# NTSB NYC07FA055: Piper PA-60-601P, N720Z, Jamestown, NY, January 8, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 8, 2007, 09:50 local (14:50 UTC) - Place: Jamestown, NY - Coordinates: 42.149444, -79.270835 - Nearby events: https://openairdocs.org/map.md?lat=42.1494&lon=-79.2708&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 30, 2008 - Report: Approved by Office Director - Parties: Piper Aircraft Inc., FAA/FSDO, Textron Lycoming Inc. - NTSB case key (mKey): 65115 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC07FA055 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/65115/pdf - Page: https://openairdocs.org/ntsb/NYC07FA055 ## Probable cause The pilot's incorrect selection of the right engine fuel selector position, which resulted in fuel starvation of the right engine, a loss of the right engine's power, and a loss of control during initial climb. Contributing to the accident were the pilot's inadequate preflight planning and preparation, and his improper use of the manufacturer's published normal operating procedures. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, takeoff - initial climb - fuel tank selector position - incorrect, pilot in command (cause) - improper use of procedure, pilot in command (contributing factor) - 1 engine - preflight planning/preparation - inadequate, pilot in command (contributing factor) - fluid,fuel - starvation - Loss of control - in flight, takeoff - initial climb - aircraft control - not maintained, pilot in command - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis During the initial climb, a "throbbing or surging" sound was heard as the airplane departed in gusting wind conditions with a 600-foot ceiling and 1/2 mile visibility in snow. Moments later the airplane came "straight down" and impacted the ground. During examination of the wreckage, it was discovered that that the fuel selector switch for the right engine had been in the "X-FEED" position during the accident. Examination of documents discovered in the wreckage revealed, three documents pertaining to operation of an Aerostar. These documents consisted of two airplane flight manuals (AFMs) from two different manufacturers, and a checklist. Examination of the first of the AFMs revealed, that it had the name of both the pilot and the operator on the cover of the document. Further examination revealed that it had been published 4 years prior to the manufacture of the accident airplane, and contained information for a Ted Smith Aerostar Model 601P, which the operator had previously owned. This document contained no warnings regarding the use of the crossfeed system during takeoff. Examination of the second of the two AFMs found in the wreckage revealed that it was the Federal Aviation Administration (FAA) approved AFM for the accident airplane. Unlike the first AFM, the second AFM advised that the fuel selector "X-FEED" position should be used in "level coordinated flight only." It also advised that each engine fuel selector "must be in the ON position for takeoff, climb, descent, approach, and landing." It also warned that, if the airplane was not in a level coordinated flight attitude, "engine power interruptions may occur on one or both engines" when "X-FEED" is selected "due to unporting of the respective engine's fuel supply intake port." Review of the checklist contained in the FAA approved AFM for the Piper Aircraft Model 601P under "STARTING ENGINES," required a check of the crossfeed system prior to engine start by selecting each fuel selector to "ON," then selecting "X-FEED," and after verifying valve actuation and annunciator light illumination, returning the fuel selector to "ON." Additionally, under "BEFORE TAKEOFF" It also required that the fuel selectors be checked in the "ON" position, and that the "X-FEED" annunciator light was out, prior to takeoff. Examination of the pilot's checklist revealed that, it consisted of multiple pages inserted into plastic protective sleeves and included both typed, and hand written information. A review of the section titled "BEFORE TAKEOFF" revealed that the checklist item "Fuel Selectors - ON Position," which was listed in the AFM, had been omitted. ## Factual narrative HISTORY OF FLIGHT On January 8, 2007, at 0950 eastern standard time, a Piper PA-60-601P, N720Z, was destroyed when it impacted terrain shortly after takeoff from Chautauqua County Airport (JHW), Jamestown, New York. The certificated private pilot was fatally injured. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the personal flight destined for Buffalo Niagara International Airport (BUF), Buffalo, New York. The flight was conducted under 14 Code of Federal Regulations Part 91. According to witness statements, the pilot "picked up" his IFR clearance to Buffalo, New York, and announced over the radio his intention to taxi to runway 25 for departure. A "throbbing or surging" sound was then heard as the airplane departed. Moments later the airplane came "straight down" and impacted the ground. The accident occurred during the hours of daylight. The wreckage was located at 42 degrees, 08.959 minutes north latitude, 79 degrees, 16.258 minutes west longitude, at an elevation of 1,701 feet mean sea level (msl). PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with ratings for airplane single-engine-land, airplane-multiengine-land, and instrument airplane. He reported a total flight time of 5,489.4 flight hours, with 2,926 hours in single-engine airplanes, and 2,377.7 hours in multiengine airplanes. His most recent FAA third-class medical certificate was issued on December 6, 2006. AIRCRAFT INFORMATION The accident airplane was manufactured in 1979 By Piper Aircraft. The most recent annual inspection was completed on October 9, 2006. At the time of the inspection, the airplane had accrued 2,783.3 total hours of operation. METEOROLOGICAL INFORMATION A weather observation taken about 1 minute after the accident, recorded the wind as 260 degrees at 16 knots, gusting to 26 knots, visibility 1/2 mile in snow, ceiling overcast at 600 feet, temperature 0 degrees Celsius, dew point -2 degrees Celsius, and an altimeter setting of 29.60 inches of mercury. AIRPORT INFORMATION JHW had two runways, oriented in a 13/31 and 07/25 configuration. Runway 25 was asphalt, grooved, and in good condition. It was equipped with high intensity runway lights and precision markings. The total length of the runway was 5,299 feet, and its width was 100 feet. WRECKAGE AND IMPACT INFORMATION The airplane came to rest in marshy terrain on a magnetic heading of 114 degrees, 945.8 feet northwest of the departure end of runway 25, and 17 feet in elevation below it. Fuel sheen on areas of standing water, along with the smell of fuel was evident at the scene. The debris path was 96 feet long and 40 feet wide, and all the major components of the airplane were accounted for at the scene. A ground scar approximately 25 feet in length, oriented on a 345-degree magnetic heading, led up to the main wreckage. Further examination revealed that the left wingtip fairing was on the end closest to the runway, and that the ground scar matched the shape of the left wing. Examination of the main wreckage revealed no evidence of any preimpact malfunctions, preimpact airframe icing, or fire. Airframe and Flight Controls The main wreckage displayed heavy crush and compression damage, and both engines separated from their mounts. The left wing and right wing, along with all of the associated flight control surfaces displayed differing degrees of damage. The forward cabin was upright, and the left wing leading edge cap had separated from the wing and was found lying in front of the wing. The right wing was bent aft at the wing root, and was pinned beneath the main wreckage. The wing flaps and wing flap actuating cylinders were in the flaps up (0-degree) position. The tail section of the airplane, along with portions of the aft fuselage, had separated from the airframe and was lying inverted next to the right side of the forward portion of the fuselage. The vertical stabilizer was separated from its attach fittings, and was located on the ground beneath the tail section. The left and right horizontal stabilizers remained attached to their fittings and displayed varying degrees of impact damage. Examination of the flight control system revealed impact damage and multiple fractures of the push-pull tubes that made up the system. The breaks in the flight control system were consistent with overload, and control continuity was confirmed from the ailerons, elevators, and rudder to the cockpit area. Continuity could not be established to the control yokes or rudder pedals due to crush damage. Elevator and rudder trim tab positions correlated to approximately neutral, and no preimpact failures or malfunctions with the primary flight controls or trim system were identified. Engine Controls Examination of the cockpit revealed that the forward portion of the airframe had been displaced into the area of the pilot's instrument panel and throttle quadrant. The throttles were at their aft stops, with portions of the crushed fuselage structure encroaching on their normal area of forward travel. The mixture controls were approximately full rich, and the propeller controls were set to high RPM. Propellers and Engines The airplane was equipped with two 3-bladed propellers. Examination of both propellers revealed areas of light to moderate scratching on an approximate 45-degree angle to the chordline of the blades, and some leading edge gouging. All of the propeller blades had remained attached to their hubs. The left propeller exhibited blade bending on all three blades in the rearward direction. One of the blades was twisted out of the low pitch position and exhibited S-bending. The right propeller had one blade that displayed no evidence of bending, while the remaining two blades, were bent aft. Examination of both engines revealed that the vacuum pumps and magnetos had separated from their respective mounts and exhibited impact damage. Both vacuum pumps could be rotated by hand and the rotors and blades were intact. Damage to the magnetos precluded any functional checks, but examination of both units did not reveal any preimpact malfunctions. The intake systems were compromised and exhibited breaks in the tubing. All four turbocharger waste gates were closed and continuity of the exhaust systems was confirmed. The crankshafts were rotated by hand, and no binding was noted. Thumb compression was obtained on all cylinders, with the exception of the No. 5 cylinder, on the right engine, which exhibited impact damage. All sparkplugs were removed for examination. The electrodes were light gray in color, with the exception of the bottom spark plugs of the No. 2 cylinders on both engines, which exhibited impact damage. Fuel System Examination of the fuel system revealed that all fuel filler caps were closed and latched and all of the fuel injectors were clear. Fuel samples obtained from each engine's fuel injection system appeared to be bright, clear, and exhibited no visible contamination. When the fuel samples were applied to a coupon containing water-finding paste, the paste did not change color, indicating that water was not present. Examination of the cockpit mounted fuel system controls revealed that, the fuel control panel for each engine had three selectable positions; "OFF," "ON," and "X-FEED" (crossfeed). These modes of operation were controlled through rotating fuel selector switches, which had detents at each of the three positions. Examination of these switches revealed that they had both been broken off of the fuel control panels. Further examination of the fuel control panel for the right engine revealed, however, the presence rotational scoring and deformation in the area of the "X-FEED" detent. The multiple sump assembly, which was installed below the fuselage tank, and all four of it ## Aircraft - Registration: [N720Z](https://openairdocs.org/deregistered/N720Z-2013-07-08), registration cancelled 2013-07-08, S/N 61P05927963262, built 1979 (OpenAirDocs) - Reported make and model: Piper PA-60-601P - Registry model: [Piper AEROSTAR 601P](https://openairdocs.org/model/piper-aerostar-601p) (registry code 7106012) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 61P05927963262 - Airframe hours: 2783.3 - Engines: Lycoming IO-540-S1A5 290 horsepower reciprocating; Lycoming IO-540-S1A5 290 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Ftba - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 1, 2006, 29.3 hours before - Departed: JHW, Jamestown, NY - Destination: BUF, Buffalo, NY - Flight plan: IFR - Airport: JHW, Chautauqua County/Jamestown, runway 25, 5,299 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review November 1, 2006; seat: left; toxicology performed; flight hours: 5,531 total, 753 in this make and model, 5,489 as pilot in command, 29 in the last 90 days, 16 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 260° at 16 knots, gusting 26 - Visibility: 0.5 statute miles - Lowest ceiling: 600 ft overcast - Temperature: 32 °F, dew point 28 °F - Altimeter: 29.60 inHg - Observed at: JHW ## 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 20070108000529A](https://openairdocs.org/incident/20070108000529A), Jan 8, 2007: Piper PA60601P, Jamestown, NY, Destroyed, 1 fatal. (-23) On January 8, 2007 at 1445 gmt a Piper aero star, PA-60-601P, N720Z crashed immediately after takeoff from runway 25 at the kjhw airport with an IFR… 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.