# NTSB NYC98FA024: Piper PA-23-150, N3EV, Fitchburg, MA, October 31, 1997 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 31, 1997, 10:15 local (15:15 UTC) - Place: Fitchburg, MA - Location: 42.5576° N, 71.7782° W: Placed by OpenAirDocs from NTSB’s distance and direction from FITCHBURG MUNI (FIT), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=42.5576&lon=-71.7782&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report February 15, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 39457 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC98FA024 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/39457/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=39457 - Page: https://openairdocs.org/ntsb/NYC98FA024 ## Probable cause The flight instructor's inadequate in-flight decision and his failure to maintain adequate airspeed which resulted in a loss of control. Contributing was the flight instructor's failure to follow standard practices while simulating and practicing emergency procedures which resulted in his initiating of a single-engine go around and reduced climb performance. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, go-around (vfr) - in-flight planning/decision - improper, pilot in command(cfi) (cause) - overconfidence in aircraft's ability, pilot in command(cfi) (cause) - airspeed - inadequate, pilot in command(cfi) (cause) - aircraft performance,climb capability - deteriorated - emergency procedure - simulated, pilot in command(cfi) (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - grass ## Analysis The flight was the second multi-engine training flight for the pilot trainee. On final approach the left engine was observed feathered and the landing gear was extended. With a clear runway ahead, a single engine go-around was initiated. The airplane was observed in a very shallow climb. Witnesses then saw the airplane descend in a nose down attitude and strike the ground. Investigation revealed the airplane had impacted the ground with the left engine propeller feathered, and the landing gear extended. No evidence of a mechanical failure or malfunction was found with the airplane or feathered engine. A check of certification requirements for the airplane revealed it was not required to perform a single engine go-around. FAA and AOPA publications cautioned against performing single engine go-arounds. The flight instructor had previously performed a single engine go-around in the same airplane, also with the left engine shut down. However, the landing gear was retracted. The student in that flight said the airplane climbed between 50 and 200 FPM. ## Factual narrative HISTORY OF FLIGHT On October 31, 1997, about 1015 eastern standard time, a Piper PA-23-150, N3EV, operated by Fitchburg Colonial Aviation, struck the ground during a go-around from the Fitchburg Municipal Airport (FIT), Fitchburg, Massachusetts. The airplane was destroyed, and the certificated flight instructor and multi-engine pilot trainee were fatally injured. Visual meteorological conditions prevailed for dual instructional flight that departed from Fitchburg about 0915. No flight plan had been filed for the flight that was conducted under 14 CFR Part 91. The accident flight was the second multi-engine training flight for the trainee. After departure from Fitchburg, the airplane was not observed until it entered the traffic pattern at Fitchburg. Two witnesses, in airplanes awaiting departure at the approach end of runway 32, observed the accident airplane in the traffic pattern for runway 32. One witness stated, "...the twin turned final and reported...'Single Engine'. I watched him on final and observed his left...[prop] stopped and, I think feathered. I noted he seemed low over the fence. At about 100 feet over the numbers the twin called 'go-around'...the twin seemed to be climbing at a very shallow attitude and banking very slightly left...." Another witness stated, "...The twin was now on final, and as he arrived on short final, I noted that his left prop was feathered...He announced that he was 'going around' his voice was normal...He was high over the threshold for a normal approach...He looked slow to me...." According to both witnesses, the runway was clear and there was nothing to prevent a landing. The airplane continued in a northwesterly direction; however, neither witness saw the airplane descend to the ground. Both pilots reported that they saw a column of smoke. Several witnesses in the area of the ground impact reported seeing a low flying airplane, and hearing an engine operating. The witnesses observed the airplane descend in a steep nose down attitude with the left wing low. It then impacted the ground, passed through a chain link fence, and came to rest upright in the back yard of a residence. A post-crash fire consumed the wings and cabin. The accident occurred during the hours of daylight at 42 degrees, 33.61 minutes north latitude, and 71 degrees, 46.72 minutes west longitude. OTHER DAMAGE During the descent, the airplane struck a television antenna mounted on the roof of a residence. Two fences were damaged during the ground impact. PERSONNEL INFORMATION The flight instructor held an airline transport pilot certificate for single engine airplanes, and a commercial pilot certificate for multi-engine airplanes. He also held a flight instructor certificate for single and multi-engine airplanes, and instrument airplane. According to his pilot logbook, he had logged a total time of 5,407 hours. He was issued a First Class FAA Airman Medical Certificate on June 2, 1997, with a limitation to wear corrective lenses for near and distant vision. He also had a vision waiver for amblyopia in the right eye. The multi-engine pilot trainee held a commercial pilot certificate with single engine land and instrument airplane ratings. According to his pilot logbook, he had logged a total time of 1,108 hours, with 1.3 hours of multi-engine training. He was issued a Second Class FAA Airman Medical Certificate on June 10, 1997, with a limitation to wear corrective lenses. AIRCRAFT INFORMATION The airplane was a 1957 Piper PA-23-150. It was maintained under an annual inspection program. The airplane was delivered with 150 horsepower engines and they had been upgraded to 160 horsepower. The propellers were not equipped with unfeathering accumulators. The airframe had been modified with Supplemental Type Certificates (STCs), known as the Geronimo conversion, and included a aerodynamic nose, a shortened rudder, and aerodynamic fairings. The wing flaps and landing gear were hydraulically operated. The left engine was equipped with an engine driven hydraulic pump. There was no hydraulic pump on the right engine. In addition, there was a hydraulic hand pump, located below the landing gear and wing flap control levers, on the center pedestal, which could be used to pressurize the hydraulic system. According to the Owner's Handbook, "...If the engine driven hydraulic pump fails, or the left engine driving the pump, extension of the landing gear or flaps is accomplished by supplying hydraulic pressure with the manual hydraulic pump. With the gear or flaps control in the desired position, 30-40 strokes of the pump handle will raise or lower the landing gear, and 12 strokes will raise or extend the flaps. AIRDROME INFORMATION According to FAA data, Fitchburg airport had an elevation of 348 feet. Runway 32 had a left handed traffic pattern, was 4,511 feet long, 100 feet wide, and had an asphalt surface. The airport did not have an air traffic control tower. Pilots communicated their intentions on a common frequency that was not recorded. WRECKAGE AND IMPACT INFORMATION The accident site was located about 3,500 feet beyond the departure end of runway 32, and about 1,500 feet left of extended runway centerline. The airplane was examined at the accident site on October 31, 1997. The airplane had impacted in the back yard of a residence, and came to rest upright, near the intersection of 4 back yards. A chain link fence, and wooden fence, located on the east side, and south side respectively of the initial ground impact were damaged. The airplane was resting on the main landing gear and nose. The fuselage cabin and wings were destroyed by fire. Both main landing gear were found in a down and locked position. The nose landing gear down lock was broken, and the landing gear had collapsed. Flight control continuity was verified between the rudder pedals, and the rudder. The elevator was actuated by a pushrod. The pushrod was attached at the elevator, but was melted in the center section of the airplane. The ailerons used control cables to the outboard wing panels, and then a pushrod to the aileron. The aileron cables were intact. Remnants of the pushrods were identified. The rudder trim was found at tab left (nose right) 10-12 degrees. Total travel was 25 degrees each way. The elevator trim was found with the leading edge horizontal stabilizer down, (nose up) 14 threads visible, which corresponds to 55% of available nose up travel. The wing flap extension cylinder corresponded to a trailing edge flap position of 30 to 35 degrees. The flap system had been compromised with burned hydraulic lines. The left propeller was found in a feathered condition. The right propeller was on the low pitch stops, and a chain link fence was wrapped around the blades. Pieces of cut steel posts were found near where the right engine propeller impacted the ground, and where a chain link fence had been located. Several indention's were found on the leading edge of one propeller blade, similar in size to the diameter of the chain link fence links. Both engines were rotated, and valve train continuity was confirmed. Compression was observed in all cylinders. The oil suction screen on both engines was free of debris. Sparkplugs from both engines were gray in appearance, and there was no impact damage to the electrodes. Both magnetos on the left engine, and the right magneto of the right engine produced spark. The internal gears of the left magneto in the right engine, were melted and could not be rotated. FIRE Soot was found on the upper and lower surfaces of the horizontal stabilizer and elevator. There were no soot patterns on any of the surfaces from the front of the airplane to the rear. No pieces of melted metal were found on the horizontal stabilizers. MEDICAL AND PATHOLOGICA ## Aircraft - Registration: [N3EV](https://openairdocs.org/deregistered/N3EV-1998-04-08), registration cancelled 1998-04-08, S/N 231084 (OpenAirDocs) - Reported make and model: Piper PA-23-150 - Registry model: [Piper PA-23-150](https://openairdocs.org/model/piper-pa-23-150) (registry code 7102303) (OpenAirDocs) - Category: Airplane - Serial number: 23-1084 - Airframe hours: 7477 - Engines: Lycoming O-320-B3B 160 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Registered owner: Fitchburg Colonial Aviation - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 17, 1997, 6 hours before - Departed: FIT - Flight plan: Unknown - Airport: FIT, Fitchburg Municipal, runway 32, 4,511 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 5,407 total, 22 in this make and model, 5,233 as pilot in command, 116 in the last 90 days, 27 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 1,900 ft broken - Temperature: 52 °F, dew point 36 °F - Altimeter: 30.00 inHg - Observed at: FIT, 1 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 19971031031589A](https://openairdocs.org/incident/19971031031589A), Oct 31, 1997: Piper PA23160, Fitchburg, MA, Destroyed, 2 fatal. CFI failed left engine on final. Low. Began go around gear down due pump on left engine. Below VMC. Crashed. Burned (.4) the flight was the second multi-engine… ## Docket (16 files) The files NTSB released with the investigation on October 6, 1998, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=39457. 3.1 MB in all. - Supplement A (item 1, .PDF, 244 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40094642&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 367 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40094643&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement E (item 3, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461304&FileExtension=.PDF&FileName=Supplement%20E-Master.PDF - NTSB Technicians Factual Report (item 4, .PDF, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40094645&FileExtension=.PDF&FileName=NTSB%20Technicians%20Factual%20Report-Master.PDF - Wreckage Diagram (item 5, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461305&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Witness Statements (item 6, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461306&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - FAA Inspector Statement (item 7, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461307&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461308&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461309&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Toxicological Reports (item 10, .PDF, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461310&FileExtension=.PDF&FileName=Toxicological%20Reports-Master.PDF - Photo #1 Cockpit-Pre-Accident-Arrow points to Hydraulic Hand Pump (item 11, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40094652&FileExtension=.PDF&FileName=Photo%20%231%20Cockpit-Pre-Accident-Arrow%20points%20to%20Hydraulic%20Hand%20Pump-Master.PDF - Photo #2 Front view of airplane (item 12, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40094653&FileExtension=.PDF&FileName=Photo%20%232%20Front%20view%20of%20airplane-Master.PDF - Photo #3 Right side view of airplane (item 13, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40094654&FileExtension=.PDF&FileName=Photo%20%233%20Right%20side%20view%20of%20airplane-Master.PDF - Photo #4 Right engine and propeller. Note fence wrapped around right propeller blade. (item 14, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40094655&FileExtension=.PDF&FileName=Photo%20%234%20Right%20engine%20and%20propeller.%20%20Note%20fence%20wrapped%20around%20right%20propeller%20blade.-Master.PDF - Photo #5 Back side of propeller blade from right engine. Note indents on blade. (item 15, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40094656&FileExtension=.PDF&FileName=Photo%20%235%20Back%20side%20of%20propeller%20blade%20from%20right%20engine.%20%20Note%20indents%20on%20blade.-Master.PDF - Photo #6 Left engine and propeller that was feathered. (item 16, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40094657&FileExtension=.PDF&FileName=Photo%20%236%20Left%20engine%20and%20propeller%20that%20was%20feathered.-Master.PDF From the NTSB's public API. 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