Excerpts of Left Engine Logbook (item 13, .PDF, 495 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409397&FileExtension=.PDF&FileName=Excerpts%20of%20Left%20Engine%20Logbook-Redacted.PDF - Excerpts of Left Propeller Logbook (item 14, .PDF, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409398&FileExtension=.PDF&FileName=Excerpts%20of%20Left%20Propeller%20Logbook-Redacted.PDF - Excerpts of Right Engine Logbook (item 15, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409399&FileExtension=.PDF&FileName=Excerpts%20of%20Right%20Engine%20Logbook-Redacted.PDF - Excerpts of Right Propeller Logbook (item 16, .PDF, 161 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409401&FileExtension=.PDF&FileName=Excerpts%20of%20Right%20Propeller%20Logbook-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 17, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409403&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 18, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409405&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 19, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409408&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo #1 - View of Accident Site (item 20, .PDF, 486 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234923&FileExtension=.PDF&FileName=Photo%20%231%20-%20View%20of%20Accident%20Site-Master.PDF - Photo #2 - View of Section of Right Wing (item 21, .PDF, 523 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234924&FileExtension=.PDF&FileName=Photo%20%232%20-%20View%20of%20Section%20of%20Right%20Wing-Master.PDF - Photo #3 - View of Accident Site (Lycoming) (item 22, .PDF, 496 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234925&FileExtension=.PDF&FileName=Photo%20%233%20-%20View%20of%20Accident%20Site%20(Lycoming)-Master.PDF - Photo #4 - View of Accident Site (item 23, .PDF, 493 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234926&FileExtension=.PDF&FileName=Photo%20%234%20-%20View%20of%20Accident%20Site-Master.PDF - Photo #5 - View of Accident Site (item 24, .PDF, 475 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234927&FileExtension=.PDF&FileName=Photo%20%235%20-%20View%20of%20Accident%20Site-Master.PDF - Photo #6 - View of Accident Site (item 25, .PDF, 456 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234928&FileExtension=.PDF&FileName=Photo%20%236%20-%20View%20of%20Accident%20Site-Master.PDF - Photo # 7 - View of Accident Site (item 26, .PDF, 516 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234929&FileExtension=.PDF&FileName=Photo%20%23%207%20-%20View%20of%20Accident%20Site-Master.PDF - Photo # 8 - View of Accident Site (item 27, .PDF, 516 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234930&FileExtension=.PDF&FileName=Photo%20%23%208%20-%20View%20of%20Accident%20Site-Master.PDF - Photo # 9 - View of Accident Site (item 28, .PDF, 483 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234931&FileExtension=.PDF&FileName=Photo%20%23%209%20-%20View%20of%20Accident%20Site-Master.PDF - Photo #10 - View of Accident Site (item 29, .PDF, 520 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234933&FileExtension=.PDF&FileName=Photo%20%2310%20-%20View%20of%20Accident%20Site-Master.PDF - Phot0 #11 - View of Left Engine (Lycoming) (item 30, .PDF, 525 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234935&FileExtension=.PDF&FileName=Phot0%20%2311%20-%20%20View%20of%20Left%20Engine%20(Lycoming)-Master.PDF - Photo #12 - View of Left Engine (Lycoming) (item 31, .PDF, 514 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234936&FileExtension=.PDF&FileName=Photo%20%2312%20-%20View%20of%20Left%20Engine%20(Lycoming)-Master.PDF - Photo #13 - View of Left Turbocharger Impeller and Shroud (item 32, .PDF, 454 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234937&FileExtension=.PDF&FileName=Photo%20%2313%20-%20View%20of%20Left%20Turbocharger%20Impeller%20and%20Shroud-Master.PDF - Photo #14 - View of Left Propeller (Hartzell) (item 33, .PDF, 486 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234939&FileExtension=.PDF&FileName=Photo%20%2314%20-%20View%20of%20Left%20Propeller%20(Hartzell)-Master.PDF - Photo #15 - View of Fractured Blade (Hartzell) (item 34, .PDF, 309 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234942&FileExtension=.PDF&FileName=Photo%20%2315%20-%20View%20of%20Fractured%20Blade%20(Hartzell)-Master.PDF - Photo #16 - View of Right Engine (Lycoming) (item 35, .PDF, 513 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234943&FileExtension=.PDF&FileName=Photo%20%2316%20-%20View%20of%20Right%20Engine%20(Lycoming)-Master.PDF - Photo #17 - View of Left Turbocharger Shroud (Lycoming) (item 36, .PDF, 493 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234944&FileExtension=.PDF&FileName=Photo%20%2317%20-%20View%20of%20Left%20Turbocharger%20Shroud%20(Lycoming)-Master.PDF - Photo #18 - View of Left Propeller (item 37, .PDF, 511 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234948&FileExtension=.PDF&FileName=Photo%20%2318%20-%20View%20of%20Left%20Propeller-Master.PDF 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.