MIA00FA163

NTSB accident investigation · Piper PA-23-160 · Titusville, FL · May 19, 2000

Accident · FatalField investigationFinal report
Date
May 19, 2000, 09:12 local (13:12 UTC)
Place
Titusville, FL
Injuries
1 fatal, 1 serious
Damage
Destroyed
Phase of flight
Approach
Aircraft
N3492PPiper PA-23-160
Weather
Visual (VMC) · Day
Status
Completed · report July 17, 2001
Report
Approved by Office Director
FAA report
20000519007829A
Case key
49232

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 failure of the PIC to maintain control of the aircraft while in the simulated engine inoperative configuration in the landing pattern during a checkout flight resulting in an uncontrolled descent and collision with trees. A factor in the accident is the inadequate monitoring of aircraft control by the checkout pilot.

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 control - in flightApproach - vfr pattern - downwind
Aircraft control - not maintainedPilot in commandCause
Monitoring - inadequateCheck pilotFactor
In flight collision with objectDescent - uncontrolled
Object - tree(s)

Analysis

According to an eyewitness, the tower controller at Space Coast Regional Airport, Titusville, Florida, (TIX), who was controlling the flight in the landing pattern, when the airplane approached the right pattern abeam-of-landing point to runway 09, it abruptly entered a wings vertical attitude and dove for the ground. The CFI, the survivor, stated postcrash, that he was giving dual check-out procedures to the rated Commercial MEL pilot who was flying. When the CFI zero-thrusted the right engine in preparation for single engine landing practice, the aircraft abruptly entered a half roll to the left, pitched down, and collided with the terrain. Postcrash examination of the engines, airframe, and their components revealed nothing causal. The CFI stated he was not 'on the controls with the pilot' and did not know what control pressures he may have been applying. He also stated that outflow from nearby power plant smoke stacks and a recent runway change from 27 to 09 may have contributed to turbulence or air instability. Two tower controllers, one with 23 years experience at the TIX airport, and the other with 19 years at the TIX airport, stated that neither of them have ever heard an aircraft in the pattern complain of smoke stack generated air instability.

Factual narrative

History of flight

On May 19, 2000, about 0912 eastern daylight time, a Piper PA-23-160, N3492P, registered to Merkado Holdings, Inc., dba Walkwitz Aviation, operating as a Title 14 CFR Part 91 checkout flight, crashed in the vicinity of the Space Coast Regional Airport, (TIX), Titusville, Florida. Visual meteorological conditions prevailed and no flight plan was filed. The airplane was destroyed, the commercially rated pilot received fatal injuries, and the certified flight instructor received serious injuries. The flight originated from Titusville's Arthur Dunn Airpark about 0730.

According to the CFI, in a statement given to two FAA inspectors at about 1630 on the day of the accident in the emergency room of Orlando Regional Medical Center, Orlando, Florida, he was giving dual check-out in MEL single engine failure procedures and simulated failed engine landings at the TIX airport. Once he was satisfied with the pilot's identification and response to a simulated failed engine, he set the right engine power controls to a zero thrust setting for engine-out approaches and landings. The pilot felt his first single engine approach was too high and too fast and a two engine go-around was conducted. During the downwind turn for the second approach, after the CFI zero-thrusted the right engine, the pilot allowed the airplane to decelerate below single engine minimum control speed, (Vmc) at which time the CFI took control and affected a recovery. A second control transfer from CFI back to the pilot resulted in a similar deceleration below Vmc and a right roll and dive that resulted in terrain collision. The NTSB 6120.1/2 form submitted by the CFI on June 9, 2000, stated that the airplane entered a left roll and dive that resulted in the ground collision.

During a telephone interview with the NTSB, on December 13, 2000, the CFI requested that certain changes be made to his previous statements. He reiterated that their TIX landing pattern work the day of the accident began with a low approach to runway 27 followed by a go-around and an entry to a left downwind to runway 09 due to tower controlled runway change from 27 to 09. The pilot's landing resulted in an extended flare because he was too fast. On the climb out and upwind right turn for a right pattern to runway 09, the pilot stated he was determined to control his airspeed more precisely the next time. It was on the downwind segment that the CFI zero-thrusted the right engine, the flight was straight and level at 800 to 900 feet, agl, and they had not started their base turn to final approach. The airspeed was not below Vmc but probably a little below Vyse, (single engine best rate of climb speed, or more commonly, the blue line on the indicator) when they entered a "1/2 snap roll to the left and the nose dropped below the horizon". He maintains that the puzzling thing to him is that the airplane rolled into the operating engine, and thus the mishap could not have been a Vmc roll. He states that he was not riding or feeling the control inputs being applied by the pilot at the instant they departed from normal flight, and that the pilot may have been cross controlling the flight controls. He stated he waited an instant to see how the pilot would react, but lacking any reaction, he took control, but ran out of altitude to recover. The CFI added that the TIX landing pattern is exposed to smoke stack outflow from a power generating plant about 3 miles southeast of the field. He maintains that the accident had to be the result of the wind change or the smoke stack outflow, or a combination of the two.

According to the tower controller on duty at the time of the accident, following a few practice touch and go landings to runway 09, N3492P entered a right downwind pattern for another approach to 09. N3492P was just past the abeam position for a landing when he observed the airplane abruptly roll left and dive for the ground where he lost sight behind the trees. The controller added that no other aircraft in the landing pattern, before, during, or after the accident, reported turbulence or unstable air. There was no radio call to indicate a problem preceding the accident. All radio transmissions from the accident airplane, including the initial call up, the go-around call, and the abeam position call for the last approach seemed routine.

Personnel information

The instructor is an Irish national aviation college student who had been authorized employment as a CFI to enhance practical training in the student's field of study. He held a Flight Instructor certificate with ratings for airplane single engine land, multiengine land, instrument airplane, and advanced and instrument ground instructor. His most recent FAA first-class medical certificate was dated October 2, 1998, with no limitations. His total flight time was 1180 hours, with 234 hours flown in multiengine aircraft. Multiengine instructor time was 192 hours.

The pilot/student was a Swedish national who had arrived in the U.S. on May 16, 2000, reportedly to work on his multiengine currency and build MEL flight time. He held a Commercial Pilot certificate with ratings for airplane single engine land, single engine sea, multiengine land, and instrument airplane. His most recent FAA first-class medical certificate was dated June 6, 1999, with no limitations. No pilot logbook was supplied to the NTSB, but the flight school application form completed by the pilot listed his flight time as of May 17, 2000 as 600 hours SEL, and 30 hours MEL. He had flown a 1.6-hour dual checkout flight on May 18, 2000, with the same CFI, which included seven or eight landings at TIX.

Aircraft information

The airplane had undergone a 100-hour inspection and its logbook signed by an FAA licensed mechanic on May 9, 2000, at an aircraft total time of 7765.8 hours and Hobbs time of 4095.0 hours. The Hobbs read 4146.5 at the wreckage site. According to engine records, the left engine had been rebuilt to new parts specifications in July, 1999, at a Hobbs time of 2507.7 hours. The left engine logbook entry indicated that engine "TTSPO" to zero time was accomplished on July, 1999. The right engine records revealed a time since overhaul of 2843 hours. Zero time left and right propellers had been installed on January 6, 2000, and both had accumulated 934 hours. The propellers were a modification per STC SA00721HC whereby the existing Hartzell HC-82YL-2C propellers, spinners and bulkheads were replaced with Hartzell HC-C2YL-2CUF propellers, spinners, and bulkheads. The aircraft records contained an STC for automotive fuel use; however, evidence at the accident site revealed use of 100LL aviation fuel. The static system was tested and inspected on April 26, 2000, and found to meet the requirements of FAR 91.411 and 91.413.

Meteorological information

The TIX tower personnel recorded a special METAR immediately following the accident at 0912. Visibility was 7 miles, cloud cover was scattered at 4,000 feet and at 20,000 feet, barometric pressure was 30.20 inches Hg., and the winds were from 120 degrees at 6 knots. WRECKAGE AND IMPACT INFORMATION

The airplane impacted dense 2-inch to 12-inch diameter scrub oak, gum, and palmetto growth at about 1.5 miles southwest of the TIX airport center at coordinates, N28 degrees, 29.92 minutes by W80 degrees, 48.72 minutes, which corresponds to the abeam-of-touchdown point for a right landing pattern to TIX's runway 09. The wreckage path was oriented about 070 degrees magnetic, measured about 65 feet in length, and began with tree collision about 40 feet above the surface in a wings level, nose down attitude. Tree foliage and palmetto fronds situated along the wreckage path exhibited evidence of fuel spewage, and the site smelled of 100LL fuel spill. The aircraft came to rest upright, heading about 125 degrees, in about a 15 degree left bank, having shed pieces of the right wing and the outer left wing pa

Aircraft

Registration
N3492P
Reported as
Piper PA-23-160
Category
Airplane
Serial number
23-1468
Airframe hours
7,817
Engine
Lycoming O-320-B3B, 160 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Registered owner
Merkado Holdings, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 9, 2000 · 52 hours before
Departed
X21 · FL
Destination
TIX · FL
Airport
TIX · Space Coast Regional, runway 9, 5,001 × 100 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
39
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
600 total · 2 in the last 90 days · 2 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 6 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 45 °F
Altimeter
30.00 inHg
Observed at
TIX, 1 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.