# NTSB MIA94FA167: Piper PA-31-325, N27872, Lantana, FL, June 24, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 24, 1994, 09:05 local (13:05 UTC) - Place: Lantana, FL - Coordinates: 26.580057, -80.070159 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.5801&lon=-80.0702&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report October 31, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 37428 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA94FA167 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37428/pdf - Page: https://openairdocs.org/ntsb/MIA94FA167 ## Probable cause THE PILOT'S IMPAIRMENT OF JUDGMENT AND PERFORMANCE DUE TO DRUGS, HIS FAILURE TO ABORT THE TAKEOFF AFTER EXPERIENCING REDUCED TAKEOFF PERFORMANCE, AND HIS FAILURE TO MAINTAIN MINIMUM CONTROL SPEED. FACTORS IN THE ACCIDENT WERE: A PARTIAL LOSS OF ENGINE POWER DUE TO IMPROPER MAGNETO-TO-ENGINE TIMING, AND A PARTIALLY BLOCKED FUEL NOZZLE. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, takeoff - roll/run - 1 engine - aircraft preflight - inadequate, pilot in command - ignition system,magneto - timing improper (contributing factor) - fuel system,nozzle - blocked(partial) (contributing factor) - Loss of control - in flight, takeoff - initial climb - aborted takeoff - not performed, pilot in command (cause) - impairment(drugs), pilot in command (cause) - use of inappropriate medication/drug, pilot in command - airspeed(vmc) - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE AIRPLANE WAS OBSERVED TO ROTATE ABOUT 3,217 FT DOWN THE 3,746-FT RUNWAY. ONE OR BOTH ENGINES WERE HEARD RUNNING ROUGH. THE AIRPLANE CLIMBED TO ABOUT 300 FT AGL, BANKED LEFT, PITCHED NOSE DOWN AND IMPACTED THE GROUND. DURING THE INVESTIGATION, THE LEFT ENG OPERATED TO FULL RATED RPM AFTER REPLACEMENT OF THE DAMAGED IGNITION HARNESS, ADJUSTMENT OF THE TURBOCHARGER DENSITY CONTROLLER, AND ADJUSTMENT OF THE MAGNETO-TO-ENG TIMING. THE RIGHT ENG ALSO OPERATED NORMALLY AFTER REPLACEMENT OF THE MAGNETO, IGNITION HARNESS, AND ENG-DRIVEN FUEL PUMP. THE DENSITY CONTROLLER REQUIRED ADJUSTMENT TO OBTAIN FULL RATED RPM. THE #3 CYL FUEL INJECTOR NOZZLE WAS ALSO PARTIALLY BLOCKED BY CONTAMINANT. THE RIGHT ENG MAGNETO CONTACT ASSEMBLIES OPERATIONALLY CHECKED OK. THE CAPACITORS WERE HEAT DAMAGED. RIGHT ENG MAGNETO-TO-ENG TIMING AND INTERNAL TIMING OF THE MAGNETO WERE NOT DETERMINED. PILOT'S TOXICOLOGICAL RESULTS WERE POSITIVE FOR BUTALBITAL (1.768 UG/ML BLOOD, 0.553 UG/ML URINE), AND ALSO POSITIVE FOR ACETAMINOPHEN & SALICYLATE (ASPIRIN) IN URINE. BUTALBITAL IS A PRESCRIPTION MEDICATION (BARBITURATE) NOT APPROVED FOR FLYING. ## Factual narrative HISTORY OF FLIGHT On June 24, 1994, about 0905 eastern daylight time, a Piper PA-31-325, N27872, registered to Roscoe M. Thorne, crashed shortly after takeoff from the 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 substantially damaged by impact and a postcrash fire and the private-rated pilot and one passenger were fatally injured. The flight originated about 0900. Before departure about 0845, the pilot requested fuel and stated that he was in a hurry. After the fuel truck arrived per the pilot's request, the outboard fuel tanks were filled and 20 gallons of fuel were added to each of the inboard fuel tanks. The fuel quantity in each inboard fuel tank before fueling was not determined. The fueler stated that he did not observe the pilot check the fuel tank for contaminants and while he was reeling in the hose after fueling, the pilot and passenger were in the left and right front seats respectively and the entry door was closed. A total of 70.2 gallons of fuel were added. The airplane was then taxied to the approach end of runway 21 and according to one witness, the airplane remained there for 2-3 minutes, but no determination could be made as to whether the pilot performed an engine runup before departure. According to another witness, the airplane rotated just beyond a taxiway which is south of runway 9/27. Calculations based on an airport map indicate that at the point of rotation about 529 feet of runway remained. The total length of runway available to the accident pilot based on reports of his using all available paved surface is 3,746 feet. The witness also stated that one or both of the engines were running rough. Witnesses reported that the airplane climbed no higher than 300 feet above ground level and banked to the left during which the nose of the airplane pitched down. During the descent the airplane collided with trees then the ground and a postcrash fire damaged the cockpit, part of the fuselage, and part of the wings. According to several witnesses, one or both of the engines were heard to be running rough or not developing what they thought to be full power. PERSONNEL INFORMATION Information pertaining to the first pilot is contained in the NTSB Factual Report-Aviation. Review of his pilot logbook revealed that the last flight logged was on August 24, 1991. At that time his total time logged was 438.9 hours. The total multi-engine flight time logged was 89.2 hours, of which 28.5 hours were logged as pilot-in-command of multi-engine airplanes. The last entry in the pilots' logbook was for a Biennial Flight Review. A certified flight instructor provided a copy of a page from his pilot logbook which indicates that the accident pilot was given a biennial flight review in the accident airplane on August 6, 1993, on a flight which lasted 1.7 hours. AIRCRAFT INFORMATION Information pertaining to the airplane is contained in the NTSB Factual Report-Aviation and Supplements A and B. Additionally, the week of the accident the accident pilot/owner asked a FAA certificated mechanic for an estimate to replace the right inboard fuel cell bladder. He inspected the tank and observed that the fuel vent nipple was "ripped out" of the tank bladder. The day before the accident flight he advised the pilot/owner by telephone that "...fuel would slush [sic] out near the engine and electrical wires." METEOROLOGICAL INFORMATION Information pertaining to the weather is contained in the NTSB Factual Report-Aviation. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that the right wing of the airplane collided with a tree about 30 feet above ground level and the left wing collided with a tree about 2 feet above ground level while on a heading of about 360 degrees. The attitude of the airplane at impact was determined to be about 45 degrees nose low and about a 30-degree left bank. The airplane then impacted the ground, rotated to the right and came to rest about 81 feet from the first impact with the trees on a heading of about 085 degrees. A postcrash fire damaged the fuselage and both wings. Examination of the aileron, elevator, and rudder flight controls revealed no evidence of preimpact failure or malfunction. Examination of the left and right fuel selector valves revealed that they were positioned to the "inboard" tanks. The crossfeed valve was determined to be closed, and examination of the left engine firewall shutoff valve revealed that it was in an intermittent position, but the push/pull rod was impact damaged. Examination of the right engine firewall shutoff valve also revealed that it was in the intermittent position. Examination of the left and right fuel delivery systems from the fuel selector valve forward to the fitting at the engine firewall revealed no evidence or blockage. Additionally, both the fuel boost pump and emergency fuel pump from the left and right fuel systems were operationally checked from a battery power source and no evidence of failure or malfunction was noted from either system. A fuel sample obtained from the left engine fuel filter was analyzed and found to contain 100-low lead fuel, water with a high chloride content, and foam used by the fire department. No sample was obtained from the right wing fuel system. The crew entry door was closed and locked when examined. Examination of the left engine at the accident site revealed that the oil quick drain was impact damaged and open. There was a residual quantity of oil in the dirt underneath the engine assembly. Examination of the engine compartment revealed no evidence of oil leakage in the cowling. The oil filler dipstick which was installed and secured was removed which revealed no evidence of oil contacting the dipstick. Examination of the left side of the airplane revealed no evidence of oil on the fuselage or left horizontal stabilizer. The flaps were determined to by symmetrically extended about 16 degrees. The propeller was removed for further examination. Examination of the left propeller revealed no evidence of preimpact failure or malfunction. The propeller blade angles for the three blades were determined to be 10 degrees, 12 degrees, and 18 degrees. The low pitch position is 13.2 degrees + or .1 degree. The feather position is 82.0 degrees + or - 1.0 degree. One of the three propeller blades pitch change knobs was failed but examination revealed evidence of overload failure. Examination of the right engine at the accident site revealed that the right engine sustained more heat damage than the left engine. The oil dipstick when removed indicated that the engine contained 12 quarts of oil. Both engines were removed from the airframe and sent to the manufacturer's facility. The left engine was examined before being placed in a test cell for an attempted engine run which revealed that about 1 ounce of oil was recovered. The magneto to engine timing was determined to be 15 degrees before top dead center(BTDC). The specification is 20 degrees BTDC. Several components were removed, a new oil filter was installed, oil was added, and the engine was started. During the initial run, the engine-driven fuel pump vent started leaking. The engine was shut down, and the pump was removed to reseat the drive. The pump was reinstalled and the engine was restarted eventually operating only using the engine-driven fuel pump. During the magneto check of the left magneto, an excessive drop was noted and the engine was again shutdown. The ignition harness was examined and found to be cut and abraded in several places. The ignition harness was replaced and the engine was restarted. The magneto drops were then within limits. The density controller was r ## Aircraft - Registration: [N27872](https://openairdocs.org/deregistered/N27872-1998-03-28), registration cancelled 1998-03-28, S/N 317912031 (OpenAirDocs) - Reported make and model: PIPER PA-31-325 - Registry model: [Piper PA-31-325](https://openairdocs.org/model/piper-pa-31-325) (registry code 7103105) (OpenAirDocs) - Category: Airplane - Serial number: 31-7912031 - Engines: LYCOMING TIO-540-F2BD 325 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Thorne, Roscoe M. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 12, 1993 - Airport: LNA, Palm Beach County Park, runway 21, 3,496 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,000 total, 3 in this make and model, 193 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 79 °F - Altimeter: 30.00 inHg - Observed at: PBI, 6 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 19940624016709A](https://openairdocs.org/incident/19940624016709A), Jun 24, 1994: Piper PA31325, West Palm Beach, FL, Substantial damage, 2 fatal. Stalled on low climbing turn after takeoff. Low MEL time. 3 hrs in type. Witness report rough engines. Unverified. 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.