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On October 6, 2010, about 1204 central daylight time, a Piper PA-32R-300, N3402Q, impacted a building after takeoff from runway 36 at Naper Aero Club Airport (LL10), Naperville, Illinois. The certificated private pilot and a passenger received serious injuries. The airplane sustained substantial damage to the fuselage and wings. Visual meteorological conditions prevailed at the time of the accident. The airplane was registered to Airplane Holding Company and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. An instrument rules flight plan was on file and the flight was destined to Allegheny County Airport, Pittsburgh, Pennsylvania. The flight was originating at the time of the accident.
A witness, who was preflighting his airplane at LL10, stated that he saw the airplane during its run-up and thought it unusual that its engine did not sound very loud compared to other higher performance airplane engines. He said he saw the airplane taxi onto runway 36 and without stopping, power was applied for the takeoff. The witness watched the airplane during the takeoff and was surprised to see it use the entire runway and not lift off. He said that it was similar to an airplane that has landed and taxies to the runway end for a turnoff. The witness said he saw the airplane in a slow climb followed by an immediate and moderate bank to the left, which was corrected for to the right. He said that the climb performance was very weak.
Another witness, who was located at the southeast corner of the building that was struck by the airplane, stated that the airplane seemed to be very low. The airplane was in a twenty degree nose-high attitude with the wings level. The engine was running but seemed to be struggling.
On November 6, 2010, the pilot was interviewed by Federal Aviation Administration (FAA) inspectors from the Dupage Flight Standards District Office, West Chicago, Illinois. During the interview, the pilot stated that the winds were from the west and there was a direct crosswind at the start of the accident takeoff roll. The pilot stated that he believed there was no tailwind for the takeoff roll. When asked if there were any ‘out of the ordinary observations’ prior to, during, and after the takeoff roll of power settings, airspeeds, manifold pressure, and engine speed settings, the pilot said that all appeared normal. The pilot stated that he has performed numerous weight and balance calculations and knew that the airplane’s load was lighter than normal and was in limits. The pilot stated that ‘everything was normal at the mid-point of the runway. I did not hear anything out of the ordinary. I rotated the aircraft at the end of the runway at the stall warning; the aircraft didn’t seem to want to climb. I tried to gain altitude so I could turn the airplane but I couldn’t.’ The pilot was then asked if he had completed a runway performance calculation prior to takeoff. The pilot then responded by saying that he would not answer anymore questions until he had an attorney.
According to the pilot’s written statement received on November 10, 2010, the pilot had performed a “normal” preflight and after liftoff, the engine was developing full power. The airplane then impacted a building while maneuvering for an emergency landing.
On November 18, 2010, two mechanics that performed the last 100-hour/annual inspection of the airplane were interviewed by the National Transportation Safety Board Investigator-in-Charge (IIC) with a court reporter.
On April 15, 2011, the pilot was interviewed by the IIC with a court reporter and his attorney present. During that interview, the pilot stated that for the takeoff, he used a short field technique with the flaps extended to the second setting (25 degrees). He set the manifold pressure to 25 inches of mercury (Hg) while the airplane was stopped, and during the takeoff roll he increased the manifold pressure to 29 inches of Hg. He first realized that there was a problem when the airplane lifted off and did not have any climb power. The liftoff occurred beyond the runway midpoint. He did not remember what the airspeed was at takeoff rotation. The stall warning horn sounded when the airplane was about 5 feet above the runway. He did not retract the flaps. The manifold pressure was about 29 inches of Hg, the mixture was full rich, and the propeller was set for full power.
The pilot, age 66, held a private pilot certificate with airplane single-engine land and instrument airplane ratings. He was issued a third class airman medical certificate on August 26, 2010.
On August 30, 1986, the pilot was issued a private pilot certificate and on October 26, 1988, he was issued an instrument airplane rating at a total flight time of 1,179 hours.
The pilot had three logbook entries dated September 29, 2010, and in the accident airplane. The first entry was a flight from LL10 to MDW that was 0.5 hours in duration with no remarks. The second entry was from MDW to MDW that was 1.6 hours in duration of which 1.6 hours was dual flight instruction with a remark of an “IPC- endorsement….” The third entry was from MDW to LL10 that was 0.4 hours in duration with no remarks. The total time for the third entry, which was also the last of all the entries in the logbook was 1,141.1 hours.
The pilot had no previous FAA record of incidents, accidents, or enforcement actions.
The pilot stated that he had been a prior president of the Naper Aero Flying Club, which he said was a type of association that not all of the homeowners at LL10 belong to. He said that he first learned of mechanic A and mechanic B, when they were recommended to him by a previous airport manager for LL10. The pilot stated that the manager had experience with maintenance personnel and had owned a flight school in Schaumberg, Illinois, which was no longer in business. The pilot said that he did not remember the name of the flight school. The pilot said that he had used both mechanics for the past 10 years.
Mechanic A and Mechanic B had known each other since the 1990s while at a maintenance training facility at Chicago Midway International Airport, Chicago, Illinois. Mechanic B had been Mechanic A's supervisor while they were employed at an air carrier. Mechanic B stated that he had been employed by Northwest Aviation, Schaumberg, Illinois, which was no longer in business. At the time of their interviews, Mechanic A was employed as an aircraft mechanic at a maintenance facility and Mechanic B was not employed.
Mechanic B said that he may have first worked on the airplane since 2006 and it was the first time that he had seen the supplemental type certificate (STC) SE85WE turbocharger installation on this or any other airplane.
Both mechanics performed the last 100-hour/annual inspection, which was owner assisted. Mechanic B signed the airplane and engine logbooks annual inspection entries.
Mechanic B stated that he worked with Mechanic A on other aircraft including his (Mechanic B's) own. Both mechanics stated that they performed aircraft maintenance that included several private and flying club airplanes at LL10. Mechanic B said that they would get paid for their maintenance work but were not trying to make a profit. Mechanic B said that he has a standard base rate which was dependent upon the aircraft owner's [work] contribution.
Mechanic A’s last renewal for (IA) under Part 65.93 was February 23, 2009, the basis of which was 5 aircraft alterations, 2 repairs, and 12 annual inspections.
Mechanic B’s last renewal for (IA) under Part 65.93 was February 19, 2009, the basis of which was 13 annual inspections. Two of the annual inspections were on his (Mechanic B) own aircraft.
The airplane was a 1977 Piper PA-32R-300, serial number 32R-7780310, which was powered by a Lycoming IO-540-K1G5D, serial number L-14210-48A, and engine. The engine was modified by the installation of a Rajay turbonormalized (to maintain sea level pressure of 29.92 inches of Hg) turbocharger system under STC SE85WE.
On November 10, 2010, the aircraft logbooks were received from the pilot's attorney following two written requests to the pilot that was dated October 18, 2010, and November 4, 2010.
A January 24, 2008, engine logbook entry for the replacement of cylinder numbers 3 and 4 was made by mechanic A at a tachometer time of 3,306.38 hours. Mechanic A signed the next entry dated January 11, 2010, at a tachometer time of 3,333.7 hours for the reinstallation of an overhauled fuel injection flow divider and replacement of 4 valve springs for the number 1 cylinder. There was no separate signed list of airworthiness directives (ADs) that had been complied with for the last annual inspection. The airframe and engine logbook annual inspection entries had cited several ADs but none of those cited AD 2009-02-03. AD 2009-02-03, effective February 9, 2009, was to be performed before further flight, for the installation of a new servo plug gasket to prevent a lean running engine, which could result in a substantial loss of engine power.
The airframe and engine 100-hour/annual inspection logbook entries since 2006 were signed by the mechanic B who had also signed the last 100-hour/annual inspection dated September 22, 2010, at a total airframe time, total engine time, and tachometer time of 3,339.85 hours. The engine time since overhaul at this inspection was 1,240.01 hours. The last 100-hour/annual inspection was owner assisted.
Engine logbook records from the last annual inspection stated that the compression ratios were: cylinder 1 – 72/80, cylinder 2 – 68/80, cylinder 3 – 77/80, cylinder 4 – 76/80, cylinder 5 – 70/80, cylinder 6 - 76/80.
The Piper Cherokee Six Service Manual, part number 753 690, for PA-32-260 PA-32-300, PA-32R-300 airplanes was issued May 1, 1965, and has had 16 revisions with the last dated March 27, 2008. The pilot was asked to provide manuals used in the last annual inspection. The only manual provided was Piper Service Manual 753 690 with a revision date of November 4, 1983. The maintenance manual for the turbocharger system was not provided.
Rajay Industries, Inc. had published a maintenance manual for the Turbocharger System with Automatic Control. The manual states that the turbocharger installation should be inspected at the 25, 50, and 100 hour inspections. Areas of inspection include but not limited to:
1. All inlet and compressor discharge ducting for loose clamps or leaks
2. Inspect engine air inlet assemble for cracks, loose clamps, and screws
The inspection requirements for 1,000 hour or annual inspections state in part:
1. Remove all turbocharger kit components from the engine. Inspect and repair as necessary.
2. Check operation of the overboost valve. Disconnect actuator cables from wastegate and wire waste gate in full closed position. Operate engine from idle to maximum power.
3. Inspect security, leakage, loose fittings, and visible wear of overboost valve, actuator, controller, hoses, cables, etc.
There was no logbook record that the 1,000 hour or annual inspection of the turbocharger system was performed.
A Piper PA-32R-300 Pilot’s Operating Handbook (POH) along with an attached Rajay POH supplement, FAA Form 337 for the STC installation, and a “High-Flying Lance” article were recovered from the accident airplane. The POH also contained weight and balance forms with the latest dated February 1, 1993. The empty weight was 2,280.80 lbs and the moment are was 83.85 inches. The maximum gross weight of the airplane was 3,600 lbs.
The pilot and passenger weights were about 200 lbs and 160 lbs, respectively. The baggage aboard the airplane consisted of about 45 lbs located between the forward and aft facing passenger seats and about 79.5 lbs of other items located through the cabin that were not part of the airplane weight and balance. The pilot reported that about 90 gallons of 100 low lead (100LL) fuel was aboard at takeoff.
According to the POH, the 25 Degree Flaps Takeoff Performance, Takeoff Distance Over 50 feet Barrier was about 1,650 feet.
The Lewis University Airport (LOT) automated weather observing system located about 8 nautical miles southeast of LL10 at an elevation of about 708 feet mean sea level, recorded at:
1205: wind – 270 degrees at 8 knots; visibility – 10 statute miles; sky condition – clear; temperature - 21 degrees Celsius (C), dew point – 5 degree C
The pilot stated that at the beginning of the takeoff roll, there was a direct crosswind from the west.
Naper Aero Club Airport (LL10) was a nontowered airport that had an elevation of 702 feet mean sea level (MSL). The airport had two runways: runway 18/36 (2,575 feet by 30 feet, asphalt and runway 9/27 (1,750 feet by 70 feet, turf).
WRECKAGE AND IMPACT INFORMATION
The airplane impacted a building located about 2,000 feet north of the departure end or runway 36 at an estimated height of 40-50 feet. The airplane was in an upright position on the roof of the building. The engine which was attached the firewall along with the forward baggage compartment was separated from the fuselage and was resting inverted. The landing gear was retracted.
Examination of the cockpit revealed that the master switch and the fuel pump switch were in the on position. The magneto switch was in the both position. The altimeter setting was about 30.06 inches of Hg and indicated about 810 feet MSL. The directional gyro indicated about 323 degrees. The tachometer indicated 3,342.86 hours. The instrument panel sustained impact damage and the wiring for the pilot intercom system that was exposed was consistent with speaker wire.
The parking brake handle was not in the engaged position.
The throttle quadrant sustained damage. The cockpit throttle control was full forward, the cockpit propeller control was about 1/4 inch from full forward, and the cockpit mixture control was near the forward position. Throttle quadrant control continuity to the engine was confirmed.
Examination of the flight controls confirmed flight control continuity from the control surfaces to the cockpit flight controls. The flaps and cockpit flap control handle were both at the flaps 25 degree positions. The pitch trim was in the neutral position.
The airplane fuel tank quantities were approximately full. The fuel selector was on the right tank position and was able to be moved by hand. The movement also confirmed that detents were present. The fuel sump filter contained a liquid consistent with 100LL. The fuel filters in the fuel system were free of blockage. A liquid consistent with 100LL was also present in flow divider, injector nozzles, engine driven fuel pump inlet and within the engine driven fuel pump. The fuel hoses were connected and no leaks were noted.
The engine air intake ducts were unobstructed.
The fuel servo, a Bendix RSA 10ED1, part number 2524273-11, serial number 58323, examination revealed that the inlet air duct coupling was separated from the servo air inlet. A clamp was present and over the inlet air duct. The clamp was secured onto itself. The duct coupling that attaches to the fuel servo inlet was not attached to the fuel servo or any portion of the clamp. There was no damage to the coupling consistent with it breaking away from the fuel servo and/or clamp during impact. The coupling displayed wear features consistent with preimpact separation. The opposite end of the coupling was attached to the inlet air duct and secured under its clamp.
The engine was attached to all of its engine mounts, and the engine frame was attached to the firewall. There was deformation of the right side of the engine frame as viewed from tail to nose of the airplane. The exterior and its accessories were covered with a residue consistent with oil/dirt in an amount indicative of a lack of a recent engine wash. A wire that was wrapped around an upper right side engine oil sump stud and was connected to the cylinder number 1 baffling in place of the engine manufacturer’s approved part. The approved part is a tie rod to restrain that baffling.
The engine was rotated by hand. Valve train and engine accessory section continuity was confirmed. Internal components of the engine did not display any gouging, failure, or discoloration consistent with oil starvation. All of the piston connecting rods had areas of brown discoloration consistent with rust. The internal components were covered with a liquid consistent with engine oil. The oil suction screen contained contaminates consistent with carbon and did not contain metallic debris. The oil filter had a date of September 16, 2010, and a tachometer time of 3,339 hours written on it. The oil filter element did not contain metallic debris. All oil hoses were connected and there was no evidence of oil leaks. Approximately 7 quarts of a liquid consistent with engine oil was drained from the engine.
The intake and exhaust inner springs (part number LW-11797) and outer spring (part number LW-11796) were compression tested using an uncalibrated spring compression tool by Poplar Airmotive, Poplar Grove, Illinois. According to Lycoming Service Instruction 1240C, dated October 3, 1991, Valve Spring Replacement, with a time of compliance during engine overhaul or earlier at owner’s discretion, lists the compression load range for the inner valve springs as 75-83 lbs, compressed to 1.33 inches, and for the outer valves springs as 116-124 lbs, compressed to 1.33 inches. The intake and exhaust spring compression values for the following cylinders were:
Cylinder 1: intake inner - 102 lbs, outer - 72 lbs; exhaust inner – 112 lbs, outer – 72 lbs
Cylinder 2: intake inner - 102 lbs, outer - 72 lbs; exhaust inner – 112 lbs, outer – 72 lbs
Cylinder 3: intake inner - 110 lbs, outer - 73 lbs; exhaust inner – 110 lbs, outer – 75 lbs
Cylinder 4: intake inner - 110 lbs, outer - 70 lbs; exhaust inner – 107 lbs, outer – 75 lbs
Cylinder 5: intake inner - 109 lbs, outer - 69 lbs; exhaust inner – 105 lbs, outer – 66 lbs
Cylinder 6: intake inner - 109 lbs, outer - 68 lbs; exhaust inner – 110 lbs, outer – 68 lbs
A differential compression test of all cylinders, at an ambient temperature of approximately 80 degrees Fahrenheit, indicated compression ratios of: cylinder 1 – 72/80, cylinder 2 – 0/80, cylinder 3 – 77/80, cylinder 4 – 65/80, cylinder 5 – 38/80, cylinder 6 - 62/80. The compression test was repeated twice on cylinders 2 and 5 and yielded the same compression ratios. Debris consistent in color with material from the building was around of the number 2 cylinder assembly intake valve.
Each cylinder assembly was removed and pressure tested using a 100 psi source of air pressure. No leaks were noted during testing.
Engine timing was verified at 20 degrees before top dead center using a magneto synchronizer. The magnetos were tested on a magneto test bench through a speed range of 100 rpm to 3,000 rpm and a spark gap above 7 mm. Spark was present at 100 rpm and above. Electrical continuity of the ignition wire harness was confirmed.
The engine starter was not engaged into the engine drive.
Examination of the exhaust system did not reveal any obstruction within the muffler or exhaust pipes. The exhaust pipe to the left turbocharger contained cracks/holes that was in an area of brown discoloration consistent with rust. The discoloration was present on the hole edges and was consistent with a preexisting condition. A hole in the exhaust pipe was near the fuel servo air inlet and soot consistent with exhaust product was present on the engine firewall.
The left turbocharger was annotated “Rajay," the data plate was missing, and the turbocharger did not have any identifying part number and/or serial number. The right turbocharger was annotated “Rajay,” with a “Reman KelPak Industries, Inc.” “REMANUFACTURED,” and had an attached data plate with part number RJ0080-102, serial number 71R6395." The engine oil supply hose to the left turbocharger had an approximate bend of 180 degrees followed by an approximate 90 degree bend. The bends were below the minimum bend radius for the hose. The vanes of both turbochargers were intact with no evidence of turbine wheel vane tip to housing rubbing. Both turbines wheels were rotated by hand and no binding was present. The inlet turbine wheel vanes had a residue consistent in color with the rust on the turbocharger inlet engine exhaust tubes.
TESTS AND RESEARCH
Examination of the fuel servo revealed that the fuel screen did not contain contaminant. The servo plug was consistent with part number 365533, which according to AD 2009-02-03 required inspection at every oil change or within every 50 hours of engine run time. The fuel servo was flow tested and the results of which were within test specifications.
Testing of the propeller governor was within test specifications.
Testing of the turbocharger overboost valve was within test specifications.
Previous Occurrence of Partial Loss of Engine Power
Mechanic A stated that the pilot complained about a loss of engine power which they could not duplicate. The mechanic stated that during a go-around, the number 1 cylinder would go “cold,” the exhaust gas temperature would drop “way off” with a corresponding power loss. They cleaned and serviced the spark plugs, swapped the spark plugs, and checked ignition leads but everything was normal. They thought the power loss was attributed to the ignition system, so they removed the magneto and the pilot took it to Aircraft System, Rockford, Illinois, for service, but found no defects. The magneto was reinstalled and they could not reproduce a power loss during a ground run but could while in-flight. They then cleaned the fuel injectors and checked the injector lines. They had the flow divider overhauled and replaced the ignition leads and replaced all the spark plugs.
Mechanic A stated that they contacted Lycoming Technical Support regarding the partial loss of engine power via telephone and email. Lycoming reportedly asked how many hours were on the engine since overhaul and if the valve springs were replaced at the overhaul. (According to Lycoming, there was no record of any such correspondence.) Mechanic A stated they looked at the logbook and could not determine if the valve springs were replaced. They then installed four new valve springs on the number 1 cylinder. The pilot then flew the airplane 3-4 times and everything was normal and the number 1 cylinder EGT would not drop off. The pilot told him that he had flown the airplane about 30 times and there were no problems with the airplane.
The pilot stated that following maintenance work to address the partial loss of engine power, there were no more occurrences over the next 11 flights that he had flown in the accident airplane.
According the flight instructor that provided the pilot's last flight review, there were no problems associated with the airplane during the pilot's flight review.
Last Annual Inspection
Mechanic A said they would normally start at 0900 and did not think they worked past 1700 while performing the annual inspection. Mechanic A and B were present during the entire annual inspection. Mechanic A stated that he did not remember when they began the annual inspection nor when it ended and the he did not know how many days the inspection took. The pilot stated that he did not remember when the inspection was begun or how long it took to complete. Mechanic B stated that the annual inspection was begun on from 0830 – 0930 and was completed on in the afternoon on the same day it was begun.
Mechanic A stated that during the last airplane annual inspection, he was assisting Mechanic B in such things as the landing gear drop check. Both mechanics placed the airplane on jacks and the pilot actuated the cockpit controls for landing gear. Mechanic A said that he would normally inspect the exhaust system, inspect the muffler, and look over the engine. Mechanic B said that Mechanic A would also check the exhaust system. Mechanic A stated that the muffler was visually checked and a pressurization check was not performed. Mechanic A said they would normally perform a differential pressure check together and also work together.
Mechanic B stated that Mechanic A had found loose ducting from the turbocharger to the fuel servo and that Mechanic A had fixed it. Mechanic B said that he thought that Mechanic A had shown the loose ducting to the pilot. Neither mechanic A nor the pilot indicated during their interviews that the ducting was found to be loose.
The pilot stated during his interview with the IIC that he reinstalled all of the airplane inspection covers and performed the engine run-up without the presence of either Mechanic A or Mechanic B.
Mechanic's Inspection Authorization Renewal
Both mechanics stated that the FAA reviews their maintenance activities on a biennial basis for the IA renewal by having mechanics submit a Mechanic's Application for Inspection Authorization, FAA Form 8610-1. Mechanic B stated that when this form is submitted to the local FAA FSDO office, it is the first time that the FAA has knowledge of which aircraft a mechanic has performed inspections on, where they were performed, and the time in service of the aircraft. Prior to the FAA's current system of IA renewal, the FAA required mechanics performing aircraft annual inspections to complete an Application for Airworthiness Certificate and/or Annual Inspection of an Aircraft, Form ACA-305, which was to be submitted to the FAA upon completion of each aircraft annual inspection, became a part of the FAA airworthiness records for the airplane. Form ACA-305, contained entries for aircraft total hours, engine serial number and total hours, and the date of last inspection and who the inspection was conducted by.