# NTSB IAD04FA040: Piper PA-31P, N57EF, Clarkson, NY, August 20, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 20, 2004, 13:34 local (17:34 UTC) - Place: Clarkson, NY - Coordinates: 43.251388, -77.868888 - Nearby events: https://openairdocs.org/map.md?lat=43.2514&lon=-77.8689&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 30, 2005 - Report: Approved by Office Director - Parties: Federal Aviation Administration, New Piper, Lycoming Engines - NTSB case key (mKey): 59951 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=IAD04FA040 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59951/pdf - Page: https://openairdocs.org/ntsb/IAD04FA040 ## Probable cause The pilot's mismanagement of the fuel by his failure to select the proper fuel tank which resulted in starvation and subsequent loss of engine power in both engines. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, cruise - normal - fluid,fuel - starvation/exhaustion (cause) - fuel management - inadequate, pilot in command (cause) - fuel tank selector position - improper, pilot in command (cause) - all engines - Forced landing, descent - In flight collision with object, emergency descent/landing - object - tree(s) ## Analysis The airplane departed from a maintenance facility, after installation of the right engine, with an unknown quantity of fuel. Shortly after takeoff, the pilot reported that he had "lost" an engine. He requested vectors for the departure airport, then amended his request to an alternate destination. From the original distress call to the last recorded radar target, approximately 2 ½ minutes, the airplane descended from 2,500 feet to 700 feet and slowed from 190 knots to about 87 knots. Several witnesses described the engine sound as "rough", and "cutting in and out" before the airplane descended out of view and sounds of impact were heard. The left wing was consumed by post-crash fire. Forty gallons of fuel were drained from the right inboard and nacelle tanks. Only trace amounts of fuel were visible in the right outboard tank. Both fuel selectors were found in the outboard tank position. Examination of flight times and ground-maintenance run times revealed that the engines were run for approximately 3 hours with the outboard tanks selected. The outboard tanks each held 40 gallons, for a total of 80 gallons. According to the pilot's operating manual, the fuel consumption rate at the maximum endurance power setting was 28 gallons per hour. ## Factual narrative HISTORY OF FLIGHT On August 20, 2004, at 1334 eastern daylight time, a Piper PA-31P, N57EF, was destroyed when it collided with terrain during a forced landing in Clarkson, New York. The certificated airline transport pilot/owner was fatally injured. Visual meteorological conditions prevailed for the positioning flight that originated at Genessee County Airport (GVQ), Batavia, New York, approximately 1325. No flight plan was filed for the flight conducted under 14 CFR Part 91. The purpose of the flight was to return the airplane to its home base of Rochester, New York, after completion of an annual inspection and the reinstallation of the right engine following repair. A review of air traffic control (ATC) radar and voice communication data revealed that, at 1327:36, the pilot contacted ATC and requested the ILS Runway 22 approach to the Greater Rochester International Airport (ROC), Rochester, New York. The controller approved the request and assigned an initial heading of 120 degrees for a vector to the final approach course. The pilot acknowledged the radio call, and the airplane assumed a track of about 120 degrees; at an altitude of 2,500 feet mean sea level (msl), and 197 knots groundspeed. The airplane continued on the track of 120 degrees for several seconds, then turned to an approximate track of 180 degrees. At 1332:06, the pilot announced that he had "lost" an engine and requested vectors back to Batavia. At 1332:20, the pilot said he could not reach Batavia and opted to land at Ledgedale Airport (7G0), Brockport, New York. By that time, the airplane had slowed to 105 knots and had descended to 1,600 feet msl. At 1334:01, the pilot said, "I don't think I'm going to make Ledgedale." At that time, the airplane's groundspeed was 97 knots and it had descended to 1,100 feet msl. There were no further communications from the pilot. Over the next 31 seconds, the airplane slowed to 87 knots groundspeed and descended to 700 feet msl, about 350 feet above ground level (agl), before the last radar return was recorded. Several witnesses around the crash site stated that they observed the airplane maneuvering at a low altitude. They described the engine sound as "rough," and "cutting in and out." Some witnesses said they saw the airplane just above the trees with the wings perpendicular to the ground before it descended out of view, and the sounds of impact were heard. The accident occurred during the hours of daylight approximately 43 degrees, 15 minutes north latitude, and 77 degrees, 52 minutes west longitude. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with a rating for airplane multi-engine land. He also held a commercial pilot certificate with ratings for airplane single engine land and sea. The pilot also held a flight instructor certificate for airplane single engine land, multi-engine land, and instrument airplane. The pilot's most recent Federal Aviation Administration (FAA) Second Class Medical Certificate was issued on May 17, 2004. The pilot reported 20,000 hours of total flight experience on that date. According to the pilot's business manager, the pilot had not kept a logbook for many years. She estimated that the pilot had accrued between 16,000 and 20,000 hours of flight experience. A review of business records revealed that the pilot had approximately 60 hours of flight experience in make and model. AIRCRAFT INFORMATION The airplane was built in 1974, and was equipped with two Lycoming TIGO-541-EA1 engines rated at 425 horsepower. The most recent annual inspection was completed on August 18, 2004. An engine run was completed prior to performing the inspection. During the inspection, examination of the oil filter and sump screen of the right engine revealed a high concentration of metal particles. After numerous discussions between the pilot/owner and the maintenance facility manager, the right engine was removed and shipped to an overhaul facility for replacement of the camshaft and all lifters. After replacement of the cam and lifters the engine was returned to the maintenance facility and reinstalled on the airplane. According to the mechanics that performed the work, the installation went smoothly, but an oil leak was detected during the first engine run. A second engine run was performed, and a leak was detected at the propeller seal. The propeller seal was replaced, and during a third engine run, oil again leaked from the engine. The engine was washed, "Zyglo" developer was applied to the engine case, and a fourth engine run determined that the oil had leaked from the engine starter adapter. The adapter assembly was repaired, and a bushing was modified prior to reinstallation of the starter adapter and the starter. After installation of the starter, a fifth engine run was performed. The engine started and ran without further oil leakage. Each engine run lasted approximately 15 minutes and included the start, the taxi to the run-up area, the actual run-up, and the return taxi to the hangar. The left engine was always run for the purpose of taxiing the aircraft to the run-up area, but the troubleshooting operations involved higher power settings on the right engine. The mechanics each stated that the fuel selectors were in the outboard position for all engine runs, and that they noted that the fuel quantity in each of the outboard tanks was "low". When asked to estimate the fuel level on fuel indicator diagrams, each mechanic marked the fuel level near the 1/4 tank striation. When the pilot/owner took delivery of the airplane, he requested that 2 quarts of oil be added to the right engine after his preflight inspection was completed. The mechanic who added the oil, and adjusted the right cowl flap at the pilot's request, asked the pilot if he had enough fuel for the trip to Rochester. According to the mechanic, the pilot responded, "Yeah, I think I have enough." METEOROLOGICAL INFORMATION At 1356, the weather reported at the Greater Rochester International Airport, 11 miles east of the crash site, included winds from 250 degrees at 9 knots, 10 statute miles visibility, a few clouds at 3,000 feet, a broken ceiling at 14,000 feet, and an overcast layer at 18,000 feet. The temperature was 72 degrees Fahrenheit, the dew point 54 degrees Fahrenheit, and the barometric pressure was 29.99 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was examined on August 21, 2004, and all major components were located at the scene. The airplane crashed in a small field of low brush prior to a tree line that bordered a larger field to the north. The site was about 5 miles north of Ledgedale Airport. The wreckage path was approximately 85 feet long and oriented about 030 degrees. The initial impact point was in a tree about 45 feet above the ground. Angular cut wood was found at the base of the tree. The propeller assemblies were separated from their engines and partially buried in the initial impact crater, about 75 feet beyond the initial impact point. Their respective propeller shafts and spur gearing remained attached to the assemblies. The airplane came to rest approximately 10 feet beyond the propellers, and was oriented 220 degrees. The cockpit and cabin area were destroyed by impact and post-crash fire. The aft 10 feet of empennage, which included the vertical fin, rudder, and left horizontal stabilizer were intact. The right horizontal stabilizer was damaged by impact. The deicing boots on the tail surfaces were melted. Both wings were separated from the airplane, but remained attached by control cables. The right engine was in the nacelle and attached to the wing, the left engine was separated. The landing gear was down and locked. The left wing was destroyed by fire. The right wing was essentially intact with a small concave dent in the leading edge, ## Aircraft - Registration: [N57EF](https://openairdocs.org/deregistered/N57EF-2005-02-23), registration cancelled 2005-02-23, S/N 31P-7400215, built 1974 (OpenAirDocs) - Reported make and model: Piper PA-31P - Registry model: [Piper PA-31P](https://openairdocs.org/model/piper-pa-31p) (registry code 7103120) (OpenAirDocs) - Registry engine: [Lycoming TIGO-541SER](https://openairdocs.org/engine/lycoming-tigo-541ser) (registry code 41539, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 31P-7400215 - Airframe hours: 3516 - Engines: Lycoming TGIO-54PEIA 425 horsepower reciprocating; Lycoming TGIO-54PEIA 425 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Registered owner: William M. Law - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 17, 2004, 1 hours before - Departed: GVQ, Batavia, NY - Destination: ROC, Rochester, NY - Airport: 7G0, Ledgedale Airpark ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; commercial, airline transport, flight instructor; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review April 30, 2004; seat: left; toxicology performed; flight hours: 20,000 total, 60 in this make and model, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 14,000 ft broken - Temperature: 72 °F, dew point 63 °F - Altimeter: 29.98 inHg - Observed at: ROC, 11 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 20040820022379A](https://openairdocs.org/incident/20040820022379A), Aug 20, 2004: Piper PA31P, Clarkson, NY, Destroyed, 1 fatal. (-23) On Friday, August 20, 2004, at approximately 1337 local, a Piper PA-31-P, registration number N57EF, registered to ceo air, inc. of 225 allens creek rd,… 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.