ERA12FA423

NTSB accident investigation · Piper PA-31P · Dalton, GA · June 30, 2012

Accident · FatalField investigationFinal report
Date
June 30, 2012, 16:20 local (20:20 UTC)
Place
Dalton, GA
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N33CGPiper PA-31P
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report September 5, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Hartzell Propeller, Textron Lycoming, Piper
FAA report
20120630017259A
Case key
84132

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s failure to maintain airplane control following loss of power in the right engine for reasons that could not be determined because of fire and impact damage. Contributing to the accident was the pilot’s delayed feathering of the right propeller following the loss of engine power and the lack of specific emergency procedures in the pilot operating handbook indicating the need to feather the propellers before engine rpm falls below 1,000 rpm.

Findings · 7

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating)Aircraft › Aircraft power plant · FailurePiper PA-31P: 2 casesAll aircraft: 497 cases
Not determinedNot determined › Not determined · Unknown/Not determinedPiper PA-31P: 3 casesAll aircraft: 2,247 cases
Propeller system: propeller feather/reversingAircraft › Aircraft propeller/rotor · Incorrect use/operationPiper PA-31P: 1 caseAll aircraft: 26 casesProbable cause
Policy/procedure: adequacy of policy/procOrganizational issues › Management · ManufacturerPiper PA-31P: 1 caseAll aircraft: 106 casesProbable cause
Action: delayed actionPersonnel issues › Action/decision · PilotPiper PA-31P: 1 caseAll aircraft: 894 casesProbable cause
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Attain/maintain not possiblePiper PA-31P: 1 caseAll aircraft: 1,310 casesProbable cause
Power plantAircraft › Aircraft power plant · Not serviced/maintainedPiper PA-31P: 1 caseAll aircraft: 198 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

According to a friend of the pilot, the pilot was taking the airplane to have an annual inspection completed. The friend assisted the pilot before departure and watched as the airplane departed. He did not notice any anomalies with the airplane during the takeoff or the climbout. According to a witness in the vicinity of the accident site, he heard the airplane coming toward him, and it was flying very low. He looked up and saw the airplane approximately 200 feet over his house and descending toward the trees. As he watched the airplane, he noticed that the right propeller was not turning, and the right engine was not running. He stated that the left engine sounded as if it was running at full power. The airplane pitched up to avoid a power line and rolled to the right, descending below the tree line. A plume of smoke and an explosion followed. Examination of the right propeller assembly revealed evidence of significant frontal impact. The blades were bent but did not have indications of rotational scoring; thus they likely were not rotating at impact. One preload plate impact mark indicated that the blades were at an approximate 23-degree angle; blades that are feathered are about 86 degrees. Due to fire and impact damage of the right engine and related system components, the reason for the loss of power could not be determined. An examination of the airframe and left engine revealed no mechanical malfunctions or failures that would have precluded normal operation. A review of the airplane maintenance logbooks revealed that the annual inspection was 12 days overdue. According to Lycoming Service Instruction No. 1009AS, the recommended time between engine overhaul is 1,200 hours or 12 years, whichever occurs first. A review of the right engine maintenance logbook revealed that the engine had accumulated 1,435 hours since major overhaul and that neither engine had been overhauled within the preceding 12 years. Although the propeller manufacturer recommends that the propeller be feathered before the engine rpm drops below 1,000 rpm, a review of the latest revision of the pilot operating handbook (POH) revealed that the feathering procedure for engine failure did not specify this. It is likely that the pilot did not feather the right propeller before the engine reached the critical 1,000 rpm, which prevented the propeller from engaging in the feathered position.

Factual narrative

HISTORY OF FLIGHT On June 30, 2012, about 1620 eastern daylight time, a Piper PA-31P, N33CG, collided with terrain while descending following loss of power in one engine shortly after takeoff from Dalton Municipal Airport (DNN), Dalton, Georgia. The private pilot was fatally injured, and the airplane sustained substantial damage by impact forces and postcrash fire. Visual meteorological conditions prevailed, and no flight plan was filed. The personal flight was conducted under 14 Code of Federal Regulations Part 91. The flight originated from DNN at 1615. According to a friend of the pilot, the pilot was en route to Douglas Municipal Airport (DQH), Douglas, Georgia, to have an annual inspection completed on the airplane. The friend said that he assisted the pilot prior to departure and watched as the airplane departed. He did not notice any anomalies with the airplane during the takeoff or the climbout, it seemed normal. According to witnesses, they heard an airplane coming towards them, and it sounded like it was flying very low. One witness looked up and saw the airplane 200 feet over his house and descending towards the trees. As he watched the airplane, he noticed that the right propeller was not turning, and the engine was not running. He went on to say that the left engine sounded as if it was running at full power. The airplane pitched up to avoid a power line and rolled to the right, descending below the tree line. A plume of smoke and an explosion followed. PERSONNEL INFORMATION The pilot, age 52, held a private pilot certificate for airplane single-engine land and multi-engine land with instrument airplane issued August 8, 1998, and a third-class airman medical certificate issued on May 1, 2012, with limitations for corrective lenses. Review of the pilot’s logbook revealed that he accumulated 1,614 flight hours as pilot in command and a total of 1,132 multi-engine flight hours as of June 16, 2012. Further review of the current logbook showed 155 multi-engine flight hours were completed during the 6 years before the accident. AIRCRAFT INFORMATION The six-seat, low-wing, retractable-gear airplane, serial number 31P-7300157, was manufactured in 1973. It was powered by two Lycoming TIGO-541-E1A 310-hp engines equipped with Hartzell HC-C3YN-2LUF hubs and FJC9684-3R blades. This type propeller is a 3-blade single-acting, hydraulically operated, constant-speed model with feathering capability. Oil pressure from the propeller governor is used to move the blades to the low pitch blade angle direction. A spring, counterweights, and an air charge move the blades to the high pitch/feather direction in the absence of governor oil pressure. The propeller incorporates a start lock mechanism that holds the blades at a low blade angle during engine start. Propeller rotation is counterclockwise as viewed from the rear. Review of copies of maintenance logbook records showed an annual inspection was completed June 18, 2011, at a recorded Hobbs reading of981.5 hours, airframe total time of 4445.6 hours. The left engine was overhauled on November 10, 1998, and its time since major overhaul as of June 18, 2011, was 580.8 hours. The right engine was overhauled on October 28, 1988, and its time since major overhaul as of June 18, 2011, was 1,435 hours. According to the Lycoming service instruction No. 1009AS, 1,200 hours are recommended between overhaul, and all engines that do not accumulate the hourly period of time between overhauls are recommended to be overhauled in the 12th year. The tachometer and the Hobbs hour-meter were not observed at the accident site. According to the airport manager at the Taylor County Airport (AAS), Campbellsville, Kentucky, the pilot took on fuel on June 24, 2012, but he fueled his own airplane, and no records were recovered showing the amount of fuel that received. The pilot did not refuel at the airport on the day of the flight. Video footage showed the airplane climbout normally prior to the accident. METEOROLOGICAL INFORMATION The reported weather at DNN, which was located about 2 miles east of the accident site, at an elevation 709 feet, at 1615, was: winds calm, visibility 10 statute miles; clear skies; temperature 39 degrees Celsius (C); dew point 15 degrees C; altimeter 29.87 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane was examined at the accident site on June 30 and July 1, 2012. The accident site was located about 2 miles west of the runway 14 in a wooded area with varied tree heights up to about 80 feet. The airplane came to rest upright in a flat attitude on a course of about 102 degrees. The cockpit, cabin, and everything forward of the empennage and wings were fire-damaged. A series of tree strikes were observed about 50 feet above the ground, south of the main wreckage. All major flight components were accounted for at the accident site. Continuity of the flight controls could not be manipulated but were verified to their respective flight control surfaces. The instrument panel was totally destroyed by impact and post impact ground fire. No useful information was acquired from any instrumentation. The engine power controls quadrant was separated from the instrument panel. The controls preimpact positions could not be reliably verified due to impact and post impact fire damage of the components. The cockpit section from the instrument panel area aft to the rear pressure bulkhead was breached and completely destroyed by ground impact and post impact ground fire. All windows and seats were destroyed by fire. No seat restraints were noted or located. Seat tracks were damaged or destroyed by impact and post impact fire. All doors were destroyed by impact and post impact ground fire. Viewable doors were noted to have the locking pins extended. The fuel selector valves were located, the left valve was heat-damaged, and the right valve was heat-damaged and exhibited some molten metal adhering to it. Due to the impact damage of the fuelvalves, the preimpact position of the fuel tank selection could not be determined. The left and right control wheels were separated from the panel and severely damaged by impact and the post impact fire. The rudder pedals were impact and fire damaged and could not be manipulated; control cables were noted in the vicinity of the pedals. Impact damage prevented fully tracing control cable continuity to the forward cabin area. The landing gear selector and flap selector were each noted in the up position. The nose gear was located under the cabin section and impact- and fire damaged. The left wing was separated from the fuselage attachment. It was completely destroyed by impact and the post impact fire. The outboard section was located in tree approximately 105 feet behind the main wreckage. The landing gear and a portion of the flap, which were in the up position, were attached and destroyed by post impact fire. All fuel tanks were breached and destroyed by post impact fire. All viewable fuel caps appeared in the closed, locked position. Aileron cables were traced from overload separation point to the cabin area. The right wing was separated from the airframe. It was destroyed by impact and the post impact fire. The landing gear and flap remnant were attached and were noted to be in the up position. Both were destroyed by post impact fire. All fuel tanks were breached and destroyed by post impact fire. All viewable fuel caps appeared in the closed, locked position. Control cable continuity was traced to the wing root separations and from there to the cabin area. The aileron trim drum indicated that the tabs were trailing-edge-down. The vertical fin was noted to be attached to the tail cone. It was impact-and fire-damaged. The rudder remained attached to the vertical fin and exhibited impact damage and post impact fire damage. It was positioned to the left of vertical fin center line with the trim tab off-set to the right. Control cable continuity was traced from the cable breaks to the rudder and from the breaks forward. Rudder movement was noted when the rudder cables were manipulated at the cable breaks. The ELT was noted in the wreckage, and it was destroyed by post impact fire. The left and right horizontal stabilizers showed impact and post impact fire damage. The elevators were attached. The left horizontal and elevator were bent upward, and both elevator trim tabs were trimmed down. No airframe preimpact anomalies were noted during the on-site inspection. Examination of the right engine revealed it remained attached to the right wing nacelle assembly frame. The propeller was broken away from the engine gear drive. All of the cylinders remained attached to the crankcase. The accessories on the engine were fire-damaged. The exhaust and induction systems exhibited damage. Both magnetos were fire-damaged and were separated from the engine. The top spark plugs were removed, and their electrodes were intact and exhibited normal operatingsignatures in accordance with the Champion aviation check-a-plug comparison chart. The fuel pump exhibited fire damage. The fuel pump drive gear was removed, and its respective coupling was intact. The crankshaft was turned, and the fuel pump gear rotated accordingly. The fuel manifold was fire-damaged, and the intake tubes were crushed. The throttle fuel control assembly exhibited fire damage. The throttle plate position was unreliable due to fire damage. No fuel was noted within the fuel system. All cylinders were inspected using a lighted borescope. The piston heads did not exhibit damage. The turbocharger exhibited impact and fire damage. The turbocharger was fire and impact damaged and remained attached to the engine. The turbocharger drive shaft partially rotated by hand. The wastegate assembly exhibited fire damage. The wastegate valve was observed in approximately the half-open position. The vacuum pump was separated from the engine and exhibited impact damage. No anomalies were noted during examination of the right engine. Examination of the left engine revealed it remained attached to the left wing nacelle assembly frame. The propeller was broken away from the engine gear drive. All of the cylinders remained attached to the crankcase. The accessories on the engine were fire-damaged. The exhaust and induction systems exhibited damage. Both magnetos were fire-damaged and were separated from the engine. The engine sump was melted away from the case, and the engine could not be rotated. The top spark plugs were removed, and their electrodes were intact and exhibited normal operating signatures in accordance with the Champion aviation check-a-plug comparison chart. The fuel pump exhibited fire damage. The fuel pump drive gear was removed, and its respective coupling was intact. The crankshaft was unable to be turned due to fire and impact damage. The fuel manifold was fire-damaged, and the intake tubes were crushed. The throttle fuel control assembly exhibited fire damage. The throttle plate position was unreliable due to fire damage. No fuel was noted within the fuel system. All cylinders were inspected using a lighted borescope. The piston heads did not exhibit damage. The turbocharger exhibited impact and fire damage and was separated from the engine. The turbocharger drive shaft could not be rotated by hand. The wastegate assembly exhibited fire damage, and the wastegate valve was impact-damaged. The vacuum pump was separated from the engine and exhibited impact damage. No anomalies were noted after examination of the right engine. Examination of the left propeller assembly revealed that the piston/cylinder assembly had separated from the propeller and was missing. The spinner dome was severely damaged due to frontal impact. Blade damage included multiple bends, rotational scoring, twisting, and leading edge damage consistent with rotation with power ON at the time of impact. An estimate of power output could not be determined. Therewere no anomalies noted that would preclude normal operation. All damage was consistent with impact damage. Examination of the right propeller assembly revealed evidence of significant frontal impact. The blades were bent but did not have indications of rotational scoring. One preload plate impact mark indicated that the blades were at an approximate 23-degrees blade angle, which is consistent with the start lock blade angle position. There were no anomalies noted that would preclude normal operation. All damage was consistent with impact damage. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was conducted by the Division of Forensic Sciences, Georgia Bureau of Investigation, Georgia. The cause of death was reported as blunt force injuries. The FAA’s Civil Aerospace Medical Institute performed forensic toxicology on specimens from the pilot. The report stated no carbon monoxide, cyanide or ethanol was detected in the blood. According to the FAA medical examiner, 10.18 (ug/ml, ug/g) Acetaminophen was detected in Blood. This over-the-counter analgesic medication is used to treat aches and pains as well as fever. The report stated that 0.079 (ug/mL, ug/g) Dihydrocodeine was detected in Liver. Dihydrocodeine is a prescription medication that is a semi-synthetic opioid analgesic (pain control). It is also is a Metabolite of Hydrocodone. The report stated that Dihydrocodeine was not detected in Blood, 0.195 (ug/ml, ug/g) Hydrocodone was detected in Liver and 0.079 (ug/ml, ug/g) Hydrocodone was detected in Blood. This prescription medication is an opioid analgesic (pain control) and antitussive (cough control). Metabolites include Hydromorphone and Dihydrocodeine, and may impair mental and/or physical ability. ADDITIONAL INFORMATION A review of the pilot operating handbook (revision date December 4, 1981), revealed in the Emergency Procedures section 3; Engine Failure During Takeoff (101 KIAS or above), Engine Failure During Takeoff (Below 101 KIAS), Engine Failure During Climb, Engine Failure During Flight (Below 83 KIAS), Engine Failure During Flight (Above 83 KIAS), Single Engine Landing, and Single Engine Go-Around did not have the feathering procedure nor did it have the Engine Securing Procedure in any of the task. The Engine Securing Procedure (Feathering Procedure) advises the pilot that the propellers must be feathered before (1,000 rpm minimum). A review of the latest revision (revision date November 1, 2001) of the pilot operating handbook revealed no mention of feathering the propellers before (1,000 rpm minimum).

Aircraft

Registration
N33CG
Reported as
Piper PA-31P
Category
Airplane
Serial number
31P-7300157
Engines
Lycoming TIGO-541SER, 400 horsepower, reciprocatingLycoming TIGO-541SER, 400 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
Holbrook Donald L
Registered owner
Holbrook Donald L
Airworthiness certificate
Special, Restricted (Special); Standard, Normal
Last inspection
Annual · July 1, 2011
Departed
DNN · Dalton, GA
Destination
DNN · Dalton, GA
Airport
DNN · Dalton Municipal Airport

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
52
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
1,685 total

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
102 °F, dew point 59 °F
Altimeter
29.87 inHg
Observed at
DNN

Docket · 31

The files NTSB released with the investigation on June 26, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 49.4 MB in all.

Police and Witness ReportsItem 1 · .PDF · 450 KBWitness StatementsItem 2 · .PDF · 881 KBHartzell Propeller ReportItem 3 · .PDF · 279 KBFAA Inspector StatementItem 4 · .PDF · 117 KBAircraft Logbook ExcerptsItem 5 · .PDF · 260 KBRight Engine Logbook ExcerptsItem 6 · .PDF · 286 KBLeft and Right Propeller Logbook ExcerptsItem 7 · .PDF · 354 KBPilot Fllight Logbook ExcerptsItem 8 · .PDF · 1.1 MBAirplane Flight Manual ExcerptsItem 9 · .PDF · 102 KBLycoming Engines Service InstructionsItem 10 · .PDF · 31 KBPropeller Drag ChartItem 11 · .PDF · 22 KBStatement of Party Representatives to NTSB Investigation- LycomingItem 12 · .PDF · 165 KBStatement of Party Representatives to NTSB Investigation- PiperItem 13 · .PDF · 104 KBStatement of Party Representatives to NTSB Investigation- HartzellItem 14 · .PDF · 271 KBToxicological ReportItem 15 · .PDF · 113 KBRetention / Release of Wreckage FormItem 16 · .PDF · 55 KBPhoto 1-Cockpit sectionItem 17 · .PDF · 4.4 MBPhoto 2-Main wreckageItem 18 · .PDF · 2.7 MBPhoto 3-EmpennageItem 19 · .PDF · 3.0 MBPhoto 4-Front view main wreckageItem 20 · .PDF · 2.6 MBPhoto 5-Rear view of main wreckageItem 21 · .PDF · 2.0 MBPhoto 6- Left EngineItem 22 · .PDF · 3.9 MBPhoto 7-Front view left engineItem 23 · .PDF · 4.2 MBPhoto 8-Left propellerItem 24 · .PDF · 4.5 MBPhoto 9- Right EngineItem 25 · .PDF · 4.1 MBPhoto 10-Right propellerItem 26 · .PDF · 4.2 MBPhoto 11-Front view right engineItem 27 · .PDF · 3.3 MBPhoto 12- Right wingItem 28 · .PDF · 1.5 MBPhoto 13- Right propellerItem 29 · .PDF · 1.8 MBPhoto 14-Left propellerItem 30 · .PDF · 1.7 MBPhoto 15-Airplane prior to flightItem 31 · .PDF · 898 KB

FAA reports on this event · 1

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

Other investigations on N33CG · 1

Matched to the same aircraft by N-number and date.