NYC98FA009

NTSB accident investigation · Piper PA-28R-180 · Morganville, NJ · October 11, 1997

Accident · FatalField investigationFinal report
Date
October 11, 1997, 10:40 local (14:40 UTC)
Place
Morganville, NJ
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N3981TPiper PA-28R-180
Weather
Visual (VMC) · Day
Status
Completed · report April 15, 1999
Report
Approved by Office Director
FAA report
19971011030589A
Case key
39453

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 inadequate maintenance by the flying club and maintenance facility, which resulted in a takeoff with a partially blocked fuel injector nozzle and the failure of the landing gear to retract after takeoff. This resulted in the pilot's diverted attention and the subsequent stall.

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 control - in flightTakeoff - initial climb
Fuel system,injector - blocked(partial)Cause
Gear retraction - not possiblePilot in commandCause
Maintenance - inadequateCompany/operator managementCause
Maintenance - inadequateOther maintenance personnelCause
Diverted attentionPilot in commandCause
Stall/mush - inadvertentPilot in command
In flight collision with objectDescent - uncontrolled
Object - tree(s)

Analysis

The pilot took off in the vicinity of the airplane's maximum gross weight and cleared 50 foot high trees 75 feet beyond the end of the runway. The airplane completed a right 180 degree turn, descended, and collided with trees with the retractable landing gear still extended. Maintenance records revealed that the number 4 cylinder had been removed due to low compression 295 hours before the accident to replace an exhaust valve, and again 76 hours before the accident due to low compression to reface the valves. Examination of the engine revealed the number 4 cylinder fuel injector nozzle was partially obstructed. An annual inspection was performed on the airplane between the two removals of the number 4 cylinder, by the maintenance facility performing the engine maintenance. The landing gear had been written up by pilots on five occasions in the 3 months prior to the accident, for not retracting after takeoff, and the airplane continued to be flown with the write-ups. The last write-up occurred 7 days prior to the accident and remained open. Maintenance was performed on the landing gear system after the last write-up and not documented in the airplane's logbooks.

Factual narrative

History of flight

On October 11, 1997, at 1040 eastern daylight time, a Piper PA-28R-180, N3981T, owned and operated by the Monmouth Area Flying Club (MAFC), was destroyed when it collided with trees in Morganville, New Jersey, during the climb after takeoff from the Marlboro Airport, Marlboro, New Jersey. The certificated private pilot and three passengers were fatally injured. Visual meteorological conditions prevailed for the personal flight that originated at the Marlboro Airport (2N8), about 1038, destined for Lebanon, New Hampshire. No flight plan had been filed for the flight conducted under 14 CFR Part 91.

The pilot was a member of the flying club, and had signed the airplane out to depart 2N8, at 1000. The listed destination was "Lebanon," with a return time of 1830 the same day. The pilot received a weather briefing from the Millville Automated Flight Service Station, for a flight to Lebanon, New Hampshire.

According to witnesses at 2N8, the pilot fueled the airplane, and then boarded the passengers. The pilot then taxied out and took off on runway 09. Witnesses observed the airplane lift off from the runway, "just beyond mid-field." None of the witnesses could recall if the flaps were extended. One witness described the rotation as abrupt and to a "high" pitch attitude. This was followed by a shallow climb and the wings rocking back and forth. Another witness described the pitch attitude as low, followed by a shallow climb angle. Both witnesses lost sight of the airplane as it flew past trees at the departure end of the runway, and observed the retractable landing gear was still extended.

Witnesses near the accident site observed the airplane flying in a southeast direction. They stated that the airplane was at a "low" altitude, wings level, with "normal" engine sounds. They also observed that the landing gear was extended. A witness observed the nose of the airplane pitch-up, followed by the airplane entering a right turn and descent.

A witness inside of her residence reported that she heard a "loud airplane." When the airplane was overhead, "the house vibrated." She then looked out a rear window and observed the airplane descending, "like it was on a landing approach," and collide with trees about 50 feet from her window.

The airplane came to rest in a ravine at the base of a tree about 40 feet below the terrain elevation of the residence. The accident site was about 1/2 mile from the departure end of runway 09, on a magnetic bearing of 117 degrees.

The accident occurred during the hours of daylight, approximately 40 degrees, 22 minutes north latitude, and 74 degrees, 15 minutes west longitude.

Personnel information

The pilot held a Private Pilot Certificate with a rating for airplane single engine land. His most recent FAA Third Class Medical Certificate was issued during October 1995.

A review of the pilot's logbook revealed the he had accumulated about 486 total flight hours, of which about 79 hours were in the PA-28R-180.

Wreckage and impact information

The airplane wreckage was examined at the accident site on October 11 and 12, 1997. The examination revealed that all major components of the airplane were accounted for at the scene.

The initial impact scars were observed about 30 feet east of the wreckage, at the tops of trees about roof level of the nearby residence. The airplane came to rest inverted, at the base of a 45 inch diameter tree.

Examination of the wreckage revealed that the landing gear was extended, and the main fuselage and center wing sections were consumed by a post crash fire. The outer wing sections and the tail section were partially burned. The manual flap handle was found in the last, upper notch, which related to a full flaps position according to the airplane owner's manual. The right flap torque tube control rod was in the vicinity of the second notch position. The left flap torque tube control rod was deformed and past the fully extended flap position.

Control continuity was established from the pilot's controls to the rudder, stabilator, and to the left and right ailerons. The stabilator trim was measured to be 7 degrees tab down. The throttle, mixture and propeller cables were all stretched.

Both propeller blades displayed "S" bending, chordwise scratches, and leading edge nicks. The outboard 7 to 8 inches of one blade tip was missing.

The engine and electric fuel boost pump were removed from the wreckage and examined at the Allaire Airport, Farmingdale, New Jersey. The boost pump was connected to an electrical source and fluid pumped freely.

The engine was rotated by hand, and valve train continuity and compression was confirmed on all cylinders. The engine oil sump screen and the fuel servo inlet filter screens were absent of debris. The inside of the muffler was examined and observed to be unrestricted. The alternate air door was in the closed position and the screen was not clogged. The propeller hub, blades, and the governor were removed and shipped to Hartzell Propeller Inc. The engine was shipped to Textron-Lycoming.

Medical and pathological information

An autopsy was performed on the pilot, on October 13, 1997, by Dr. Jay A. Peacock, of the Monmouth County Medical Examiners office, Monmouth County, New Jersey.

Toxicological testing of the pilot and front seat passenger was conducted by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated the following:

0.347 (ug/ml, ug/g) Oxycodone detected in Urine 0.401 (ug/ml, ug/g) Oxymorphone detected in Urine Pseudoephedrine was detected in Urine PhenylpropanoLamine was detected in Urine 43.8 (ug/ml, ug/g) Salicylate detected in Urine No Drugs detected in Blood.

Tests and research

Propeller and Governor

The propeller and propeller governor were examined at Hartzell Propeller Inc. Piqua, Ohio, on January 8, 1998. The examination was conducted under the supervision of an FAA Inspector from the MIDO, Vandalia, Ohio.

Examination of the propeller blades and hub did not reveal any preimpact failures.

The propeller governor, A Hartzell model F-2-7A, bearing serial number 872W, was placed on a governor test bench, and performed satisfactorily. The following settings were obtained: Specification High RPM Stop setting (RPM): 2455 2330+/- 10 Pressure relief setting (psi): 265 275 - 300 Internal leakage (Oz/minute): 10.0 8.0 or less Capacity (Qts/minute): 7.8 8 - 12

Engine

On December 10, 1997, the engine was examined at the Textron-Lycoming Facility, Williamsport, Pennsylvania, under the supervision of the Safety Board Investigator. The examination revealed the fuel servo contained about 1/2 ounce of clear fluid that was absent of water when tested with water finding paste.

The left and right magneto spark plug wires were replaced due to impact damage. The left magneto timing was determined to be set correctly by the use of a timing light. When the right magneto timing was checked, it had an open circuit and could not be timed. The starter motor was replaced due to impact damage.

The engine was placed in a test cell and fuel pressure was applied to the fuel system. The fuel inlet fitting to the fuel pump was not damaged, but leaked fuel at the "O" ring gasket. The "O" ring was replaced and the fitting no longer leaked. The number 2 fuel manifold line was bent at the injector fitting. The line was disconnected and flow checked normally.

The engine was started and ran rough on the left magneto only. The right magneto did not produce spark. The engine was shut down and the fuel injector nozzles were removed, then reconnected to the manifold lines for a flow check. Fuel pressure was applied for less than a minute, which resulted in the following fuel flow into measured containers:

Number 1 injector nozzle - 104 ml Number 2 injector nozzle - 1

Aircraft

Registration
N3981T
Reported as
Piper PA-28R-180
Category
Airplane
Serial number
28R-30331
Airframe hours
6,633
Engine
Lycoming IO-360B1E, 180 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Monmouth Area Flying Club
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 1997 · 231 hours before
Departed
2N8 · Marlboro, NJ
Destination
LEB · Lebanon, NH
Airport
2N8 · Marlboro, runway 9, 2,156 × 50 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
65
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
486 total · 79 in this make and model · 370 as pilot in command · 15 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 39 °F
Altimeter
30.00 inHg
Observed at
BLM, 15 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.

Other investigations on N3981T · 1

Matched to the same aircraft by N-number and date.