NYC99LA045

NTSB accident investigation · Piper PA-28-161 · Methuen, MA · January 5, 1999

Accident · Serious injuriesLimited investigationFinal report
Date
January 5, 1999, 16:00 local (21:00 UTC)
Place
Methuen, MA
Injuries
3 serious, 1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N9683CPiper PA-28-161
Weather
Visual (VMC) · Day
Status
Completed · report April 18, 2001
Report
Approved by Office Director
FAA report
19990105000179A
Case key
45596

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 pilot's failure to ensure the engine primer was in and locked prior to takeoff which resulted in a loss of engine power. A factor in this accident was the pilot's lack of experience in airplanes equipped with reciprocating engines.

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 engine powerTakeoff - initial climb
Fuel system,primer system - unlockedCause
Checklist - not complied withPilot in commandCause
Lack of experiencePilot in commandFactor
In flight collision with terrain/waterManeuvering
Stall - inadvertent
Object - tree(s)

Analysis

The pilot reported a loss of power during the initial climb after takeoff. A witness who observed the airplane depart stated 'the engine didn't sound right,' and the airplane just barley cleared the trees located at the end of the runway. During a turn back towards the airport, the airplane pitched down and impacted trees. Examination of the wreckage did not disclose any pre-impact mechanical malfunctions of the airframe or engine. The airplane was equipped with a manual 3-point primer system. Spark plugs removed from the three cylinders which contained primer lines revealed a 'heavy coat of black sooty material' present on the electrodes. The spark plug removed from the cylinder which did not contain a primer line was 'clean.' Additionally, the primer control in the cockpit was observed in a forward, but unlocked position. Except for a 1.8 hour check out in the airplane, all 270 hours of flight experience the pilot had logged since August 1996, were in turbine powered airplanes. Review of the airplane's operating handbook, revealed that part of the 'Normal Procedures, Before Takeoff' checklist, included the item, 'Primer...locked.'

Factual narrative

On January 5, 1999, about 1600 Eastern Standard Time, a Piper PA-28-161, N9683C, was substantially damaged when it impacted terrain in Methuen, Massachusetts. The certificated commercial pilot and two passengers were seriously injured. A third passenger was not injured. Visual meteorological conditions prevailed and no flight plan had been filed for the local flight that was conducted under 14 CFR Part 91.

The airplane departed from Runway 32, at the Lawrence Municipal Airport, Lawrence (LWM), Massachusetts.

According to a Federal Aviation Administration (FAA) inspector, shortly after takeoff, the pilot reported to the LWM air traffic control tower that the airplane's engine was losing power. The airplane turned back towards the airport, descended, and impacted the tops of 50-foot tall trees. The airplane came to rest about one-half mile from the departure runway.

In a telephone interview, a witness at the airport stated he was working on an airplane in the north ramp area, when he heard an "engine that didn't sound right." He described the sound as a "murmur," and stated, "it just didn't sound like it was producing full power." He turned around and observed the accident airplane on its takeoff roll. He said the airplane just barely cleared the trees located at the end of the runway. The airplane went straight out and made a left turn back towards the airport. It then pitched down and dropped behind the tree line.

Examination of the wreckage by an FAA Inspector did not disclose any pre-impact mechanical malfunctions of the airframe or engine. The airplane was equipped with a manual 3-point primer system. Spark plugs removed from the three cylinders which contained primer lines revealed a "heavy coat of black sooty material" present on the electrodes. The spark plug removed from the cylinder that did not contain a primer line was "clean." Additionally, the primer control in the cockpit was observed in a forward, but unlocked position.

The pilot received his military pilot rating on November 30, 1998. On December 29, 1998, the pilot received a temporary FAA Commercial Pilot Certificate with ratings for single engine land and instrument airplane based on his military experience. On his application for an airman certificate, the pilot reported he had flown at least 10 hours as pilot-in-command during the previous 12 months in a T45A, a United States Navy two-seat jet trainer. Three days prior to the accident, the pilot received a 1.8 hour check out in a PA-28-151, from a certificated flight instructor. According to the pilot's log book, the pilot accumulated about 270 hours of flight experience between August 1996, and the accident flight. With the exception of the 1.8-hour check out, all of the flight time was in airplanes equipped with turbine engines.

Review of the airplane's operating handbook, revealed that part of the "Normal Procedures, Before Takeoff" checklist, included the item, "Primer...locked."

FAA Advisory Circular 20-105B-"Reciprocating Engine Power-Loss Accident Prevention and Trend Monitoring," stated in part:

"Engine Primer. The primer is a simple system in which raw fuel is drawn from the engine supply line and injected into two or more of the engine's cylinders by means of a small hand operated pump. If the primer pump handle is not locked in the closed position, raw fuel will continue to be drawn into the cylinders by the suction created in the affected cylinders during the intake cycle."

The airplane's most recent flight prior to the accident was an instructional flight that was conducted on January 3, 1999. The certified flight instructor reported for the flight reported the all systems operated normally. The student pilot said the airplane performed "flawlessly." He also stated that he had flown the accident airplane 22 hours in the 15 months prior to the accident and had not experienced any mechanical problems.

Aircraft

Registration
N9683C
Reported as
Piper PA-28-161
Category
Airplane
Serial number
28-7816515
Engine
Lycoming O-320, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Eagle East Aviation Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 13, 1998
Departed
LWM · Lawrence, MA
Airport
LWM · Lawrence Municipal, runway 32, 3,901 × 100 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
26
Certificates
Commercial, Military
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
322 total · 2 in this make and model · 59 as pilot in command · 21 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
25 °F, dew point 3 °F
Altimeter
30.00 inHg
Observed at
LWM

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.