# NTSB WPR14LA027: Piper PA-23-150, N3162P, Tucson, AZ, October 23, 2013 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 23, 2013, 10:40 local (17:40 UTC) - Place: Tucson, AZ - Coordinates: 32.11222, -110.933334 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.1122&lon=-110.9333&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report September 29, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA - NTSB case key (mKey): 88289 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14LA027 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88289/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88289 - Page: https://openairdocs.org/ntsb/WPR14LA027 ## Probable cause The pilot’s failure to maintain airplane control during takeoff following the loss of left engine power due to the failure of the left engine-driven fuel pump’s diaphragm. Contributing to the accident was the pilot’s failure to use the electric fuel boost pumps for takeoff in accordance with checklist procedures and to conduct the engine failure emergency procedure. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause) ## Analysis The private pilot, who did not have a multiengine rating, reported that, during takeoff, the airplane's nose starting turning left; he did not realize that it was due to the left engine losing power. As a result, he did not perform the engine failure emergency procedure. A witness reported hearing one of the engines "misfiring" and subsequently seeing the airplane drift left, roll into a steep left bank, and then impact the ground. Postaccident examination revealed no fuel in the left engine's fuel strainer and carburetor; the right engine's fuel strainer and carburetor both contained fuel. Fuel was present in both the left and right wing fuel tanks, and no evidence of fuel contamination was found. The left engine-driven fuel pump's diaphragm was found to be brittle and cracked in several locations, which resulted in its inability to provide sufficient fuel pressure to maintain engine power during takeoff. No other anomalies were found with the left engine's fuel system. The electric fuel boost pump switches were both found in the "off" position, indicating that the pilot had not turned them on before takeoff as called for in both the owner's handbook before takeoff checklist and the before takeoff checklist located on a placard on the instrument panel. If the pilot had turned on the electric fuel boost pumps, the left engine would not have lost power because the electric pump would have compensated for the malfunction of the engine-driven pump. ## Factual narrative On October 23, 2013, about 1040 mountain standard time, a Piper PA-23-150 Apache D, N3162P, was substantially damaged when it impacted terrain following a loss of aircraft control on takeoff at Tucson International Airport, Tucson, Arizona. The private pilot, the sole occupant on board, was seriously injured. The airplane was being operated by the owner under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the personal local flight, which was originating at the time of the accident. A flight plan had not been filed. The pilot purchased the airplane, after a mechanic performed an annual inspection, on February 22, 2013, in New Smyrna Beach, Florida. Because he did not have a multi-engine rating, he had a flight instructor fly with him on the trip from New Smyrna Beach to Tucson. He did not fly the airplane again until the day of the accident. The pilot told a Federal Aviation Administration (FAA) inspector that shortly after liftoff from runway 11R, crosswinds were blowing the airplane to the left. He said the airplane lost altitude and rolled left impacting terrain with the wings near 90 degrees of bank. The airplane completely cartwheeled before coming to rest upright. The airplane's nose, both wings, and the empennage were bent and wrinkled. In a written statement to the National Transportation Safety Board (NTSB) investigator-in-charge, the pilot reported that after takeoff, the nose of the airplane started turning left, and he "misinterpreted this as being an effect of the wind." He further reported that he realized after the accident that the uncontrollable turn to the left was due to the left engine losing power. A witness, who was an airport operations officer with the Tucson Airport Authority, reported that he observed the airplane's takeoff, and he heard one of the airplane's engines "misfiring." The airplane "drifted" to the left, rolled into a steep left bank, and impacted the ground. Postaccident examination of the airplane by the FAA inspector revealed that both propeller controls were full forward, the mixture controls were full rich, and the throttles were full aft. Both fuel selectors were in the off position. Later it was determined that Tucson Airport firefighters had moved the throttles from full forward to full aft and placed both fuel selectors in the off position. The landing gear was down, and the flaps were up. Both electric fuel pump switches were in the off position. The FAA inspector found no fuel in the left fuel strainer and carburetor; the right fuel strainer and carburetor both contained fuel. He visually examined fuel taken from both the left and right wing fuel tanks and found the fuel to be "clear and bright" with no evidence of contamination. On November 27, 2013, an NTSB investigator examined the left engine's fuel system at the facilities of Air Transport in Phoenix, Arizona. All fuel lines throughout the left wing were found intact and tight at theirfittings. All lines were disconnected at their fittings, examined, and found to be free of obstructions. The left fuel selector and left fuel selector valve were examined, and no anomalies were noted. The fuel strainer screen, the carburetor finger screen, and the left main and left auxiliary fuel tank finger screens were found to be free of obstruction. Power was applied to the left electric fuel pump, and it produced a repetitive clicking sound, consistent with normal operation. On December 11, 2013, an NTSB investigator disassembled the left engine-driven fuel pump and found the pump's rubber diaphragm to be brittle and cracked in several locations. The Apache Owner's Handbook listed "electric fuel pumps on" as a step in the before takeoff checklist. Additionally, a placard attached to the right side of the airplane's instrument panel provided a takeoff checklist that included "elec. fuel pumps on" as one of the items to be completed. The Apache Owner's Handbook described the emergency procedure for an engine failure, indicating that yaw in the direction of the dead engine should be corrected with the rudder; the propeller on the dead engine should be feathered; and the dead engine wing should be held up about 3 degrees higher than level to help counteract the airplane's tendency to turn in that direction. ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event) - [Takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) ## Aircraft - Registration: [N3162P](https://openairdocs.org/deregistered/N3162P-2018-03-05), registration cancelled 2018-03-05, S/N 23-1094, built 1957 (OpenAirDocs) - Reported make and model: PIPER PA-23-150 (Apache D) - Registry model: [Piper PA-23](https://openairdocs.org/model/piper-pa-23) (registry code 7102302) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 23-1094 - Year built: 1957 - Airframe hours: 4169 - Engines: LYCOMING O-320 SERIES 150 horsepower reciprocating; LYCOMING O-320 SERIES 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2013 - Departed: TUS, Tucson, AZ - Destination: TUS, Tucson, AZ - Airport: TUS, Tucson Intern Arpt, runway 11R, 8,408 × 75 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 75; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; restraint: none; flight hours: 400 total, 14 in this make and model, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 28 °F - Altimeter: 29.96 inHg - Observed at: DMA, 4 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 20131023022819A](https://openairdocs.org/incident/20131023022819A), Oct 23, 2013: Piper PA-23, Tucson, AZ, Substantial damage. On October 23, 2013, about 1040 local time, a Piper PA-23 airplane, N3162P, sustained substantial damaged during a tale off at Tucson airport (tus), Tucson,… ## Docket (14 files) The files NTSB released with the investigation on July 31, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88289. 9.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 773 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414607&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statement, Airport Operations Officer (item 2, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414608&FileExtension=.PDF&FileName=Witness%20Statement,%20Airport%20Operations%20Officer-Redacted.PDF - FAA Inspector’s Statement (item 3, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414609&FileExtension=.PDF&FileName=FAA%20Inspector%E2%80%99s%20Statement-Redacted.PDF - NTSB Left Fuel System Examination Report (item 4, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414610&FileExtension=.PDF&FileName=NTSB%20Left%20Fuel%20System%20Examination%20Report-Master.PDF - Photo 1 – Right Front View of Aircraft (item 5, .PDF, 417 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414611&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93%20Right%20Front%20View%20of%20Aircraft-Master.PDF - Photo 2 – Front View of Aircraft (item 6, .PDF, 345 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414612&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20Front%20View%20of%20Aircraft-Master.PDF - Photo 3 – Left Side View of Aircraft (item 7, .PDF, 431 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414613&FileExtension=.PDF&FileName=Photo%203%20%E2%80%93%20Left%20Side%20View%20of%20Aircraft%0D%0A-Master.PDF - Photo 4 – Right Rear View of Aircraft (item 8, .PDF, 400 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414614&FileExtension=.PDF&FileName=Photo%204%20%E2%80%93%20Right%20Rear%20View%20of%20Aircraft-Master.PDF - Photo 5 – Left Engine Driven Fuel Pump Diaphragm (item 9, .PDF, 922 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414615&FileExtension=.PDF&FileName=Photo%205%20%E2%80%93%20Left%20Engine%20Driven%20Fuel%20Pump%20Diaphragm-Master.PDF - Photo 6 – Fuel Tank Selector Switches (item 10, .PDF, 643 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414616&FileExtension=.PDF&FileName=Photo%206%20%E2%80%93%20Fuel%20Tank%20Selector%20Switches-Master.PDF - Photo 7 – Electric Fuel Boost Pump Switches (item 11, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414617&FileExtension=.PDF&FileName=Photo%207%20%E2%80%93%20Electric%20Fuel%20Boost%20Pump%20Switches-Master.PDF - 12. Annual Maintenance Documentation Annual Maintenance Documentation_Redacted (item 12, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414618&FileExtension=.PDF&FileName=12.%09Annual%20Maintenance%20Documentation%0D%0AAnnual%20Maintenance%20Documentation_Redacted%0D%0A-Redacted.PDF - Owner’s Handbook (item 13, .PDF, 503 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414619&FileExtension=.PDF&FileName=Owner%E2%80%99s%20Handbook-Master.PDF - Pilot’s Logbook Excerpts (item 14, .PDF, 398 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414620&FileExtension=.PDF&FileName=Pilot%E2%80%99s%20Logbook%20Excerpts-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; 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.