MIA98FA250

NTSB accident investigation · Piper Aerostar 600 · N. Myrtle Beach, SC · September 20, 1998

Accident · FatalField investigationFinal report
Date
September 20, 1998, 14:31 local (18:31 UTC)
Place
N. Myrtle Beach, SC
Injuries
5 fatal; on the ground: 1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N17MTPiper Aerostar 600
Weather
Visual (VMC) · Day
Status
Completed · report February 22, 2000
Report
Approved by Office Director
FAA report
19980920025389A
Case key
44026

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 pilot's failure to maintain airspeed (Vs) during a single engine approach resulting in an inadvertent stall. Factors contributing to the accident were a fatigue crack in the exhaust pipe in the right engine, the aircraft weight and balance was exceeded, degraded aircraft performance and the pilot's diverted attention.

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) - mech failure/malfTakeoff - initial climb
1 engine
Exhaust system,manifold/pipe - fatigueFactor
Exhaust system - leakFactor
Loss of control - in flightManeuvering
Aircraft weight and balance - exceededPilot in commandFactor
Aircraft performance - deterioratedFactor
Airspeed(vs) - not maintainedPilot in commandCause
Diverted attentionPilot in commandFactor
Stall - inadvertentPilot in commandCause
In flight collision with objectDescent - uncontrolled
Object - tree(s)
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

After takeoff while over the departure end of the runway, deep gray colored smoke was observed by the tower controller trailing the right engine. The pilot was alerted of this and advised the controller the flight was returning. Witnesses reported seeing smoke trailing the right engine and that the airplane rolled to the left, pitched nose down, impacted trees, and then the ground. A fatigue crack was detected in the exhaust aft of the No. 6 cylinder of the right engine; and incomplete fusion of a weld repair was also noted. Heat damaged components from the right engine were replaced and the engine was started and found to operate normally. A foreign object of undetermined origin was found in the intake area of the No. 3 cylinder. Analysis of the voice tape revealed both engines/propellers were operating near full rated rpm when the pilot acknowledged the transmission that smoke was trailing the right engine, one engine/propeller rpm then decreased to about 2,160 rpm. Examination of the flight controls revealed no evidence of preimpact failure or malfunction. Flap positions at impact could not be determined. Calculations indicate that the airplane was approximately 55 pounds over the maximum certificated takeoff weight at takeoff.

Factual narrative

History of flight

On September 20, 1998, about 1431 eastern daylight time, a Piper Aerostar 600, N17MT, registered to a private individual, crashed shortly after takeoff from the Grand Strand Airport, North Myrtle Beach, South Carolina. Visual meteorological conditions prevailed at the time and an Instrument Flight Rules (IFR) flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was destroyed by impact forces and a postcrash fire. The commercial-rated pilot and three passengers were fatally injured. An individual on the ground who was injured by fire, subsequently died 6 days after the accident. The flight originated about 3 minutes earlier.

According to a line service person employed by Ramp 66, North Myrtle Beach, the airplane had been hangared since arrival 3 days earlier and before the flight departed, he noted that the pilot was seated in the left front seat and a younger looking person of the three passengers was seated in the right front seat. Both engines started "ok", and the pilot waited on the ground for about 20-25 minutes with the engines idling. During that time he observed the pilot wiping sweat from his face using a cloth; he was doing something on the panel, and he put on his headset and kneeboard. He reported that he drove a golf cart to a corner of the field for the purpose of watching the takeoff, and while there, the airplane arrived at the run-up area. He did not hear an engine run-up, and noted that the engines remained at idle while the airplane was stopped there for about 5-6 minutes. He then positioned his cart to a point about midfield of the runway to observe the takeoff; the airplane departed with no flaps extended. During the climbout, he observed the landing gear retracting and a slight amount of black smoke trailing the airplane.

Review of a transcription of communications with the Grand Strand Airport Air Traffic Control Tower revealed that at 1420:24, the pilot contacted ground control, requested and received his IFR clearance then at 1421:07, the controller cleared the flight to taxi to runway 23. The pilot was provided the wind and barometric setting information. At 1427:34, the pilot radioed the local controller and advised that the flight was ready for departure on runway 23. The controller cleared the flight to takeoff at 1427:39, which was acknowledged by the pilot 6 seconds later. At 1428:32, the local controller advised the controller from the arrival position of Myrtle Beach Approach Control that "aerostar seven mike tango's rolling...." At 1429:19, the local controller radioed the pilot and advised him "seven mike tango appears to have smoke trailing from your right side." The pilot acknowledged the transmission and at 1429:37, the pilot radioed the local controller and stated "seven mike tango we're going to come around and land." The local controller acknowledged the pilot's transmission and asked the pilot if he was declaring an emergency or did he need any assistance. The pilot replied negative. At 1429:58, the local controller cleared the flight to land on runway 23, which was acknowledged by the pilot. Further transmissions from the pilot recorded on the voice tape were unintelligible. At 1430:53, the local controller advised the approach controller that the airplane had crashed and smoke was observed.

The controller who observed the smoke reported in a personnel statement that "...as the aircraft was passing in front of the tower it appeared to be trailing smoke. I picked up the binoculars and confirmed my observation and identified the smoke as coming from the right engine and smoke was beginning to increase in intensity. I advised the pilot (He was crossing the departure end of runway 23) that the right engine appeared to be trailing smoke...." He later stated that the smoke appeared to be deep gray in color with two dark edges that appeared to be 1 to 1.5 feet apart with distinct separation. He did not see any fire or flames.

Numerous witnesses near the accident site reported observing a low flying airplane with smoke trailing from the right engine. They reported seeing the airplane bank to the left and a pilot-rated witness reported, "...the right engine was trailing smoke the aircraft made a turn to the left as if trying to return to the airport possibly due to the south tower he continued to tighten his turn to the left I told my wife 'he's in trouble' He appeared to stall and went below the tree line...." A copy of his statement is attached. Several witnesses reported seeing the airplane pitch nose down, impact trees then the ground followed by an explosion. One witness reported "...planes engines were at high speed, no smoke, no fire", while another witness reported seeing the plane fly over the ocean and "...it sounded like the engine was cutting out...." Copies of the witness statements are attachments to this report.

Personnel information

According to the pilot's second pilot logbook, his total logged flight time was 1,321 hours which included 474 hours in make and model. His first flight in the accident airplane was logged as taking place on March 31, 1998, and he had accumulated a total of 30 hours in the accident airplane. He logged a total of 1,184 hours as pilot-in-command, and 956 hours in multi-engine airplanes. His first pilot logbook was not located. Further information pertaining to the pilot is contained on page 3 of the Factual Report-Aviation.

Aircraft information

Current logbook records for the aircraft and engines were not located after the accident. According to a work order and invoice from Flying Tigers, Inc., a maintenance facility that had maintained the airplane, an annual inspection had been performed on January 29, 1998. The airplane total time, and time since major overhaul of the left and right engines at that time were 3,360 hours, 1,307 and 2,030 hours, respectively. The airplane had accumulated approximately 53 hours since the annual inspection at the time of the accident. According to the engine manufacturer, the recommended time between overhaul for the Lycoming IO-540-K1J5 engine is 2,000 hours; compliance is not mandatory.

Logbooks for the right engine which begin with an entry dated May 22, 1979, and end with an entry dated December 3, 1993, were recovered; no further logbooks for the right engine were located. Review of the logbooks revealed several entries which indicate that the exhaust was repaired. The first entry dated April 2, 1980, indicates that the cracked exhaust stacks were repaired, but it does not indicate which side of the exhaust stack was repaired. The second entry dated August 22, 1980, indicates that the left exhaust assembly was repaired. The third entry dated February 5, 1981, indicates that the aft section of the inboard exhaust stack was repaired. The final entry pertaining to repairs of the exhaust system was dated February 21, 1984. The entry indicates that the cracked exhausts were repaired.

Airworthiness directive (AD) 87-07-09, which was issued on May 15, 1987, and applicable to this make and model airplane, required a one time inspection of the exhaust system. An entry in the engine logbook dated October 31, 1987, indicates compliance with the AD. Additionally, Aerostar Service Bulletin No. 920A, dated September 12, 1991, for this make and model airplane by serial number, indicates that the exhaust system is required to be inspected at the next regularly scheduled inspection not to exceed 10 hours, and thereafter each 25 hours time in service. Review of the right engine logbook from that date to the last entry in the engine logbook revealed no entry which specifically states that the inspection was accomplished. Compliance with the Service Bulletin is not mandatory.

According to the president of Flying Tigers, Inc., where the airplane was maintained, he was aware of Ser

Aircraft

Registration
N17MT
Reported as
Piper Aerostar 600 (AEROSTAR 6)
Category
Airplane
Serial number
600641796120
Airframe hours
3,413
Engine
Lycoming IO-540-K1J5, 290 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Henry K. Sagel
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 29, 1998 · 53 hours before
Departed
CRE
Destination
N71 · Marietta, PA
Flight plan
IFR
Airport
CRE · Grand Strand

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
Certificates
Commercial, 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
1,321 total · 474 in this make and model · 1,184 as pilot in command · 15 in the last 90 days · 5 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 6 knots
Visibility
7 statute miles
Lowest ceiling
3,000 ft broken
Temperature
82 °F, dew point 72 °F
Altimeter
29.00 inHg
Observed at
CRE, 2 nm away

Docket · 46

The files NTSB released with the investigation on January 13, 2000, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.4 MB in all.

Supplement A - Wreckage DocumentationItem 1 · .PDF · 253 KBSupplement B - Cockpit DocumentationItem 2 · .PDF · 365 KBSupplement S - Aircraft Occupant and Injured Ground PersonnelItem 3 · .PDF · 64 KBAir Traffic Control Recording 17 - Factual Report of Group ChairmanItem 4 · .PDF · 278 KBMaterials Laboratory 15 - Factual Report of Group ChairmanItem 5 · .PDF · 138 KBWitness StatementsItem 6 · .PDF · 1.1 MBWeather Reports and RecordsItem 7 · .PDF · 81 KBTranscript of Radio CommunicationsItem 8 · .PDF · 130 KBReports from Federal AgenciesItem 9 · .PDF · 192 KBReports from Local AgenciesItem 10 · .PDF · 481 KBReports from Parties to the InvestigationItem 11 · .PDF · 737 KBFlight Plan InformationItem 12 · .PDF · 45 KBRecord of Interview with Tom HilderbrandItem 13 · .PDF · 71 KBRecord of Conversations with Dan BartramItem 14 · .PDF · 95 KBRecord of Conversation with Bob LongItem 15 · .PDF · 50 KBType Certificate Data SheetItem 16 · .PDF · 583 KBAircraft Maintenance Records and Maintenance Related DocumentsItem 17 · .PDF · 1.7 MBService Bulletins 920 and 920AItem 18 · .PDF · 1.0 MBService Instruction No. 1009AMItem 19 · .PDF · 479 KBStatement from Lewis E. RichardsItem 20 · .PDF · 41 KBFueling RecordsItem 21 · .PDF · 101 KBStatements from Jay StoutItem 22 · .PDF · 62 KBRecord of Interview with Greg T. MurrayItem 23 · .PDF · 171 KBRecord of Conversation with Dr. Eugene OrdwayItem 24 · .PDF · 52 KBRecord of Conversation with Jay StoutItem 25 · .PDF · 56 KBRecord of Conversation with Harold BoyerItem 26 · .PDF · 117 KBRecord of Conversation with Steve SpeerItem 27 · .PDF · 52 KBStatement of Party Representatives to NTSB InvestigationItem 28 · .PDF · 76 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 29 · .PDF · 117 KBToxicological ReportItem 30 · .PDF · 109 KBPhoto 1: View of the wreckage at the accident site.Item 31 · .PDF · 134 KBPhoto 2: View of the wreckage at the accident site.Item 32 · .PDF · 147 KBPhoto 3: View of the right engine at the accident site.Item 33 · .PDF · 122 KBPhoto 4: View of the dual tachometer.Item 34 · .PDF · 83 KBPhoto 5: View of the engine compartment of the right engine. The arrow points to a crack in the exhaust aft of the No. 6 cylinder.Item 35 · .PDF · 137 KBPhoto 6: Close up view of the exhaust aft of the No. 6 cylinder of the right engine. Arrow points to the crack in the exhaust.Item 36 · .PDF · 118 KBPhoto 7: View of cylinder Nos. 2, 4, and 6 of the right engine.Item 37 · .PDF · 103 KBPhoto 8: View of the aft side of the right engine.Item 38 · .PDF · 93 KBPhoto 9: View of the right propeller.Item 39 · .PDF · 76 KBPhoto 10: View of the left propellerItem 40 · .PDF · 87 KBPhoto 11: View of the recovered baggage including the golf clubs. No negative.Item 41 · .PDF · 140 KBPhoto 12: View of the foreign object inside the intake port of the No. 3 cylinder of the right engine noted after the engine run at the manufacturer's facility. No negative.Item 42 · .PDF · 76 KBPhoto 13: View of the No. 3 cylinder intake valve from the right engine. No negative.Item 43 · .PDF · 97 KBPhoto 14: View of the foreign object. Note the non-sooted corner.Item 44 · .PDF · 71 KBPhoto 15: View of the inlet fitting for the right engine servo fuel injector.Item 45 · .PDF · 73 KBPhoto 16: View of the pressure test of the inlet fitting from the servo fuel injector of the right engine. No negative.Item 46 · .PDF · 99 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.