# NTSB ERA10LA162: Piper PA-34-200T, N103GK, Vero Beach, FL, March 5, 2010

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: March 5, 2010, 14:37 local (19:37 UTC)
- Place: Vero Beach, FL
- Coordinates: 27.655555, -80.417778 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=27.6556&lon=-80.4178&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-VFR pattern downwind: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Serious injuries
- Injuries: 2 serious
- Status: Completed, report November 17, 2011
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: Continental Engines, FAA/FSDO, Piper Aircraft Company
- NTSB case key (mKey): 75444
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA162
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75444/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75444
- Page: https://openairdocs.org/ntsb/ERA10LA162

## Probable cause

The certified flight instructor's failure to monitor the airspeed while the student performed a single-engine approach.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA-34-200T, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7103406), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-34-200T, 3 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7103406), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md)
- [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-34-200T, 3 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7103406), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [Piper PA-34-200T, 1 case](https://openairdocs.org/ntsb-events/600/sequence.md?model=7103406), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md)
- [Approach-VFR pattern downwind: Altitude deviation](https://openairdocs.org/ntsb-events/282); cases with it: [Piper PA-34-200T, 2 cases](https://openairdocs.org/ntsb-events/282/sequence.md?model=7103406), [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/282/sequence.md)
- [Approach-VFR pattern downwind: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-34-200T, 7 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7103406), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-34-200T, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103406), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The certified flight instructor (CFI) and student had completed several multiengine maneuvers at altitude including single-engine procedures. During the approach, the CFI retarded the left throttle to simulate an engine failure, and the student correctly identified the affected engine. The CFI then set zero thrust on the left engine, and the student continued the approach, utilizing the right engine. On the downwind leg of the traffic pattern, the CFI noted that the altitude had dropped to about 500 to 650 feet above ground level and took control of the airplane. He stated that he added power on both engines; however, no increase in power was noted on either engine. The CFI attempted to troubleshoot the problem but, due to the low altitude, he elected to perform a forced landing; the airplane collided with trees and sustained substantial damage. A postaccident examination of the airplane and both engines and reports from the CFI did not reveal any mechanical malfunctions that would have precluded normal operation. It is likely that the CFI allowed the airspeed to decrease below the minimum controllable speed for single-engine operations.

## Factual narrative

On March 5, 2010, at 1437 eastern standard time, a Piper PA-34-200T, N103GK, received substantial damage when it collided with trees while on approach to Vero Beach Municipal Airport (VRB), Vero Beach, Florida. The certificated flight instructor (CFI) and the commercial-rated student pilot received serious injuries. Visual meteorological conditions prevailed and no flight plan was filed for the local, instructional flight. The airplane was registered to Lois Aviation LLC and operated by Paris Air, Incorporated under the provisions of 14 Code of Federal Regulations Part 91. The flight originated from VRB about 1320. According to the owner of Paris Air, Inc., the purpose of the flight was instructional and when asked when the last time the airplane was fueled, he stated that it was topped off with 51 gallons of fuel just prior to the accident flight. According to the CFI, the flight departed VRB, with full fuel tanks for a local training flight on multiengine procedures. Beginning with power-on and -off stalls, slow flight, and single engine demonstrations, he then contacted Miami Center for a visual practice approach. They were instructed to fly the Global Positioning System (GPS) approach to runway 11R, then circle to land runway 4. The throttle was pulled back to idle to simulate a left engine failure. The student correctly identified and verified the engine and the CFI set zero thrust on the left engine while continuing on the right downwind for runway 4. The CFI said that at that time he noticed that they had lost altitude when at midfield downwind for runway 4. The airplane continued losing altitude until about 500 and 650 feet above ground level (AGL). The CFI took the controls in response to the altitude loss and attempted to add power to the left engine and operative right engine with no noted increase in power from either engine. When they approached the right base turn for runway 4, the CFI began searching for a place to put the airplane down for a forced landing. The airplane, as the CFI could best estimate, was at about 400 feet agl at this time and sinking rapidly with partial controllability to maneuver the airplane to where it finally impacted the trees. Examination of the accident site by a Federal Aviation Administration (FAA) inspector and a representative from Piper Aircraft revealed that the airplane was impaled on a large tree limb that penetrated the airplane’s floor at the right crew seat position; rising up between the right seat occupant’s leg area and exiting the forward cabin door window. The trees in contact with the airplane were also in contact with overhead power lines and in turn were providing an electrical charge to the airframe. Power to the residential area was subsequently turned off to allow first responders and investigators to proceed unimpeded and to eliminate a possible ignition source for leaking fuel which pooled in a shallow ditch adjacent to the airplane’s left wing. Once the two occupants wereremoved, the accident site was shut-down for the evening. The following morning examination of the wreckage revealed that the airplane had come to rest in the upright position. Broken tree limbs came to rest on top of the wreckage. The nose cone was separated and damaged. The left side of the windshield was destroyed. The top and bottom cabin area had impact damage. All engine control levers were full forward. Both control yokes were turned to the right. The electrical switches on the pilot’s left side panel were all in the off position except for the magneto switches which were all in the on position. The flap handle was in the flaps up position. The nose gear was down and in the locked position. The landing gear lever was in the up position. The fuel selector valves were both found in the crossfeed position. Flight control continuity was established from the flight control surfaces to their respective cockpit controls except for impact-related separations. The pilot reported no anomalies with the airframe and none were noted during the examination. Both engines were transported to Air & Sea Recovery in Fort Pierce, Florida, for further examination. On May 28, 2010, representatives from the FAA, Teledyne Continental Motors, and Piper Aircraft were present during the examinations. The right engine was found separated from the airframe and placed on a rack. The three-bladed constant speed propeller remained attached to the crankshaft flange. All of the cylinders and accessories remained attached to the crankcase. The oil dip stick revealed oil present in the engine. All damage observed was consistent with the impact. The fuel manifold valve exhibited a lead seal and was safety wired. The fuel manifold valve was disassembled and a liquid with an odor consistent with that of aviation fuel was observed. The fuel manifold valve screen exhibited no obstructions or debris. No indication of fuel leakage was observed in the vent chamber side of the diaphragm. No damage was observed to the fuel manifold valve body or diaphragm, and the plunger and diaphragm retaining nut were tight and secure. The exhaust system was damaged. The induction system was intact. The impulse coupling engagement was observed from both left and right magnetos and a blue spark was observed at all ignition leads when the crankshaft was turned by hand with the propeller. The ignition harness was intact. The top spark plugs exhibited normal operating signatures in accordance with the Champion Aviation Check-a-Plug comparison chart. The bottom spark plugs were inspected using a light borescope and exhibited normal operating signatures in accordance. The fuel pump mixture control cable remained attached to the fuel pump mixture control lever, which exhibited damage. The fuel pump mixture control lever was observed near the mid-travel position, and moved freely by hand. The fuel pump was removed from the engine and examined. An undetermined quantity of liquid with an odor consistentwith that of aviation fuel was observed when the fuel pump outlet fuel line was removed. No indication of water in the liquid was observed when water indication paste was applied. The fuel pump drive shaft rotated freely when turned by hand. The fuel pump drive coupling was intact. A lead seal and safety wire were present. The fuel pump functioned through its full range of operation when the fuel pump drive shaft was turned using a hand tool. The right propeller governor control cable remained attached to the propeller governor control arm, which was observed near the mid-travel position. All three blades were loose in the hub, and exhibited leading edge damage. Propeller blade number 3 exhibited a twisting bend. The inspection of the engine did not reveal any anomalies that would have prevented the ability to produce rated horsepower. The left engine was found separated from the airframe and placed on a rack. The three-bladed constant speed propeller remained attached to the crankshaft flange. All of the cylinders and accessories remained attached to the crankcase. The oil dip stick revealed oil present in the engine. All damage observed was consistent with the impact. The fuel manifold valve exhibited a lead seal and was safety wired. The fuel manifold valve was disassembled and a liquid with an odor consistent with that of aviation fuel was observed. The fuel manifold valve screen exhibited no obstructions or debris. No indication of fuel leakage was observed in the vent chamber side of the diaphragm. No damage was observed to the fuel manifold valve body or diaphragm, and the plunger and diaphragm retaining nut was tight and secure. The exhaust system was damaged. The induction system was intact. The impulse coupling engagement was observed from both left and right magnetos and a blue spark was observed at all ignition leads when the crankshaft was turned by hand with the propeller. The ignition harness was intact. The top spark plugs exhibited normal operating signatures.. The bottom spark plugs were inspected using a light borescope and exhibited normal operating signatures. No anomalies with the engines were noted during the examination. The airplane was equipped with an engine data monitor (EDM) which was sent to the National Transportation Safety Board’s Vehicle Recorder Division in Washington, DC, for examination. The J.P. Instruments EDM-760 was a panel-mounted gauge that the operator could monitor and record up to 24 parameters related to twin engine operations. The accident flight data, covered a time period from 13:23:44 to 14:37:22. Five power cycles were recorded in the data and were noted in the plot with “Data On” and “Data Off.” During the flight, two events were recorded that showed power being reduced to the left engine and then subsequently power being reapplied. At the end of the recorded data, the data recorded a power reduction in the right engine. The data did not record a reapplication of power to the right engineprior to the end of the recorded data. A review of the Pilot’s Operating Handbook, Section 3, Emergency Procedures, Single engine landing, stated in part: “Maintain additional altitude and speed during approach, keeping in mind that landing should be made right the first time and that a go-around should be avoided if at all possible. A final approach speed of 91 knots indicated air speed (KIAS) and the use of 25-degree rather than full wing flaps will place the airplane in the best configuration for a go-around should this be necessary. Under some conditions of loading and density altitude a go-around may be impossible, and in any event the sudden application of power during single engine operation makes control of the airplane more difficult. A single engine go around should be avoided if at all possible.” In addition, under Section 4, Normal Procedures, Paragraph 4.50 VSSE-Intentional one engine inoperative speed: “Vsse is a speed selected by the aircraft manufacturer as a training aid for pilots in the handling of multi-engine aircraft. It is the minimum speed for intentionally rendering one engine inoperative in flight. This minimum speed provides a margin the manufacturer recommends for use when intentionally performing engine inoperative maneuvers during training in the particular airplane. The intentional one engine inoperative speed, Vsse, for the Seneca II is 76 KIAS.” Paragraph 4.51, VMC-Minimum Single Engine Control Speed: “Vmc is airspeed below which a twin-engine aircraft cannot be controlled in flight with one engine operating at takeoff power and the other engine wind milling. Vmc for the Seneca II has been determined to be 66 KIAS. Under no circumstances should an attempt be made to fly at a speed below this Vmc with only one engine operating. As a safety precaution, when operating under single-engine flight conditions either in training or in emergency situations, maintain an indicated airspeed above 76 KIAS, Vsse. Reduce airspeed approximately 1 knot per second until Vmc is reached. The Vmc demonstration required for the FAA flight test for the multi-engine rating approaches an uncontrolled flight condition with power reduced on one engine. The demonstration should not be performed at an altitude of less than 3500 feet above the ground. Initiate recovery during the demonstration by immediately reducing power on the operating engine and promptly lowering the nose of the airplane to accelerate to Vsse.”

## Aircraft

- Registration: [N103GK](https://openairdocs.org/deregistered/N103GK-2013-05-06), registration cancelled 2013-05-06, S/N 347970330, built 1979 (OpenAirDocs)
- Reported make and model: PIPER PA-34-200T
- Registry model: [Piper PA-34-200T](https://openairdocs.org/model/piper-pa-34-200t) (registry code 7103406) (OpenAirDocs)
- Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 347970330
- Airframe hours: 5640
- Engines: CONT MOTOR TSIO-360 SER 225 horsepower reciprocating; CONT MOTOR TSIO-360 SER 225 horsepower reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Operator: Paris Air, Inc
- Registered owner: Lois Aviation LLC
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, January 12, 2010, 15 hours before
- Departed: VRB, Vero Beach, FL
- Destination: VRB, Vero Beach, FL
- Airport: VRB, Vero Beach Municipal Airport

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor; age 28; injuries: serious; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review December 20, 2008; seat: right; flight hours: 1,928 total, 18 in this make and model, 1,758 as pilot in command, 120 in the last 90 days, 60 in the last 30 days, 0 in the last 24 hours
- Student pilot; age 22; injuries: serious; private, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review February 18, 2010; seat: left; flight hours: 223 total, 0 in this make and model, 147 as pilot in command, 9 in the last 90 days, 9 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 40° at 9 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 61 °F, dew point 36 °F
- Altimeter: 30.05 inHg
- Observed at: VRB, 1 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 20100305030599A](https://openairdocs.org/incident/20100305030599A), Mar 5, 2010: Piper PA-34-200T, Vero Beach, FL, Destroyed. On March 5, 2010, N103GK, a Piper seneca ii (PA-34-200T) crashed in a neighborbood, about one mile south of the Vero Beach municipal airport. An eyewitness…

## Docket (8 files)

The files NTSB released with the investigation on September 29, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75444. 1.9 MB in all.

- Engine Data Monitor (EDM) - Specialist's Factual Report (item 1, .PDF, 265 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40337906&FileExtension=.PDF&FileName=Engine%20Data%20Monitor%20(EDM)%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- Engine Data Monitor (EDM) - Attachment 1 - Tabular Data - Flight - (CSV Format) (item 2, .CSV, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40337907&FileExtension=.csv&FileName=Engine%20Data%20Monitor%20(EDM)%20-%20Attachment%201%20-%20Tabular%20Data%20-%20Flight%20-%20(CSV%20Format)-Master.csv
- Correspondence; Memorandom of Record, Flight School Owner. (item 3, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352544&FileExtension=.PDF&FileName=Correspondence;%20Memorandom%20of%20Record,%20Flight%20School%20Owner.-Master.PDF
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 4, .PDF, 453 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352545&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352546&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Other Pertinent Forms and Reports; Piper Seneca II, POH. (item 6, .PDF, 670 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352547&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports;%20Piper%20Seneca%20II,%20POH.-Master.PDF
- Reports from Local Agencies; Police Incident Report. (item 7, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352548&FileExtension=.PDF&FileName=Reports%20from%20Local%20Agencies;%20Police%20Incident%20Report.-Redacted.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 248 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352549&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.

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