FTW04LA059

NTSB accident investigation · Piper PA-23-160 · Fort Worth, TX · January 9, 2004

Accident · No injuriesLimited investigationFinal report
Date
January 9, 2004, 15:30 local (21:30 UTC)
Place
Fort Worth, TX
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N3289PPiper PA-23-160
Weather
Visual (VMC) · Day
Status
Completed · report September 1, 2004
Report
Approved by Office Director
Parties
FAA FSDO, Textron Lycoming, New Piper Aircraft
FAA report
20040109007659A
Case key
58599

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 pilot's failure to maintain control and the partial loss of engine power as a result of an improperly installed mixture control linkage.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(partial) - mech failure/malfTakeoff - initial climb
1 engine
Maintenance,installation - improperOwner/pilot mechanicCause
Mixture control,linkage - disengagedFactor
Loss of control - in flightTakeoff - initial climb
Directional control - not maintainedPilot in commandCause
In flight collision with objectTakeoff - initial climb
Object - hangar/airport building
Object - aircraft parked/standing

Analysis

Prior to departure, the airplane's fuel tanks were topped-off with 72 gallons of 100LL aviation fuel. On the take-off roll, when the airplane's airspeed increased to 85 miles per hour (mph) (red-line on the airspeed indicator), the pilot rotated, and the airplane began to climb. When the airspeed increased to 95 mph (blue-line on the airspeed indicator), the airplane suddenly yawed to the right and the airspeed decreased. The pilot said it, "felt like my right engine stopped working." In 3 to 4 seconds, the airplane was over a row of hangars. The pilot lowered the nose of the airplane in an attempt to gain airspeed. But, there was insufficient altitude to clear the hangars and subsequently the airplane collided with one of them, then impacted two parked aircraft. Examination of the right engine revealed that the mixture control cable was disengaged from the carburetor mixture control arm and the cotter pin used to secure the tension nut on the mixture cable was not installed. The mixture control swivel, stud, and a segment of the mixture control cable were examined at the NTSB's Material's Laboratory, Washington DC. According to a Safety Board metallurgist, examination of some of the components indicated wear damage. But, the mixture control cable did not exhibit any longitudinal gouge marks or wear damage that would have been consistent with it being separated during the accident sequence. In addition, the engine was test-run and it operated at various power settings up to 1,500 RPM. The engine ran continuously and without hesitation for approximately 10 minutes. The propeller was actuated and operated normally. Both magnetos were checked and no anomalies were noted. The engine driven fuel pump produced suction and exhaust, and oil was noted draining from the forward crankshaft area. The pilot reported a total of 377 flight hours, of which, 41 hours were in twin-engine aircraft. He also reported a total of 10 hours in the same make and model airplane. A weight and balance computation was made using the airplane's original factory weight and balance. Based on the calculations, the airplane was within weight and balance limits.

Factual narrative

On January 9, 2004, approximately 1530 central standard time, a Piper PA-23-160 twin-engine airplane, N3289P, was substantially damaged following a partial loss of engine power on takeoff from Hicks Airfield (T67), near Forth Worth, Texas. The commercial pilot and the two passengers were not injured. The airplane was owned and operated by a private individual. No flight plan was filed and visual meteorological conditions prevailed for the personal flight conducted under 14 Code of Federal Regulations Part 91.

In a written statement, the pilot reported that prior to departure he filled both fuel tanks (for a total of 72 gallons) and performed a pre-flight inspection, which included sumping both fuel tanks. No debris or water was noted.

The pilot, along with his two passengers, boarded the airplane, started both engines, and taxied to the run-up area located near the end of Runway 32 (a 3,740 feet long by 60 feet wide asphalt runway). Utilizing the aircraft checklist, he increased RPM on both engines, and performed a check of the magnetos, propeller governors, carburetor heat, and alternators. No anomalies were noted and both engines ran "well and smooth." Additionally, a scan of the engine instruments revealed no discrepancies.

The pilot taxied the airplane onto the runway, slowly increased power on both engines to full RPM, and began the take-off roll. When the airplane's airspeed increased to 85 miles per hour (mph) (red-line on the airspeed indicator), he rotated, and the airplane began to climb. When the airspeed increased to 95 mph (blue-line on the airspeed indicator), the airplane suddenly yawed to the right and the airspeed decreased. The pilot said it, "felt like my right engine stopped working." In 3 to 4 seconds, the airplane was over a row of hangers. The pilot lowered the nose of the airplane in an attempt to gain airspeed. But, there was insufficient altitude to clear the hangars and subsequently the airplane collided with one of them, then impacted two parked aircraft.

A Federal Aviation Administration (FAA) inspector performed an on-scene examination of the airplane on the day of the accident. According to the inspector, the airplane came to rest upright at the base of a row of hangars. The left wing remained attached to the airframe, and the right wing, which also exhibited impact damage, had separated and was located to the right of the fuselage. The engine had also separated and came to rest upside down, forward of the right wing.

Examination of the right engine revealed that the mixture control cable was disengaged from the carburetor mixture control arm and the cotter pin used to secure the tension nut on the mixture cable was not installed. The mixture control arm was in the idle cut-off position. The airplane owner was instructed to recover the wreckage and secure it in his hangar for future examination.

An engine examination was scheduled January 21, 2004, at the owner/operator's hangar facility. Shortly after the investigative team arrived, a decision was made to transport the engine to another facility for examination.

Examination of the engine revealed that when the propeller was removed, a front crankshaft seal had not been installed, and the propeller attachment nuts were not properly secured. The engine case, cylinders, and accessories were coated with engine oil.

The crankshaft flange displayed aft bending on one side and two of the propeller flange bushings were displaced. One of the propeller blades was bent aft approximately 3 degrees, and exhibited front chordwise scoring and polishing. The second blade was bent aft approximately 10 degrees, and exhibited chordwise scoring near the tip.

The engine was manually rotated at the crankshaft flange, and valve train continuity and compression were established on each cylinder. During the compression check, spark was produced on the bottom ignition leads. The lower spark plugs were removed and examined. Examination of the plugs revealed excessive carbon and lead deposits, and electrode erosion beyond the limits specified in the Champion Spark Plug Wear Guide P/N AV-27.

The inlet and outlet lines to the engine driven fuel pump had separated.

In addition, there were no case match-numbers or crankshaft numbers. The engine serial number stamped on the crankcase did not match the engine serial number stamped on the engine data plate.

The exhaust system had several screw-type clamps installed, which supported heat shrouds that had sustained chaffing damage and holes. A stainless-steel clamp was installed on the #3 exhaust stack, which partially covered a pencil-sized hole.

The engine was then transported to Air Salvage Of Dallas (ASOD), Lancaster, Texas, where a test-run was conducted on January 22, 2004, under the supervision of the Safety Board.

Prior to the engine run, timing was verified, the cylinders were inspected with a lighted borescope, and the spark plugs were removed and inspected. The fuel line to the carburetor had separated in the accident sequence, and a dead bee was found in the fuel inlet screen. Additionally, the propeller was reinstalled, an engine mount was replaced, the oil dipstick housing was replaced, and throttle, mixture, and propeller control cables were installed. Due to impact damage, the engine driven fuel pump was bypassed. Five and half quarts of fuel were added to the engine and a gravity fuel source was utilized.

The engine started and was operated at various power settings up to 1,500 RPM. Due to excessive vibrations created by the bent crankshaft and propeller, the engine was not tested above this speed. The engine ran continuously and without hesitation for approximately 10 minutes. The propeller was actuated and operated normally. Both magnetos were checked and no anomalies were noted. The engine driven fuel pump produced suction and exhaust, and oil was noted draining from the forward crankshaft area.

The mixture control swivel, stud, and a segment of the mixture control cable were examined at the NTSB's Material's Laboratory, Washington DC, on April 12, 2004. According to a Safety Board metallurgist, examination some of the components indicated wear damage. But, the mixture control cable did not exhibit any longitudinal gouge marks or wear damage that would have been consistent with it being separated during the accident sequence.

During the initial engine examination, the owner/operator reported that he had performed the engine's overhaul, but did not replace the bearings. According to engine manufacturer, the bearings are a mandatory replacement item during engine overhaul.

A weight and balance computation was made using the airplane's original factory weight and balance. Based on the calculations, the airplane was within weight and balance limits.

The pilot reported a total of 377 flight hours, of which, 41 hours were in twin-engine aircraft. He also reported a total of 10 hours in the same make and model airplane.

The weather at Hicks Field was reported as clear skies, and wind from 350 degrees at 11 to 13 knots.

Aircraft

Registration
N3289P
Reported as
Piper PA-23-160
Category
Airplane
Serial number
23-1239
Airframe hours
7,057.5
Engines
Lycoming O-320-B1A, 160 horsepower, reciprocatingLycoming O-320-B1A, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 14, 2003 · 52.9 hours before
Departed
T67 · Fort Worth, TX
Airport
T67 · Hicks Field Airport, runway 32, 3,740 × 60 ft, asphalt

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
23
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
July 28, 2003
Seat
Left
Flight hours
377 total · 10 in this make and model · 319 as pilot in command · 27 in the last 90 days · 12 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 28 °F
Altimeter
30.37 inHg
Observed at
AFW, 5 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.

Other investigations on N3289P · 1

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