# NTSB MIA94FA020: Piper PA-31-350, N27687, Orlando, FL, November 12, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 12, 1993, 06:29 local (11:29 UTC) - Place: Orlando, FL - Coordinates: 28.550951, -81.299148 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.5510&lon=-81.2991&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 2 minor; on the ground: 2 minor - Status: Completed, report December 19, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 37406 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA94FA020 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37406/pdf - Page: https://openairdocs.org/ntsb/MIA94FA020 ## Probable cause WAS IN FLIGHT LOSS OF CONTROL FOR FAILURE OF THE PILOT-IN-COMMAND TO MAINTAIN VMC SHORTLY AFTER TAKEOFF. CONTRIBUTING TO THE ACCIDENT WAS PARTIAL LOSS OF ENGINE POWER FROM THE LEFT ENGINE DUE TO PARTIAL BLOCKAGE OF SEVERAL OF THE FUEL INJECTOR NOZZLES. ALSO CONTRIBUTING TO THE ACCIDENT WAS WEIGHT AND BALANCE EXCEEDED BY THE PILOT-IN-COMMAND AND INADEQUATE SURVEILLANCE BY THE COMPANY AND BY THE FAA. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, takeoff - initial climb - fuel system,nozzle - blocked(partial) (contributing factor) - Loss of control - in flight, other - airspeed(vmc) - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground - aircraft weight and balance - exceeded, pilot in command (contributing factor) - inadequate surveillance of operation, faa(organization) (contributing factor) - inadequate surveillance of operation, company/operator mgmt (contributing factor) - Fire/explosion, other ## Analysis CARGO WAS NOT WEIGHED AND WEIGHT AND BALANCE CALCULATIONS WERE NOT PERFORMED. THE AIRPLANE WAS ABOUT 321 POUNDS OVER GROSS. WHILE TAXIING, A WITNESS REPORTED SEEING BLACK SMOKE TRAILING THE LEFT ENGINE WHICH HAD BEEN WORKED ON THE NIGHT BEFORE THE ACCIDENT. 2 CYLINDERS WERE WORKED ON AND A FUEL INJECTOR NOZZLE WAS CLEANED. THE CLIMB AFTER TAKEOFF WAS 'LOW AND SLOW' DURING WHICH THE AIRPLANE ROLLED LEFT, PITCHED NOSE DOWN, AND IMPACTED THE GROUND COMING TO REST ADJACENT TO A HOUSE. EXAMINATION OF EACH ENGINE REVEALED NO EVIDENCE OF INTERNAL MECHANICAL FAILURE OR MALFUNCTION. HEAT DAMAGE PRECLUDED TESTING OF THE MAGNETOS, TURBOCHARGER COMPONENTS, AND FUEL SERVOS OF EACH ENGINE. EXAMINATION OF EACH PROPELLER REVEALED NO EVIDENCE OF PREIMPACT FAILURE OR MALFUNCTION. THE FUEL NOZZLES FROM THE LEFT ENGINE WERE EXAMINED WHICH REVEALED THAT THEY WERE BLOCKED IN VARIOUS PLACES DUE TO CONTAMINANTS. AFTER THE ACCIDENT THE FAA PERFORMED A FOCUSED INSPECTION OF THE OPERATOR REVEALING THAT THE CARGO WAS NOT BEING WEIGHED, THE CHIEF PILOT OF THE COMPANY WAS IN NAME ONLY, AND LOAD MANIFESTS WERE NOT BEING KEPT BY THE COMPANY. ## Factual narrative HISTORY OF FLIGHT On November 12, 1993, about 0629 eastern standard time, a Piper PA-31-350, N27687, registered to Cherokee Leasing, Inc., operated by Cherokee Express, crashed into a residential area shortly after takeoff from the Orlando Executive Airport, Orlando, Florida. The flight was operating under 14 CFR Part 135 as a nonscheduled, domestic, cargo flight, call sign Blue Max 500. Visual meteorological conditions prevailed at the time and a VFR flight plan was filed for the flight to Tampa, Florida. The airplane was destroyed by a postcrash fire and the pilot was fatally injured. One house was fire damaged and one of the two occupants received minor injuries. The flight was originating at the time of the accident. Before takeoff the airplane was loaded with checks and bank documents and the pilot-in-command did not complete the required load manifest nor did she leave a copy with the company as required by the FAA approved company operations manual. At 0622.49, Blue Max 500 was cleared to taxi to runway 7. While taxiing to takeoff, the accident airplane passed in front of another airplane which gave the other pilot an unobstructed view of the left side of the Blue Max 500 airplane. The pilot stated that he observed "a lot" of black smoke trailing from the exhaust of the left engine. He further stated that the Blue Max 500 airplane was at the runup area for about 1-2 minutes, but he couldn't hear whether the pilot had performed an engine runup of each engine before departure. His attention was diverted and he did not witness the takeoff roll or accident. At 0626.28, the pilot of the Blue Max 500 flight contacted the tower controller and advised that the flight was ready for departure, southwest. At 0626.35, the tower controller advised the pilot that the flight was cleared for takeoff, which the pilot acknowledged 8 seconds later. At 0628.53, the pilot of the Blue Max 500 flight advised the controller "... i i need to come back round and land on uh runway 25 here." At 0628.58, the controller advised the pilot that the flight was cleared to land on runway 25. There was no further radio contact with the pilot of the Blue Max 500 flight. According to one witness who observed the takeoff roll and initial climb, the takeoff roll seemed slower than normal and the pilot seemed to use more runway than normal for this type of airplane. He also stated that he heard popping sounds from the engines during the takeoff roll. He observed the airplane climbing slowly maintaining runway heading but then observed the airplane descending after which the airplane began to bank to the left loosing altitude during the turn. After 180 degrees of turn had been completed the wings were observed to level with respect to the horizon, then the nose of the airplane was observed to pitch down and the airplane banked to the left in about a 90- degree angle of bank. The airplane then descended nose and left wing low until he lost sight of the airplane due to obstructions. He then observed black smoke. According to numerous other witnesses near the accident site, the airplane was observed flying east-northeast bound after takeoff low and slow and was observed to bank to the left in what one witness described as the right wing was nearly vertical. The airplane then descended through several trees, impacted the ground, and came to rest adjacent to a house. The airplane was destroyed by a postcrash fire and the house was damaged by the fire. PERSONNEL INFORMATION Information pertaining to the first pilot is contained in the NTSB Factual Report-Aviation, and Supplement U. According to company personnel, she was provided a place to sleep at her last stop earlier that morning at the Tampa, Florida, location. AIRCRAFT INFORMATION Information pertaining to the airplane is contained in the NTSB Factual Report-Aviation, and Supplements A and B. Additionally, according to a company pilot, 3 days before the accident he was scheduled to fly the accident airplane but aborted the flight during the takeoff roll due to a rough running engine. He also stated that both inboard and outboard fuel tanks were filled before he received the airplane. Review of company maintenance work order No. 2742 opening date November 9, 1993, closing date November 11, 1993, revealed that the Nos. 3 and 5 cylinder differential compression readings were 34/80 and 54/80 respectively. The corrective action was to remove Nos. 3 and 5 cylinders. The No. 5 cylinder was honed and the exhaust valve, valve springs, and valve keepers were replaced along with the installation of a new ring set. The No. 3 cylinder was removed and the cylinder was honed and new rings were installed. Several other nonengine related discrepancies were corrected. The left engine was then operated and it was discovered that at full throttle the tachometer was indicating 2,200 rpm. Full throttle rpm should be 2,575 according to the engine run in limits table in the Lycoming overhaul manual. The engine was shutdown and the cowling was removed. Based on the temperature of the No. 3 cylinder valve cover, the fuel injector nozzle and line were "blown clear and reinstalled." The engine was restarted and determined to develop full-rated power. The right engine cowling was removed and the engine was checked for leaks, none were found. Both engine cowlings were reinstalled and the Director of Maintenance stated that he flew the airplane around the traffic pattern, a flight which lasted according to company personnel about 18 minutes. Both engines reportedly operated normally during the test flight with no discrepancies noted. This was the last flight before the accident flight. According to a letter by the President of Cherokee Express to the FAA, Orlando, Florida, based on fuel receipts, a statement from a company pilot, the pilot's operating handbook, and aircraft records, all fuel tanks were full before the accident flight departed. METEOROLOGICAL INFORMATION Information pertaining to the weather is contained in the NTSB Factual Report-Aviation. COMMUNICATIONS Two-way radio contact had been established with the Orlando Executive Airport Air Traffic Control Tower. WRECKAGE AND IMPACT Examination of the airplane at the accident site revealed that the airplane first impacted the ground while on a heading of about 160 degrees, collided with several small trees, rotated to the right and came to rest upright on a heading of about 270 degrees adjacent to a duplex. The accident site was located about 1.6 nautical miles on the 048-degree radial from the Orlando Vortac. Both engines were separated from the airframe and the airplane was destroyed by a postcrash fire. The right wing which separated from the airplane was located along the flight path of the airplane. Examination of the cargo section of the airplane revealed several cargo net metal hooks remaining engaged in the tie down rings. The cargo was removed from the airplane and the weight was determined to be about 1,675 pounds. The CG location was not determined. Examination of the aileron, rudder, and elevator flight controls revealed no evidence of preimpact failure or malfunction. No fuel system components for the right engine were located. The fuel crossfeed valve was determined to be in the off position and the left engine fuel selector valve was determined to be between the off position and the outboard tank position. The left engine firewall shutoff valve was determined to be in the "off" position. Both engines were removed from the airframe for further examination. Examination of the left engine revealed crankshaft, camshaft, and valve train continuity. The mixture and throttle cables were attached to the fuel servo which was heat damaged precluding testing. The mixture control arm at the fuel servo was in the ## Aircraft - Registration: [N27687](https://openairdocs.org/deregistered/N27687-1996-05-21), registration cancelled 1996-05-21, S/N 317852107 (OpenAirDocs) - Reported make and model: PIPER PA-31-350 - Registry model: [Piper PA-31-350](https://openairdocs.org/model/piper-pa-31-350) (registry code 7103110) (OpenAirDocs) - Category: Airplane - Serial number: 31-7852107 - Airframe hours: 8393 - Engines: LYCOMING TIO-540-J2BD 350 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Operator: Cherokee Express, Inc. - Registered owner: Cherokee Leasing, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, October 30, 1993, 5 hours before - Departed: ORL - Destination: TPA, TAMPA, FL - Flight plan: VFR - Airport: ORL, Orlando Executive, runway 7, 5,998 × 150 ft ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; commercial, airline transport, flight instructor; 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: 2,465 total, 69 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Dawn - Wind: 10° at 2 knots - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 55 °F - Altimeter: 30.00 inHg - Observed at: ORL, 225 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 19931112042589A](https://openairdocs.org/incident/19931112042589A), Nov 12, 1993: Piper PA31350, Orlando, FL, Destroyed, 1 fatal. Power loss left engine. Began return. Did not feather. Lost control below VMC. Over gross weight. Clogged injectors ## Other investigations on N27687 (1) 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. - [NTSB LAX81DA107](https://openairdocs.org/ntsb/LAX81DA107), Jul 22, 1981: Piper PA-31 (N27687), Tusayan, AZ, substantial damage 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.