MIA04FA128
MIA04FA128

HISTORY OF FLIGHT

On September 23, 2004, about 1006 central daylight time, a Cessna R182, N5157T, registered to PropCo, Inc., operated by MC Aviation, Inc., experienced an in-flight loss of control and crashed in a residential area located .30 nautical mile west-northwest from the departure end of runway 36 at Peter Prince Field Airport, Milton, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 local, personal flight from Peter Prince Field Airport. The airplane was destroyed by impact and a postcrash fire and the commercial-rated pilot and three passengers were fatally injured. The flight originated about 5 minutes earlier from Peter Prince Field Airport.

An acquaintance of the pilot reported the purpose of the flight was to survey damage to the church in which he and the passengers were members of, to survey damage to the homes of church members, and to survey the area in general as a result of Hurricane Ivan to see where assistance from the church was needed.

One witness reported seeing four adults board the airplane and three separate witnesses reported hearing the pilot have a difficult time starting the engine, then after it was started, all three reported hearing the engine running "rough." One of the witnesses is a FAA certificated airframe and powerplant (A & P) mechanic. The airplane was observed taxiing to the approach end of runway 36 and one of the three witnesses reported, "During the run up his mag check sounded like it had excessive drop. He increased rpm's and held it there." The witness who is an A & P mechanic reported, "They taxied to the run-up area and in my opinion had an unsatisfactory pre-flight run-up/test. Evidently they chose to take off with the poorly running engine." The third witness reported, "...Got to the runway to do a run up. [Magneto] check sounded rough...."

The airplane was taxied onto the 3,700 foot long runway and began the takeoff roll but one of the witnesses reported the engine was, "making sounds as if it was not developing power." The A & P mechanic and one other witness reported the airplane became airborne when it was approximately 3/4 down the runway. The A & P mechanic stated, "The aircraft used 3/4 of the runway trying to get airborne and never developed full power. I would estimate they achieved 100 feet of altitude...." One witness reported seeing the landing gear retract after the airplane became airborne, while another witness reported hearing a rough running engine when the airplane flew overhead her position.

A pilot-rated witness who was airborne at the time of the accident reported seeing the flight depart from runway 36. The pilot-rated witness further reported that, "after he had turned downwind the airplane appeared to stall, then pitch straight down." He discontinued his approach, circled the crash site, observed fire, and advised FAA air traffic control of the accident.

PERSONNEL INFORMATION

The pilot was the holder of a commercial pilot certificate with airplane single engine land, airplane multi-engine land, and instrument airplane ratings. His commercial pilot certificate was first issued on January 27, 1999. The certificate issued on that date had airplane single engine land and instrument airplane ratings. He was issued a first class medical certificate on March 23, 2004, with the restriction, "must wear corrective lenses."

A review of copies of his pilot logbooks that contained entries from his first flight on December 14, 1996, to the last entry dated March 7, 2002, revealed no logged flights in the accident make and model airplane. He logged a total time of 2,046.6 hours, 519.1 hours in airplane single engine land airplanes, and 1,482.4 in airplane multi-engine land airplanes. He also logged 647.6 hours as pilot-in-command, and 1,357.8 hours as second-in-command. Further review of his pilot logbook revealed the remarks section of an entry dated January 5, 2001, indicating "Hired at Continental [Express] Part 121." From that date (January 5, 2001), to the last entry in the logbook (March 7, 2002), he logged only 1 flight in a general aviation airplane. That flight occurred on August 3, 2001, the duration was 1.0 hour, and the remarks section for that entry indicates, "Aircraft [check] out PA28-161."

According to FAA records, the right front seat occupant was not a certificated pilot.

AIRCRAFT INFORMATION

The airplane was manufactured in 1981 by Cessna Aircraft Company as model R182, and was designated serial number R18201826. It was certificated in the normal category and was equipped with a Textron Lycoming O-540-J3C5D engine rated at 235 horsepower when operated at 2,400 rpm. The airplane was also equipped with a McCauley B3D32C407-B constant speed propeller.

Review of the airplane maintenance records revealed the airplane was last inspected in accordance with a 100-Hour inspection on August 16, 2004. At that time the airplane had accumulated 3,150.0 hours total time. The airplane had accumulated 40.3 hours since the inspection at the time of the accident.

Further review of the maintenance records revealed the engine was overhauled by Don George, Inc., in November 1992, and installed in the airplane following overhaul on December 11, 1992. The engine was removed from the airplane due to a propeller strike, disassembled and inspected in October 1993. The engine was reinstalled in the airplane on October 27, 1993, and remained installed until removed postaccident. On August 16, 2004, an entry in the engine logbook indicates in part, "all cylinders were removed and overhauled by John Jewel Aircraft CRS JUJR300L, due to exhaust flange erosion." At the time of the accident the engine had accumulated 920 hours since major overhaul, and approximately 40 hours since the overhauled cylinders were installed.

METEOROLOGICAL INFORMATION

A surface observation weather report taken at the Pensacola Regional Airport (KPNS), Pensacola, Florida, on the day of the accident at 0953, or approximately 13 minutes before the accident indicates the wind was from 080 degrees at 9 knots, clear skies existed, the temperature and dew point were 24 and 18 degrees Celsius, respectively, and the altimeter setting was 30.14 inHg. The accident site was located approximately 14 nautical miles and 045 degrees from KPNS.

AIRPORT INFORMATION

The Peter Prince Airport is equipped with one asphalt runway designated 36/18, which is 3,700 feet in length by 75 feet wide. The airport elevation is 82 feet, and the airport is equipped with a common traffic advisory frequency (CTAF)/UNICOM of 122.975 mHz, that is not recorded.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed in the sideyard of a house located at 7732 Erudition Avenue, Milton, Florida. The accident site was located at 30 degrees 38.721 minutes North latitude and 086 degrees 59.911 minutes West longitude, or approximately .30 nautical mile and 303 degrees magnetic from the departure end of runway 36. The accident site was located .61 statute mile and 333 degrees from the center of the airport.

Examination of the accident site revealed the wreckage was upright on a magnetic heading of 035 degrees magnetic near a lake. The engine assembly was beneath ground level with only the outer 10 inches of one propeller blade visible. The "backbone" of the engine was at an angle of approximately 40 degrees with respect to the nearly level ground. The smell of 100 low lead fuel was noted in the ground while digging the earth away from the engine. Fire damage to grass was noted surrounding the left wing, fuselage, empennage, aft portion of the right wing, and at the right wingtip resting location.

Examination of the airplane revealed the fuselage was consumed by the postcrash fire from the instrument panel aft to approximately 6 inches forward of the leading edge of the horizontal stabilizer, and fire damage was noted to both wings. Fire damage was also noted to both horizontal stabilizers, the vertical stabilizer, the left elevator, and to a portion of the rudder. Slight paint discoloration was noted on the inboard leading edge and inboard upper skin of the right elevator. All components necessary to sustain flight remained attached to the airplane or were in close proximity to the main wreckage. Bulging of the upper wing skins of both wings consistent with hydraulic deformation was noted in the areas where the fuel tank was installed. Flight control continuity was confirmed for pitch and yaw. Examination of the aileron flight control system revealed both primary flight control cables were fractured near each wing root area; the cables were fractured in tension overload. The aileron balance cable was continuous from the left aileron bellcrank to the right aileron bellcrank. The propeller remained secured to the engine which remained secured to the airframe. One propeller blade was separated from the propeller hub but was found in the engine impact crater. The flaps were retraced based on the examination of the flap actuator, and the landing gear was retracted.

Examination of the fuel system revealed the outlet screens of the left and right fuel tanks were free of obstructions. The fuel line from the left fuel tank to the fuel selector was compromised in several locations due to fire, and the fuel line from the right fuel tank was noted going down the aft door post but was not connected in the wing root area due to an excessive gap at the right wing root. The crossover vent line was free of obstructions. The fuel selector was free of obstructions. No obstructions were noted in any fuel line from the fuel selector valve to carburetor inlet fitting. The fuel strainer screen was clean. Vented fuel caps were installed on both fuel tanks. The auxiliary fuel pump was removed for further examination.

Examination of the cockpit revealed the mixture, throttle, and carburetor heat controls were full-in. The propeller control was near full-in, and was bent down. The fuel selector handle was bent; the fuel selector was found positioned between the "both" and "right" positions. The primer was in and locked, and the cowl flap selector was in the full open position. The magneto switch was on the "right" magneto position, and the landing gear selector was in the "up" position. The needle of the tachometer was separated from the shaft but when first viewed, the pointer was indicating approximately 2,450 rpm; the recording time was 0378.2 The fuel quantity gauge, amp meter, oil pressure and temperature, and the cylinder head temperature gauges were unreadable. A "Pilot's Operating Handbook" for model R182 was found in the co-pilot's seat back pocket, and a laminated checklist was found in the wreckage.

The engine was examined by a representative of the engine manufacturer with FAA oversight. The examination revealed crankshaft, camshaft, and valve train continuity. Suction and compression was noted at each cylinder during rotation of the engine by hand. The single-drive dual magneto (magneto) and carburetor were separated from the engine but recovered from the impact crater. The magneto was rotated by hand and spark was noted at all ignition leads which were cut very close of the cap. The ignition harness was impact damaged which precluded bench testing. Examination of the top spark plugs revealed all exhibited "low service life condition" with the No. 4 exhibiting dark discoloration consistent with a rich condition, and was wet with oil. Examination of the bottom plugs revealed the plug from the No. 1 cylinder could not be removed; the remainder of the plugs also exhibited a "low service life condition" with the Nos. 2 and 4 wet with oil. The No. 5 plug exhibited coloration consistent with a lean fuel/air ratio. Impact and heat damage was noted to the engine driven fuel pump. Disassembly of it revealed no evidence of preimpact failure or malfunction; no fuel was found inside. Examination of both mufflers revealed both flame cones were intact with no internal restriction noted. The oil suction screen was clean. The carburetor, magneto, propeller, and propeller governor were removed for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examinations of the pilot and passengers were performed by the District 1 Medical Examiner's Office. The cause of death for all was listed as multiple blunt force injuries.

Toxicological analysis of specimens of the pilot was performed by the FAA Toxicology and Accident Research Laboratory (CAMI), and the University of Florida Diagnostic Referral Laboratories (University of Florida), located in Gainesville, Florida. The results of analysis of specimens by CAMI was negative for carbon monoxide, cyanide, and volatiles. Acetaminophen (11.88 ug/ml) was detected in urine, and unquantified amounts of ephedrine, and pseudoephedrine were detected in blood and urine. Additionally, an unquantified amount of phenylpropanolamine was detected in urine. The results of analysis by the University of Florida was negative in blood and urine for volatiles, negative in blood for the "Comprehensive Drug Screen", and cyanide. The result was positive in urine for ephedrine/pseudoephedrine, and phenylpropanolamine, and the carboxyhemoglobin level was 4 percent saturation.

Toxicological analysis of specimens of the passengers was performed by University of Florida. The results of analysis of specimens of the right front seat passenger was negative in blood and urine for volatiles, and the "Comprehensive Drug Screen." The results was negative for cyanide in blood, and the carboxyhemoglobin level was 5 percent saturation. The results of analysis of specimens of the left rear seat passenger was negative in bile and blood for volatiles, and the "Comprehensive Drug Screen." The results was negative for cyanide in blood, and the carboxyhemoglobin level was 3 percent saturation. The results of analysis of specimens of the right rear seat passenger was negative in blood and bile for volatiles, and negative in blood for cyanide. Citalopram was detected in blood and bile. The carboxyhemoglobin level was 3 percent saturation.

TESTS AND RESEARCH

Examination of the auxiliary fuel pump was performed by the NTSB Materials Laboratory, located in Washington, D.C. The examination revealed blue colored material approximately 1/4 inch in diameter was noted in the inlet port of the fuel pump housing, and also covering a hole that connects the internal bushing area with the outlet port cavity. The blue colored material was consistent with the bushing material which is reportedly made of Turcite A. Rotational damage was noted to the seal face and ring face which are adjacent to the rotor. The pump vanes were all in good condition with no obvious damage. Following removal of the vanes, blue colored material (bushing material consistent with Turcite A) was noted to have flowed beyond the ring into the vane slots. There was no failure of fuel pump components.

Examination of the propeller and propeller governor was performed by a representative of the propeller manufacturer with FAA oversight. The examination revealed the propeller was rotating at impact but the exact amount of power at impact could not be determined. The butt end of the No. 2 propeller blade exhibited an impact mark related to spring coil marks. The location of the mark on the butt end of the blade correlated to a blade angle of approximately 18.2 degrees. The low pitch blade angle is 16.0 degrees. No evidence of preimpact failure or malfunction was noted to any components of the propeller. The propeller governor was placed on a test bench and the pressure relief setting was at 329 psi (specification is 290 + or - 20 psi). The representative of the propeller manufacturer reported the issue of the relief valve pressure being out of specification, "...would not cause any aircraft systems related problem since single-engine constant speed propellers never operate at pressure relief setting." The pump capacity, leakage rate, and control head setting were within limits. The maximum rpm was at 2,459 (specification is 2,275 + - 10 rpm). The representative of the propeller manufacturer reported the issue of the maximum rpm being too high would allow the propeller and engine to overspeed in-flight unless this was manually controlled from the cockpit. The control arm travel was at 75 degrees (specification is 60 degrees + or - 7 degrees). The representative stated the maximum rpm and control arm travel were corrected by moving the control lever position one spline clockwise; this resulted in the maximum rpm and control arm travel being within limits.

Examination of the carburetor was performed at the manufacturer's facility with FAA oversight. The examination revealed the exterior of the unit was blackened and impact damaged which precluded bench testing. The engine mounting flange was broken off the throttle body. One inlet fitting was torn out of the cover and is missing along with the strainer screen. The nylock nuts on the accelerator pump were melted and the locking material had flowed out. The idle mixture needle was set all the way in (bottomed out). The idle passages/nozzle/bleeds were "Clear, OK", and the economizer setting was found to be flush plus 1/4 turn (specification is flush plus 2 1/8 turns). The venturi, float needle valve/seat were reported to be "OK" while moderate wear was noted on the needle tip. The accelerator pump piston seal was badly worn exposing most of the sealing spring, and rust was noted in the drain cavity below the float bowl. Additionally, the portion of the drain plug inside the carburetor was rusty, and a small amount of debris was noted in the main bowl chamber. Examination of the float revealed the solder was melted on the bracket and the float halves were split; foam was extruded from the split.

According to a representative of the carburetor manufacturer, the discharge of the accelerator pump is upstream of the venturi; therefore, a worn accelerator pump seal would not result in an excessive fuel flow rate. Additionally, the as found setting of the economizer would result in a leaner fuel/air ratio. When asked about the markings "OAC" on the economizer lead seal, the representative stated those markings meant nothing to him. The badly worn accelerator pump piston seal would result in reduced accelerator pump discharge. The representative also provided Service Bulletin MSA-3, dated November 18, 1991, which indicates in part that the time between overhaul for carburetors is the same as the engine TBO specified by the engine manufacturer for the engine on which the carburetor is installed, or 10 years since placed in service or last overhauled, whichever occurs first.

Review of the maintenance records revealed the carburetor was last overhauled by a FAA certified repair station on October 23, 1992, which coincided with overhaul of the engine. The overhauled carburetor was installed on the overhauled engine which was installed in the accident airplane on December 11, 1992. The engine was disassembled in October 1993, as a result of a propeller strike. The entry in the engine logbook indicates the engine is "ready for installation of accessories and test run per [Service Instruction] 1427A. There was no record that the carburetor was overhauled after the 1992 overhaul. The carburetor had accumulated 920 hours time-in-service, or approximately 11 years 9 months since installation following overhaul.

Examination of the single-drive dual magneto was performed at the manufacturer's facility with FAA oversight. The examination revealed the exterior surfaces of the magneto were sooted. The left magneto p-lead center conductor was shorted to the cap nut by heat-damaged solder. The left capacitor was found to be shorted to ground which was consistent with the heat damage at the p-lead terminal, while the right capacitor was functional. The distributor gear timing was correct, the magneto shaft was noted to turn freely, and the impulse coupling was noted to function normally at low speeds. The e-gap measured 7 degrees for the left magneto and 11 degrees for the right magneto (new specification is 6 to 8 degrees). The breakers and cam followers were in good condition. Slave capacitors and a test harness were installed, the magneto was placed on the test bench, and spark was noted at all ignition leads from a magneto speed of 250 to 2,000 rpm.

The airplane was fueled last on September 22, 2004 (the day before the accident), by Million Air Mobile, located at the Mobile Regional Airport, Mobile, Alabama. The airplane was fueled at approximately 1430 hours from Av Gas truck No. 2; the fueler reported both fuel tanks were topped. A total of 8.3 gallons of 100 low-lead (100LL) fuel were added. Following the accident a sample of fuel was taken from the truck that fueled the airplane and was submitted by Million Air for testing by ConocoPhillips. According to the results, the sample met ASTM D 910 specification for 100LL aviation fuel, but exceeded the recommended particulate content. The testing facility reported "Poor sampling and handling may cause elevated particulate content."

A review of the fuel log sheet from the truck that fueled the airplane last revealed one airplane was fueled after the accident airplane was fueled. A discussion with the owner of that airplane revealed that his fuel tanks were topped off during that fueling. His airplane remained hangared that night (9/22/2004), and the next morning he checked his airplane's fuel tanks for water; none was found. The flight departed to Vero Beach, Florida, where approximately 2 hours into the flight, the Nos. 5 and 6 cylinders were running hotter than the rest of the cylinders. The flight continued and he landed uneventfully. The owner further reported that the type of fuel injectors installed require cleaning approximately every 100 hours, and at the time they were due to be cleaned. As a result of his flight in which 2 of the cylinders were running hotter than the rest of the cylinders, the fuel injector nozzles and spark plugs were cleaned. The owner also stated he did not feel the issue related to the 2 cylinders running hotter was due to the fuel received at Million Air in Mobile, Alabama.

A certified flight instructor (CFI) who flew with the accident pilot in the accident airplane the day before the accident for the purpose, "...to check him out in N5157T", reported that the accident pilot called and requested to be checked out in a Cessna with subsequent rental and overnight stay. The CFI asked the pilot how much complex time he had and the reported response was "...hundreds of hours." The checkout flight was scheduled for 1000 hours on September 22nd; the accident pilot arrived that day at approximately 1030 hours. The CFI reported giving the accident pilot a "...study sheet with V speeds for N5157T." He reported they then walked to the airplane, and performed a preflight inspection; nothing unusual was found. The engine was started and the flight was taxied to the runway where an engine run-up was performed. During the right magneto check, the rpm decrease was greater than 200 rpm and the engine ran "roughly." He leaned the fuel/air ratio in an attempt to "burn off any deposits on the spark plugs", and performed the magneto check again several times with the same results. The airplane was taxied back to the ramp for maintenance and a mechanic checked the spark plugs and noted one of the bottom plugs was "...very dirty." The spark plugs were cleaned, reinstalled, and an engine run-up was performed by maintenance. The airplane was then approved for return to service. The CFI and the accident pilot again taxied to the runway and noticed no problems during the "Before Take Off Check." The flight departed, remained in the traffic pattern where the accident pilot performed two landings then the CFI reduced power to idle to simulate a loss of engine power. The CFI further reported the accident pilot turned to the runway and had his best landing of the day. The airplane was then taxied to the ramp. The CFI reported telling the pilot that if he had any maintenance problems in Milton, to have the airplane worked on and the maintenance cost would be deducted from the bill.

According to records provided by Million Air, on August 27, 2004, the engine was noted to have "bad mag drops." The spark plugs were removed, inspected, cleaned, tested, rotated and reinstalled. Following installation an engine run-up was performed, the result was listed as "good." The next discrepancy dated September 3, 2004, relates to a fuel leak on top of the right wing. The next discrepancy dated September 22nd, relates to the rough running engine found during the accident pilot's check out flight. The corrective action for that discrepancy indicates, "Cleaned, inspected, tested and rotated spark plugs. Run up and operational check was good. All work [in accordance with] standard practices."

According to the pilot's father who was a passenger in the accident airplane with his son the day before the accident date on a flight from Mobile Regional Airport, Mobile, Alabama, to Peter Prince Field Airport, Milton, Florida, the flight was uneventful and he video taped a portion of the flight. He did report that he has mechanical ability and is in the trucking business and was not concerned about the engine during his flight. He reported his son did not say anything negative about the airplane except the right main landing gear tire had a "...pretty noticeable flat spot on it." The father reported that while taxiing after landing the right main landing gear tire did make, "...a fair thumping noise I did ask Traves about it and he said that there were no threads showing and it was not a clear and present danger but would need service fairly soon." The airplane was stopped on the ramp and tied down.

There was no fuel purchased and no maintenance was performed or requested to be performed on the airplane while at the Peter Prince Airport.

Image recording equipment located in the wreckage consisting of a HI-8 camcorder, a digital camera, a 35mm film camera, 4 HI-8 videocassettes, and a VHS cassette were retained for further examination by the NTSB Vehicle Recorder Division. The results of the examination of the HI-8 camcorder revealed no tape on the take-up reel. The examination of the digital camera and 35mm film camera revealed no CD was installed, and no pictures on the loaded roll of film, respectively. The examination of the 4 videocassettes revealed all did not have any images or sound. The examination of the VHS cassette revealed it contained ground and in-flight footage taken the day before the accident date on the flight piloted by the accident pilot with the pilot's father on-board.

The airplane was estimated to be under gross weight at the time of the accident. An exact weight at the time of takeoff could not be made because the amount of fuel consumed during the flight from Mobile, Alabama, to Milton, Florida, was unknown. As previously reported in the "History of Flight" section of this report, several witnesses including an airframe and powerplant mechanic noted the airplane became airborne when it was 3/4 down the 3,700 foot runway, or approximately 2,828 feet down the runway. A review of the "Short Field" takeoff distance charts found in section 5 of the airplane's "Information Manual" revealed that at maximum gross weight of 3,100 pounds (worse case scenario), sea-level pressure altitude, and outside air temperature of 24 degrees Celsius which was taken 13 minutes before the accident at an airport located 14 nautical miles away, the ground roll distance and total distance to clear a 50-foot obstacle were interpolated to be approximately 880 feet and 1,685 feet, respectively. No wind was factored into the distance calculations. Section 5 of the "Information Manual" titled "Performance" also has information that indicates the charts are for short field takeoff technique and, "Conservative distances can be established by reading the chart at the next higher value of weight, altitude and temperature." Taking that information into account and going to the next higher temperature (30 degrees Celsius), keeping the weight and sea level pressure altitude values the same, the ground roll and total distance to clear a 50-foot obstacle were 910 and 1,745 feet, respectively.

ADDITIONAL INFORMATION

The airplane minus the retained components was released to Dr. Donald J. Muller, President of PropCo, Inc., on February 1, 2006. All NTSB retained components were also released to Dr. Donald J. Muller, President of PropCo, Inc., on March 6, 2006.

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