# NTSB NYC05FA053: Piper PA-23-250, N2343Z, Coatesville, PA, March 6, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 6, 2005, 14:13 local (19:13 UTC) - Place: Coatesville, PA - Coordinates: 39.95222, -75.852218 - Nearby events: https://openairdocs.org/map.md?lat=39.9522&lon=-75.8522&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 25, 2006 - Report: Approved by Office Director - Parties: Lycoming Engines, New Piper Aircraft, FAA/FSDO, Hartzell Propeller - NTSB case key (mKey): 61089 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC05FA053 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/61089/pdf - Page: https://openairdocs.org/ntsb/NYC05FA053 ## Probable cause The pilot's inadequate remedial action during an engine failure, which resulted in a loss of airplane control. A factor was the pilot's improper fuel management, which resulted in fuel starvation to one engine, and its subsequent loss of engine power. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, approach - vfr pattern - final approach - fluid,fuel - starvation - fuel management - improper, pilot in command (contributing factor) - 1 engine - Loss of control - in flight, approach - vfr pattern - final approach - remedial action - inadequate, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The pilot took off from his home airport, and flew to an airport approximately 1 hour away. Prior to his return flight, he fueled the twin-engine airplane with 20 gallons of fuel, with 10 gallons added to each outboard fuel tank. About 45 minutes after departing the intermediate airport, witnesses observed the airplane on final approach to the pilot's home airport. During the approach, the airplane made a "hard left turn," and impacted a field. One witness reported hearing "at least one engine running," and another witness reported hearing the airplane's engine "throttle, and then no throttle, and throttle again," prior to the impact. Post-accident examination of the airplane revealed that both the right inboard and right outboard fuel tanks were ruptured; however, more than 15 gallons of fuel was drained from the right wing. The right fuel selector valve and handle were selected to the "inboard" position, and the right engine propeller blades displayed rotational signatures. Both the left inboard and left outboard fuel tanks remained intact. The outboard tank contained a "trace" amount of fuel, and the inboard tank contained about 10 gallons of fuel. The left engine fuel selector valve was selected to the outboard tank, and no fuel was observed in the fuel line from the left engine fuel pump to the fuel servo. A "trace" amount of fuel was observed in the left engine fuel distributor, as well as the regulator section of the fuel servo. In addition, the left engine propeller revealed no rotational signatures and was not in the feathered position. No pre-impact mechanical anomalies were noted with either the airplane or the engines. The procedure outlined in the pilot operating handbook, for a loss of engine power in flight, called for the pilot to feather the propeller of the failed engine, to reduce the yaw that would occur in the direction of that engine. ## Factual narrative HISTORY OF FLIGHT On March 6, 2005, at 1413 eastern standard time, a Piper PA-23-250, N2343Z, was substantially damaged when it impacted a cornfield during an approach to the Chester County Airport (40N), Coatesville, Pennsylvania. The certificated airline transport pilot and passenger were fatally injured. Visual meteorological conditions prevailed and no flight plan was filed for the flight that originated at the York Airport (THV), York, Pennsylvania, about 1330. The personal flight was conducted under 14 CFR Part 91. According to radar data provided by the Federal Aviation Administration (FAA), a target that correlated to be the accident airplane was first observed on radar about 2 miles east of the York Airport, at 1345, at an altitude of 2,800 feet. The target flew a direct path to the Coatesville area, and approached the Chester County Airport from the south. The target then flew to the east of the airport (passing to the east of the approach end of runway 29), and continued in a circular pattern above the airport, gradually descending from 2,600 feet. The target continued to circle back toward the south and passed through the final approach for runway 11, on a southeasterly heading, at an altitude of 1,900 feet. Fourteen seconds later, the target was observed at an altitude of 1,500 feet, continuing on a southeasterly heading. The last radar return was observed 14 seconds later, at 1402, at an altitude of 500 feet, about 1 mile to the south of the airport. A witness, who was sitting in his car at the Coatesville Airport, observed the accident airplane enter the traffic pattern on a "normal" 45-degree angle to the downwind leg. Shortly thereafter, he observed the airplane's landing gear extend. The airplane was on final approach (approximately 1/4 mile from the runway), when it made a "hard left turn" and then descended behind a tree line. The witness heard the airplane for several more seconds, "like it was running at a very high rpm", and then heard the sound of an impact. Another witness, who had just gotten out of his car in the driveway of his residence, heard the sound of a "failing engine," coming from overhead. He noticed the twin-engine airplane flying in a westerly direction, which was unusual for the Coatesville traffic pattern (the airport was in a north/northwest direction from the witness's residence). The witness then observed the airplane in a 35-40-degree left bank, and heard "the engine throttle, and then not throttle, and finally throttle again as it flew west." A third witness reported observing the airplane on short final for runway 29. The witness looked away momentarily and when he looked back, he observed the airplane, wings level, on a heading 90 degrees perpendicular to the runway (heading approximately 200 degrees). The airplane then dropped below the tree line; however, the witness heard "at least one engine running strong." He then heard the sound of an impact 20-30 seconds later. A pilot flying on the downwind leg of the traffic pattern for runway 29, at Chester County, stated that he heard another pilot report on the UNICOM frequency that he was "on the cross wind leg for runway 29." As the (witness) pilot was on short final, the same pilot reported he was "clear of the pattern to the south." The (witness) pilot stated the other airplane did not land, and he could not recall the registration number or type of aircraft making the transmissions. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with a rating for airplane multi-engine land. He also held a commercial pilot certificate with a rating for airplane single-engine land. His most recent Federal Aviation Administration (FAA) second-class medical was issued on October 14, 2004. According to an insurance form submitted by the pilot on February 28, 2005, he reported 12,783 total hours of flight experience. He also reported 72 total hours of flight experience in the make and model of the accident airplane, 2 of which were accumulated in the past 12 months. AIRCRAFT INFORMATION Examination of the airplane maintenance records revealed the most recent annual inspection was completed on March 1, 2004, with no anomalies noted. METEOROLOGICAL INFORMATION Weather reported at an airport 22 miles to the southeast, at 1351, included wind from 220 degrees at 21 knots, gusting to 27 knots, visibility 10 statute miles, a broken cloud layer at 11,000 feet, temperature 46 degrees Fahrenheit, dew point 27 degrees Fahrenheit, and altimeter setting of 29.73 inches Mercury. COMMUNICATIONS The pilot contacted the Williamsport Flight Service Station on March 6, 2005, at 0929, and requested a weather briefing for a visual flight rules (VFR) flight from York Airport to Chester County Airport. The weather briefer provided the pilot with the current and forecasted weather conditions, as well as an AIRMET for occasional moderate turbulence. The briefing was concluded at 0934. Information provided by the FAA revealed the pilot did not file a flight plan. Additionally, there was no record of air traffic control communication with the pilot. WRECKAGE AND IMPACT INFORMATION The airplane came to rest in a cornfield, approximately 1 mile to the south of the airport. The wreckage was examined on March 7, 2005, at the accident site. All major components of the airplane were accounted for at the accident site, and were contained in close proximity to the main wreckage. A row of 80-foot trees, located along the airplane's flight path, approximately 75 feet from the main wreckage, was undisturbed. The main fuselage was oriented on an approximate heading of 243 degrees. Both wings remained attached to the fuselage. The right wingtip was separated from the wing, and located approximately 3 feet to the right rear of the wing. The right aileron and flap remained attached to the wing, and displayed minimal damage. Both the inboard and outboard fuel tanks were ruptured; however, more than 15 gallons of fuel was drained from the right wing. The right fuel selector valve (located in the engine nacelle) was selected to the inboard tank, and the fuel selector handle in the cockpit was selected to the "inboard" position. The right engine remained attached to the wing, and observation of the propeller blades revealed they were S-bent, and displayed chordwise scratching. The left wingtip was also separated from the wing, and located about 1 foot to the left of the wing. The left aileron and flap remained attached to the wing; however, the left flap was observed folded under the inboard section of the wing. Both the inboard and outboard fuel tanks remained intact. The fuel tanks were drained, and the outboard tank contained a "trace" amount of fuel, and the inboard tank contained about 10 gallons of fuel. The left engine fuel selector valve (located in the engine nacelle) was selected to the outboard tank, and the left fuel selector handle (located in the cockpit) was selected to the "off" position; however, the handle was impact damaged. The cross-feed selector was in the "off" position. The left engine remained attached to the wing and observation of the propeller blades revealed no signatures of chordwise scratching or rotational bending. The propeller did not appear to be in the feathered position. Flight control continuity was confirmed from all control surfaces to the cockpit controls. A measurement of the flap actuator revealed the flaps were in the full-extended position (50-degrees), and the flap handle in the cockpit was selected to the "down" position; however, the handle was impact damaged. The landing gear was observed in the retracted position. Measurements of the actuators for the horizontal stabilator and rudder trim were consistent with trim settings in the neutral position. The left engine tachometer gauge in the cockpit displayed a reading of 400 rp ## Aircraft - Registration: [N2343Z](https://openairdocs.org/deregistered/N2343Z-2006-09-21), registration cancelled 2006-09-21, S/N 27-8054018, built 1979 (OpenAirDocs) - Reported make and model: Piper PA-23-250 - Registry model: [Piper PA-23-250](https://openairdocs.org/model/piper-pa-23-250) (registry code 7102308) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 27-8054018 - Airframe hours: 5336 - Engines: Lycoming IO-540-C4B5 250 horsepower reciprocating; Lycoming IO-540-C4B5 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Richard Simons - Registered owner: Bar Aviation Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2004, 89 hours before - Departed: THV, York, PA - Destination: 40N, Coatesville, PA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: fatal; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; toxicology performed; flight hours: 12,783 total, 72 in this make and model, 10,937 as pilot in command, 6 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 21 knots, gusting 27 - Visibility: 10 statute miles - Lowest ceiling: 11,000 ft broken - Temperature: 46 °F, dew point 27 °F - Altimeter: 29.72 inHg - Observed at: ILG, 22 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 20050306009509A](https://openairdocs.org/incident/20050306009509A), Mar 6, 2005: Piper PA23250, Coatesvilla, PA, Destroyed, 2 fatal. (-23) Aircraft impacted the ground approximately at 1405 local EST time, 0.7 miles south of 40N (Chester county airport, PA) on Sunday March 6th, 2005,… 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.