MIA99LA016

NTSB accident investigation · Piper PA-34 · Ormond Beach, FL · October 27, 1998

Accident · No injuriesLimited investigationFinal report
Date
October 27, 1998, 12:41 local (17:41 UTC)
Place
Ormond Beach, FL
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N45SAPiper PA-34
Weather
Visual (VMC) · Day
Status
Completed · report August 27, 1999
Report
Approved by Office Director
FAA report
19981027040569A
Case key
45153

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 Vmc speed, which resulted in a loss of control, and his improper operation of the throttle given the known full rich operating condition of the left engine. A sand-contaminated fuel control was a contributing factor.

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) - nonmechanicalGo-around (vfr)
1 engine
Engine shutdown - simulatedPilot in command
Fuel system,fuel control - contamination,other than water
Maintenance,inspection - inadequateCompany maintenance personnel
Fuel system,fuel control - excessive flow/output
Throttle/power control - excessivePilot in command(cfi)Cause
Loss of control - in flightGo-around (vfr)
Airspeed(vmc) - not obtainedPilot in command(cfi)
Directional control - not possiblePilot in command(cfi)
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - runway

Analysis

The instructor simulated the failure of the left engine by reducing the manifold pressure to 11 inches Hg., while on the downwind leg. She stated they did not clear the engine during the visual approach and that the engine had been running rich. On short final approach, the instructor took control of the aircraft and applied full power to both engines for a go-around. The left engine did not accelerate and the aircraft rolled rapidly to the left. The instructor reduced engine power and the aircraft rolled to a level attitude and touched down in a side slip on the runway, collapsing the landing gear. Postcrash examination of the left engine showed the spark plugs were fouled with combustion deposits and the fuel control was operating at a rich mixture in the idle range due to sand contamination.

Factual narrative

On October 27, 1998, about 1241 eastern standard time, a Piper PA-34, N45SA, registered to International Aeronautical Consultants, Inc., crashed during a go-around at Ormond Beach Municipal Airport, Ormond Beach, Florida, while on a Title 14 CFR Part 91 instructional flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The aircraft received substantial damage and the commercial-rated flight instructor, commercial-rated dual student, and one passenger were not injured. The flight originated from Daytona Beach, Florida, the same day, about 1130.

The instructor stated they had performed an instrument approach to runway 17 at Ormond Beach Municipal Airport followed by a circle to land on runway 08. They performed a go-around and entered the traffic pattern for a visual approach to runway 08. On the downwind leg she simulated failure of the left engine for the student by moving the throttle to 11 inches of manifold pressure. The student continued the approach with the simulated failure of the left engine and on final approach the student allowed the aircraft to drift to the right of runway centerline. The aircraft's nose was pointing to the left and the aircraft was approaching the runway at an angle. The flight instructor took control of the aircraft and moved both throttles to the full power position to perform a go-around. The left engine did not respond and the aircraft's left wing dropped down. The flight instructor closed both throttles and the aircraft returned to a wings level attitude. The aircraft then impacted hard on the runway while angled to the left. The landing gear collapsed and the aircraft came to rest upright. The instructor stated further that the left engine had been "running rich" in the recent past, and that they did not clear the engine during the simulated engine out approach to runway 8.

Postcrash examination of the left engine was performed by a FAA inspector and a representative of Lycoming Engines. Fuel was found in the engine fuel system. The engine-driven fuel boost pump and electric driven fuel boost pump operated normally. The magneto timing was checked and the left magneto was found set to 24 degrees before top center (BTC) and the right magneto was set to 25 degrees BTC. Lycoming Service Instruction No. 1325A, dated May 14, 1976, states the previously approved 25 degrees BTC setting should be changed to 20 degrees BTC. Each magneto produced spark through the respective leads when the engine was rotated by hand. Continuity of the engine crankshaft, camshaft, valve train, and accessory drives was confirmed. Each cylinder produced normal compression. The spark plugs were removed and found to have black to brown soot deposits on them. The spark plug models found in the engine were not approved by Lycoming Engines for use in the engine. (See attached Lycoming Engine Report)

The engine fuel system was tested under NTSB supervision at a fuel system overhaul facility. The inlet screen of the fuel servo was checked before testing and found to contain sand. The sand was removed and the unit was tested. The servo operated normally except at the idle setting. The fuel flow as tested at the idle setting was 37.6 pounds per hour. The specification calls for a fuel flow of 22 to 28 pounds per hour. The servo was disassembled and sand was found in the internal areas of the unit, which prevented the diaphragm ball from seating and giving a normal idle fuel flow.

The fuel manifold operated normally when tested and the fuel injector nozzles operated normally. Each of the fuel injector nozzles was found to have cracks in the fuel line attach areas. Two of the injectors had small leaks due to these cracks.

Aircraft

Registration
N45SA
Reported as
Piper PA-34
Category
Airplane
Serial number
34-7250234
Airframe hours
7,184
Engine
Lycoming IO-360-C1E6, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Int'L. Aero. Consultants, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · October 13, 1998 · 43 hours before
Departed
DAB · Daytona Beach, FL
Airport
ORM · Ormond Beach Municipal, runway 8, 4,004 × 100 ft, asphalt

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
26
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
1,797 total · 73 in this make and model · 1,703 as pilot in command · 253 in the last 90 days · 125 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 64 °F
Altimeter
30.00 inHg
Observed at
DAB, 10 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.