NYC08FA020
NYC08FA020

HISTORY OF FLIGHT

On October 27, 2007, about 2012 eastern daylight time, a Piper PA-28-181, N8155C, operated by Rohan Aviation, Incorporated, doing business as Kemper Aviation, was substantially damaged when it impacted trees and terrain in Boynton Beach, Florida following a loss of engine power. The certificated flight instructor (CFI) and the certificated private pilot receiving instrument instruction were fatally injured, and the passenger was seriously injured. Night visual meteorological conditions prevailed, and no flight plan had been filed for the instructional flight, which was operating under the provisions of 14 Code of Federal Regulations Part 91.

According to Federal Aviation Administration (FAA) air traffic control (ATC) information, radar contact with the accident airplane was initially established about 1813, shortly after the airplane departed its base at Palm Beach County Park Airport (LNA), Lantana, Florida. The pilots then conducted four practice instrument approaches at four different airports in Florida. These included Kendall-Tamiami Executive Airport (TMB), Miami, Opa-Locka Executive Airport (OPF), Miami, Ft. Lauderdale Executive Airport (FXE), Ft. Lauderdale, and Pompano Beach Airpark (PMP), Pompano Beach.

Communications between the PMP air traffic control tower (ATCT) and the airplane indicated that the pilots planned to conduct a low approach to runway 15 at PMP, followed by the missed approach and then the very high frequency omnidirectional radio range (VOR) approach to return to LNA. About 1956, the pilots initiated the missed approach. The ground track derived from ATC radar data initially depicted the airplane when it was approximately 4 1/2 miles northwest of PMP, and proceeding to the northwest. The airplane maintained this track at an altitude of 2,700 feet for approximately 4 miles, and then flew in a more northerly direction for another 4 miles. About 1957, PMP ATCT instructed the pilots to contact Palm Beach Approach once they were "established northeast bound." About 2001, the pilots contacted Palm Beach Approach, and were initially cleared "direct Lantana." The pilots responded that they wanted the "full VOR" approach, and about 2002 the Palm Beach Approach controller instructed the pilots to "proceed direct [to the] Palm Beach" VOR, and to "maintain VFR at two thousand five hundred for now."

About 2003, the airplane turned to the northeast, towards the VOR. About the same time, the pilots radioed that they needed to descend to 2,000 feet to remain in visual meteorological conditions, and were approved to do so by the controller. About 2006, the ground radar data indicated that the airplane departed 2,000 feet and began a descent of approximately 300 feet per minute (fpm). There were no communications from the airplane regarding this descent. About 2009, when the airplane was at an altitude of approximately 1,000 feet, the pilots reported to the controller that "we have engine problems, we need to land as soon as possible." The controller first responded with a query as to whether the pilots preferred to "come to Palm Beach or go to Lantana?" After 10 seconds and two unsuccessful attempts to communicate their preference, the pilots radioed that they were "unable to maintain altitude" and that they did "not know how long the engine is gonna hold for us." The controller advised the pilots that "Lantana airport is twelve o'clock and four miles you just want to land there?" There was no response, and eight seconds later the controller repeated the transmission. The pilots responded, but the transmissions were only partially intelligible. The final transmission from the airplane was received 1 minute and 35 seconds after the initial declaration of the engine problem, and appeared to indicate that the pilots intended to land on a road. Radar data indicated that during this period, the airplane flew to the northeast, then turned north, and then turned to the east, all while it was in a continuous descent. The final four radar data points depicted a flight path that nearly reversed course to the west in a sharp right turn, and descended from an altitude of 500 feet. The last radar data point indicated an airplane altitude of 100 feet, at a time of 2011.

Several persons on the ground either heard or saw an airplane in the area with engine problems. Most of these witnesses reported that unusual engine noises drew their attention to the airplane; almost uniformly, the witnesses described the engine as "sputtering." Two individuals who were located in a house approximately 300 feet from the impact point heard the impact, but when they stepped outside and visually scanned the area, they did not see the wreckage.

According to FAA communications transcripts, about 2010 the Palm Beach controller solicited the assistance of another airplane in the area to locate the accident airplane. About 2014, another airplane contacted the controller and offered search assistance, and about 2017 the pilot of that airplane reported receiving an emergency locator transmitter (ELT) signal. In the ensuing hour, several other airplanes assisted in the search, and were able to determine the general location of the ELT signal. About 2129, a Palm Beach County Sheriff's Office helicopter reported to the controller that it had located the wreckage.

Several months after the accident, the surviving passenger was interviewed about the accident flight. The passenger had approximately 23 total hours of flight experience, all in Cessna 152 airplanes, and he had been invited along on the flight as an observer by the pilot. He was seated in the rear seat, on the right side of the airplane, and could hear and communicate with the two pilots in the front via his headset. He could also hear the ATC communications. According to the passenger, the airplane was headed back to LNA when "the engine quit." He said that the pilots immediately notified ATC that they had an engine problem, and that both pilots were focused exclusively on looking for a place to land, but that it was difficult due to the darkness. He could not recall either pilot making any attempt to diagnose the reason for the engine failure, or taking any actions to restart the engine. The passenger recalled that at some point, the pilot pointed out a road on the left side of the airplane as a suitable landing area, but that the CFI countered the suggestion with a decision to have the pilot land on a golf course. The passenger said that the airplane hit trees and "cartwheeled" during the attempted landing on the golf course. When he was asked about it in the interview, the passenger could not recall any in-flight discussion by the pilots regarding fuel management, and was he not aware of the pilot switching fuel tanks during the flight.

PERSONNEL INFORMATION

The pilot in the left seat held a private pilot certificate with airplane single engine land (ASEL) rating. His most recent first-class medical was dated November 15, 2006. He began his flight training in December 2006. According to his logbook, the pilot had approximately 360 hours of flight experience, including 42 hours of night experience, and received 180 hours of flight instruction. The pilot had accrued approximately 17 hours of flight time in the 30 days prior to the accident. The accident flight was the pilot's first flight since October 22, 2007. The pilot's toxicology report noted that no screened compounds were detected.

The CFI in the right seat began instructing at the flight school in June 2007. His most recent second-class medical was dated April 24, 2007. He held an Airline Transport Pilot certificate with ASEL and airplane multiengine land (AMEL) ratings, a Flight Instructor certificate with ASEL, AMEL and instrument airplane ratings, and a Ground Instructor certificate with advanced and instrument ratings. He reported approximately 12,500 hours of total flight experience on his last medical application. A summary sheet provided to the flight school by the CFI indicated that, as of April 2007, he had provided approximately 1,300 hours of flight instruction in single engine airplanes.

The CFI's toxicology report noted the presence of labetalol, amlodipine, and irbesartan. The CFI’s most recent application for his FAA first-class medical certificate, dated October 18, 2007, indicated the use of these three medications, which are used to control blood pressure, and was approved by the FAA.

AIRPLANE INFORMATION

According to FAA records, the airplane was manufactured in 1980. It was equipped with a Lycoming O-360-A4M engine, and two fuel tanks. Each tank had a maximum capacity of 25 gallons, including 1 gallon of unusable fuel. The fuel selector valve control was located on the left cockpit sidewall panel, forward of the pilot’s seat. Fuel selector positions were "Off," "Left Main," and "Right Main."

Each fuel tank was equipped with an individual drain at the bottom, inboard aft corner. A fuel strainer, located on the lower left front of the firewall, had a drain which was accessible from outside the nose section. According to the Pilot's Operating Handbook (POH), the fuel drains "should be opened daily prior to first flight to check for water or sediment" and the strainer "should also be drained before the first flight of the day." Fuel quantity and pressure were indicated on gauges located on the left side of the instrument panel. An auxiliary electric fuel pump was provided "in case of failure of the engine driven pump. The electric pump should be on for all takeoffs and landings, and when switching tanks."

According to the POH, the flaps were manually operated, and spring-loaded to return to the up/retracted position.

According to FAA and maintenance records, the airplane had accumulated approximately 5,200 hours total time in service, and the engine had accumulated approximately 3,300 hours since the previous major overhaul. The airplane had accumulated approximately 1,000 hours in service in the year preceding the accident. The airplane was on a 100 hour inspection program. The most recent 100 hour inspection was signed off on September 7, 2007, and the most recent annual inspection was signed off on October 3, 2007. At the time of the annual inspection, an overhauled fuel sending unit and a fuel drain were replaced on the right fuel tank.

METEOROLOGICAL INFORMATION

The 1953 weather observation at Palm Beach International Airport (PBI), located approximately 10 miles north of the accident site, reported winds from 070 degrees at 11 knots, few clouds at 3,000 feet, scattered clouds at 8,000 feet, temperature 27 degrees Celsius (C), dew point 21 degrees C, and an altimeter setting of 30.02 inches of mercury. The 2053 PBI observation reported winds from 070 degrees at 10 knots, few clouds at 3,000 feet, the same temperatures as the previous report, and an altimeter setting of 30.03 inches of mercury. Local sunset occurred at 1842, and the moon was two days past the new phase.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located on a residential golf course, approximately 5 1/2 miles south of LNA. All major components of the airplane were found at the accident site. Tree strikes indicated that the final flight track was oriented on a magnetic heading of 270 degrees. The airplane first impacted a tree approximately 30 feet above the ground. Approximately 160 feet beyond the first tree strike, the airplane impacted a stand of taller, more substantial trees, and the outboard two feet of the left wing was found at the base of these trees. The airplane then struck another tree 110 feet beyond that, at a height of approximately 15 feet above the ground. It first impacted the ground 70 feet beyond the last tree, and came to rest approximately 40 feet beyond the initial ground scar.

The final fuselage attitude was approximately 135 degrees right wing down, and the longitudinal axis was oriented along a magnetic heading of 230 degrees. The forward top cabin was crushed down and aft. The cabin door was separated and crushed, and the upper half of this door was found in the initial ground scar. The windshield was fractured into numerous pieces, and fragments were found in and near the initial ground scar.

The instrument panel exhibited crush damage and buckling. The mixture and throttle levers were found in the forward position. The carburetor heat lever was found in a mid position. The key was in the ignition switch, and the switch was in the "Both" position. The master and electric fuel pump switches were in their respective "On" positions. The flap handle was found in a position that corresponded to flaps retracted. The fuel selector valve was found selected to the right fuel tank. The fuel selector valve was field tested by applying low pressure air through the broken fuel lines at the left and right wing root areas. The fuel selector valve functioned correctly in all three of its setting positions.

The left wing was separated from the airplane at the wing root. Palm Beach County Sheriff's Office video showed that the left wing initially remained attached to the fuselage by control cables, but was subsequently separated from the fuselage by rescue personnel. The flap and most of the aileron remained attached to the wing. The left wing root flap mechanism eyebolt was measured to be approximately 3 1/4 inches from the bottom of the fuselage, which corresponded to the flaps being fully retracted. The forward inboard end of the fuel tank was breached. The fuel cap was found installed and secure. Blue liquid presumed to be 100LL avgas was found in the tank. Some of this was drained from the tank, and it contained unidentified contamination, and approximately 2 ounces of water. Approximately six gallons of fuel was recovered from the tank. The fuel tank finger screen was removed, and was clean and free from blockage.

The right wing was separated from the airplane at the wing root, and was found inverted, several feet forward of the main wreckage. The fiberglass wing tip was found near the initial ground scar. The aileron and flap remained attached to the wing. The right wing root flap mechanism eyebolt was measured to be approximately 3 1/4 inches from the bottom of the fuselage, which corresponded to the flaps being fully retracted. The fuel tank was not breached, and the cap was installed and secure. Approximately 1/2 cup of blue liquid, presumed to be 100LL avgas, was found in the tank. This fuel was clear and bright, with no visible contamination or water. The fuel tank finger screen was removed, and was clean and free from blockage.

The stabilator, stabilator trim tab, vertical fin, and rudder remained attached to the airplane. The fin, rudder, and left side of the stabilator had no significant damage. Approximately two feet of the right outboard end of the stabilator was bent down approximately 45 degrees. The stabilator trim tab was found in a neutral position. Flight control continuity was established from the cockpit to all flight control surfaces, excluding impact- and recovery-related separations.

The electric fuel pump and fuel strainer were removed from the firewall as an assembly, and the components were examined separately. The electric fuel pump was field tested, and was operational. Fuel was found in the electric fuel pump. Fine-grained, dark, irregularly shaped particles, were found in the electric fuel pump and fuel pump screen. Laboratory examination using X-ray energy dispersive spectroscopy in the scanning electron microscope indicated that the particles were primarily carbon and sulfur, but their origin was not determined.

The fuel strainer bowl was found safetied, but loosely affixed to the fuel strainer housing. The bowl could be rotated, and had vertical freeplay of approximately 1/64 to 1/32 inches. Since the bowl mounted to the underside of the housing, the freeplay resulted in a gap of 1/64 to 1/32 inch between the upper circumference of the bowl and the housing. The gap was not in accordance with the fuel strainer design, which specified a fluid-tight seal between the bowl and the housing. A metal washer was found between the fuel strainer bowl tightening screw and the bowl. Neither the maintenance manual nor the parts catalog specified a washer in this location for this assembly. The outlet line fitting was finger tight in the fuel strainer housing. The fuel strainer filter was retained and submitted to the Safety Board Materials Laboratory for further examination, with results indicating a 5 percent occlusion by contaminants characterized as “curly fibrous/filaments,” and “light gray in color.”

A longitudinal blue/black-tinted stain, approximately 2 feet long, was found on the exterior side of the fuselage bottom skin. The stain began at the firewall just below and aft of the fuel strainer, and was approximately 6 inches wide at its origin. It tapered aft to a width of approximately 1 inch.

The engine remained partially attached to the airplane, and was found right-side up. No preimpact mechanical anomalies were noted during the on-site examination. All spark plug electrodes exhibited moderate wear, medium gray color, and had normal gap settings. Borescope examination revealed that the combustion chambers exhibited the same gray color as the spark plugs, and no anomalies were observed. The crankshaft was rotated by hand, and continuity of the crankshaft, camshaft, valve train, and accessory drives was established. Each cylinder produced thumb compression when the crankshaft was rotated. The engine oil suction screen and oil filter element were free from contaminants. Both magnetos produced spark at all towers during hand rotation. The vacuum pump drive coupling was intact.

The engine-driven fuel pump was intact and was removed from the engine. Pumping action was noted when the fuel pump was actuated by hand. The diaphragm and internal valves were intact. Water droplets and fuel were found in the pump.

The carburetor was intact and remained attached to the engine. No fuel stains were observed on the exterior. The throttle valve and mixture controls were found in their mid-range positions. The throttle control cable end and the mixture control arm stop were broken. The carburetor air box and heat valve were impact-damaged, and the heat valve was in the mid-range position. Approximately 1 ounce of fuel was found in, and drained from, the carburetor bowl. The fuel was cloudy in appearance. It was allowed to stand for approximately 2 hours to permit settling of any contaminants, but no settling of any materials was observed. The accelerator pump operated normally. The carburetor fuel inlet screen was clean. The carburetor bowl screws were found secured and properly torqued. The venturi was intact, and the condition and height adjustment of the plastic carburetor float were within limits. The needle valve operated normally when low-pressure air was applied to the unit, and the needle valve and seat conditions were normal.

The two bladed fixed pitch metal propeller remained attached to the crankshaft flange. One blade was bent approximately 15 degrees aft at its root. The cambered side of this blade displayed polishing that removed the paint approximately 1 inch chordwise from the leading edge, and along most of the span. The other blade was unremarkable.

ADDITIONAL INFORMATION

Departure Fuel on Board

According to records provided by the flight school and the fuel provider, the airplane was fueled with 13.9 gallons just prior to the accident flight. According to the individual who pumped the fuel into the airplane, he had "topped off" the airplane.

Trip Duration

Comparison of the values on the airplane dispatch records with the values obtained from the instruments in the airplane at the accident site, indicated that the airplane had accumulated 2.1 hours on both the engine tachometer and the electric engine hour meter during the accident flight.

POH Guidance Regarding Fuel Tank Selection

The "Cruising" paragraph in the "Amplified Procedures" section of the "Normal Procedures" chapter of the POH contained the following regarding fuel tank selection: "In order to keep the airplane in best lateral trim during cruising flight, the fuel should be used alternately from each tank. It is recommended that one tank be used for one hour after takeoff, then the other tank be used for two hours: then return to the first tank, which will have approximately one and one half hours of fuel remaining if the tanks were full at takeoff. The second tank will contain approximately one half hour of fuel."

The paragraph also contained the following guidance: "Do not run tanks completely dry in flight. If the signs of fuel starvation should occur at any time during flight, fuel exhaustion should be suspected, at which time the fuel selector should be immediately positioned to the other tank and the electric fuel pump switched to the 'ON' position."

Fuel Consumption

According to the "best power" chart information in the "Performance" chapter of the POH, approximate fuel consumption rates of between 7.8 and 10.5 gallons per hour (gph) could be expected for the accident flight. The information in this chapter also indicated that approximately 2 gallons and 5 minutes would be required for each climb to 2,500 feet. Postaccident calculations to estimate the approximate fuel consumption used these values and the flight profile, and yielded a minimum trip fuel consumption value of 23 gallons, and a maximum trip fuel consumption value of 27.5 gallons.

Accident Site Fuel Survey

A private contractor was hired by the property owner to assess the fuel spill and resultant contamination in the sandy soil. According to the contractor, the estimated quantity of spilled fuel was approximately 20 to 30 gallons.

FAA Airplane Flying Handbook Excerpts

Chapter 16 of the FAA Airplane Flying Handbook (AFH, publication FAA-H-8083-3A) contained information on dealing with emergency situations in flight. The AFH stressed the importance of familiarity with, and adherence to, the procedures contained in the manufacturer's POH. The "Emergency Landings" section provided guidance intended "to instill in the pilot the knowledge that almost any terrain can be considered "suitable" for a survivable crash landing if the pilot knows how to use the airplane structure for self-protection and the protection of passengers." The AFH listed three primary "psychological hazards" that had the potential to "interfere with a pilot’s ability to act promptly and properly when faced with an emergency." These were "reluctance to accept the emergency situation, desire to save the airplane, and undue concern about getting hurt."

The paragraph regarding "desire to save the airplane" stated that "The pilot who has been conditioned during training to expect to find a relatively safe landing area...may ignore all basic rules of airmanship to avoid a touchdown in terrain where airplane damage is unavoidable." The paragraph stated that the "desire to save the airplane, regardless of the risks involved, may be influenced by...the certainty that an undamaged airplane implies no bodily harm," and suggested that there "are times, however, when a pilot should be more interested in sacrificing the airplane so that the occupants can safely walk away from it."

The paragraph regarding "undue concern about getting hurt" stated that "the survival records favor pilots who maintain their composure and know how to apply the general concepts and procedures that have been developed through the years. The success of an emergency landing is as much a matter of the mind as of skills." The AFH stated that a "pilot who is faced with an emergency landing in terrain that makes extensive airplane damage inevitable should keep in mind that the avoidance of crash injuries is largely a matter of: (1) keeping vital structure (cockpit/cabin area) relatively intact by using dispensable structure (such as wings, landing gear, and fuselage bottom) to absorb the violence of the stopping process before it affects the occupants, (2) avoiding forceful bodily contact with interior structure." The AFH then noted that it "is important that the actual touchdown during an emergency landing be made at the lowest possible controllable airspeed, using all available aerodynamic devices."

The AFH section entitled "Basic Safety Concepts" stated that "If beyond gliding distance of a suitable open area, the pilot should judge the available terrain for its energy absorbing capability," and that "as a general rule, the pilot should not change his or her mind more than once; a well-executed crash landing in poor terrain can be less hazardous than an uncontrolled touchdown on an established field."

The AFH emergency procedures section entitled "Airplane Configuration" stated that "Since flaps improve maneuverability at slow speed, and lower the stalling speed, their use during final approach is recommended when time and circumstances permit."

PA-28-181 POH Engine Failure Procedures

Sections 3.2 and 3.6 of the "Emergency Procedures" portion of the manufacturer's POH respectively provided checklist and amplified procedures for engine failure in flight. Both portions of the guidance directed the pilot(s) to reconfigure certain fuel and engine controls to restore power. If power restoration was unsuccessful, the guidance stated that the airplane should be prepared for a power-off landing by trimming for an airspeed of 76 knots, and selecting a "suitable field." The guidance stated that at 1,000 feet above ground level (agl), the airplane should be in a "position for normal landing approach." The guidance then stated that when the selected landing point could "easily be reached," the airplane should be slowed to 66 knots, with "full flaps" deployed for landing.

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