# NTSB ERA20LA127: Piper PA23, N335W, Albemarle, NC, March 5, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: March 5, 2020, 14:22 local (18:22 UTC) - Place: Albemarle, NC - Coordinates: 35.416667, -80.150833 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.4167&lon=-80.1508&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 101075 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA127 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101075/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101075 - Page: https://openairdocs.org/ntsb/ERA20LA127 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel pumps](https://openairdocs.org/ntsb-findings/01022822): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Piper PA-23-250, 1 case](https://openairdocs.org/ntsb-findings/01022822/cases.md?model=7102308), [All aircraft, 71 cases](https://openairdocs.org/ntsb-findings/01022822/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-23-250, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7102308), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Piper PA-23-250, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7102308), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-23-250, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102308), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-23-250, 2 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102308), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Piper PA-23-250, 9 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102308), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-23-250, 7 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102308), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-23-250, 16 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102308), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N335W-2021-06-05), registration cancelled 2021-06-05, S/N 27-3017 (OpenAirDocs) - Reported make and model: Piper PA23 (250) - Registry model: [Piper PA-23-250](https://openairdocs.org/model/piper-pa-23-250) (registry code 7102308) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 27-3017 - Year built: 1962 - Airframe hours: 4027 - Engines: Lycoming TIO-540 250 horsepower reciprocating; Lycoming 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; 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 - Other flight crew; age 26; injuries: none; 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 ## 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 20200305001989A](https://openairdocs.org/incident/20200305001989A), Mar 5, 2020: Piper PA-23-250, Albermarle, NC, Substantial damage. On March 5, 2020, Piper aircraft (N335W), ser. No. 27-3017, departed from vuj at approximately 1415 local time using runway 4R. The aircraft received a full… ## Docket (8 files) The files NTSB released with the investigation on June 10, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101075. 5.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484248&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Interview Summary (item 2, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484249&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF - Excerpts From Maintenance Records (item 3, .PDF, 459 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484250&FileExtension=.PDF&FileName=Excerpts%20From%20Maintenance%20Records-Master.PDF - Excerpts from AFM and Owner's Manual (item 4, .PDF, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484251&FileExtension=.PDF&FileName=Excerpts%20from%20AFM%20and%20Owner%27s%20Manual-Master.PDF - Photo Array (item 5, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484252&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Mechanic Statement Regarding Engine Examination (item 6, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484253&FileExtension=.PDF&FileName=Mechanic%20Statement%20Regarding%20Engine%20Examination-Master.PDF - Correspondence Regarding Testing of Mechanical Fuel Pumps (item 7, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484254&FileExtension=.PDF&FileName=Correspondence%20Regarding%20Testing%20of%20Mechanical%20Fuel%20Pumps-Master.PDF - Evidence Control Form (item 8, .PDF, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484256&FileExtension=.PDF&FileName=Evidence%20Control%20Form-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.