FTW98FA229

NTSB accident investigation · Piper PA-23-160 · Guthrie, OK · May 18, 1998

Accident · FatalField investigationFinal report
Date
May 18, 1998, 18:20 local (23:20 UTC)
Place
Guthrie, OK
Injuries
2 fatal, 1 serious
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N4410PPiper PA-23-160
Weather
Visual (VMC) · Day
Status
Completed · report December 1, 1999
Report
Approved by Office Director
FAA report
19980518009919A
Case key
20421

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 designated pilot examiner's decision to execute a single engine go-around which exceeded the airplane's engine out climb capability in the gear down configuration. Factors were the arcing of an electrical wire that grounded the engine starter and the high density altitude.

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(total) - mech failure/malfManeuvering
1 engine
Engine shutdown - intentionalDesignated examiner
Engine accessories,engine starter - not engagedFactor
Emergency procedure - simulated
Airframe/component/system failure/malfunctionManeuvering
Engine accessories,engine starter - inoperative
Electrical system,electric wiring - shorted
Starting procedure - not possiblePilot in command
In flight collision with objectGo-around (vfr)
Aircraft performance,engine out capability - exceededCause
Go-around - attemptedDesignated examinerCause
Object - tree(s)
Weather condition - high density altitudeFactor

Analysis

During a multi-engine certification check flight, the left engine was shut down and feathered. The designated pilot examiner then had the applicant restart the engine. The restart was unsuccessful, and the examiner took control of the aircraft, returning to the originating airport. The applicant performed the manual gear extension procedures, but the landing gear position could not be verified, and the gear was not down and locked on final approach. The examiner executed a go-around; however, the airplane was unable to maintain altitude. The airplane impacted trees, and terrain while descending during the go-around. A post impact fire destroyed the aircraft. The landing gar was found in the retracted position, and the left propeller was found in the retracted position, and the left propeller was found feathered. Metallurgical examination found areas of electrical arcing in the part of the starter cable passing through the wing root. When the left engine starter was energized using an exemplary cable, the starter rotated the engine crankshaft. Density altitude was calculated at 3,100 feet. The aircraft manufacturer reported ad single-engine aircraft climb capability of -7 feet per minute with the landing gear extended.

Factual narrative

History of flight:

On May 18, 1998, at 1820 central daylight time, a Piper PA-23-160 twin engine airplane, N4410P, registered to Seward Leasing, Inc., and operated by Crabtree Aircraft Company, Inc., of Guthrie, Oklahoma, as a 14 CFR Part 91 flight, crashed while attempting a single engine go-around at the Guthrie Municipal Airport. Visual meteorological conditions prevailed and a flight plan was not filed. The airplane was destroyed by a post impact fire. The commercial pilot/flight instructor who was designated by the FAA as a pilot examiner was conducting a commercial multiengine certification flight check for a private pilot. The pilot examiner, and the passenger received fatal thermal injuries during the post impact fire and the private pilot received serious thermal injuries. The flight originated from Guthrie at 1800.

According to the operator and the private pilot's flight instructor, the flight departed with the main fuel tanks full (72 gallons) of 100LL aviation fuel for the purpose of conducting the flight portion of the practical examination for the commercial multiengine certification. The FAA Designated Pilot Examiner (DPE) was seated in the right seat to administer the flight portion of the examination. The flight instructor reported that during the private pilot's training, he had shut down and feathered the right engine; however, he never shut down and feathered the left engine during the private pilot's training. The private pilot had received ground instruction on the emergency gear extension procedures and had used the emergency gear extension handle to extend the flaps during preflight inspections only.

During interviews conducted by the investigator-in-charge, and on the enclosed statement, the private pilot reported that the flight check was being conducted at 3,500 feet msl. During the latter portion of the flight check, the pilot examiner requested that the applicant shut down, feather, and then restart the left engine. During the restart procedures, the left engine propeller would not rotate and the engine would not restart. The airplane was loosing altitude and the pilot examiner took control of the airplane for the return flight to the airport.

The pilot examiner flew the airplane at the single engine best rate-of-climb speed for a downwind entry for runway 16 at the Guthrie Municipal Airport. The landing gear handle was placed in the down position and the emergency gear extension procedure performed. However, on final approach at 1,700 feet msl, the private pilot noticed that there were no green lights, indicating that the gear was not fully extended. When the private pilot advised the pilot examiner that there were no green gear lights, the examiner directed the private pilot to perform the gear retraction procedures while she continued to fly the airplane for a go-around. The private pilot performed the emergency gear retraction procedure. The pilot examiner flew the airplane with the throttle full forward for the right engine and the airspeed at the single engine best rate-of-climb speed; however, the airplane did not maintain altitude.

During the forced landing, the wings of the airplane struck trees and the ground. The door of the airplane jammed; however, the private pilot and the passenger kicked the door open to egress the airplane. A post impact fire erupted in the right engine and spread to the surrounding grass.

The Guthrie Police Chief, traveling southbound on Division Street, observed the beige airplane during the base to final turn for runway 16. Within less than 5 minutes, he saw the smoke coming from the accident site. A witness, driving northbound on Interstate 35 observed the airplane flying "just above the tree tops. The [air]plane was rocking from side to side but was level." The landing gear was not down and there was no visible smoke or fire while the airplane was airborne.

Other witnesses, who observed the airplane descending near a construction area along Interstate 35, reported that the airplane barely missed hitting a 70 foot construction crane boom and high lines before descending toward the ground.

Personal information:

The FAA records reviewed by the investigator-in-charge (IIC) revealed that the FAA Designated Pilot Examiner (DPE)/commercial pilot reported a total flight time of 10,000 hours on her last medical certificate application dated January 2, 1998. Pilot weight on the medical certificate was 149 pounds. The commercial pilot/flight instructor had been authorized as a DPE for airplanes since 1989. She was the chief pilot/flight school manager for Crabtree Aircraft Company, Inc., a FAA Designated Written Test Examiner, a FAA Accident Prevention Counselor, and a Gold Seal Flight Instructor. At the time of the accident, the DPE was authorized by the FAA to perform the duties of pilot examiner in the following multiengine aircraft: BE-55, BE-58, CE-310, and the PA-23. On March 11, 1998, the DPE received a FAA flight check in N4410P during the annual renewal of her examiner designation. This 0.9 hour flight included stalls, VMC demonstrations, steep turns, single engine (zero thrust) landings, and cross wind landings.

The FAA and flight school records revealed that the multiengine applicant received his private pilot certificate with the airplane single engine land rating on June 2, 1997. He added the instrument rating on December 17, 1997. In April, 1998, he received 8.2 hours of dual instruction toward the commercial single engine land rating. In May 1998, he received 20.2 hours of dual instruction for the commercial multiengine land rating. The accident occurred during his commercial multiengine certification flight check. The pilot weight on his medical certificate was 145 pounds.

The Oklahoma Drivers License for the passenger listed his weight as 185 pounds.

Aircraft information:

The aircraft (serial number 23-1922) was manufactured in 1960 and registered to the current owner in 1995. Aircraft records revealed that the carbon dioxide bottle for the emergency gear extension was replaced in February 1995. The last recorded maintenance on the aircraft was a 100 hour inspection. This inspection was conducted at 3,491.0 hours total aircraft time on May 5, 1998. At the time of this inspection, the left engine (O-360-A1A, serial number L-13515-36A) had 2,430.0 hours total time and the right engine (serial number L-13514-36A) had 2,484.95 hours total time. At the time of the entry, the operator's maintenance board indicated that 78.6 hours remained until the time of the next inspection. The 180 horsepower engines were installed new on the aircraft on October 21, 1968, at an aircraft time of 1,006 hours, in accordance with a Doyn Aircraft supplemental type certificate (STC) installation.

The propellers (HC-C2YK-2RBS) were inspected at the last 100 hour inspection with no discrepancies noted. At the time of this inspection, the propellers had accumulated 1,028 hours since the last propeller overhaul in June 1997.

The left engine maintenance records stated that in November 1968 an overhauled starter was installed on the left engine. A work order dated November 16, 1996, stated "L[eft/H[and] starter Inop[erative] Replace Starter with O[ver]/Hauled Unit." A work order dated May 9, 1997, stated "Remove L[eft] H[and] Starter replace Drive & Reinstall."

Meteorological information:

The National Weather Service Observation for Guthrie at 1853 indicated that the winds were from 160 degrees at 11 knots. Visibility was 10 statute miles with a temperature of 32 degrees Centigrade [89.9 degrees Fahrenheit] a dewpoint of 21 degrees Centigrade [69.8 degrees Fahrenheit]. The IIC calculated the density altitude at 3,100 feet.

The Oklahoma Climatological Survey at the University of Oklahoma, Norman, Oklahoma, reported that the Oklahoma Mesonet Guthrie site (2.5 miles west of the Guthrie Muni

Aircraft

Registration
N4410P
Reported as
Piper PA-23-160
Category
Airplane
Serial number
23-1922
Engine
Lycoming O-360-A1A, 180 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Part 91
Registered owner
Seward Leasing Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 15, 1998
Departed
GOK
Airport
GOK · Guthrie Municipal, runway 16, 4,102 × 75 ft, concrete

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
48
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
10,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 70 °F
Altimeter
29.00 inHg
Observed at
GOK, 2 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 N4410P · 1

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