ERA23FA313

The pilot told a mechanic that he was planning to remain in the airport traffic pattern to make sure the airplane was ready for a long cross-country flight the next morning. An earwitness reported hearing the airplane begin its takeoff roll and continued to hear engine noises for a total of about 45 seconds until the airplane impacted the ground. The one eyewitness described the airplane as being in a steep left turn with the wings perpendicular to the ground just before it impacted the terrain. The accident occurred on the first flight after having a new interior and propeller installed, and after the completion of an annual inspection. Postaccident examination of the airplane and engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The ground impact scars at the accident site, compact distribution of wreckage, and the eyewitness statement were consistent with the airplane entering an aerodynamic stall and left rotating spin in the left crosswind segment of the traffic pattern. At impact, the landing gear were selected to the down position and the flaps were set to the full position, which was not consistent with the with the configurations in the airframe manufacturer’s operating manual for either normal or short-field takeoff procedures. It is possible that this configuration, particularly the fully extended flaps, degraded the airplane’s climb performance and contributed to the aerodynamic stall.

During the installation of the new interior, the airplane had also undergone an annual inspection. Additionally, the existing 2-blade Hartzell constant speed propeller was replaced with a new 3-blade McCauley constant speed propeller. The original Hartzell propeller governor remained installed on the engine. According to the airframe manufacturer, with the wing fuel tanks filled to the tabs each fuel tank would contain 18 gallons of fuel. The Piper PA-28R-200 Pilot’s Operating Manual (POM) recommended short- and soft-field takeoffs be performed with flaps set to the 25° position. The POM made no mention of taking off with the flaps set to the full 40° position. The POM listed the stall speeds for the landing gear-down, flaps 40° setting to be 64 mph with 0° of bank, 66 mph with 20° of bank, 73 mph with 40° of bank, and 90 mph with 60° of bank. The POM also stated that the best rate of climb with the landing gear down was obtained at 95 mph and the best angle of climb was obtained at 85 mph with the landing gear down. No data was available to determine the expected rate of climb with the flaps set to full and the landing gear in the down position. On July 25, 2023, about 1906 eastern daylight time, a Piper PA-28R-200, N34PT, was substantially damaged when it was involved in an accident near Churchville, Maryland. The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airport manager, who was also the owner of the fixed base operator (FBO) at the airport where the airplane was based, reported that he spoke with the pilot the morning of the accident. He reported that the pilot was frustrated that the new interior for the airplane had taken so long to be installed as he was planning to leave the next day to have the airplane’s avionics upgraded. He also added that the purpose of the flight was for the pilot to complete some flights in the airport traffic pattern with the new propeller installed before the long cross-country flight the following morning. The airport manager left the airport about 1850 as the pilot was completing his preflight inspection of the airplane. A mechanic for the FBO reported that he spoke with the pilot just before the accident flight and that the pilot told him about the upcoming trip to Florida the next day and that he wanted to take the airplane for a test flight just to make sure the airplane was performing normally before the long cross-country flight. The mechanic also reported that he had fueled the airplane’s wing tanks to the “tabs” the day before the accident, as the fuel had been drained to facilitate a new weight and balance calculation due to maintenance that had been recently completed. The mechanic did not witness the airplane start, taxi, or take off as he had already left for the day. An earwitness who lived near the airport and accident site, and was outside doing yardwork, reported that about 1905 he heard an airplanestart its takeoff roll and that he did not hear the airplane perform an engine run-up. He stated that runway 1 was in use, and that when this runway was being used airplanes in the traffic pattern would usually bank left and pass over his house. He reported that the sound from the engine was normal, and that the rpm tone did not change for the duration of the flight. Another witness, the only witness to see the airplane in flight, reported that he was outside in his yard when he saw the airplane in a steep left bank with the wings perpendicular to the ground. He said that he could only see the underside of the airplane, that the landing gear appeared to be down, and that it was much lower than usual. The earwitness reported that the entirety of the flight lasted about 45 seconds from when he first heard the airplane to when he heard it impact the ground. No track data was available either from air traffic control primary radar targets or from ADS-B. According to the autopsy report from the Office of the Chief Medical Examiner for the State of Maryland, the pilot’s cause of death was multiple blunt force injuries and the manner was accident. Toxicology testing for the pilot, performed by the Federal Aviation Administration Forensic Sciences Laboratory, detected glucose, atorvastatin, azacyclonol, fexofenadine, and minoxidil. Atorvastin is a cholesterol lowering agent, fenoxfenadine is a non-sedating antihistamine usually marketed as Allegra, and Azacyclonol is a metabolite of fenoxfenadine. Minoxidil, the main ingredient in Rogaine (used to treat male pattern baldness), can also be used to treat high blood pressure. None of these drugs are generally considered impairing. The testing was negative for ethanol and carboxyhemoglobin. Both the airport manager and the mechanic reported that early in the day the weather had been poor but that the weather had become better as the day progressed. A witness reported the weather was clear with a light breeze out of the north; he said it was “a perfect evening to fly.” The airplane came to rest in a cut hay field on a heading of about 350° and at an elevation of 386 ft. There were multiple ground impact scars; the initial ground impact scar contained remnants of red lens glass. There was a large ground impact scar about 20 ft from the initial ground impact scar. The airplane came to rest about 18 ft from the initial ground impact scar. All major components of the airplane were located in the vicinity of the main wreckage and sustained heavy impact damage. Control continuity was confirmed from all flight control surfaces to the controls in the cockpit. The flap handle was found in the flaps fully extended position. The flap position was confirmed by counting the chain links from the flap handle to the gear on the flap torque tube. The landing gear handle in the cockpit was in the down position. Both fuel tanks were breached, and fuel blight was observed around the wreckage. Continuity was confirmed from thefuel selector to the fuel injectors with the presence of liquid consistent with 100 low-lead aviation fuel throughout. The engine remained attached to the fuselage at all engine mounts. Compression and suction were confirmed on all cylinders using the thumb method and crankshaft and valvetrain continuity were confirmed when the crankshaft was rotated through 720° of rotation. Postaccident examination revealed no mechanical malfunctions or failures with the engine that would have precluded normal operation. A postaccident examination of the propeller governor was conducted at the manufacturer’s facility. The governor was mounted on the test stand with a new gasket for a functional test. The governor was not flushed before the test. There was no foreign debris detected in the oil coming from the governor during this test. The governor was disassembled, and the only abnormal wear was some rotational scoring between the drive gear and body and between the flyweight unit and body. Otherwise, there were no unusual visual discrepancies noted, nor any debris found on any internal components during the disassembly and inspection of the governor. Postaccident examination of the propeller at the manufacturer’s facility found the blade angle actuation components exhibited gross part deflection and structural overload failure consistent with the impact sequence. All three pitch change links were broken, the piston rod was bent, and the piston return spring was deformed. Specific blade angles at the time of impact could not be determined. Internal witness marks did not give an indication of the blades being outside of the normal operating range of the propeller. The propeller blades exhibited chordwise scratches, leading edge polishing, and leading edge gouges and nicks.