LAX02FA191
LAX02FA191

HISTORY OF FLIGHT

On June 8, 2002, about 1405 mountain standard time, a Piper PA-23-160, N4302P, crashed under unknown circumstances near Rio Rico, Arizona. Accelerated Flight Crew Training, Chandler, Arizona, operated the rental airplane under the provisions of 14 CFR Part 91. Post impact fire destroyed the airplane. The private pilot, the commercial rated pilot, and a pilot-rated passenger were fatally injured. Visual meteorological conditions prevailed for the cross-country flight that departed Nogales, Arizona, about 1355. The flight was destined for Stellar Airpark Airport (P19), Chandler. The wreckage was at 31 degrees 26.212 minutes north latitude and 110 degrees 55.255 minutes west longitude.

The commercial pilot (examinee), his certified flight instructor (CFI), and the private pilot passenger flew from Chandler to Nogales for the examinee's CFI multiengine check ride. Nogales was 3 miles on a magnetic bearing of 090 degrees from the accident site.

Witnesses stated that the weather was calm winds with a temperature of 93 degrees Fahrenheit. The airplane departed runway 21, which was 7,199 feet in length by 90 feet wide.

WITNESS STATEMENTS

Statement from the Designated Pilot Examiner (DPE)

According to the DPE, the accident airplane arrived at Nogales at 1050. The examinee was testing for his flight instructor airplane multiengine certificate. Once the examinee and DPE completed a walk-around inspection of the airplane, they boarded and taxied to the run-up area for runway 21. According to the DPE the examinee set the mixtures at the "number three (3) position;" however, the left engine did not develop sufficient power for the check. The examinee then had the DPE readjust the mixture setting to a richer setting and then a leaner setting. The leaner setting restored normal engine power to the left engine. The examinee readjusted the right engine power settings to match the left engine, and conducted a normal engine run-up.

On takeoff, the DPE simulated an engine failure, which the examinee recovered from, and aborted the takeoff. Both pilots elected to then continue the takeoff from their current position, as there was enough remaining runway. The DPE stated that the takeoff roll and initial climb out were normal until they were over the departure end of the runway. There was a loss of climb performance, and the airplane yawed slightly to the left. He noted that the left engine manifold pressure gage read between 21.5-22.0 inches, and both engines were indicating 2,600 rpm (revolutions per minute). The DPE, the pilot flying, initiated a turn toward a golf course. The airplane was still climbing about 200-300 feet per minute, and was able to climb to 4,800 feet mean sea level (msl) aided by an updraft.

The DPE indicated that while on the downwind leg for landing at Nogales, he noted that the right engine oil temperature had climbed near the upper limit, and the oil pressure was showing a decrease. A discussion ensued between the pilots about how the DPE should deal with the situation.

As the airplane turned onto the final approach, the DPE noted that the oil pressure on the right engine had dropped further and was now near the lower redline limit. After touchdown, he idled the right engine, and the oil pressure increased to the lower green limit. As they cleared the runway; he noted that the oil temperature had dropped and the pressure further improved.

After clearing the runway, the DPE and examinee decided to discontinue the check ride. They also decided in order to provide a confirmation of the problem to the flight school's mechanic; they decided to double check the mixtures and attempt to troubleshoot the problem. They taxied to the run-up area to do another engine performance check. They noted that the left engine was not developing power equal to that of the right engine. Since the results were different than that of the first run-up, they decided to discontinue troubleshooting, and taxied back to the ramp where they shutdown the engines.

Further discussions ensued in which the DPE and examinee decided to let the airplane cool down and check the engines further. When they got back into the terminal area, the DPE had a discussion with the CFI where he indicated that they had mechanical problems during the flight check, and he felt that they should not continue flying the airplane. The CFI indicated that she would contact her company.

In the meantime the DPE, the examinee, and a local instructor went back to the airplane. The DPE manually rotated the propeller for the left engine. He indicated that the number 1 and 2 cylinders felt normal; the number 3 cylinder provided some resistance, and the number 4 cylinder was just slightly less than the number 3 cylinder. All of the cylinders on the right engine were the same. The examinee then did the same check, and both of them had the same result on both engines.

After returning to the terminal area, the CFI told the DPE that she had been in contact with the school's mechanic, who told her that "there is a problem and you are right not to fly, but it should be safe to fly home, but don't push it." She also told the DPE that the mechanic thought that the gage was probably faulty. The DPE told them again not to fly the airplane. However, the CFI stated that it would be okay "and they would fly airport to airport on the way home." The DPE stated that the other two pilots made no additional comments about the airplane in his presence.

Prior to their departure, the private pilot asked the DPE, "If I lost an [engine] on takeoff here I shouldn't go straight ahead should I?" The DPE told him that, because of the mountains, straight ahead would not be the best idea, and that either a left or right turn would provide him with more options (golf course or river beds).

About 5 minutes later, while in his office, the DPE saw the airplane taxiing out. He observed the CFI in the rear seat, the private pilot in the left seat, and the examinee in the right seat. He then went outside and watched the airplane take off. On the takeoff roll, he observed the airplane yaw to the left three times, each time returning to the runway centerline. He thought that they were going to liftoff at taxiway "C"; however, the airplane continued down the runway rotating about 3,300 feet down the runway. The nose pitched up abruptly, and the landing gear was retracted immediately. The airplane began to settle toward the runway. About 15 feet above the ground, the nosed pitched to level, and the airplane accelerated and began a slow climb out. The DPE stated that the airplane sounded normal, and he went back into his office. A couple of minutes later he heard a loud shriek on UNICOM, and then received a phone call from a deputy from Santa Cruz Sheriff's Department that a 911 call had been made reporting a downed airplane. The deputy asked if any airplanes had just taken off from the airport, and the DPE said yes. The DPE then got on the radio and tried to contact the airplane with no success. An airplane on final for Nogales was asked to look for and confirm that an airplane was down, which the pilot was able to confirm.

Statement of flight school mechanic

According to the flight school's mechanic, he spoke to the CFI about 1200 the day of the accident. She had called him to say that the DPE reported that during the check ride the left engine was producing less power than the right engine. They discussed engine instrument indications inside the cockpit for the left engine. The CFI indicated that the manifold pressure was at 25 inches, the engine rpm was 2,600, and the oil temperature and pressure were normal.

The mechanic then questioned her about whether they had any problems on the way down, and the CFI responded, "None, everything is good." She then indicated that the DPE said that the right engine was "running hot." The mechanic asked if the engine instrument was "in the red," to which she replied "no." The mechanic indicated that he thought the right engine was a little bit hot, but wasn't sure because he wasn't over at the hangar and couldn't look at the logbooks. He then asked her about the oil quantity and pressure. The CFI reported that both were "normal."

The mechanic told her that he didn't know what to tell her, but that everything sounded "pretty normal to me." The CFI said that she thought so too. He then told her that it was her decision to continue operating the airplane. He was available via cell phone if she wanted him to come down and pick them up. He did not hear from her again.

A compilation of witnesses in the airport terminal/diner area overheard the DPE indicating to the CFI that the airplane was not in an airworthy condition, and he would not fly it for the check ride. They saw the CFI make a cell phone call, after which the CFI indicated that they would fly back to Stellar Airpark.

One witness, a local flight instructor, over heard the CFI say to the DPE that the accident airplane was a "poor performer." The DPE replied that the left engine was indicating 2 inches lower manifold pressure than the right engine, and the right engine was overheating. The same witness noted the "irregular steering" during the early part of the takeoff roll, which he attributed to nonsymmetrical power. The airplane used about 3,500 feet of the runway before it lifted off.

PERSONNEL INFORMATION

Private pilot - seated in the left forward seat

A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a private pilot certificate with an airplane multiengine land rating.

The pilot held a first-class medical certificate issued on May 31, 2001. It had no limitations or waivers.

No personal flight records were located for the pilot, and the aeronautical experience listed in this report was obtained from a review of FAA form 8710-1 (00-04) titled Airman Certificate and/or Rating Application. He listed a total time of 29.0 hours in the accident make and model.

Commercial Multiengine pilot (examinee) - seated in the right forward seat

A review of FAA airman records revealed that the examinee held a commercial pilot certificate with an airplane multiengine land rating and an instrument airplane rating.

The examinee held a first-class medical certificate issued on May 7, 2002. It had a limitation that the examinee must have available glasses for near vision.

No personal flight records were located for the examinee, and the aeronautical experience listed in this report was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma, and from FAA form 8710-1. These records indicated a total flight time of 725 hours with 165.0 hours in the accident make and model, and 120.0 hours logged as pilot-in-command.

Certified Flight Instructor - seated in the middle section of seats

A review of Federal Aviation Administration (FAA) airman records revealed that the CFI held a commercial pilot certificate with an airplane multiengine land rating and instrument airplane rating. The commercial pilot multiengine certificate was issued on March 15, 2002. The pilot also held a certified flight instructor certificate with an airplane multiengine land rating and instrument airplane rating. The CFI certificate was issued on May 20, 2002.

The CFI held a first-class medical certificate issued on June 20, 2001. It had no limitations or waivers.

No personal flight records were located for the CFI, and the aeronautical experience listed in this report was obtained from a review of FAA form 8710-1. She listed a total time of 191.0 hours in the accident make and model with 136.0 total hours logged as pilot-in-command.

AIRCRAFT INFORMATION

The airplane was a Piper PA-23-160, serial number 23-1803. The airplane logbooks were destroyed in the accident. The operator estimated a total airframe time of 5,000 hours. The last annual inspection was in September 2001. The last 100-hour inspection was on May 20, 2002, with 50 hours since the last inspection.

The airplane had a Textron Lycoming O-320-B3B engine, serial number L-2644-39, installed on the left side. The operator further reported that the left engine had a top overhaul on August 14, 2001, and was flown about 300 hours since that time. The tachometer for the left engine read 1,148.8 hours at the last inspection.

The airplane had a Textron Lycoming O-320-B3B engine, serial number L-2788-39, installed on the right side. A top overhaul of the right engine was conducted in 2000, and flew about 40 hours between 2000 and 2001. After 2001, about 300 hours had been placed on the engine. The tachometer for the right engine read 2,903.45 hours at the last inspection.

According to the operator, the airplane had 60 gallons of 100-low lead aviation fuel on board when it departed Stellar Airpark.

WRECKAGE AND IMPACT INFORMATION

The accident site was located a remote rural residential area. The area was indicative of flat desert terrain with loose rocks and scrub brush. The main wreckage, which was nearly consumed in the post impact fire, came to rest near a residence in a small grove of trees at an elevation of 3,635 feet. Red lens fragments were at the initial point of contact (IPC), at an elevation of 3,644 feet. The left wing tip came to rest about 5 feet beyond the IPC. The rest of the wreckage from the IPC to the main wreckage was in a straight line, approximately 125-feet in length, on a magnetic bearing of 108 degrees.

The empennage separated from the fuselage of the airplane with a portion of a guide wire from the adjacent telephone pole embedded in the separation point. Flight control continuity was established on scene. The private pilot and CFI were ejected from the airplane; the examinee remained in the airplane.

Flight control continuity could not be established; however, all flight control surfaces were located at the main wreckage. The left and right wing control cables were thermally destroyed, and all balance weights for the control surfaces were located at the main wreckage. Flight control cables aft of the baggage compartment remained attached via push-pull tubes and bellcrank assemblies. Flight control cables that remained were thermally damaged and exhibited broomstrawing at the separation points.

According to the airframe manufacturer, the airplane was equipped with a normalizing type of turbocharger. The system was to be utilized during cruise. The cockpit vernier controls for the turbocharger waste gates were in the OPEN (turned off) position.

Left side

The left wing tip was about 5 feet from the IPC. A portion of the burned left fuel tank was about 40 feet from the IPC. The left wing separated at the wing root, and the left engine separated from the left wing. The left engine came to rest upright and the propeller remained attached to the engine via the crankshaft. The propeller blades exhibited S-bending, leading edge gouging, and chordwise striations.

Right side

The right wing and engine remained attached to the fuselage, but came to rest inverted. The propeller remained attached to the engine via the crankshaft. Both propeller blades exhibited chordwise striations and leading edge gouging. One blade exhibited S-bending. The other blade separated about 2/3 the length of the blade. The portion of separated blade was about 50 feet from the IPC in the driveway of the residence. The separation area was angular and granular.

MEDICAL AND PATHOLOGICAL INFORMATION

The Pima County Medical Examiner's Office conducted an autopsy of all three pilots on June 11, 2002.

The FAA Toxicology and Accident Research Laboratory, Oklahoma City, performed a toxicological analysis of specimens from all three occupants.

The analysis of specimens from the private pilot was negative for carbon monoxide, cyanide, volatiles, and tested drugs.

The analysis of specimens from the examinee was negative for carbon monoxide, cyanide, volatiles, and tested drugs.

The results of the analysis of the CFI's specimens were negative for carbon monoxide and cyanide. The report contained the following positive results for VOLATILES: 28 (mg/dL, mg/hg) ethanol detected in blood, 50 (mg/dL, mg/hg) ethanol detected in blood, 21 (mg/dL, mg/hg) ethanol detected in brain, 14 (mg/dL, mg/hg) acetaldehyde detected in blood, 8 (mg/dL, mg/hg) N-propanol detected in blood, and 4 (mg/dL, mg/hg) N-propanol detected in muscle. In the NOTES section of the toxicology it stated, "the ethanol found in this case may potentially be from postmortem ethanol formation and not from the ingestion of ethanol."

The report also contained the following positive results for tested DRUGS: ephedrine detected in the blood and the liver, pseudoephedrine detected in the blood, and phenylpropanolamine detected in the liver.

TESTS AND RESEARCH

Investigators examined the airframe and powerplants at Air Transport, Phoenix, Arizona, on June 11, 2002.

There were no discrepancies noted with the airframe.

Both powerplants exhibited thermal damage internally and externally.

Left Engine

Investigators slung the engine from a hoist to facilitate a visual and mechanical examination. The ignition harness sustained thermal damage; however, the wires remained attached to their respective spark plugs. The top spark plugs were removed, and exhibited thermal discoloration. There were no anomalies noted with the spark plugs.

A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder heads. Investigators manually rotated the engine. Mechanical and valve train continuity were established, and thumb compression was obtained in all cylinders in firing order. A differential compression check was conducted using a baseline of 80 psi. The results were as follow:
#1 70/80 psi
#2 55/80 psi
#3 68/80 psi
#4 16/80 psi
The number 2 and 4 cylinder exhaust valves were staked (struck) with a rubber mallet and a second differential check was conducted. The compression reading did not change for the number 2 cylinder. The compression reading for the number 4 cylinder was 70/80 psi. Investigators noted that there were leaks through the exhaust valve areas. The cylinders were removed and examined further. The results of the examination were as follow:

Number 2 Cylinder Intake Valve Guide
0.4078

Number 2 Cylinder Intake Valve Guide
0.5049

Number 2 Cylinder Exhaust Valve Stem
Top - 0.4943
Mid - 0.4936

Number 2 Cylinder Intake Valve Stem
Top - 0.4028
Mid - 0.4022

Number 4 Cylinder Intake Valve Guide
0.4057

Number 4 Cylinder Exhaust Valve Guide
0.5084

Number 4 Cylinder Exhaust Valve Stem
Top -0 .4937
Mid - -0.4934

Number 4 Cylinder Intake Valve Stem
Top - 0.4027
Mid - 0.4023

The left magneto remained attached and secured to its accessory pad. It sustained thermal damage, and was disassembled for inspection. The internal components were present, but sustained thermal damage and were melted. The engine-driven fuel pump was manually rotated with no restrictions. The carburetor sustained impact damage; however, all components were accounted for. There were no other mechanical anomalies noted with the engine.

Right Engine

Investigators slung the engine from a hoist to facilitate a visual and mechanical examination. The ignition harness sustained thermal damage; however, the wires remained attached to their respective spark plugs. The top spark plugs were removed. The spark plugs were oil wetted due to the engine being inverted prior to recovery. No mechanical deformation was noted with any of the spark plugs.

A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder heads. Investigators manually rotated the engine. Mechanical and valve train continuity were established, and thumb compression was obtained in all cylinders in firing order. A differential compression check was conducted using a baseline of 80 psi. The results were as followed:
#1 10/80 psi
#2 65/80 psi
#3 44/80 psi
#4 58/80 psi
The number 1 cylinder exhaust valve was staked (struck) with a rubber mallet and a second differential check was conducted. The compression reading for the #1 cylinder was 55/80 psi.

The right magneto remained attached and secured to its accessory pad. It sustained thermal damage, and was not disassembled. The engine-driven fuel pump was manually rotated with no restrictions. The carburetor had split into two pieces, with the metal float located near the right wing. There were no other mechanical anomalies noted with the engine.

ADDITIONAL INFORMATION

The National Transportation Safety Board investigator released the wreckage to the owner's representative on June 10, 2002.

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