LAX00FA310

NTSB accident investigation · Piper PA-31-350 · Hilo, HI · August 26, 2000

Accident · FatalField investigationFinal report
Date
August 25, 2000, 17:35 local (Aug 26, 2000, 03:35 UTC)
Place
Hilo, HI
Injuries
1 fatal, 8 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N923BAPiper PA-31-350
Weather
Visual (VMC) · Day
Status
Completed · report April 17, 2003
Report
Approved by Office Director
Parties
New Piper Aircraft, Textron Lycoming, Federal Aviation Administration
FAA report
20000825006919A
Case key
50125

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

Deterioration and failure of the oil filter converter plate gasket, which resulted in a loss of engine power and a subsequent in-flight fire.

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/malfCruise
1 engine - failure,partial
Inadequate surveillance,inadequate procedureManufacturerFactor
Lubricating system,oil gasket - inadequateCause
Material inadequateSupplier/distributor of partsCause
Lubricating system,oil gasket - deterioratedCause
Lubricating system,oil gasket - failureCause
Fluid,oil - leak
Engine compartment - fire
Forced landingDescent - emergency
DitchingEmergency landing
Aircraft performance,engine out capability - exceeded
Altitude - not maintained

Analysis

The pilot ditched the twin engine airplane in the Pacific ocean after experiencing a loss of engine power and an in-flight engine fire while in cruise flight. The flight was operating at 1,000 feet msl, when the pilot noticed a loss of engine power in the right engine. At the same time the pilot was noticing the power loss, passengers noted a fire coming from the right engine cowling. The pilot secured the right engine and feathered the propeller. He attempted to land the airplane at a nearby airport; however, when he realized that the airplane was unable to maintain altitude he elected to ditch the airplane in the ocean. Prior to executing the forced landing, the pilot instructed the passengers to don their life jackets and assume the crash position. After touchdown, all but one passenger exited the airplane through the main cabin and pilot doors. It was reported that the remaining passenger was frightened, and could not swim. One survivor saw the remaining passenger sitting in the seat with the seat belt still secured and the life vest inflated. The pilot and passengers were then rescued from the ocean via rescue helicopter and boat. Postaccident examination of the airplane revealed that the right engine's oil converter plate gasket had deteriorated and extruded from behind the converter plate, allowing oil to spray in the accessory section and resulting in the subsequent engine fire. The engine manufacturer had previously issued a mandatory service bulletin (MSB) requiring inspection of the gasket every 50 hours for evidence of gasket extrusion around the cover plate or oil leakage. Maintenance records revealed that the inspection had been conducted 18.3 hours prior to the accident. At the time of the accident, the right engine had accumulated 386.8 hours since its last overhaul, and gasket replacement. The MSB was issued one month prior to the accident, after the manufacturer received reports of certain oil filter converter plate gaskets extruding around the oil filter converter plate. The protruding or swelling of the gasket allowed oil to leak and spray from between the plate and the accessory housing. A series of tests were conducted on exemplar gaskets by submerging them in engine oil heated to 245 degrees F; after about 290 hours, the gasket material displayed signs of deterioration similar to that of the accident gasket. A subsequent investigation revealed that the engine manufacturer had recently changed gasket suppliers, which resulted in a shipment of gaskets getting into the supply chain that did not meet specifications. As a result of this accident, the engine manufacturer revised the MSB to require the replacement of the gasket every 50 hours. The FAA followed suit and issued an airworthiness directive to mandate the replacement of the gasket every 50 hours.

Factual narrative

History of flight

On August 25, 2000, at 1735 Hawaiian standard time, a Piper PA-31-350 twin engine airplane, N923BA, operated as Big Island Air flight number BI 57, was substantially damaged during an emergency ditching in the Pacific Ocean following a loss of engine power while in cruise flight. The pilot was attempting to land at the Hilo International Airport, Hilo, Hawaii, when the ditching occurred. One passenger received fatal injuries, while the commercial pilot and remaining 7 passengers received minor injuries. Big Island Air, Inc., was operating the airplane as a nonscheduled sightseeing tour under 14 CFR Part 135, when the accident occurred. The local flight originated from Kailua-Kona, Hawaii, at 1700, and was en route to the Hilo area with a planned return to Kona, without landing at Hilo. Visual meteorological conditions prevailed at the time of the accident and a visual flight rules flight plan was filed and activated.

The pilot reported that he was at 1,000 feet mean sea level (msl) near Laupahoehoe, Hawaii, when he felt the airplane yaw to the right, and noted that the right engine's manifold pressure had dropped to about 25 inches. He immediately switched from the right main fuel tank to the right auxiliary fuel tank and turned on the fuel boost pump. He then moved the throttles, propellers, and mixture controls full forward, and identified the right engine was not producing thrust. He shutdown the right engine by reducing the throttle to idle, bringing the mixture control into idle cutoff, and then by moving the propeller control into the feather position. He noted, however, that the right propeller continued to rotate intermittently after shutdown.

At the same time the pilot noted the power loss, at least two passengers indicated to him that a fire was visible through the louvers on the right engine cowling. The pilot announced that they were going to land at the Hilo International Airport (ITO), which was 23 miles ahead.

As the airplane deviated toward Hilo, the pilot noted that with the airspeed at blue line (Vyse) he was unable to maintain altitude. The airplane continued to descend between 100 and 50 feet per minute. He checked to ensure that the cowl flaps were closed on both engines, and noted that the left engine was producing 41.5 inches of manifold pressure with the left propeller in the full forward position.

Considering the distance to the airport, the pilot estimated that he would not be able to reach land or the airport. He then instructed the passengers to don their life vests and briefed them to prepare for ditching. He made MAYDAY distress calls to the ITO control tower and to the Honolulu Flight Service Station. He also set the transponder to squawk 7700.

About 250 feet msl and 5 miles from the airport, the pilot began configuring the airplane for ditching. He slowed the airplane and gradually added full flaps, keeping full power on the left engine. He felt the tail of the airplane touch the water; followed by a jolt that momentarily stunned him. When he fully regained his senses, the water in the cockpit was already chest high. He opened the left pilot door and noticed the right front seat passenger climbed across him and exited first.

After exiting, the pilot moved to the rear main cabin door (located on the left side of the cabin) to assist the passengers. The right front seat passenger remained by the left cockpit door to assist any passengers who might be using that exit.

A passenger reported that water pressure against the right emergency window exit prevented its use. The airplane began to take on water immediately upon landing. As the nose sank first, the airplane began a gradual roll to the right, disappearing below the water within 60 seconds. The pilot attempted to dive below the water to check for any remaining passengers but reported that the murky water restricted his vision.

The pilot signaled for the passengers to remain in a group and within about 15 minutes a Hilo fire department helicopter and rescue personnel were on the scene. One passenger was determined to be missing and an unsuccessful search was initiated. Subsequently, the missing passenger was located in the airplane.

The following day the airplane was located by U.S. Coast Guard sonar under 80 feet of water. The site was 3.1 miles from ITO and on a 123-degree magnetic bearing to the airport. The airplane was recovered on August 27, 2000, and secured in the Civil Air Patrol hangar at ITO.

Personnel iformation

The commercial pilot held ratings in single engine land, multiengine land, and instrument airplanes. He also held a flight instructor rating for single engine airplane. He was issued a first-class medical certificate on July 7, 2000, with no limitations. According to the Pilot/Operator Aircraft Accident Report that the pilot submitted, he reported having accumulated a total of 2,067 hours of flight time, of which 1,096 hours were accumulated in multiengine airplanes.

According to Big Island Air records, the pilot was hired on September 13, 1999, and underwent basic indoctrination, ground instruction, flight instruction, and general emergency training between September 15, and 21, 1999. The pilot passed the FAR Part 135 Airman Competency/Proficiency Check on September 21, 1999. The pilot accumulated approximately 465.3 hours in the PA-31-350 after he became a line pilot for Big Island Air.

Meteorological information

At 1753, the Hilo, Hawaii, weather observation facility reported the wind from 080 degrees at 8 knots; visibility 10 statute miles; a few clouds at 2,300 feet agl; temperature 26 degrees Celsius; dew point 21 degrees Celsius; and an altimeter setting of 30.00 inches of mercury.

Aircraft information

The twin engine Piper Chieftain airplane was powered by two TEXTRON Lycoming 350-horsepower TIO-540-J2BD turbo-charged engines and two 3-bladed, constant-speed, full-feathering Hartzell propellers. The left engine (serial number RL-9827-61A) rotates clockwise and the right engine (serial number L-1650-68A) rotates counterclockwise as viewed from the pilot seat. Lycoming recommends an engine overhaul interval of 1,600 hours.

The propeller blade pitch is adjusted via the combination of nitrogen or air pressure, a spring, blade counterweights and governor-regulated oil pressure. The nitrogen or air pressure, spring and blade counterweight force are utilized to move the blades to the high pitch (decreased rpm) and feathered positions. The opposing governor-regulated oil pressure moves the blades to the low pitch (increased rpm) positions. Moving the propeller control lever aft decreases the propeller rpm as the propeller governor decreases the oil pressure to the hub, and the air pressure, spring, and blade counterweights move the propeller blades to the high pitch or, if selected, the feathered position.

The PA-31-350 Pilot Information Manual's (PIM) Emergency Procedures section supplies recommended procedures for coping with various types of emergencies. The recommended emergency procedures for an ENGINE FIRE IN FLIGHT are as follows:

"Fire wall fuel shutoff...............OFF

Throttle.......................................Idle

Propeller....................................FEATHER

Mixture........................................Idle Cut-off

Inoperative Engine.................Secure

If fire persists, Airspeed.........Increase in attempt to blow out fire.

Land at nearest suitable airport."

The ENGINE SECURING PROCEDURE (FEATHERING PROCEDURE) instructs the pilot to:

"Throttle....................................close

Propeller..................................FEATHER (1000 RPM min.)

Mixture.......................................IDLE CUT-OFF

Cowl flaps................................close

Air conditioner........................OFF

Magneto switch......................OFF

Emergency fuel pump.......

Aircraft

Registration
N923BA
Reported as
Piper PA-31-350
Category
Airplane
Serial number
31-8252024
Airframe hours
3,492.3
Engines
Lycoming LTIO-540-J2BD, 350 horsepower, reciprocatingLycoming TIO-540-J2BD, 350 horsepower, reciprocating
Damage
Substantial damage
Fire
In-Flight
Flight
Part 135
Operator
Big Island Air, Inc., doing business as Big Island Air, Inc.
Registered owner
Tom Beard
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · August 21, 2000 · 18 hours before
Departed
KOA · Kailua-Kona, HI
Flight plan
VFR
Airport
KOA · Hilo International

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
33
Injuries
Minor
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
September 21, 1999
Seat
Left
Flight hours
2,067 total · 465 in this make and model · 1,917 as pilot in command · 163 in the last 90 days · 64 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
80° at 12 knots
Visibility
10 statute miles
Lowest ceiling
3,400 ft broken
Temperature
79 °F, dew point 70 °F
Altimeter
30.07 inHg
Observed at
ITO, 3 nm away

Docket · 43

The files NTSB released with the investigation on February 22, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 25.6 MB in all.

Survival Factors 6 - Factual ReportItem 1 · .PDF · 1.1 MBSurvival Factors 6 - Attachment 1 - Big Island Air Safety Briefing CardItem 2 · .PDF · 150 KBSurvival Factors 6 - Attachment 2 - Passenger StatementsItem 3 · .PDF · 3.4 MBSurvival Factors 6 - Attachment 3 - Photographs (1 thru 10)Item 4 · .PDF · 17 KBSurvival Factors 6 - Photo 1. View of the left side of N923BA after it had been recovered from the ocean floor. Note: The crown of the fuselage is collapsed into the cabin.Item 5 · .PDF · 42 KBSurvival Factors 6 - Photo 2. View of the tail section of N923BA. Note: The main entry door remained hinged to the fuselage.Item 6 · .PDF · 46 KBSurvival Factors 6 - Photo 3. View of the right side of the airplane with arrows pointing to the emergency exit hatch latches found in the up and latched position.Item 7 · .PDF · 31 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 8 · .PDF · 420 KBSurvival Factors 6 - Photo 4. View of the left side of the airplane and the headphone chords extended across the cabin and interwined with a life vest.Item 9 · .PDF · 43 KBSurvival Factors 6 - Photo 5. Close up view of the life vest tangled in the headphone chords.Item 10 · .PDF · 34 KBSurvival Factors 6 - Photo 6. View of seats 1 and 2 in the cockpit of N923BA.Item 11 · .PDF · 34 KBSurvival Factors 6 - Photo 7. View of seat 3 where the fatally injured passenger was seated.Item 12 · .PDF · 42 KBSurvival Factors 6 - Photo 8. View of seat 4. Note: The headphone chord extended across the right arm rest.Item 13 · .PDF · 31 KBSurvival Factors 6 - Photo 9. View of seats 9 and 10 in the severed aft end of the cabin.Item 14 · .PDF · 44 KBSurvival Factors 6 - Photo 10. View of the Hawaii County Fire Department's rescue basket used to pull the survivors out of Hilo Bay.Item 15 · .PDF · 55 KBSurvival Factors 6 - Attachment 4 - Map of the accident site and Hilo Bay, Hawaii & Running Log for the Hawaii County Fire DepartmentItem 16 · .PDF · 917 KBFAA Statement of Pilot InterviewItem 17 · .PDF · 99 KBWitness StatementsItem 18 · .PDF · 138 KBATC Transcripts and DataItem 19 · .PDF · 402 KBPilot InformationItem 20 · .PDF · 907 KBWeight and Balance InformationItem 21 · .PDF · 65 KBExcerpts from Pilot Information ManualItem 22 · .PDF · 939 KBMaintenance Record ExcerptsItem 23 · .PDF · 3.7 MBEngine Manufacturer's Field NotesItem 24 · .PDF · 481 KBTextron Lycoming ReportItem 25 · .PDF · 1.9 MBReport from Hartzell Propeller Inc.Item 26 · .PDF · 260 KBStatement of Party Representatives to NTSB InvestigationItem 27 · .PDF · 326 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 28 · .PDF · 39 KBPhoto 1. Recovery of aircraft wreckage.Item 29 · .PDF · 884 KBPhoto 2. Aircraft recovery.Item 30 · .PDF · 735 KBPhoto 3. Aircraft recovery. Note: Aircraft is inverted; black sooting on right wing.Item 31 · .PDF · 673 KBPhoto 4. Aircraft recovery. Note: Extensive damage during recovery (tail separated).Item 32 · .PDF · 479 KBPhoto 5. Right propeller. Piper photo.Item 33 · .PDF · 690 KBPhoto 6. Left propeller. Piper photo.Item 34 · .PDF · 704 KBPhoto 7. Sooting and fire damage (looking at firewall aft). Piper photo.Item 35 · .PDF · 690 KBPhoto 8. Fire damage to flap. Piper photo.Item 36 · .PDF · 495 KBPhoto 9. Right engine. Piper photo.Item 37 · .PDF · 748 KBPhoto 10. Right engine oil filter. Piper photo.Item 38 · .PDF · 707 KBPhoto 11. Right engine oil filter converter plate. Piper photo.Item 39 · .PDF · 703 KBPhoto 12. Right engine oil filter converter plate and gasket. Piper photo.Item 40 · .PDF · 758 KBPhoto 13. Right engine oil filter converter plate gasket. Note: missing section. Piper photo.Item 41 · .PDF · 807 KBPhoto 14. Closer view of right gasket. (Photo courtesy of Piper no negative)Item 42 · .PDF · 104 KBPhoto 15. Left engine converter plate and gasket. Piper photo.Item 43 · .PDF · 762 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.