ERA11FA054
ERA11FA054

HISTORY OF FLIGHT
On November 11, 2010, at 1805 eastern standard time, a Piper PA44-180, N883FT, registered to and operated by the Florida Institute of Technology (FIT) Aviation LLC, collided with the ground after an engine failure, shortly after takeoff from runway 10R at the Palm Beach International Airport (PBI), West Palm Beach, Florida. The instructional flight was operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91, with a night visual flight rules (VFR) flight plan filed. The certificated flight instructor (CFI), a certificated commercial pilot and two passengers were killed, and the airplane was substantially damaged. There was a postcrash fire. The airplane was departing at the time of the accident, enroute to Melbourne, Florida (MLB).

According to information from the Federal Aviation Administration (FAA) air traffic control tower at PBI, a female voice, later determined to be the CFI, transmitted during initial climb that they had an engine failure and "needed to turn-around and land." The controller cleared the flight to land "any runway" and there was no further communications with the flight.
A security video, provided by Galaxy Aviation located at PBI, showed the accident airplane taking off from runway 10R. The video was of poor quality due to the lights glaring into the camera from the main terminal. All that was viewable was the airplane's rotating beacon as it climbed and then started a slow turn to the left. The accident airplane continued to turn left until a large explosion was observed.

According to the FIT flight training department, this flight was being conducted as a supervised solo cross-country training flight for familiarization on international operations.

PILOT INFORMATION

The pilot, age 22, held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane, which was last issued on December 16, 2009, and a first-class airman medical certificate issued on August 14, 2007, with a restriction that he must wear corrective lenses. A review of the pilot's logbook indicated that he had accumulated a total time in all aircraft of 298.2 hours. The pilot's total multiengine time prior to the accident flight was 46.7 hours. The pilot's most recent flight in a multiengine airplane was November 15, 2009.
The CFI, age 26, held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane, which was last issued on September 16, 2010, and a first-class airman medical certificate issued on May 22, 2008, with a restriction that she must wear corrective lenses. The CFI held a certificated flight instructor certificate, with ratings for airplane single-engine, airplane multiengine, and instrument airplane. A review of the CFI's flight records indicated that she had accumulated a total flight time in all aircraft of 2,278 hours, and 492 hours in multiengine airplanes.

AIRPLANE INFORMATION

The airplane was a four-seat, low-wing, retractable gear, twin engine airplane, serial number (S/N) 4496249, manufactured on July 2, 2008. It was powered by two Lycoming O/LO-360-A1 H6 (counter rotating), 180-horsepower engines. A review of the aircraft's most recent 100-hour inspection record found that the inspection had been performed on October 25, 2010, at an airframe/engines total time of 1,638.3 hours.

METEOROLOGICAL INFORMATION

A review of recorded weather data from the PBI automated weather observation station, elevation 19 feet, revealed at 1753, conditions were winds 200 degrees at 9 knots, visibility 10 statute miles, clouds scattered 6,000 feet above ground lever (agl), temperature 24 degrees Celsius, dew-point temperature 13 degrees Celsius, altimeter 30.12 inches of mercury.

WRECKAGE/IMPACT INFORMATION

Examination of the crash site revealed the airplane impacted taxiway hotel (H) in a nose-down, right wing low attitude. The airplane impacted the taxiway on a heading of 340 degrees magnetic and slid 80 feet before coming to rest upright on a 060-degree heading.

The left wing remained attached to the fuselage. The inboard side of the engine nacelle received fire damage. The outboard side of the engine nacelle had no major damage. The main gear was down and locked and had impact and fire damage. The fuel cap was in place and fuel, blue in color, remained in the fuel tank. The left fuel system fuel lines were all free from blockage. No fuel was found from the fuel selector valve forward to the engine driven fuel pump. The fuel selector lever and fuel selector valve were found in the off position. The electric fuel pump was removed and inspected. The screen was free from blockage and no fuel was observed. The pump was field tested by applying battery power and water in the inlet. The pump operated and the water placed in the inlet was observed pumping out of the outlet.

The left aileron remained attached to the wing and had no major damage. Control continuity was established from the left aileron to the main cabin area. The outboard section of the left flap remained attached to the outboard hinge. The inboard section of the flap was destroyed by fire.
The right wing was destroyed by impact and postimpact fire. The outboard fiberglass wing tip was separated and found along the debris path. The fuel cap was in place and the fuel tank was destroyed by fire. The main gear was down and locked and had impact and fire damage. The electric fuel pump was removed. The outlet fitting was separated from the pump. Damage was noted in this area. The screen was free from blockage and residual fuel was observed on the bottom of the fuel pump. The pump was field tested by applying battery power and water in the inlet. The pump operated and the water placed in the inlet was observed pumping out of the outlet.

The right aileron and flap were destroyed and consumed in the postimpact fire. The aileron bell crank was separated from the wing. Both aileron cables remained attached to the bell crank. Aileron control continuity was established from the bell crank to the main cabin area.
The empennage was destroyed in the postimpact fire. The stabilator and rudder cables were strung over the right wing. Both rudder cables remained attached to the rudder. The rudder trim drum was separated and destroyed. The top section of the empennage, including the stabilator, was separated from the aircraft and located along the debris path. The stabilator trim drum displayed 3.5 threads, which is constant with a neutral trim position.
The fuselage received impact damage and was consumed in the postimpact fire. The cabin roof was separated and destroyed. Forward of the instrument panel was crushed aft and to the left. Aft of the rear seats, the fuselage was destroyed and consumed in the postimpact fire. The interior cabin furnishings were consumed in the fire. All seats were found in place.

The landing gear lever was in the down position. The left fuel selector was found in the off position, 1 inch aft of the forward stop, and the right fuel selector was found in the on position. The fuel selector valves remained attached. The left fuel selector valve was found in the off position and the right fuel selector valve was found in the on position. Both valves were field tested by applying low pressure air and were operational in all positions. Both fuel gascolator filters were free from blockage. Fuel control continuity was established from the fuel levers in the cockpit to the fuel selector valves.

All engine control levers were forward and found approximately 1 inch aft of the forward quadrant stop, except the right throttle lever, which was found approximately 2 inches aft of the forward quadrant stop. Throttle quadrant continuity was established from the throttle quadrant to the respective engine controls. The flap handle was bent over to the side. The left engine magnetos were on. The overhead panel and electrical switches were destroyed. The left carburetor heat lever was in the off position and the right was in the on position. The rudder trim indicator was in the neutral position. The pilot's primary flight display (PFD) and the multi function display (MFD) and all radios had impact and fire damage. The standby instruments, airspeed, altimeter, and attitude, were all damaged. No airframe anomalies were found during the on-site examination.

Both propellers separated from each engine, consistent with impact. The crankshafts were broken aft of the propeller flange. The right propeller spinner was crushed and the propeller hub, piston dome, piston, spring, and counterweights were separated and displaced. Both blades of the right propeller exhibited torsion twisting damage and chordwise scoring.

The left propeller spinner was partially crushed on one side. Both propeller blades remained attached to the hub. One blade had rotated from the normal pitch position; the internal pitch change mechanism was broken. The other blade remained in normal pitch position. Both blades were only slightly damaged. Neither propeller was in the feathered position.

The right engine remained attached to the airframe firewall assembly and was displaced aft and to the left, heavy fire damage was noted; the wing nacelle was essentially destroyed. The engine mount assembly was buckled. Impact damage was noted on the outboard side and the exhaust pipes were crushed. The engine accessories remained attached and secured to the engine and were scorched by fire. Except for the propeller control which was melted, the engine control cables remained attached to each respective control arm. The throttle was in full open position. The mixture control was full rich. The carburetor heat control was in the cold or off position. Initial examination of the engine revealed no outward indication of any mechanical malfunction. The spark plugs were removed and exhibited tan color combustion deposits. Electrode wear was moderate and gap settings were normal. Borescope examination of the top end components was unremarkable. The carburetor bowl drain plug was removed and clean blue fuel was observed.
The right engine was removed from the airframe and the valve covers, governor, rear mounted components and carburetor were removed. The engine was rotated using a drive tool adapter inserted into the governor spline. Rotation of the crankshaft established internal gear and valve train continuity. All four cylinders produced compression. Internal gear timing was confirmed. The magnetos were fire damaged, which precluded field testing. The fuel pump was intact and scorched by fire. The pump contained clean blue fuel and pumping action was noted when the pump was actuated by hand. The pump was opened, which revealed no internal anomalies. The accelerator pump was checked and found to operate normally and expelled fuel. The carburetor fuel inlet screen was removed and found clean. The carburetor bowl screws were found secured with safety tabs. The safety tabs were opened and the screws were found to be tight. The carburetor bowl was opened. A residual amount of blue fuel was found remaining in the carburetor bowl. The carburetor venturi was intact. The needle valve was checked and found to operate normally when low pressure air was applied to the unit, the float height measured approximately .187 inch. The carburetor float was composite type. The mixture control valve operated normally and was removed; the valve components were intact and secure. The governor oil screen was found clean. The engine oil filter element and oil suction screen were both found clean. At the conclusion of the engine examination, no evidence of any preimpact mechanical failure or malfunction was found.

The left engine remained attached to the airframe firewall and was displaced aft, upward, and to the left. Slight fire damage was noted and the wing nacelle was not heavily damaged. The engine mount assembly was buckled. Impact damage was noted on the inboard side. The engine accessories remained attached and secured to the engine and were slightly scorched by fire. The engine control cables remained attached to each respective control arm. The governor arm was approximately .250 inch from the high rpm stop. The throttle was in full open position. The mixture control was full rich. The carburetor heat control was in off or cold position.
Initial examination of the left engine revealed no outward indication of any mechanical malfunction. The spark plugs were removed and exhibited light gray color combustion deposits. Electrode wear was moderate and gap settings were normal. Borescope examination of the top end components was unremarkable. The carburetor bowl drain plug was removed and was found to be void of fuel.

The left engine was removed from the airframe and the valve covers, governor, rear mounted components and carburetor were removed. The engine was rotated using a drive tool adapter inserted into the governor spline. Rotation of the crankshaft established internal gear and valve train continuity. All four cylinders produced compression. Internal gear timing was confirmed. The magnetos were field tested and produced spark from all towers. The fuel pump was intact and contained a residual amount of clean blue fuel and pumping action was noted when the pump was actuated by hand. The pump was opened, which revealed no internal anomalies. The accelerator pump was checked and found to operate normally; however, no fuel was expelled. The carburetor fuel inlet screen was removed and found clean. The carburetor bowl screws were found secured with safety tabs. The safety tabs were opened and the screws were found to be tight. The carburetor bowl was opened. No fuel was found remaining in the carburetor bowl. Blue stains were observed at the low point of the bowl. The carburetor venturi was intact. The needle valve was checked and found to operate normally when low-pressure air was applied to the unit. The float height measured approximately .187 inch. The carburetor float was metal type. The mixture control valve operated normally and was removed for inspection. The valve components were intact and secure. The governor oil screen was found clean. The engine oil filter element and oil suction screen were both found clean. At the conclusion of the engine examination, no evidence of any preimpact mechanical failure or malfunction was found.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the commercial pilot on November 11, 2010, by the Office of the District Medical Examiner, District 15-State of Florida, Palm Beach County, West Palm Beach, Florida. The autopsy findings included "Thermal injuries." Forensic toxicology was performed on specimens from the commercial pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report indicated that there was no carbon monoxide or cyanide detected in blood, no ethanol detected in vitreous, and no drugs detected in urine.
An autopsy was performed on the CFI on November 11, 2010, by the Office of the District Medical Examiner, District 15-State of Florida, Palm Beach County, West Palm Beach, Florida. The autopsy findings included "multiple blunt force injuries." Forensic toxicology was performed on specimens from the CFI by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report indicated that there was no carbon monoxide or cyanide detected in blood, no ethanol detected in vitreous, however, 25.43 (ug/ml, ug/g) Acetaminophen and Salicylamide was detected in urine.

ADDITIONAL INFORMATION

The MFD and PFD received fire damage. The NTSB retained the PFD and MFD flash cards for further examination. Examination and data download revealed that at 18:00:50, Eng1 rpm and Eng 2 rpm began to increase. At 18:01:08, Eng1 rpm and Eng2 rpm both reached 2,650 rpm. At 18:01:08, the recorded Eng1 fuel flow began to decrease, followed by a drop in Eng1 rpm. At 18:01:38, the recorded Eng1 fuel flow was approximately 1 gph and Eng1 rpm was approximately 1,270 rpm. The last recorded engine data was at 18:01:50, when the Eng1 fuel flow was approximately 4 gph and Eng1 rpm was 1,480 rpm. From approximately 18:01:08 to the end of the recorded engine data, Eng 2 rpm remained at 2,650 rpm and Eng2 fuel flow remained between 15 and 16 gph.
POH Checklists

A review of the pilot operating handbook (POH) found that during the taxi checklist (paragraph 4.5e), the fuel selector was to be switched from the on position to the cross feed position, to ensure that the crossfeeds were working properly. Once the airplane was in the run-up area and prior to takeoff (paragraph 4.5g), the pilot was to move the fuel selector from the crossfeed position to the on position. During both of these procedures, the fuel selector must pass through the off position before reaching on/crossfeed position.


4.5e Taxiing Checklist (4.17)

TAXING (4.17)

Taxi Area..............................................................................CLEAR
Throttles.......................................................................APPLY SLOWLY
Brakes.................................................................................CHECK
Steering...............................................................................CHECK
Flight Instruments.....................................................................CHECK
Electric Fuel Pumps..............................................................AS REQUIRED
Fuel Selectors............................................................ON/CHECK CROSSFEED


4.5g Before Takeoff Checklist (4.21)

BEFORE TAKEOFF (4.21)

Flight Controls........................................................................CHECK
Flight Instruments.....................................................................CHECK
Engine Instruments.....................................................................CHECK
Fuel Quantity/Imbalance...................................................................ON
Battery Master Switch.....................................................................ON
Alternators...............................................................................ON
Electric Fuel Pumps.......................................................................ON
Pitot Heat.......................................................................AS REQUIRED
Radio Master Switch.......................................................................ON
Autopilot/FD................................................................Disengaged/"RDY"
Mixtures...........................................................................FULL RICH
Carburetor Heat..........................................................................OFF
Cowl Flaps..............................................................................OPEN
Flaps............................................................................CHECK & SET
Stabilator and Rudder Trims..............................................................SET
Fuel Selectors............................................................................ON

Ground Run Tests

The NTSB, FIT Aviation and Piper Aircraft performed an aircraft ground tests on a 2008 PA-44-180 Seminole, N884FT at FIT Aviation (MLB).

First Test:

Performed a normal engine ground run per FIT Checklist.
Time 6 minutes.

Second Test:

Imitate a normal takeoff on the ground following FIT Checklist.
Except:
Placed the right fuel selector valve to the on position.
Placed the left fuel selector valve to the off position.
Set engine throttles to takeoff power.
Left engine sputter 30 seconds.
Left engine quit 36 seconds.

Third Test:

Prior to taxi placed the left fuel selector valve to the off position.
Taxied on airport property at engine rpm 1000 -1100.
Left engine quit after five minutes and 50 seconds.

Forth Test:

Imitate taxi in the ground run up area, placed the left fuel selector valve to the off position.
Throttle engines at approximately 1000-1100 rpm.
After five minutes applied full takeoff power.
Left engine quit 10 seconds later.

Pilot Operating Handbook

Section 3, Emergency Procedures for the PA-44-180, Seminole, Part 3.5a Engine Inoperative Procedures.


Engine failure during takeoff (speed above 75 KIAS).

Mixture Controls...............................................................FULL FORWARD
Propeller controls.............................................................FULL FORWARD
Throttle Controls..............................................................FULL FORWARD
Directional Control................................................................MAINTAIN
Flaps...............................................................................FULL UP
Landing Gear Selector...............................................................CHEK UP
Inoperative Engine......................................................IDENTIFY and VERIFY
Throttle (Inop. Engine)...............................................................CLOSE
Propeller (Inop. Engine) ...........................................................FEATHER
Mixture (Inop. Engine).........................................................IDLE CUT-OFF
Establish Bank........................................2 to 3 degrees INTO OPERATIVE ENGINE
Climb Speed..............................................................................88 KIAS
Trim..........................................................ADJUST TO 2 TO 3 DEGREES BANK TOWARD OPERATIVE ENGINE WITH APPROXIMATELY
1/2 BALL SLIP INDICATED ON THE SKID/SLIP INDICATOR

Cowl Flap (Inop. Engine)..............................................................CLOSE
Alternator Switch (Inop. Engine)........................................................OFF
Magneto Switches (Inop. Engine).........................................................OFF
Electric Fuel Pump (Inop. Engine).......................................................OFF
Fuel Selector (Inop. Engine).................................................................................OFF
Land as soon as practical at the nearest suitable airport.

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