Sunday, September 9, 2018

Piper PA-28-140 Cherokee, N4329T: Fatal accident occurred March 25, 2017 at Burg Lake Aero Airport (30TX), Stonewall, Gillespie County, Texas

James Sidney Ethridge
September 28, 1942 - March 25, 2017

James Sidney Ethridge passed away on Saturday, March 25th, 2017 in Stonewall, Texas. James was raised in Blanco, Tx where he grew up working on cars under the big shade tree in front of his parent’s home with his best friend, Winston Moore that was later married to James’ sister, Dorothy. He was drafted into the Army on May 6, 1964.

James had a strong passion for flying and Michael, his brother helped him to buy his first plane and he eventually was able to pick up his second plane in Albany, New York in 2016. He worked for his brother Mike for over 44 years and he loved his job. He passed away while flying and doing what he loved.

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; San Antonio, Texas
Lycoming Engines; Williamsport, Pennsylvania
Piper Aircraft, Inc; Vero Beach, Florida

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N4329T

Analysis 

The airplane owner and a mechanic completed the airplane's annual inspection the morning of the accident. The mechanic did no work but returned the airplane to service with an endorsement that the annual inspection/airworthiness requirements had been met based on his determination that the engine runup was satisfactory. The airplane departed but returned to the airport shortly after the departure. During the return, a witness said that the airplane was "way too high," and its approach was "pretty steep." The airplane touched down about halfway down the short-grass runway and was "going way too fast." The airplane overran the end of the runway and into a pond where it became submerged. Postaccident examination of the runway revealed the presence of skid marks from the airplane main landing gear wheels along the last 300 ft of the runway.

The propeller exhibited rotational signatures but with some loss of torque. Postaccident examination of the airplane revealed numerous unairworthy maintenance items and/or lack of maintenance to the engine and accessories; further the engine and various accessories surpassed their manufacturers' recommended time for overhaul/replacement. The exhaust manifold was blocked with internal fractured pieces that would have resulted in power loss. The condition of these pieces was consistent with a failure that had been preexisting. The induction hose to the carburetor was the wrong part for the installation. The hose was collapsed and would have restricted airflow into the carburetor resulting in power loss. Both magnetos were no longer serviceable and would have produced minimal ignition. The engine timing was not set to the engine manufacturer's specification. Had the mechanic conducted a proper annual inspection, he would have identified many of the issues found during the airplane's postaccident examination.

Based on the evidence, the pilot likely returned to the airport due to a loss of engine power. It could not be determined which of the many discrepancies led to the loss of engine power. Further, the pilot did not attain a power-off approach glideslope that would have led to a proper touchdown point near the approach end of the runway.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to attain a proper touchdown point following a loss of engine power and his inability to stop the airplane on the short, soft runway. Contributing to the accident was the inadequate maintenance of the airplane by the owner and the mechanic and the improper annual inspection by the mechanic. 

Findings

Aircraft
Descent/approach/glide path - Not attained/maintained (Cause)
Engine (reciprocating) - Damaged/degraded (Cause)
Engine (reciprocating) - Incorrect service/maintenance (Factor)

Personnel issues
Incorrect action performance - Pilot (Cause)
Scheduled/routine maintenance - Maintenance personnel (Factor)
Scheduled/routine maintenance - Owner/builder (Factor)
Scheduled/routine inspection - Maintenance personnel (Factor)

Factual Information

History of Flight

Prior to flight
Aircraft maintenance event

Enroute
Loss of engine power (partial)

Landing-landing roll
Landing area overshoot (Defining event)

Runway excursion
Collision with terr/obj (non-CFIT)


Location: Stonewall, TX
Accident Number: CEN17FA139
Date & Time: 03/25/2017, 1530 CDT
Registration: N4329T
Aircraft: PIPER PA-28-140
Aircraft Damage: Substantial
Defining Event: Landing area overshoot
Injuries: 1 Fatal
Flight Conducted Under:  Part 91: General Aviation - Personal 

On March 25, 2017, about 1530 central daylight time, a Piper PA-28-140, N4329T, impacted a fence and pond during a landing overrun on runway 18 at Burg Lake Aero Airport (30TX), Stonewall, Texas. The commercial pilot received fatal injuries, and the airplane sustained substantial damage. The airplane was owned by the pilot and his brother and operated by the pilot under Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Day visual meteorological conditions prevailed at the time of the accident and no flight plan had been filed. The flight originated from 30TX about 1525 and was destined to New Braunfels Regional Airport (BAZ), New Braunfels, Texas, but returned to 30TX.

The accident flight was the airplane's first flight after its annual inspection and the replacement of one of the fuel pumps. The pilot's brother-in-law stated that the pilot performed a full-power run-up, which was "okay.". The airplane engine cowl was then put back onto the airplane, and the pilot fueled the airplane from the airport fuel tank to a level that was at the fuel tank "tabs." The pilot then performed another engine run-up at full power near the approach end of the runway 18. During the takeoff, the airplane was not more than 10 ft above the runway when it was at about half down the length of the runway. The brother-in-law thought the airplane was going to hit trees located near the departure end of the runway. The airplane had been gone for about 5-10 minutes before it returned to airport. The brother-in-law reported that the airplane touched down about halfway down the runway, and it was "going way too fast." He thought that the pilot never increased engine power after the airplane touched down and that the engine power was at idle during the landing but was "not sure" because he was in his hangar, and the airplane does not produce much engine noise at idle.

A witness who was driving westbound toward Stonewall, Texas, saw an airplane descend toward the 30TX runway. He said the airplane was "way too high," and its approach was "pretty steep." He said that he thought to himself that the airplane was "not going to make it." He stated that he was in his truck with the windows closed and could not hear the airplane engine.

The airplane overran the departure end of the runway during the landing, went through a barbed wire fence, and into a pond. 

Pilot Information

Certificate: Commercial
Age: 74, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 11/30/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 12/21/2016
Flight Time:  (Estimated) 495 hours (Total, all aircraft), 495 hours (Pilot In Command, all aircraft), 0 hours (Last 90 days, all aircraft), 0 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft) 

According to the pilot's logbook, his last flight entry was a flight review in a Piper PA-28R-200 on December 21, 2016; the duration was 1.1 hours. The entry did not have a flight review endorsement by the flight instructor who provided the review.

The Federal Aviation Administration (FAA) had no record of any previous accidents, incidents, or enforcement actions for the pilot. The pilot's brother-in-law stated that the pilot had previously landed at the airport "several times" because the airplane received 2 or 3 annual inspections at 30TX.

The mechanic held an airframe and powerplant mechanic certificate with inspection authorization, which was renewed on March 17, 2017, by an FAA inspector from the San Antonio flight standards district office (SAT FSDO). The FAA had no record of any previous enforcement actions against the mechanic. 

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N4329T
Model/Series: PA-28-140
Aircraft Category: Airplane
Year of Manufacture: 1971
Amateur Built: No
Airworthiness Certificate: Normal; Utility
Serial Number: 28-7225146
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 03/25/2017, Annual
Certified Max Gross Wt.: 2150 lbs
Time Since Last Inspection: 0 Hours
Engines: 1 Reciprocating
Airframe Total Time: 5063.72 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: Not installed
Engine Model/Series: O-320-E3D
Registered Owner: Pilot (Co-owner)
Rated Power: 150 hp
Operator: Pilot (Co-owner)
Operating Certificate(s) Held: None 

The 1971-model-year Piper PA-28-140 (Cherokee) airplane was purchased by the pilot and his brother on November 3, 2010, and the aircraft registration was accepted on February 9, 2011

The airplane was powered by a Lycoming O-320-E3D, serial number L-46554-27A, case number 4865, engine that underwent its last overhaul by the engine manufacturer dated June 29, 1988, at an engine total time of 1,945.45 hours. The engine underwent its last overhaul, which was performed by an airframe and power plant mechanic, dated May 29, 1998, at an engine total time of 2,991.8 hours and a tachometer time of 4,236.2 hours.

The Hobbs meter and tachometer indications at the accident site were 889.5 hours and 5,063.7 hours, respectively.

According to an airframe and powerplant mechanic, the pilot called him at the end of February 2017 to schedule an annual inspection of the airplane. The pilot did not report any issues and said that the airplane had been flying "beautifully." On the day of the inspection, March 4, 2017, the mechanic arrived and the airplane was at 30TX and the airplane was already "opened up." The pilot reported that the airplane was having occasional fuel pressure problems. Upon completion of the inspection, the airplane was towed outside, started easily, and the engine was run for about 10 minutes. The mechanic stated that the engine was running "satisfactorily," and he signed off the logbooks.

According to an FAA inspector from the SAT FSDO, the mechanic, who signed off the annual inspection, stated that he watched but did not work on the airplane. The mechanic and the pilot used an inspection checklist that was not the inspection checklist in the Piper Cherokee Service Manual. It is unknown if the mechanic or the pilot used the Piper Cherokee Service Manual during the inspection of the airplane.

Since 2011, all of the annual inspections, which were performed every year, were signed by the mechanic that had signed off the annual inspection.

Lycoming Service Instruction No. 1009AZ stated, in part:

Engine deterioration in the form of corrosion (rust) and the drying out and hardening of composition materials such as gaskets, seals, flexible hoses and fuel pump diaphragms can occur if an engine is out of service for an extended period of time. Due to the loss of a protective oil film after an extended period of inactivity, abnormal wear on soft metal bearing surfaces can occur during engine start. Therefore, all engines that do not accumulate the hourly period of TBO specified in this publication are recommended to be overhauled in the twelfth year.

A review of the engine and airframe logbooks revealed that the magnetos, exhaust, fuel and oil lines, and carburetor had not been replaced/overhauled since the engine's last overhaul in 1998.

The Piper Cherokee Service Manual states that a 100-hour inspection is a complete inspection of the airplane, identical to an annual inspection. The manual stated to replace the engine flexible hoses (fuel, oil, etc.) as required but not to exceed 1,000 hours time-in-service, 8 years, or engine overhaul, whichever comes first; no fluid hose may exceed 20 years time-in-service.

The Airplane Flight Manual (AFM) provided landing distance versus density altitude information for the only the following conditions: flaps 40°; power off; paved, level runway; no wind; maximum braking; short field effort; and airplane gross weight of 2,150 lbs. Based upon a density altitude of 1,535 ft, the landing distance at gross weight was about 550 ft, and the landing distance over a 50-ft obstacle was about 1,100 ft.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: T82, 1695 ft msl
Distance from Accident Site: 14 Nautical Miles
Observation Time: 1535 CDT
Direction from Accident Site: 270°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 260°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.98 inches Hg
Temperature/Dew Point: 26°C / 2°C
Precipitation and Obscuration:  No Obscuration; No Precipitation
Departure Point: Stonewall, TX (30TX)
Type of Flight Plan Filed: None
Destination: New Braunfels, TX (BAZ)
Type of Clearance: None
Departure Time: 1525 CDT
Type of Airspace: Class G

Based upon the 1535 recorded weather, the density altitude was about 1,314 ft. 

Airport Information

Airport: Burg Lake Aero Airport (30TX)
Runway Surface Type: Grass/turf
Airport Elevation: 1463 ft
Runway Surface Condition: Dry
Runway Used: 18
IFR Approach: None
Runway Length/Width: 2200 ft / 160 ft
VFR Approach/Landing: 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude:  30.229444, 98.655278 (est) 

The airplane was completely submerged and inverted in an 18- to 20-ft-deep pond that was about 80 to 100 ft from with the departure end of the runway 18. While inverted, the airplane nose was pointing toward the runway. The bottom of the fuselage had a longitudinal tear along its left side that extended from the firewall to the left wing trailing edge, consistent in width with a round barbed wire metal fence post that was between the runway and the pond and was bent over about 30° toward the pond. About the upper 8 inches of the post exhibited paint transfer from the airplane.

The airplane cockpit/cabin door had been opened by a diver using the top and side latches. Postaccident examination of the door latches revealed that the door was able to be opened using the top and side latches. There was no binding of the door during its opening or closing.

Ground scars consistent with skidding from the main landing gear wheels were present along the last 300 ft of runway 18. A ground scar was in front of the post, which was consistent with the airplane tail tie-down that was broken off the airplane. The barbed wire fence was not attached to the airplane nor was it wrapped around the propeller. The wing flaps were in the 40° extended position.

One blade of the two-bladed metal propeller exhibited spanwise scratches that were angled about 20° to 45° relative to the blade chord, consistent with rotation. The second blade was straight. Neither blade exhibited S-shaped bending consistent with torque.

Examination of the cockpit revealed that the magneto key switch was in the "both" position, the master switch was in the "on" position, the auxiliary fuel pump switch was in the "on" position, and the engine primer was in and locked. The cockpit throttle control was near the idle position, and the cockpit mixture control was about ¾ forward of the idle cut off position. The cockpit flap selector was in the 40° position. The shoulder harness for the left pilot seat was stowed to its ceiling retainer.

Examination of the flight control system confirmed flight control continuity from all the control surfaces to left and right seat cockpit flight controls. The tailcone cover did not exhibit accident-related impact damage. All eight tailcone cover retaining screw holes along the longitudinal axis of the airplane had vertical cracks from the hole edges and through the cover. The four tailcone cover screws that were perpendicular to the longitudinal axis of the airplane were dark brown, consistent with long-term corrosion and non-recent removal. The screw heads were stripped. The tailcone was removed to expose the underlying flight control system components: the rudder cable ends, the stabilator trim screw, the stabilator screw/tab links, the stabilator hinge points, and the rudder trim assembly. These components exhibited a dry appearance, consistent with a lack of lubrication. According to the Piper Cherokee Service Manual, the components are to be lubricated every 100 hours with MIL-L-7870 and Aero Lubriplate lubricants.

Examination of the electrically driven fuel pump revealed that it operated with no mechanical anomalies when tested on the airplane by the turning the airplane master switch and auxiliary fuel pump switch on and by removal and connection of the pump to an automotive battery. Testing of the pump before its removal from the airplane revealed that the cockpit fuel pressure gauge was inoperative.

The three-position cockpit fuel selector control handle was positioned to the left fuel tank. The fuel selector handle did not turn freely using hand pressure through repetitive selections to the left fuel tank, right fuel tank, and off positions. The cockpit fuel selector had to be placed in a vice and a wrench used to remove the plastic fuel selector plug valve, with difficulty from the valve body. The valve stem exhibited a dull white colo,r consistent with oxidation. No obstruction to the attached ports for the fuel lines or when the valve was selected to all three positions was found.

Examination of the engine revealed that the fuel and oil lines were intact. The engine sump contained liquid consistent in appearance with that of engine oil and water. The top and bottom plugs were removed, and the engine was rotated through when rotated by hand. During rotation, air was drawn into and expelled through the spark plug holes. Engine continuity to the accessory section, valve train, and drive train was confirmed. The spark plugs each had their electrodes intact and displayed features of normal operation as depicted in Champion Aerospace Aviation Service Manual V6-R, August 2014, Electrode Conditions.

The engine-driven fuel pump was removed and actuated by hand pressure. It produced suction and expulsion of air through the pump inlet and outlet ports. Disassembly of the pump revealed that the pump diaphragm had no debris.

The air inlet hose leading to the carburetor was SCAT hose (air duct hose commonly used for heating and cooling), which was the incorrect part for the application and installation. The hose did not exhibit impact damage and was collapsed.

The right exhaust pipe bolt leading to the heat exchanger/muffler could not be unscrewed, and the pipe had to be cut for the heat exchanger to be examined. The heat exchanger housing had two repairs, one was a weld and the other was a riveted square metal patch. The heat exchanger exhaust was blocked about 50 percent with fractured internal heat exchanger pieces. The fracture surfaces of the blockage were brown in color, consistent with a long-term preexisting fracture. The Piper Cherokee Service Manual stated that the heat exchanger/muffler is to be replaced at or near 1,000 hours time-in-service.

The engine timing was 27° top dead center (TDC); the engine data plate specified an engine timing of 25° TDC. The left magneto (Slick Magneto, model 4371, serial number 01120168) was manufactured in 2001, and the right magneto (Slick Magneto, model 4250, serial number 7090045) was manufactured in 1970. The left magneto did not spark, and the right engine magneto did not turn freely and exhibited corrosion of its bearing.

The magnetos were examined at Navajo Accessories, Inc., San Antonio, Texas, under the supervision of the FAA inspector from the SAT FSDO. The left magneto exhibited corrosion on the impulse coupling, and the unit was nonfunctional. The rotor was worn and had flat spots. The points were seized and nonfunctional. The right magneto rotor and bearings exhibited corrosion, the capacitor wire was pinched and broken, the points were seized, and the coil was "obsolete." Both magnetos were issued red tags as not serviceable.

The flexible fuel line leading to the carburetor was hardened and difficult to bend using hand pressure. The fire sleeve for the flexible fuel line was removed exposing its date code showing that it was manufactured in 1971. According to the airplane service manual, the flexible fuel lines are to be replaced or overhauled as required or at engine overhaul. The Piper Cherokee Service Manual stated that flexible fuel lines are to be inspected at 100-hour intervals and replaced as necessary.

Examination of the carburetor was performed at RLB Accessories, Addison, Illinois under the supervision of the National Transportation Safety Board investigator-in-charge. The examination revealed that the throttle arm shaft was loose due to wear. The fuel screens did not contained debris. The float was a metallic brass float that exhibited a float travel of about half of the required 7/32-inch travel. The RLB Accessories representative stated that the brass float should have been replaced in accordance with a service bulletin issued about 1990. The carburetor needle valve had the incorrect cotter pin installed. The gap distance between the throttle body valve and the carburetor throat body when in a closed position was 4/1000 inch but should have been about 20/1000 inch. The carburetor drain plug had safety wire in place. The RLB Accessories representative stated that the engine should have been washed as part of annual inspection but was not washed based on the external condition of carburetor. The representative stated the condition of the carburetor should have resulted in the engine operating with a rich fuel mixture.

The airplane emergency locator transmitter (ELT) was not present in the airplane and ELT's retaining hardware was undamaged and in an open/unretained position.

AIRPORT INFORMATION

Runway 18 was the only runway at the nontowered, privately-owned airport. The runway was grass covered with bare areas of dirt. The runway grass length after the accident was measured to be about 2-3 inches. The runway exhibited a downslope and a rise of about 5 ft over the last 20 ft of the runway.

The airport owner stated that he had a 1,000-gallon fuel tank that contained 100 low lead aviation fuel for the airport. The tank was equipped with a sediment filter and a water filter. There was no sediment or water contamination noted when the filters were examined. 

Medical And Pathological Information

Central Texas Autopsy, PLLC, Lockhart, Texas, performed an autopsy of the pilot. The autopsy report stated that the cause of death was "fresh water drowning."

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. No carbon monoxide was detected in blood (femoral), cyanide testing was not performed, no ethanol was detected in vitreous, amlodipine was detected in liver and in blood (femoral). Amlodipine is a blood pressure control medication that is not generally considered impairing. 

Additional Information

FAA safety publication, On Landings Part II, FAA-P-8740-12 (2008), Runway Surface, stated:

Runway surface make a big difference on landing long because it plays a big role in braking.

A dry, concrete runway offers one of the best braking surfaces, a runway covered with wet, clear ice offers the worst braking surface. Most other conditions fall somewhere between the two.

Grass is a much less effective braking surface. Wet or frost-covered grass is even worse.

NTSB Identification: CEN17FA139
14 CFR Part 91: General Aviation
Accident occurred Saturday, March 25, 2017 in Stonewall, TX
Aircraft: PIPER PA-28-140, registration: N4329T
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On March 25, 2017, about 1530 central daylight time, a Piper PA-28-140, N4329T, impacted a fence and pond during a landing overrun on runway 18 (2,200 feet by 160 feet, turf) at Burg Lake Aero Airport (30TX), Stonewall, Texas. The airplane sustained substantial damage. The commercial pilot received fatal injuries. The airplane was operated by the pilot under 14 Code of Federal Regulations Part 91 as a personal flight that was not operating on a flight plan. Visual meteorological conditions prevailed at the time of the accident. The flight originated from 30TX about 1525 and returned to 30TX.

2 comments:

Anonymous said...

quite a testament to Piper's build that a nearly 50 year old plane managed to keep flying despite a complete lack of any real maintenance and care. Despite all the plane's worn out and non functioning parts, it's not even clear it was mechanical failure that lead to the final crash.

Anonymous said...

If any of us had asked about his plane, I'm sure he would have said it was well maintained. I see this too often.