ERA20LA127

NTSB accident investigation · Piper PA23 · Albemarle, NC · March 5, 2020

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 5, 2020, 14:22 local (18:22 UTC)
Place
Albemarle, NC
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N335WPiper PA23
Defining event
Initial climb: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20200305001989A
Case key
101075

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 pilots' failure to ensure that the electric fuel pumps were on before takeoff, which resulted in a partial loss of power on both engines during initial climb.

Findings · 4

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.

Fuel system: fuel pumpsAircraft › Aircraft systems · Not used/operatedPiper PA-23-250: 1 caseAll aircraft: 71 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · PilotPiper PA-23-250: 1 caseAll aircraft: 191 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · Instructor/check pilotPiper PA-23-250: 1 caseAll aircraft: 191 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA-23-250: 4 casesAll aircraft: 1,391 casesProbable cause

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

The owner of the multiengine airplane was receiving a check out in the airplane from the flight instructor. During the initial climb, about 200 ft above ground level, the instructor noticed a decrease in airspeed and the pilot receiving instruction stated that both engines were losing power. The instructor immediately confirmed that the mixture levers were full rich and that the propeller and manifold levers were full forward. He also turned on the electric fuel pumps, which had not been turned on before takeoff. With insufficient runway remaining on which to land, the pilots continued over trees at the end of the runway before landing in a field. The instructor further stated that the electric fuel pump switches were on the far left of the instrument panel and he was unable to see their position before the loss of engine power. He added that he believed that the loss of engine power was the result of the electric fuel pumps being off. Examination of the engines, fuel systems, ignition systems, and induction systems did not reveal any preimpact mechanical malfunctions, and examination of fuel samples from each fuel tank and both engine fuel sumps did not reveal any anomalies. Subsequent testing of the left and right engine mechanical fuel pumps revealed that they operated within specifications. Review of checklists in an owner's manual and airplane flight manual for the airplane make and model revealed instructions in both to use the electric fuel pumps during takeoff. Thus, it is likely that the pilot receiving instruction did not turn on the electric fuel pumps, which were located on his side of the instrument panel, before takeoff, and the instructor did not ensure that they were on.

Factual narrative

On March 5, 2020, about 1422 eastern daylight time, a Piper PA-23-250, N335W, was substantially damaged when it was involved in an accident near Stanley County Airport (VUJ), Albermarle, North Carolina. The airline transport pilot and pilot receiving instruction were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to a Federal Aviation Administration (FAA) inspector, the owner of the airplane was not onboard during the accident flight but was taking a video recording of the accident takeoff. The owner did not possess a multiengine land rating. The owner's flight instructor was seated in the left seat, receiving a "check out" in the make and model airplane from the pilot-in-command (PIC) flight instructor seated in the right seat. After the "check out," the owner's flight instructor could then provide training to the owner. The accident flight was the first flight after an annual inspection was completed on the airplane. Additionally, the airplane was completely fueled prior to the accident flight. According to the PIC, during initial climb, about 200 ft above ground level, the pilot receiving instruction was the pilot flying. The PIC noticed a decrease in airspeed and the pilot receiving instruction stated that the engines were losing power. The PIC immediately made sure the mixture levers were full rich, and the propeller and manifold levers were full forward. He also switched on the electric fuel pumps, which had not been turned on prior to takeoff. The PIC further stated that the electric fuel pump switches were on the far left of the instrument panel and he was unable to see their position prior to the loss of engine power. The PIC added that he believed that was the mistake that caused the dual loss of engine power. The PIC then coached the pilot receiving instruction to push forward on the yoke to retain airspeed; however, the airplane was too fast to land back on the remaining runway. The engines never fully recovered power and they climbed over trees at the end of the runway before making a hard landing in a muddy field. Examination of the accident site by the FAA inspector revealed that during impact with the field, the airplane slid for about 190 ft. The left main landing gear separated and the nose gear collapsed, followed by the airplane rotating 180° before coming to rest upright. The inspector observed damage to the left wing spar, left wheel well, nose wheel well, and lower fuselage. Review of a copy of the video corroborated the pilots' statements. Further examination of the engines was performed by an independent mechanic. The top spark plugs were removed from both engines and no anomalies were observed with their electrodes. The crankshaft was rotated by hand on both engines and valve train continuity was confirmed to the rear accessory section. Additionally, thumb compression was attained on all cylinders. Examination of the induction systems did notreveal any blockages or obstructions. Eight-ounce fuel samples were obtained from each of the four fuel cells as well as the left and right engine fuel sumps. All samples were noted to be blue in color and no water or debris were detected in any of the six samples. The magnetos were removed from both engines and rotated at 420 rpm for 10 seconds. All four magnetos produced spark at all leads. The left and right engine mechanical fuel pumps were then removed and forwarded to a facility for testing. Both pumps tested satisfactorily within specifications. Review of checklists in an owner's manual and airplane flight manual for the make and model airplane revealed instructions in both to turn the electric fuel pumps on prior to takeoff.

Aircraft

Registration
N335W
Reported as
Piper PA23 (250)
Category
Airplane
Serial number
27-3017
Built
1962
Airframe hours
4,027
Engines
Lycoming TIO-540, 250 horsepower, reciprocatingLycoming TIO-540, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 2, 2020 · 0 hours before
Departed
VUJ · Albemarle, NC
Destination
VUJ · Albemarle, NC
Airport
VUJ · Stanley County, runway 04R, 5,499 × 100 ft, asphalt
Equipment
ADS-B, Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
58
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine sea, Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
January 31, 2019
Seat
Right
Restraint
Lap only
Flight hours
16,000 total · 40 in this make and model · 194 in the last 90 days
Role
Other flight crew
Age
26
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
December 22, 2018
Seat
Left
Restraint
Lap only
Flight hours
1,019 total · 0 in this make and model · 689 as pilot in command · 210 in the last 90 days · 46 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 43 °F
Altimeter
30.12 inHg
Observed at
VUJ, 1 nm away

Docket · 8

The files NTSB released with the investigation on June 10, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.2 MB in all.

FAA reports on this event · 1

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