MIA95FA141

NTSB accident investigation · Piper PA-23-250 · Opa-Locka, FL · June 1, 1995

Accident · FatalField investigationFinal report
Date
June 1, 1995, 12:30 local (16:30 UTC)
Place
Opa-Locka, FL
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N5832YPiper PA-23-250
Weather
Visual (VMC) · Day
Status
Completed · report April 1, 1996
Report
Approved by Office Director
FAA report
19950601018139A
Case key
37652

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

A loss of engine power due to water contamination of the fuel, the pilot's inadequate preflight, and his intentional operation of the airplane with known deficiencies in equipment which resulted in an inadvertent stall at an altitude inadequate for recovery. Factors which contributed to the accident were: the pilot's lack of recent experience in the airplane and his self-induced pressure to accomplish the flight.

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 engine power(partial) - nonmechanicalTakeoff - initial climb
1 engine
Fluid,fuel - contamination,waterCause
Aircraft preflight - inadequatePilot in commandCause
Loss of control - in flightManeuvering - turn to reverse direction
Operation with known deficiencies in equipment - intentionalPilot in commandCause
Self-induced pressurePilot in commandFactor
Aircraft control - not maintainedPilot in commandFactor
Lack of recent experience in type of aircraftPilot in commandFactor
Stall - inadvertentPilot in command
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The airplane had been parked at least 16 days with the inboard fuel tanks about 1/3 full before being filled the day of the accident. After departing, the flight returned reporting that the flaps were not operational and the landing gear would not retract. A mechanic who had recently worked on the hydraulic system operationally checked the flaps more than 10 times with no discrepencies noted. The airplane was not placed on jacks for an operational test of the landing gear. The flight departed, and during initial climb the pilot advised the ATC controller of a rough running engine. The airplane was observed to bank left, pitch nose down, and impact the ground. Water was detected at the fuel injector nozzles and fuel manifold assembly of several cylinders of the left engine. No evidence of water contamination was found by operators of other airplanes fueled from the same source. Postaccident examination revealed that the left propeller was not feathered, the flaps were partially extended and the landing gear was fully extended.

Factual narrative

History of flight

On June 1, 1995, about 1230 eastern daylight time, a Piper PA-23-250, N5832Y, crashed shortly after takeoff from the Opa-Locka Airport, Opa-Locka, Florida, while on a 14 CFR Part 91 business flight. Visual meteorological conditions prevailed at the time and a visual flight rules flight plan was filed for the flight. The airplane was destroyed and a postcrash sire ensued, which was extinguished by the Metropolitan Dade County Fire Rescue Department. The commercial-rated pilot and private pilot-rated passenger were fatally injured. The flight was originating at the time of the accident. Damage to Florida Power and Light (FPL) property consisted of a damaged guy wire and heat damage to a power line pole.

The airplane had been parked for at least 16 days with the inboard fuel tanks about 1/3 full. At about 1040 on the day of the accident, the inboard fuel tanks were filled.

A mechanic stated that on the flight before the accident flight, the pilot returned and landed reporting that the flaps were not operational and the landing gear would not retract. According to the owner's handbook the landing gear and flaps are hydraulically operated and pressure is supplied from an engine- driven hydraulic pump mounted to the left engine. The mechanic stated that he inspected the left engine compartment, and reservoir for leaks; none were found. He then operated both engines and raised and lowered the flaps greater than 10 times to full extension noting that each time the flap selector handle returned to neutral; no discrepancies were noted. He asked the pilot if he had hydraulic pressure; to which the pilot responded he did not know. The owner's handbook indicates that after full extension of the flaps or landing gear, hydraulic pressure within the selector valve forces the flap or landing gear control lever to the neutral or off position. The owner's handbook also indicates that landing gear retraction occurs in about 10-12 seconds. The mechanic stated he then observed the pilot reload the nose baggage compartment and the airplane was positioned by a tug to a taxiway. The pilot was then observed to have difficulty starting each engine and after each engine was started, the pilot taxied to takeoff. The mechanic did not witness the accident. The airplane was not placed on jacks for an operational test of the landing gear.

The pilot taxied to runway 9L and according to recorded communications with the Opa-Locka Air Traffic Control Tower (ATCT), the flight was cleared to takeoff. Shortly after takeoff an occupant of the airplane advised the ATCT controller that the flight was returning due to a rough running engine. When the ATCT controller asked if the pilot needed assistance the occupant replied negative. The flight was then cleared to land on any runway and the pilot was advised that the wind was from 120 degrees at 12 knots. The ATCT controller inquired about the rough running engine but there was no reply.

A witness who is an FAA certificated airframe and powerplant mechanic stated he was working on an airplane inside a hangar which is east of the ATCT. He heard a "backfiring" sound, walked outside of the hangar and observed the accident airplane about abeam the ATCT. Calculations indicate that the tower is located about 5,202 feet down the 8,002-foot runway. He thought the backfiring was from the left engine of the accident airplane and observed it about tower height (141 feet) in a shallow climb. He thought the pilot was going to land and the airplane climbed no higher than 300 feet. He then observed the airplane in a left bank of about 30 degrees with both engines operating but one of the engines sounded as if it was not developing full power. The airplane then "spun" to the left, pitched nose down, and he heard the impact.

Another witness who is also a mechanic stated he was working with the above mentioned mechanic who alerted him to the accident airplane. He observed the airplane and heard "alot of backfiring" which he thought was associated with the left engine. He stated that the airplane was observed to bank to the left and descended losing 150-200 feet of altitude. The airplane was observed to regain the altitude then banked "sharply" to the left. The airplane then pitched nose down and impacted the ground. He estimated the airplane climbed to about 500 feet while over the runway and the flight was about just east of the ATCT. He also stated that he did not observe any smoke trailing the airplane. Calculations indicated that about 2,437 feet of runway remained when the witness first observed the airplane and heard an engine malfunction.

Another witness who was located about 60-80 yards north of the crash site stated that he observed the airplane fly over trees which were later determined to be about 60-feet tall. The airplane was then observed in a 45-60 degree right bank, descended, impacted the ground nose low, then exploded. No damage to the trees was noted.

Personnel information

Information pertaining to the pilot-in-command seated in the left front seat is contained in the NTSB Factual Report-Aviation. Review of his pilot logbook dated from 1981 to the last entry dated November 5, 1994, revealed he logged about 28 hours in 1987, in the accident make and model airplane. There was no other similar make and model entries in his logbook. The last entry logged was a 2 hour 51 minute flight in a single engine airplane which took place on November 5, 1994. The last entry logged in a multiengine airplane took place on October 21, 1992, in an Aero Commander 500 airplane. Information pertaining to the private pilot-rated right front seat passenger is contained in Supplement E.

Aircraft information

Information pertaining to the airplane is contained in the NTSB Factual Report-Aviation and Supplements A and B. Additionally, an optional engine driven hydraulic pump was not installed to the right engine. According to a mechanic, work began on May 24, 1995, and ended on May 26, 1995, in which deteriorated left engine hydraulic hoses were removed and replaced, and the hydraulic reservoir was serviced. The airplane was then placed on jacks and using the hand pump at the power pak assembly and a hydraulic mule, the landing gear and flaps were retracted and extended about 13 times. The maintenance work was not documented in the aircraft logbooks.

Meteorological information

Information pertaining to the weather is contained in the NTSB Factual Report-Aviation.

Wreckage and impact

The airplane crashed on a road in a residential and industrial area and it was observed to be upright on a magnetic heading of about 295 degrees. All components necessary to sustain flight were attached to the airframe and the cockpit, and both wings were fire damaged. A cargo net was not installed and the cargo, which consisted in part of frozen food, was found shifted in the airplane. During recovery of the airplane it was noted that the main and nose landing gears were collapsed. The crash site was located about 045 degrees and .94 nautical mile from the Opa-Locka Airport.

Examination of the aileron, elevator, and rudder flight controls revealed no evidence of preimpact failure or malfunction. The landing gear and flap selector handles were in the down position. Weight calculations indicate that the airplane was about 268 pounds under gross weight. Rust like contaminant was found in the left engine fuel strainer. No rust like contaminant was found in the right engine fuel strainer. The crossfeed valve was determined to be in the "on" position and using water finding paste, water was detected on a drain plug. Both engines were removed for further examination.

Visual examination of the left engine revealed that the propeller was still connected to the crankshaft. Crankshaft, camshaft, and valve train c

Aircraft

Registration
N5832Y
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-2981
Airframe hours
5,200
Engine
Lycoming IO-540-C4B5, 250 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Registered owner
Jose A. Petit
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 11, 1994 · 12 hours before
Departed
OPF · Miami, FL
Destination
MYA · Congo Town, OF
Flight plan
VFR
Airport
OPF · Opa-Locka

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
56
Certificate
Commercial
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
2,617 total · 28 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 12 knots
Visibility
15 statute miles
Lowest ceiling
2,500 ft broken
Altimeter
30.00 inHg
Observed at
OPF, 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.