Tuesday, July 23, 2019

Loss of Control in Flight: Piper PA-31P Pressurized Navajo, N82605; fatal accident occurred March 08, 2018 at Laredo International Airport (KLRD), Webb County, Texas

Dr. Kelle David Hein
1961 - 2018

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 Aircraft Engines; Williamsport, Pennsylvania
Piper Aircraft; Vero Beach, Florida

Aviation Accident Factual 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/N82605

Webb County Medical Examiner Corinne Stern is shown at the scene of the Piper PA-31P Pressurized Navajo crash at the Laredo International Airport on March 8th, 2018.

Location: Laredo, TX
Accident Number: CEN18FA116
Date & Time: 03/08/2018, 1038 CST
Registration: N82605
Aircraft: PIPER PA 31P
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

HISTORY OF FLIGHT

On March 8, 2018, about 1038 central standard time, a Piper PA-31P twin-engine airplane, N82605, impacted terrain during an approach to the Laredo International Airport (LRD) Laredo, Texas. The pilot and student rated passenger were fatally injured, and the airplane was destroyed. The airplane was registered to and operated by a private individual, as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions existed near the accident site about the time of the accident, and no flight plan was filed for the local flight.

Shortly after departing runway 18R, the tower controller contacted the pilot and reported that smoke was coming from the left side of the airplane. The pilot reported, "… we're gonna fix that." The airplane turned back toward the airport and was cleared to land on runway 18L.

Witnesses reported seeing the airplane trailing smoke as it approached the airport. Two of the witnesses reported that the smoke came from the left engine. Several airport security cameras captured the accident airplane while airborne. A review of the video also showed a trail of white smoke behind the airplane. While the airplane was on a left downwind leg for landing, the smoke trail was not visible. As the airplane turned left from base leg to final, its bank angle increased past 90 degrees. The airplane impacted terrain in a nose down, near-vertical attitude just short of runway 18L; a post-crash fire ensued.



PERSONNEL INFORMATION

The pilot held a commercial pilot certificate with ratings for airplane single-engine land, multi-engine land, and instrument airplane. He held a flight instructor certificate for airplane single-engine and instrument airplane. He also held a ground instructor (basic) certificate. The pilot's second-class Federal Aviation Administration medical certificate was issued on May 15, 2017, with the limitation, "must have available glasses for near vision." On the application for the medical certificate, the pilot reported 4,243 total hours of flight experience and 45 hours in the previous six months. The pilot's logbook was not available during the investigation for review.

The passenger held a student pilot certificate and a mechanic certificate with a powerplant rating. A third-class medical certificate was issued on August 1, 2014, with no limitations. At the time of the medical certificate examination, he reported 48.9 total hours and 48.9 hours in the last six months. The student's logbook was found at the accident site, but due to the accident, some of the entries were illegible, but it appeared that the student had 194 total hours in single-engine airplanes, with the last logbook entry dated February 2018. Additionally, he had been signed off for the private pilot check ride in November 2017; however, there was no record of him taking the pilot test.



AIRCRAFT INFORMATION

The Piper PA-31P Navajo is low-wing, cabin-class, pressurized, twin-engine airplane with retractable landing gear. The accident airplane was powered by two 425-horsepower Lycoming TIGO-541 reciprocating six-cylinder engines, which each drove a three-bladed, full-feathering Hartzell propeller. Review of the airplane's maintenance records revealed that the airplane's annual inspection was conducted on January 3, 2018, at a total airframe time of 3,185 hours. At the time of the annual inspection, the Hobbs time on both the left and right engines were 2,089.2 hours, and 1,027.3 since factory remanufacture.

METEOROLOGICAL INFORMATION

At 1056, the weather observation facility at LRD recorded wind from 140° at 14 knots gusting to 17 knots, 10 miles visibility, a clear sky, temperature 70°F, dew point 45°F, and an altimeter setting of 30.23 inches of mercury.



COMMUNICATIONS

A review of communications data between air traffic controllers and N82065, (it was not determined whether the pilot or student rated passenger was operating the radios) revealed a pilot contacted LRD ground control and received a clearance to runway 18R. About 12 minutes later, a pilot contacted the tower controller and requested a southeast departure to the practice area.

Just after takeoff, the tower controller reported to N82065, "I have you, ah, smoking actually pretty bad, ah, looks, appears to be your left-hand side". A pilot responded "… we're gonna fix that".

The controller asked if they needed to come back around and land, and if they need any assistance.

A pilot reported that they were going to turn for the downwind 18R; and they were not requesting any assistance.

The tower controller cleared the airplane for 18L, and a pilot acknowledged 18L.

About one minute later, the tower controller notified crash rescue of the accident.



AIRPORT INFORMATION

Laredo International Airport (LRD) is a publicly owned, tower-controlled airport located 3 miles northeast of Laredo, Texas at an elevation of 508 ft mean sea level. LRD has three concrete runways;18L/36R is 8,236 ft long by 150 ft wide, 18R/36L is 8,743 ft long by 150 ft wide, and 14/32 is 5,927 ft long by 150 ft wide.

WRECKAGE AND IMPACT INFORMATION

The front of the airplane cabin/cockpit area was largely destroyed by the impact and fire. The major components of the airplane were located at the accident site. Separated pieces were scattered between the aft cabin and the impact crater, and several fragments of the airplane were scattered away from the impact point.

Both wings were separated from the fuselage and displayed heavy thermal and impact damage.

The airplane was examined at the site by the NTSB investigator-in-charge and technical representatives from the engine and airframe manufacturers. Flight control continuity was confirmed from the front cabin to the left and right aileron bellcranks. The rudder cables were traced from the cockpit to the rudder. The control column and rudder pedals were impact and fire damaged. All three of the airplane's landing gear were extended. The wing flap actuator was in the up position, which corresponded to the flaps retracted position. The cockpit instrument panel and avionics were destroyed by impact and fire damage. The airplane's emergency locator transmitter, located in the empennage, was found in the "off" position with the antenna coaxial cable disconnected; the replacement battery date was labeled as Sept 2019.

Both engines separated from the wing nacelles and were located near the fuselage. The engines were moved and examined in a nearby facility.

The left engine sustained extensive fire and impact damage. Due to impact damage, the engine would not rotate by hand. Engine components, such as the magnetos, fuel metering unit, ignition harness, and fuel pump all sustained fire and impact damage and could not be field tested. Fuel and oil lines were consumed by fire. The turbocharger separated from the engine during the impact damage and would not rotate.

The top sparkplugs were removed; the plugs exhibited normal combustion deposits and wear signatures. The engine was disassembled and, other than extensive fire and impact damage, no abnormalities were noted, and the source of the smoke was not found.

The right engine's components were fire/impact damaged and could not be field tested. The top set of sparkplugs were removed; the plugs exhibited normal combustion deposits and wear signatures.

Both left and right engine turbocharger's V-band clamps were found in place on the turbocharger exhaust system.

The left propeller separated from engine with a section of the propeller shaft. The left engine propeller blades were labeled A, B, and C for identification purposes. Blades A and C were in a high-pitch position, with blade C bent aft, and displayed leading-edge polishing. Blade B was loose in the hub and exhibited chordwise scratching and leading-edge polishing.

The right propeller also separated from the engine with a section of the propeller shaft. The blades for the right propeller where labeled A, B, and C for identification purposes. Blade A exhibited bending and curling beginning about mid-span, with about 2 inches of the blade tip torn off. Blade B was bent forward and exhibited leading edge polishing and gouging. Blade C had fractured and separated outside of the propeller hub. The blade exhibited twisting, curling and leading-edge polishing.

Although the examination was limited by thermal and impact damage, no pre-impact abnormalities were noted during the airframe or engine examinations.



MEDICAL AND PATHOLOGICAL INFORMATION

The Office of the Chief Medical Examiner, Webb County Medical Examiner, Laredo, Texas, conducted an autopsy on the occupants. The cause of death was determined to be, "multiple blunt force and crushing injuries."

The FAA Forensic Sciences Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing. For the pilot, the specimens were not tested for cyanide and carbon monoxide. The tests were negative for ethanol and tested drugs. For the student pilot rated passenger, the specimens were not tested for cyanide. The tests were negative for and carbon monoxide and ethanol. The test was positive for cetirizine in the blood and urine.

Cetirizine is an over the counter antihistamine and commonly marketed under the trade names: Zyrtec, Aller-Tec, or Alleroff. The medication is taken to relieve the symptoms of hay fever and allergy.



ADDITIONAL INFORMATON

The FAA Airplane Flying Handbook (FAA-H-8083-3B), Chapter 12, Transition to Multiengine Airplanes, addresses in part, operational procedures and hazards associated with twin-engine airplanes and the loss of engine power:

General

The basic difference between operating a multiengine airplane and a single-engine airplane is the potential problem involving an engine failure. The penalties for loss of an engine are twofold: performance and control. The most obvious problem is the loss of 50 percent of power, which reduces climb performance 80 to 90 percent, sometimes even more. The other is the control problem caused by the remaining thrust, which is now asymmetrical. Attention to both these factors is crucial to safe OEI [one engine inoperative] flight. The performance and systems redundancy of a multiengine airplane is a safety advantage only to a trained and proficient pilot.

Engine Failure After Lift-Off

A takeoff or go-around is the most critical time to suffer an engine failure. The airplane will be slow, close to the ground, and may even have landing gear and flaps extended. Altitude and time is minimal. Until feathered, the propeller of the failed engine is windmilling, producing a great deal of drag and yawing tendency. Airplane climb performance is marginal or even non-existent, and obstructions may lie ahead. An emergency contingency plan and safety brief should be clearly understood well before the takeoff roll commences. An engine failure before a predetermined airspeed or point results in an aborted takeoff. An engine failure after a certain airspeed and point, with the gear up, and climb performance assured result in a continued takeoff. With loss of an engine, it is paramount to maintain airplane control and comply with the manufacturer's recommended emergency procedures.

Control

The first consideration following engine failure during takeoff is to maintain control of the airplane. Maintaining directional control with prompt and often aggressive rudder application and STOPPING THE YAW is critical to the safety of flight. Ensure that airspeed stays above VMC [minimum control speed with the critical engine inoperative]. If the yaw cannot be controlled with full rudder applied, reducing thrust on the operative engine is the only alternative. Attempting to correct the roll with aileron without first applying rudder increases drag and adverse yaw and further degrades directional control. After rudder is applied to stop the yaw, a slight amount of aileron should be used to bank the airplane toward the operative engine. This is the most efficient way to control the aircraft, minimize drag, and gain the most performance.

The PA-31P Pressurized Navajo, Pilot's Operating Handbook, Section III, C, Emergency Procedures, states in part:

FEATHERING PROCEDURE

a. Maintain Direction and Airspeed
b. Mixtures – forward
c. Props – forward
d. Throttles – forward
e. Gear – retract
f. Flaps – retract
g. Emergency Pumps – on
h. Identify inoperative engine
i. Throttle on inoperative engine - retard to verify
j. Prop on inoperative engine - feather
k. Mixture on inoperative engine - idle cut off
l. Emergency pump on inoperative engine – off
m. Magnetos on inoperative engine – off
n. Prop Synchronizer - off, if installed
o. Cowl Flaps - close on inoperative engine, as required on good engine
p. Alternator on inoperative engine - off (use circuit breaker switch)
q. Electrical Load - reduce, to prevent battery depletion
r. Trim - as required
s. Fuel Management - fuel off on inoperative engine, consider crossfeed
t. Land at first opportunity

ENGINE FAILURE DURING CLIMB

a. Follow feathering procedure.

b. Hold single engine best rate-of-climb speed of 133 MPH

c. Monitor cylinder head temperature - adjust cowl flap as required.

SINGLE ENGINE LANDING

a. Complete feathering procedure
b. Before landing check list
(1) Do not extend landing gear until certain of making field. Maintain 133 MPH.
(2) Do not lower flaps until certain of making field. Maintain 116 MPH.
c. Trim for landing - (rudder)
d. Do not land pressurized above .3 psi.



Pilot Information

Certificate: Flight Instructor; Commercial
Age: 56 
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 05/15/2017
Occupational Pilot:
Last Flight Review or Equivalent:
Flight Time: 4243 hours (Total, all aircraft)

Pilot-Rated Passenger Information

Certificate: Student
Age: 19
Airplane Rating(s): None
Seat Occupied: Unknown
Other Aircraft Rating(s):
Restraint Used: 
Instrument Rating(s):
Second Pilot Present: Yes
Instructor Rating(s): 
Toxicology Performed: Yes
Medical Certification: Unknown
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 194 hours (Total, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N82605
Model/Series: PA 31P UNDESIGNATED
Aircraft Category: Airplane
Year of Manufacture: 1977
Amateur Built: No
Airworthiness Certificate: Utility
Serial Number: 31P-7730010
Landing Gear Type: Retractable - Tricycle
Seats:
Date/Type of Last Inspection: 01/03/2018, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: Reciprocating
Airframe Total Time: 3185 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: C91  installed, not activated
Engine Model/Series: TIGO-541
Registered Owner: On file
Rated Power: 425 hp
Operator: On file
Operating Certificate(s) Held: On-demand Air Taxi (135)

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KLRD
Distance from Accident Site:
Observation Time: 1056 CST
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 14 knots / 17 knots
Turbulence Type Forecast/Actual:
Wind Direction: 140°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.23 inches Hg
Temperature/Dew Point: 21°C / 7°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Laredo, TX (KLRD)
Type of Flight Plan Filed: None
Destination: Laredo, TX (KLRD)
Type of Clearance: VFR
Departure Time: 1035 CST
Type of Airspace: Class D

Airport Information

Airport: Laredo International (KLRD)
Runway Surface Type: Concrete
Airport Elevation: 508 ft
Runway Surface Condition: Dry
Runway Used: 18L
IFR Approach: None
Runway Length/Width: 8236 ft / 150 ft
VFR Approach/Landing: Precautionary Landing; Traffic Pattern

Wreckage and Impact Information

Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: In-Flight and On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude:  27.560833, -99.457500

1 comment:

Jim said...

Strange that NTSB did not want to investigate who was in what seat. Might have been a factor. They also were not interested in who which pilot was on the radio.