LAX95LA314

NTSB accident investigation · Piper PA-23-250 · Marana, AZ · August 30, 1995

Accident · FatalLimited investigationFinal report
Date
August 30, 1995, 05:53 local (12:53 UTC)
Place
Marana, AZ
Injuries
1 fatal, 2 minor; on the ground: 2 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N7156TPiper PA-23-250
Weather
Visual (VMC) · Dawn
Status
Completed · report April 1, 1996
Report
Approved by Office Director
FAA report
19950830027069A
Case key
29202

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 poor installation of the propeller which allowed the propeller to become loose, and the pilot's improper emergency procedure by feathering the wrong propeller.

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.

Propeller failure/malfunctionClimb - to cruise
Propeller system/accessories - looseCause
Maintenance,installation - improperPilot in commandCause
Forced landingEmergency descent/landing
In flight collision with objectEmergency descent/landing
Object - tree(s)
Object - wire,static
Object - residence
Emergency procedure - improperPilot in commandCause
Wrong propeller featheredPilot in command
Diverted attentionPilot in commandFactor

Analysis

The pilot was beginning a flight to transport marijuana in duffle bags. Shortly after takeoff the right propeller began to separate from its mounting flange. The pilot turned the airplane toward the airport, feathered the wrong propeller and began to throw out the duffle bags. The airplane collided with a tree, wires, and a privately owned residence. Two persons in the residence sustained minor injuries. The post accident wreckage examination revealed that the propeller mounting studs safety wire was broken and three of the six propeller mounting studs were broken. The remaining mounting studs had backed off. The right engine oil system contained extensive metal particles and the propeller governor oil screen was altered to allow unfiltered oil flow.

Factual narrative

On August 30, 1995, at 0553 hours mountain standard time, a Piper PA-23-250, N7156T, collided with a tree, wires, and a privately owned residence about 2.5 miles northwest of Avra Valley Airport, Marana, Arizona. The pilot was beginning a visual flight rules (VFR) flight to an undetermined destination and was returning to the airport after sustaining a loss of power on the right side engine. The airplane, owned and operated by the pilot, was destroyed by impact forces and the postimpact fire. The certificated commercial pilot, the sole occupant, received severe burn injuries and died on September 14, 1995.

The on-scene postcrash investigation was conducted by two airworthiness inspectors from the Federal Aviation Administration (FAA), Scottsdale [Arizona] Flight Standards District Office. An inspector reported that witnesses stated the engine lost power shortly after departing the airport. The witnesses also said that while returning to the airport, several duffle bags were "thrown out" of the airplane before it struck the tree. Examination of the recovered duffle bags revealed a substantial quantity of marijuana.

The inspectors found some airplane maintenance logbooks at the accident site. Examination of the logbooks revealed that there were no maintenance entries made after the airplane was imported to the United States in 1990. Further investigation and search for current logbooks were unsuccessful. A witness told a National Transportation Safety Board investigator that he often saw the pilot doing maintenance on various aircraft. An FAA inspector stated that other witnesses reported seeing the pilot working on the accident airplane. The pilot did not hold a mechanic certificate.

Safety Board investigators conducted a telephone interview with the sales manager of Double Eagle Aviation, Haskell, Oklahoma, on November 10, 1995. The sales manager reported that he sold the airplane to the pilot, in a cash transaction, on August 25, 1995. According to Double Eagle records, at the time of the sale, the airplane's annual inspection was due on March 1, 1996. The airplane accrued 5,732 flight hours and the engines accrued 1,010 and 1,802 hours, left and right, respectively, since major overhaul.

The on-site investigation of the scene revealed that the cabin/cockpit area was incinerated by the postcrash fire. The FAA inspectors examined the engines and propeller assemblies at Air Transport, Phoenix, Arizona, on September 2, 1995. Both engines sustained extensive fire damage and their respective accessories could not be functionally tested.

Left Engine Examination:

Continuity of the engine gear and valve train assemblies was established. Thumb compression was noted on all cylinders when the crankshaft was rotated. The number 6 cylinder head was melted and its piston was exposed.

The spark plugs, except the number 2 lower spark plug, displayed normal operating signatures. The number 2 lower spark plug was oil soaked.

The oil was found free of contaminates.

The inspectors found the left propeller blades in a feathered position.

Right Engine Examination

Continuity of the engine gear and valve train assemblies was established. Thumb compression was noted on all cylinders when the crankshaft was rotated.

The main engine oil screen contained extensive metal particles.

Disassembly examination of the engine showed that the cylinders, pistons, and piston rings displayed normal operating signatures. The forward main bearing display edextruded bearing material and wear patterns between the crankshaft thrust face and the crankshaft surface. Some connecting rod bearings displayed high temperature distress.

The upper spark plugs displayed normal operating signatures. The numbers 1 and 2 lower spark plugs were oil soaked and the remaining lower spark plugs displayed some lead deposits.

The oil, however, contained extensive metal particles.

The right propeller blades were near the low pitch, high rpm, position. One propeller blade was bent toward the face side and displayed many chordwise scuffing signatures; the remaining blade displayed minor chordwise scuffing signatures. Neither blade displayed any "S" twisting deformation.

The right propeller assembly was found loose on the crankshaft mounting flange. Three of the six studs were found sheared; the remaining studs were found "back-off" from the crankshaft mounting flange. The mounting flange studs' safety wire was found broken. Examination of the broken safety wire showed characteristics of a tensile overload fracture.

The mating faces of the engine output shaft and the propeller extension displayed metal transfer signatures.

A 1/2-inch hole was found drilled through the propeller governor screen. According to the Lycoming representative, this alteration allowed full unfiltered oil flow and is not an authorized repair procedure.

The Maricopa County Medical Examiner reported that the pilot expired on September 14, 1995, due to complications of thermal burns. Toxicology examinations were not conducted.

Aircraft

Registration
N7156T
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-3601
Engine
Lycoming IO-540, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Other work use · Part 91
Registered owner
Richard A. Fenimore
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 1995
Departed
E14 · AZ
Destination
Unknown
Airport
E14 · Avra Valley

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
39
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
2,000 total

Weather

Conditions
Visual (VMC) · Dawn
Wind
160° at 6 knots
Visibility
30 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 63 °F
Altimeter
29.00 inHg
Observed at
TUS, 31 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.