MIA00FA118
MIA00FA118

HISTORY OF FLIGHT

On March 26, 2000, about 1813 central standard time, a Piper PA-24-260, N9204P, registered to a private individual, crashed into West Bay approximately 2.5 statute miles west-northwest of the Panama City-Bay County International Airport, Panama City, Florida. Instrument meteorological conditions prevailed at the airport at the time of the accident and no flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was destroyed and the private-rated pilot, the sole occupant was fatally injured. The flight last departed from the Frank Sikes Airport, Luverne, Alabama, at an undetermined time.

The flight initially departed with full fuel tanks from the airport where the airplane was based (Walker County-Bevil Field Airport, Jasper, Alabama), and returned two times immediately after takeoff due to a discrepancy related to the landing gear warning system. The landing gear warning system was disconnected by the pilot and the flight departed a third time between 1300 and 1330; after takeoff the pilot reported the flight was departing the traffic pattern to the south.

According to a transcription of communications with the Anniston, Alabama, Automated Flight Service Station (Anniston AFSS), the pilot twice phoned the facility on the day of the accident, the calls were received at 1552:22 and 1637:25 local. The caller advised at the beginning of both phone calls that he was on the ground in Luverne, it was raining, and he intended on flying to Panama City. He asked during both phone calls when the weather would, "blow over" and "blow through", respectively, to which the specialist replied, two or three hours, and one or two hours, respectively. The pilot was asked during the first call whether the flight would proceed under instrument flight rules (IFR), to which he replied, "uh i could but i'm i'm not ifr i was just airport hopping." The pilot was advised that visual flight rules was not recommended and there was adverse weather south of Luverne, and also west of his location, moving his way. The pilot closed the first phone call by stating, "uh huh okay well i may have to concoct an ifr flight plan and call you back then alright thank you." During the second phone call, the pilot was advised thunderstorms were expected along the route of flight. The pilot reported the airplane was not equipped with a stormscope, the AWOS at Panama City was indicating the ceiling was 1,400 feet, and if he could just get there, "...it sounds like it's pretty much okay." The pilot was advised of widely scattered thunderstorms embedded in rain that existed along his route, and most of the thunderstorms were west, north, or east of Panama City. After 1800 local in Panama City, the forecast was for the ceilings to improve to 3,500 feet with occasional IFR conditions with thunderstorms and rain showers for another 1.5 hours at Panama City. The pilot advised he would call back, "...in an hour or so", to which the briefing specialist advised him to request a standard weather briefing when he did call back. There was no further record of the pilot obtaining an additional preflight weather briefing.

There were no known witnesses who saw the flight depart from the Frank Sikes Airport, located in Luverne, Alabama. According to a transcription of communications with the Jacksonville Air Route Traffic Control Center (JAX ARTCC), at 1752:19, the pilot contacted the facility and advised the controller that the flight was, "...just off geneva like vfr to uh panama city." The pilot was provided with a discrete transponder code and the airplane was radar identified. The flight continued and at 1759:38, the controller broadcast on the frequency advising of convective sigmet 38E which was available on hiwas flight watch or flight service. The pilot was provided a vector for weather avoidance and at 1801:55, the pilot requested a lower altitude to avoid clouds. The controller responded by advising the pilot in part to maintain vfr. At 1806:36, the controller advised the pilot in part, "...be advised they are advertising the vor runway three two approach there at panama city do you think you're still gonna be able to get the airport in sight." The pilot advised the controller that the flight was between layers with the lower layer, "...barely broken." At 1807:15, the JAX ARTCC controller communicated with the Panama City Air Traffic Control Tower (KPFN ATCT) controller and advised of handling a vfr target and questioned whether the airplane would be able to land under visual flight rules. The KPFN ATCT controller advised the JAX ARTCC controller that the ceiling was at 1,400 feet and, "...if he can get down below that he should be able to make it." At 1809:42, the pilot of another airplane who had just performed a missed instrument approach to the KPFN airport advised on the frequency of encountering heavy rain during the approach. The controller questioned the accident pilot if he heard the report from the other pilot and he reported that he had. He also reported, "...i've got good ground visibility now uh i think i'll just run right over the airport and i should see it." The JAX ARTCC controller terminated radar services at 1810:44; air traffic control communications were transferred to KPFN ATCT.

According to a transcription of communications with the KPFN ATCT, the pilot established contact with that facility at 1811:08, and advised that the flight was 6 miles northwest of the airport, inbound for landing. The controller advised the pilot to enter a left downwind for runway 32, and at 1812:07, advised the pilot, "and uh zero two papa panama city weather is currently below basic vfr minimums say intentions." The pilot responded, "uh zero four pop zero four papa i guess i should turn around and go north." The pilot replied when asked that he did not have the airport in sight. The controller advised the pilot to maintain vfr, and if he elected to proceed northbound to contact JAX ARTCC. At 1812;43, the pilot advised the KPFN ATCT controller that the flight was, "...turning northbound", there was no further contact with the KPFN ATCT. The pilot reestablished communications with the JAX ARTCC at 1813:03, advising, "uh nine two zero four papa but i did not have it in sight and i'm turning north." There was no further contact with the JAX ARTCC, and there were no known eyewitnesses to the accident.

According to an individual who lives approximately 4 nautical miles north-northeast of the accident site, on the day of the accident about 1830, he was at his house under the porch because of bad weather that consisted of pouring down rain. He heard a noise and commented to his wife, "that somebody was flying in pretty crappy weather." He felt confident the sound he heard was associated with a single engine airplane. He did not observe it and reported it was dark outside. The engine sounded fine at what he thought was midpower setting, and, "it wasn't missing a beat." He could not determine the route of flight and thought that the airplane was no higher than 400 to 500 feet. A record of conversation with the individual is an attachment to this report.

Review of a National Track Analysis Program (NTAP) from the Jacksonville ARTCC revealed that between 1808:07, and 1813:07 (last radar return), the airplane descended from 2,000 feet mean sea level (msl) to 800 feet msl, while on a south-southeast heading. Between the time of the first communication with the KPFN ATCT (1811:08), and the last radar return (1813:07), the airplane descended from 1,100 to 800 feet msl. The radar data indicates the airplane descended an additional 400 feet after the pilot was advised by the KPFN ATCT controller that the weather conditions were below VFR weather minimums and the last radar return. Plotting of the radar returns on a map revealed that between 1810:55, and the last radar return, the airplane was flying over water of West Bay. Additionally, between 1812:07, and the last radar return, the radar data reflects the airplane turned to the left. The last radar return was located at 30 degrees 13 minutes 29 seconds North latitude and 085 degrees 43 minutes 39 seconds West longitude. Radar data is an attachment to this report.

A search for the airplane was performed by the Florida Fish and Wildlife Conservation Commission, U.S. Coast Guard, and Bay County Sheriff's Department. The wreckage was located 062 degrees and approximately .4 nautical mile from the last radar target. The pilot's body was not located until the morning of March 29, 2000.

PERSONNEL INFORMATION

Review of the FAA pilot's airman file revealed that he held a private pilot certificate with ratings airplane single engine land, instrument airplane. The instrument rating was added to his private pilot certificate on April 19, 1997; the application for that rating indicates his total flight time was 309 hours. He was issued a third class medical certificate on January 17, 1997, with the limitation that the holder must have available glasses; the pilot was 52 years old at the time of the examination.

Review of 14 CFR Part 61.23 revealed a third class medical certificate issued on or after September 16, 1996, expires at the end of the 24th month after the month of the date of examination shown on the certificate if the person has reached his or her 40th birthday on or before the date of the examination.

The pilot's pilot logbook was not located therefore flight time and instrument currency information could not be determined.

AIRCRAFT INFORMATION

The airplane was a Piper Aircraft Corporation model PA-24-260, serial number 24-4699, that was manufactured in 1967. It was equipped with a Lycoming IO-540-D4A5 engine and a Hartzell model HC-C3YR-1RF propeller that was purchased and installed in accordance with supplemental type certificate (STC) SA288CH. The airplane was not equipped with weather avoidance radar or a stormscope.

Review of copies of work orders provided by the facility that had maintained the airplane for the past 2 years revealed that the last annual inspection was signed off on November 5, 1999. The airplane had accumulated approximately 52 hours since the inspection at the time of the accident. Additional review of work orders revealed the altimeter and artificial horizon were replaced on September 28, 1999. According to the mechanic, the owner of the airplane had the artificial horizon replaced again in November at an unknown facility in Mobile, Alabama. He advised the owner at the time he replaced the artificial horizon in September 1999, to have the pitot static system, altimeter, and transponder checks performed. He also reportedly advised the owner again in November to have pitot static system checked. Further review of the work orders indicate that the engine was overhauled on May 5, 1998. No determination was made as to the engine total time since major overhaul at the time of the accident. A copy of the statement from the mechanic and copies of the provided work orders are an attachment to this report.

The permanent aircraft maintenance records were not located; therefore, no determination was made as to when the pitot-static system check was last performed.

METEOROLOGICAL INFORMATION

There was no record of the pilot obtaining preflight weather briefings from either of the DUAT vendors. There was no record that the pilot contacted the Macon or Gainesville Automated Flight Service Stations for a preflight weather briefing.

A METAR weather observation taken at the Panama City-Bay County International Airport at 1812, indicates that the wind was calm, the visibility was 2.5 statute miles with heavy rain and mist, broken clouds existed at 800 feet, overcast clouds existed at 1,600 feet, the temperature and dew point were approximately 67 and 65 degrees Fahrenheit respectively, and the altimeter setting was 29.88 inHg.

On the day and approximate location of the accident, the sunset was calculated to have occurred at 1758 hours and the end of civil twilight was calculated to occur at 1822 hours.

COMMUNICATIONS

Transcriptions of communications of the abbreviated weather briefings from the Anniston, Alabama, Automated Flight Service Station, and of communications with the Jacksonville Air Route Traffic Control Center and Panama City-Bay County International Airport Air Traffic Control Tower are an attachment to this report. There were no reported communications with Cairns, Birmingham, Montgomery, Pensacola, or Eglin Approach Control facilities. Additionally, there was no reported communication with the Atlanta Air Route Traffic Control Center.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located by personnel from the Florida Fish and Wildlife Conservation Commission, who were alerted by the Bay County Sheriff's Department. The main wreckage which consisted of the fuselage was located at 30 degrees 13.66 minutes North latitude, and 085 degrees 43.18 minutes West longitude. That location when plotted was located approximately 2.45 statute miles and 292 degrees from the Panama City-Bay County International Airport. According to personnel from the Florida Fish and Wildlife Conservation Commission, fuel was noted on the water near the crash site. The NTSB did not travel to the accident site; the wreckage was recovered and secured for NTSB examination.

Examination of the recovered wreckage revealed all major structure and components necessary for flight were accounted for. The forward portion of the fuselage was fragmented. The cabin roof was fractured at two locations, 32 and 105 inches aft of the windshield, respectively. The rear portion of the fuselage was structurally separated approximately 55 inches forward of the leading edge of the stabilator. Both wings were separated from the airframe near each wing root. The left wing was fragmented; the main spar was fractured and bent up at an approximately 45-degree angle and also bent aft beginning about 45 inches outboard of the fuselage attach point (see photograph 8). The leading edge of the left wing main spar was twisted down. The right wing was comprised of two major sections (see photograph 7). Both horizontal stabilators were attached to the airframe; the left was cut during recovery of the airplane. The tip of the left horizontal stabilator exhibited chordwise crushing; the main spar of it was displaced aft approximately 15 degrees (see photograph 5). The vertical stabilizer and rudder remained installed. The landing gear was determined to be retracted. Examination of the flap actuator revealed the flaps were extended approximately 10 degrees. Examination of the aileron, rudder, and stabilator flight control cables revealed no evidence of preimpact failure or malfunction. There was no evidence of fire to any of the recovered wreckage. The electronic tachometer, attitude indicator, and altimeter were retained for further examination (see TESTS AND RESEARCH section of this report). The engine with attached propeller which remained secured to the airframe was removed for further examination.

Examination of the engine revealed impact damage to the crankcase. A crease was noted in the bottom of the No. 4 cylinder head; the air induction pipe for it was creased and folded adjacent to the creased location of the cylinder. Damage to bottom of cylinder fins of the cylinder head of No. 6 cylinder was noted to be in line with the impact damage to the crease found in the bottom of the No. 4 cylinder (see photograph 14). Impact damage to the engine precluded rotation of the engine. The No. 2 cylinder head was separated and was not located (see photograph 11). The No. 2 cylinder barrel fins were bent at head end of fins; the No. 2 cylinder injector line was missing and both hydraulic tappet sockets were also missing. No abnormal scoring was noted on the No. 2 cylinder piston skirt or on the inside diameter of the No. 2 cylinder barrel. The piston rings in the No. 2 cylinder were free to move. There was no evidence of fretting on any of the cylinders base pads. Disassembly of the engine revealed valve and gear train continuity; the internal timing of the crankshaft and camshaft gears was correct. The No. 1 cylinder oil control ring was broken. The oil filter and suction screen were clean; no metal was found. All pistons were noted to be intact. No lubrication discrepancies were noted. The left and right magnetos were placed on a test bench and operated normally; the only discrepancy noted was intermittent firing of the No. 6 top lead of the left magneto. Visual examination of the servo fuel injector revealed the butterfly position did not correlate with idle and full open position stops; the butterfly was noted to be bent. Examination of the fuel manifold valve revealed corrosion on the inside portion of the cover, in the housing, and in the sediment area on the bottom of the manifold valve. The diaphragm was torn near a screw location. The Nos. 1, 5, and 6 fuel injector nozzles were blocked. The No. 3 cylinder fuel injector nozzle had slight contamination, and the No. cylinder 4 fuel injector nozzle was partially blocked. Salt water was found inside No. 5 cylinder fuel injector nozzle. The flange of the propeller governor remained secured to the engine crankcase; however, the governor was not recovered. No preimpact failure or malfunction of the engine was noted. The No. 2 cylinder barrel, vacuum pump, servo fuel injector, and No. 1 cylinder oil control ring were retained for further examination (see TESTS AND RESEARCH section of this report).

Examination of the three-bladed propeller which remained secured to the engine revealed all three blades remained secured inside the propeller hub. All propeller blades exhibited leading edge twisting towards low pitch. Propeller blades Nos. 1, 2, and 3 as marked were bent aft approximately 80 degrees, 70 degrees, and 65 degrees respectively, beginning about 25 inches, 26 inches, and 23 inches inboard from each blade tip, respectively. Propeller blade No. 1 as marked exhibited gouges on the leading edge of the blade approximately 12.5, 14, 16, and 19 inches respectively from the blade tip (see photograph 15). Blade No. 2 as marked exhibited damage to the leading edge approximately 9 inches from the blade tip. Blade No. 3 as marked exhibited minimal gouging on the leading edge of the blade. No evidence or preimpact failure or malfunction of the propeller was noted. The No. 1 propeller blade was saw cut near the propeller hub to compare damage to it and to the No. 4 cylinder barrel (see TESTS AND RESEARCH section of this report).

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination of the pilot was performed by Marie A. Herrmann, M.D., District 14 Medical Examiner, Panama City, Florida. The cause of death was listed as multiple blunt impact injuries.

Toxicological analysis of specimens of the pilot was performed by the University of Florida Diagnostic Referral Laboratories, and the FAA Toxicology and Accident Research Laboratory (CAMI). The results of analysis by the University of Florida was negative in the urine for ethanol and for the comprehensive drug screen. The results was positive in the blood (0.03 g/dL) for ethanol, and negative for the comprehensive drug screen. The results of analysis by CAMI was negative for cyanide, volatiles, and tested drugs; carbon monoxide testing was not performed.

TESTS AND RESEARCH

According to the President of a fixed base operator located at the Geneva Municipal Airport, Geneva, Alabama, to his knowledge no person was at the airport about 1800 hours on the on the day of the accident.

Examination of the No. 1 propeller blade and the damage to the No. 4 cylinder by an FAA inspector revealed the damage to the leading edge of the blade was consistent with contact to the No. 4 cylinder. Additionally, the same FAA inspector observed that the crankshaft flange was bent greater than .250 inch. Copies of statements from the FAA inspector are an attachment to this report.

Examination of the No. 2 cylinder barrel by the engine manufacturer with NTSB oversight revealed the barrel inside diameter measured within limits. The barrel threads were examined by a metallurgist with the engine manufacture; no mechanical damage was noted. The barrel inside diameter was checked by the engine manufacturer to determine whether it was within limits pertaining to being out-of-round (OOR). The barrel was found to be OOR greater than the specified limits at 3/4 inch and 1.75 inches up from the head end of the barrel. The remainder of checks for OOR were within limits. An outward bulge was noted on the cylinder barrel below the damaged area of the cooling fins.

Examination of the broken oil control ring from the No. 1 cylinder by a metallurgist with the engine manufacturer revealed localized areas of corrosion products. A copy of the report is included with the engine manufacturer's report which is an attachment to this report.

Examination of the vacuum pump revealed that the drive coupling and the drive spline were not failed (see photograph 16). The unit could not be rotated by hand. Disassembly of the vacuum pump with FAA oversight revealed the rotor and vanes were intact, corrosion prevented the unit from being rotated. A piece of rubber material was noted between the rotor and one of the vanes. The hose material was noted to be similar to a portion of hose that was still attached to the exhaust of the vacuum pump. No evidence of preimpact failure or malfunction was noted. A copy of the statement from the FAA inspector is an attachment to this report.

Examination of the electronic tachometer with FAA oversight revealed the tach time in memory was the same tach time as when the unit was sold and shipped to the airplane owner on August 27, 1997. According to the manufacturer, the absence of change in the tachometer time indicates the unit was not powered and operated past 1,300 rpm for a period greater than 6 minutes. A copy of the report from the manufacturer is an attachment to this report.

Examination of the attitude indicator revealed the rotor turned freely inside the rotor housing; the rotor bearings were satisfactory. No scoring was noted on the rotor. No evidence of preimpact failure or malfunction was noted. Examination of the directional gyro revealed that the gimball housing appeared to be satisfactory; the unit appeared to work acceptably when the gimball housing was moved by hand. The rotor housing was cut open to examine the rotor revealing slight circumferential scoring on the top side at the edge of the maximum outside diameter. No evidence of scoring was noted on the rotor near the rotor buckets. The rotor bearings appeared satisfactory. No evidence of preimpact failure or malfunction was noted.

Examination of the altimeter revealed that the hundred foot hand assembly was contacting the 10,000-foot pointer disk. The hairspring wheel top pivot and the top sector pivot were broken. The top sector pivot jewel exhibited a hairline crack, and the diaphragms were separated from each other. No evidence of preimpact failure or malfunction was noted.

Examination of the servo fuel injector revealed impact damage that precluded bench testing. The servo mount flange was fractured and separated above the throttle shaft, and the throttle shaft pin was found sheared. The mixture control shaft was fractured at the roll pin area of the shaft. The inlet fitting and screen were not located. Internal corrosion and salt water contamination was noted. The fuel diaphragm stem was checked using a dial indicator and found to indicate 0.069 inch total deflection. No evidence of preimpact failure or malfunction was noted.

ADDITIONAL DATA/INFORMATION

A "IFR Enroute Low Altitude" chart designated L17/18 was discovered in a black bag that was recovered with the wreckage. The chart expired on February 24, 2000, and depicted the original and intermediate departure airports as well as the destination airport.

The airplane minus the retained components was released to Marshall B. Dean, Assistant V.P., USAIG, on April 11, 2000. All retained components were also released to Marshall Dean, on December 17, 2002.

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