NYC07IA164

NTSB incident investigation · Piper PA-31-350 · Orlando, FL · July 11, 2007

Incident · No injuriesIncident investigationFinal report
Date
July 11, 2007, 12:15 local (16:15 UTC)
Place
Orlando, FL
Injuries
1 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N105GCPiper PA-31-350
Weather
Visual (VMC) · Day
Status
Completed · report February 28, 2008
Report
Approved by Office Director
Parties
FAA/FSDO
FAA report
20070711020629I
Case key
66189

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The mechanic's failure to secure the right engine cowling fasteners. Contributing to the incident was the pilot's inadequate preflight inspection.

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.

Airframe/component/system failure/malfunctionCruise
Cooling system,cowling - not secured
Procedures/directives - not followedCompany maintenance personnelCause
Aircraft preflight - inadequatePilot in commandFactor
Forced landingEmergency descent/landing

Analysis

The airplane had undergone routine maintenance, and was returned to service on the day prior to the incident flight. The mechanics who performed the maintenance did not secure the right engine cowling using the procedure outlined in the airplane's maintenance manual. The mechanic who had been working on the outboard side of the right engine could not remember if he had fastened the three primary outboard cowl fasteners before returning the airplane to service. During the first flight following the maintenance, the right engine's top cowling departed the airplane. The pilot secured the right engine, but the airplane was unable to maintain altitude, so he then identified a forced landing site. The airplane did not have a sufficient glidepath to clear a tree line and buildings, so he landed the airplane in a clear area about 1,500 yards short of the intended landing area. The airplane came to rest in a field of scrub brush, and about 5 minutes after the pilot deplaned, the grass under the left engine ignited. The subsequent brush fire consumed the airplane. Examination of the right engine cowling revealed that the outboard latching fasteners were set to the "open" position. When asked about the security of the cowling during the preflight inspection, the pilot stated that he "just missed it."

Factual narrative

On July 11, 2007, about 1215 eastern daylight time, a Piper PA-31-350, N105GC, was undamaged following a forced landing to a field near Orlando, Florida. The certificated airline transport pilot was not injured. Visual meteorological conditions prevailed, and the airplane was operating on an instrument flight rules flight plan, destined for Orlando International Airport (MCO), Orlando, Florida. The positioning flight, which departed Melbourne International Airport (MLB), Melbourne, Florida, at 1143, was conducted under 14 Code of Federal Regulations (CFR) Part 91.

According to the operator, the airplane had undergone routine maintenance, and was returned to service on the day prior to the incident flight. The purpose of the incident flight was to reposition the airplane to MCO and pick up passengers for a 14 CFR Part 135 revenue flight. The incident flight was the first since the airplane was returned to service.

While in cruise flight at 4,000 feet msl, the pilot heard a "loud bang," and saw that the right forward windscreen and right side window had broken. He then saw that the right engine's top cowling was missing, and felt the aircraft "shudder" as it began to descend. The "strong vibration" of the airframe continued, and the pilot elected to secure the right engine, and continued to the airplane toward MCO, the nearest suitable airport. Although full power was applied to the left engine, the airplane would not maintain altitude, so the pilot attempted to land the airplane on a paved site he had identified. The pilot subsequently realized, while attempting to land, that the airplane did not have a sufficient glidepath to clear a tree line and buildings, and landed the airplane in a clearing about 1,500 yards short of the intended landing area.

The airplane came to rest in a field of scrub brush, and about 5 minutes after the pilot deplaned, the grass under the left engine ignited. The subsequent brush fire consumed the airplane.

The pilot held an airline transport pilot certificate with ratings for airplane single and multiengine land, and instrument airplane. He reported 13,000 total hours of flight experience, 200 hours of which were in the incident airplane make and model.

Examination of the remaining portion of the right engine cowling, by Federal Aviation Administration inspectors, revealed that the outboard latching fasteners were set to the "open" position.

During an interview with company personnel, the mechanics who had performed the most recent maintenance on the airplane stated that they were comfortable with the cowling installation procedure, and did not reference the aircraft maintenance manual. A subsequent review of the maintenance manual revealed that the procedure the mechanics used was not the one described in the manual. The mechanic who had been working on the outboard side of the engine stated that he was not certain that he fastened the three primary outboard cowl fasteners before he left the airplane during the installation to retrieve a step ladder. Additionally, when asked about the security of the cowling during the preflight inspection, the pilot stated that he "just missed it."

Aircraft

Registration
N105GC
Reported as
Piper PA-31-350
Category
Airplane
Serial number
31-7652130
Engine
Lycoming TIO-540, 350 horsepower, reciprocating
Damage
Minor damage
Fire
On-Ground
Flight
Positioning · Part 91
Operator
Baer Air, Inc.
Registered owner
Baercraft Leasing LLC
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · July 1, 2007
Departed
MLB · Melbourne, FL
Destination
MCO · Orlando, FL
Flight plan
IFR

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
54
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
April 1, 2007
Seat
Left
Flight hours
13 total · 200 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
4 knots
Visibility
10 statute miles
Lowest ceiling
3,500 ft broken
Temperature
90 °F, dew point 79 °F
Altimeter
30.12 inHg
Observed at
MCO, 12 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.