# NTSB MIA04FA047: Piper PA-23-160, N4293P, Lake Worth, FL, January 22, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 22, 2004, 11:48 local (16:48 UTC) - Place: Lake Worth, FL - Coordinates: 26.590555, -80.07611 - Nearby events: https://openairdocs.org/map.md?lat=26.5906&lon=-80.0761&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 28, 2005 - Report: Approved by Office Director - Parties: Textron Lycoming Engines, New Piper Aircraft Corp., FAA FSDO - NTSB case key (mKey): 58655 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA04FA047 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58655/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58655 - Page: https://openairdocs.org/ntsb/MIA04FA047 ## Probable cause The pilot's inadequate control of the aircraft by his use of an excessive bank angle, and his failure to maintain airspeed which resulted in a stall and a loss of control following a loss of power in one engine. The reason for the loss of the engine power was not determined. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, climb - to cruise - reason for occurrence undetermined - 1 engine - Loss of control - in flight, approach - vfr pattern - base leg/base to final - aircraft handling - excessive, pilot in command (cause) - airspeed(vs) - not maintained, pilot in command (cause) - stall/mush - inadvertent, pilot in command - In flight collision with object, descent - uncontrolled - object - tree(s) - object - wire,transmission - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The pilot reported shortly after the takeoff from runway 27 that he was returning to land with a lost of power in one of the engines. The airplane subsequently crashed in a residential area, collided with trees, powerlines, and came to rest in the yard of a residence. Witnesses observed the flight fly the downwind leg for runway 27 at 400 feet. The flight then turned on the base leg while descending and then overshot the final leg. While at an altitude of 100-150 feet the flight continued turning toward the runway and the bank angle increased to 50-60 degrees and the nose dropped down.. Recorded radar shows the flight climbed to 3,000 feet while maintaining a southwesterly heading. The flight turned left back to the airport and began a descent from which he entered downwind for runway 27 at an altitude of between 400 and 500 feet, while about 1/4 mile south of the runway, at a groundspeed of between 95 and 105 knots. The flight turned onto base leg at an altitude of about 300 feet, while about 1/2 mile from the arrival end of runway 27, at an approximate groundspeed of between 75 and 80 knots. The last radar contact showed the airplane at an altitude of 82 feet at a groundspeed of 66 knots. The examination of the airplane did not reveal evidence of mechanical malfunction. The Owner's Handbook for the Piper PA23-160 showed that the stall speed for the airplane with wing flaps down and engine power off is 53 knots. Stall speed would increase about 25 percent at a bank angle of 50 degrees and 40 percent at a bank angle of 60 degrees. This would increase stall speed to between 66 and 74 knots at the reported bank angle of 50-60 degrees used by the pilot. ## Factual narrative History of the Flight On January 22, 2004, about 1148 eastern standard time, a Piper PA-23-160, N4293P, crashed in a residential area while returning to land at West Palm Beach County Park Airport, Lantana, Florida, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The airplane was destroyed and the private-rated pilot and one passenger received fatal injuries. The flight originated from West Palm Beach County Park Airport, the same day, about 1137. After departure from West Palm Beach County Park Airport, the pilot of N4293P contacted the FAA, West Palm Beach International Airport Departure Control, and requested visual flight rules flight following for a flight to Everglades City, Florida. The pilot was given a transponder code. Shortly after this, the pilot reported to the controller that he needed to return to the West Palm Beach County Park Airport. The controller approved this and told the pilot that radio frequency change was approved. Shortly after this, the pilot transmitted on the Unicom frequency for the West Palm Beach County Park Airport, that he was 4 miles southwest of the airport, inbound for landing "on one engine". A flight instructor and dual student located in a Cessna 152 at the end of runway 27, who were awaiting takeoff, reported hearing the pilot of N4293P transmit on the Unicom frequency that he was 3 miles southwest of the airport, returning to the airport on one engine. They then heard the pilot report entering downwind for runway 27. They looked and observed the airplane abeam the end of runway 27 at about 400 feet altitude. The airplane then turned base leg for runway 27 and continued to lose altitude. The pilot then "overshot" the final turn for runway 27, to the north, while at an altitude of about 100-150 feet. The bank angle increased to 50-60 degrees and the nose of the airplane dropped to a low attitude. The airplane was now at about 50 feet altitude and descended in this attitude into the neighborhood. They then observed a ball of flame and smoke coming from the scene. The NTSB obtained from the West Palm Beach International Airport Authority, recordings of transmissions made by the pilot of N4293P on the West Palm Beach County Park Airport Unicom frequency , 122.7 MHz. The recordings showed that the pilot transmitted he was "four miles to the southwest inbound on one engine". A short time later, he transmitted that he was "three point five miles southwest". The pilot's final transmission was when the pilot reported "downwind for two seven". Recorded radar data from the FAA, West Palm Beach International Airport Approach Control showed that after takeoff from West Palm Beach County Park Airport the pilot climbed to 3,000 feet while maintaining a southwesterly heading. The pilot then made a left turn back to the airport and began a descent from which he entered downwind for runway 27 at an altitude of between 400 and 500 feet, while about 1/4 mile south of the runway, at a groundspeed of between 95 and 105 knots. The pilot turned onto base leg at an altitude of about 300 feet, while about 1/2 mile from the arrival end of runway 27, at an approximate groundspeed of between 75 and 80 knots. The last radar contact showed the airplane at an altitude of 82 feet at a groundspeed of 66 knots. Personnel Information The pilot held an FAA private pilot certificate with airplane single engine land, airplane multiengine land, airplane single engine sea, and instrument airplane ratings, last issued on July 10, 1993. The pilot held an FAA third class medical certificate, issued on March 22, 2002, with limitations that the holder wear corrective lenses for distant vision and possess glasses for near vision while exercising the privileges of the certificate. On the application for this medical certificate the pilot reported he had 2,500 total flight hours and that he had flown 40 flight hours in the previous 6 months. Examination of the pilot's logbook showed that at the time of the accident he had accumulated about 2,754 total flight hours and 2,435 total flight hours in the Piper PA-23-160. The pilot had accumulated about 20 total flight hours, all in the PA-23-160, in the previous 90 days. The pilot received a biennial flight review on January 16, 2002. Airplane Information The airplane was a Piper Aircraft Corporation model PA-23-160, serial number 23-1793, manufactured in 1959. At the time of the accident the airplane had accumulated about 6,334 total flight hours. The airplane was last inspected on December 4, 2003, about 20 flight hours before the accident, when it received an annual inspection. The airplane was equipped with two Lycoming O-360-A1D, 180 horsepower engines. The left engine was overhauled on December 6, 2002, about 114 flight hours before the accident. The right engine was overhauled on June 21, 1999, about 396 flight hours before the accident. The airplane was equipped with two Hartzell HC-C2YK-2, two-bladed propellers. Meteorological Information The Palm Beach International Airport, 1153 surface weather observation was winds from 310 degrees at 6 knots, visibility 10 statute miles, sky few clouds at 2,500 feet and scattered clouds at 10,000 feet, temperature 72 degrees F, dew point temperature 57 degrees F, and altimeter setting 30.15 inHg. Palm Beach International Airport is located about 5 miles north of the accident site. Wreckage and Impact Information The airplane crashed in the yard of a house located at 1812 Crest Drive, Lake Worth, Florida. The main wreckage came to rest at position 26 degrees 35.440 minutes North latitude and 080 degrees 04.572 West longitude. Examination of the accident site showed the airplane collided with a tree at about the 20-foot level. Several tree limbs up to 2 inches in diameter were cut from the tree. The airplane continued on about a 236-degree heading and collided with cable television lines. The airplane then touched down on the ground, collided with another tree, and turned around, coming to rest on a 110-degree heading. The nose landing gear, left wing, left propeller, right engine, and right propeller separated from the airplane during the accident sequence. All of these components were found within 15 feet of the main wreckage. The right propeller had television cables wrapped around it. A postcrash fire erupted and consumed the cabin and inboard right wing. All components of the airplane which are necessary for flight were located on or around the main wreckage of the airplane. Continuity of the aileron, elevator, rudder, rudder trim, and elevator trim systems was established. All separation of control cables was consistent with overload separation or fire damage. The elevator trim was found in the neutral position. The rudder trim was found in the neutral position. The wing flap actuator was found extended to the flaps 21 degree extended position. The landing gear was found in the extended position. Examination of the airframe fuel system showed that the fuel selectors in the cockpit were in the full forward or main tank position. The left main fuel tank contained about 30 gallons of blue aviation fuel. The right main fuel tank was consumed by the postcrash fire. The left and right fuel valves located in the wings were found in the outboard tank position and the cables between the cockpit fuel selector handles and the valves had sustained impact damage. The left engine fuel strainer contained blue aviation fuel and no contamination. The right fuel strainer was consumed by the postcrash fire. All fuel lines in the left wing and engine were unobstructed. The fuel lines in the right wing were consumed by fire. The left wing outboard fuel tank cap was in place after the accident. The left wing inboard tank fuel cap separated during the accident and was found lying near the wreckage. There were no fuel stains on the wing around the lef ## Aircraft - Registration: [N4293P](https://openairdocs.org/deregistered/N4293P-2004-03-02), registration cancelled 2004-03-02, S/N 23-1793, built 1959 (OpenAirDocs) - Reported make and model: Piper PA-23-160 - Registry model: [Piper PA-23-160](https://openairdocs.org/model/piper-pa-23-160) (registry code 7102304) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 23-1793 - Airframe hours: 6334 - Engines: Lycoming O-360-A1D 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Donald W. Dubois - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 4, 2003, 19 hours before - Departed: LNA, Lantana, FL - Destination: X01, Everglades City, FL - Airport: LNA, Palm Beach County Park, runway 9, 3,489 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 79; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; last flight review April 16, 2002; seat: left; toxicology performed; flight hours: 2,754 total, 2,435 in this make and model, 20 in the last 90 days, 6 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 57 °F - Altimeter: 30.14 inHg - Observed at: PBI, 5 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 20040122011129A](https://openairdocs.org/incident/20040122011129A), Jan 22, 2004: Piper PA23160, West Palm Beach, FL, Destroyed, 2 fatal. (-23) N4239P was fueled at Florida airmotive, inc. with 12.4 gal. Of 100LL. The a/c departed lantana airport (klna) donald dubois (PIC) and his daughter… ## Docket (23 files) The files NTSB released with the investigation on February 17, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58655. 23.7 MB in all. - Sound Spectrum Study ATC Tape (item 1, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40218183&FileExtension=.PDF&FileName=Sound%20Spectrum%20Study%20ATC%20Tape-Master.PDF - Witness Statement (item 2, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225331&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 3, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225332&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 4, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357109&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Other Pertinent Forms and Reports: Radar Data (item 5, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225335&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%3A%20Radar%20Data-Master.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 6, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225337&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Other Pertinent Forms and Reports: Aircraft Maintenance Records (item 7, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357139&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%3A%20Aircraft%20Maintenance%20Records-Redacted.PDF - Miscellaneous: Condensor Information (item 8, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225341&FileExtension=.PDF&FileName=Miscellaneous%3A%20Condensor%20Information-Master.PDF - Other Pertinent Forms and Reports: Fuel Test (item 9, .PDF, 431 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357135&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%3A%20Fuel%20Test-Redacted.PDF - Other Pertinent Forms and Reports: Fueling Records (item 10, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225343&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%3A%20Fueling%20Records-Master.PDF - Miscellaneous: NTSB Metalurgist e-mail. (item 11, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225344&FileExtension=.PDF&FileName=Miscellaneous%3A%20NTSB%20Metalurgist%20e-mail.-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 344 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357142&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Pilot Records (item 13, .PDF, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225863&FileExtension=.PDF&FileName=Pilot%20Records-Redacted.PDF - Photo 2: View of tail section of N4293P. NTSB Digital Photo. (item 14, .PDF, 449 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225874&FileExtension=.PDF&FileName=Photo%202%3A%20View%20of%20tail%20section%20of%20N4293P.%20NTSB%20Digital%20Photo.-Master.PDF - Photo 3: View of left wing of N4293P. NTSB Digital Photo. (item 15, .PDF, 430 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225875&FileExtension=.PDF&FileName=Photo%203%3A%20View%20of%20left%20wing%20of%20N4293P.%20NTSB%20Digital%20Photo.-Master.PDF - Photo 4: View of left engine from N4293P. NTSB Digital Photo. (item 16, .PDF, 441 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225876&FileExtension=.PDF&FileName=Photo%204%3A%20View%20of%20left%20engine%20from%20N4293P.%20NTSB%20Digital%20Photo.-Master.PDF - Photo 5: View of right engine from N4293P. NTSB Digital Photo. (item 17, .PDF, 447 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225877&FileExtension=.PDF&FileName=Photo%205%3A%20View%20of%20right%20engine%20from%20N4293P.%20NTSB%20Digital%20Photo.-Master.PDF - Photo 6: View of left propeller from N4293P. NTSB Digital Photo. (item 18, .PDF, 445 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225878&FileExtension=.PDF&FileName=Photo%206%3A%20View%20of%20left%20propeller%20from%20N4293P.%20NTSB%20Digital%20Photo.-Master.PDF - Photo 7: View of right propeller from N4293P. Note television cable wrapped around propeller. NTSB Digital Photo. (item 19, .PDF, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225882&FileExtension=.PDF&FileName=Photo%207%3A%20View%20of%20right%20propeller%20from%20N4293P.%20Note%20television%20cable%20wrapped%20around%20propeller.%20NTSB%20Digital%20Photo.-Master.PDF - Photo 8: View of tree limb which was cut by N4293P. NTSB Digital Photo. (item 20, .PDF, 447 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225883&FileExtension=.PDF&FileName=Photo%208%3A%20View%20of%20tree%20limb%20which%20was%20cut%20by%20N4293P.%20NTSB%20Digital%20Photo.-Master.PDF - Photo 9: View of right engine after examination. NTSB Digital Photo. (item 21, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225884&FileExtension=.PDF&FileName=Photo%209%3A%20View%20of%20right%20engine%20after%20examination.%20NTSB%20Digital%20Photo.-Master.PDF - Photo 10: View of Left engine during examination. NTSB Digital Photo. (item 22, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225885&FileExtension=.PDF&FileName=Photo%2010%3A%20View%20of%20Left%20engine%20during%20examination.%20NTSB%20Digital%20Photo.-Master.PDF - Photo 1: View of house and yard where N4293P came to rest. NTSB Digital Photo. (item 23, .PDF, 440 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225896&FileExtension=.PDF&FileName=Photo%201%3A%20View%20of%20house%20and%20yard%20where%20N4293P%20came%20to%20rest.%20NTSB%20Digital%20Photo.-Master.PDF 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.