N6933Y

HISTORY OF FLIGHT

On November 27, 1997, at 1235 hours Pacific standard time, a Piper PA-23-250, N6933Y, rolled inverted during the takeoff initial climb and impacted a hangar at the Carson City, Nevada, airport. The aircraft was destroyed and the commercial pilot and three passengers were fatally injured. Visual meteorological conditions prevailed for the personal flight. The flight was originating at the time and was destined for Nacadoches, Texas.

A private pilot witnessed the takeoff from near the midfield location adjacent to runway 27. The runway is 5,900 feet long and the airport elevation is 4,697 feet. The witness reported that the accident aircraft lifted off prior to reaching his location and passed in front of him at 30 - 50 feet agl. The nose gear had retracted and the main gear was in transit. The engines sounded normal. As the aircraft continued west over the runway, the witness sensed that something was wrong as the aircraft reached 150 - 200 feet agl, it yawed slightly, and appeared to mush. The nose pitched up and the aircraft rolled to the left, then the nose dropped and the aircraft disappeared behind a parked aircraft in a vertical dive and he heard the impact in the hangar. When the aircraft pitched up and rolled to the left, he had a view of the top of the aircraft from the rear and could see that the nose baggage door on the right side of the nose was open. As the aircraft continued to roll, the baggage door appeared to fold back over the nose in front of the windshield but it did not come off. He did not observe anything fall from the aircraft and the engine sound was normal except that there was what the witness termed a "Doppler shift" as the aircraft spun toward the ground.

Another witness, a commercial pilot who was on the midfield ramp about 200 feet south of the runway edge, also reported that the engines sounded normal as the aircraft passed midfield. His attention was attracted to the aircraft by its abnormally steep climb angle. However, this witness reported hearing a pop - pop sound which he attributed to one of the aircraft's engines immediately before the nose pitch up and "VMC roll".

Another pilot/witness observed the aircraft climbing out at a very steep angle and stated, "As we continued to watch the plane continued up on a steep angle, until the plane stalled. At the stall the plane nosed down to the left and went directly down into a [hangar]."

Still another witness reported that the aircraft appeared to climb normally to about 200 feet agl and then it "appeared to zoom upward at an excessive rate for about 100 ft. more and then nosed over in a dive straight for the ground."

Another commercial pilot, who did not witness the accident, reported landing at Carson City about 1130 behind the landing Aztec and taxiing behind the aircraft to the (unattended) self-fueling pumps. He said that there were two young men in the aircraft and he spoke to the one who was the pilot. The pilot said that he had rented the aircraft in Southern California and had flown to Santa Rosa to pick up his brother. They were now picking up his mother and girlfriend and going to Texas. While they were talking a car drove up with the two women. The other young man, who did not appear knowledgeable about airplanes, asked the pilot where to load the baggage. The pilot said to put the heavy bags up front and the second man loaded approximately two to four pieces of luggage in the nose baggage compartment. It appeared that the pilot fueled all the tanks of the accident aircraft to capacity. This pilot fueled his aircraft after the pilot of the accident aircraft fueled his and recalled clearing the pump which read about 109 gallons. (According to the facility operator, there is only one grade of fuel sold at the self-fueling facility, 100LL.) This pilot then took off about 1200 while the accident aircraft was still on the fueling ramp and returned to Stead Airport and reported no problem with the fuel.

A modest amount of burned luggage residue was found in the area of the nose baggage compartment at the accident site. Two separate foot searches of the runway environs failed to locate any items from the aircraft. The husband of the pilot's mother brought her to the airport and helped load luggage. He reported through a friend of the family that the group only had about 20 pounds of soft luggage. He reported that he only helped load the baggage and did not operate the baggage door.

No fuel sample was retained by the fuel pump operator (Texaco). However, refueling records for the time following the refueling of the accident aircraft (attached), show three other aircraft were fueled after the accident aircraft and no abnormalities were reported. The records show that the pilot added 119.6 gallons. The clock times on the record are erroneous.

PERSONNEL INFORMATION

The pilot was employed as a flight engineer at a supplemental air carrier. The pilot's logbook was located in the wreckage with fire damage. It indicated total flying time of 484 hours as of November 15, 1997. The pilot's multiengine airplane rating was issued June 26, 1997, after 7.2 hours of instruction and check ride in a Beech BE-95. On August 1, 1997, the pilot logged 1.9 hours in a Piper PA-34-200 and 2.3 hours in a Beech BE-58. On November 14 and 15, 1997, the pilot flew 8.6 hours during his checkout in the accident aircraft.

One of the two flight instructors who performed the checkout in the accident aircraft said that they do not normally simulate engine failures on takeoff or do Vmc demonstrations during checkout of a rated pilot. They did do slow flight, steep turns, and stalls, as well as a high altitude airport landing and takeoff. They also practiced engine out procedures by retarding the mixture control while in cruise flight. This instructor considered the pilot a "very good pilot" who flew well and kept the airplane under control.

There were no further entries in the pilot's logbook after November 15. The Safety Board investigator, using a DUATS, no wind, flight plan, estimated that the pilot flew an additional 3.1 hours in the accident aircraft while en route from Pomona, California, to Santa Rosa, California, to Carson City preceding the accident.

AIRCRAFT INFORMATION

The aircraft's weight and balance at the time of the accident was estimated by the Safety Board investigator using postaccident weights of the occupants provided by the Coroner's office, together with baggage and fuel weights reported from other sources. The initial calculation indicated that the takeoff center of gravity position was 100.32 inches aft of datum. However, a subsequent examination of the aircraft weighing record dated October 29, 1997, revealed an error in the calculation which caused the empty weight center of gravity position to be reported 2.4 inches aft of the true position. After compensating for this error, the calculation showed the takeoff weight of the accident aircraft was 4,730 pounds and the center of gravity was at 98.5 inches aft of datum. According to the weight and balance documents, the maximum takeoff weight is 5,200 pounds and the center of gravity limits (at 4,730 pounds) are 95.3 to 100.5 inches.

In the operator's "Flight Squawk Record" document, squawk number 2, dated September 15, 1997, is "door ajar lt inop." The corrective action, dated September 16, 1997, is "adjusted fwd baggage compartment door switch. Light works good." According to the operator, the door ajar light was located on the glareshield in front of the right seat passenger.

METEOROLOGICAL INFORMATION

According to a deputy from the Carson City Sheriff's Department, weather at Carson City at the time of the accident was clear and sunny, calm wind, and temperature in the mid 40-degree Fahrenheit range.

WRECKAGE AND IMPACT INFORMATION

The aircraft impacted in the roof of a "Porta-Hangar" single aircraft, T-hangar located approximately 1,000 feet from the departure end of runway 27 and 200 feet south of the runway centerline. The hanger, in the center row of three rows of "Porta-Hangar's" was identified as B6 and is located at latitude 39 degrees 11.13 minutes north, and longitude 119 degrees 44.26 minutes west (GPS). There was a fire following impact with the ground and the entire aircraft was destroyed by the fire. Burned debris associated with the aircraft was found on the floor of the hangar approximately in the planform of the aircraft with the fuselage aligned approximately 300 degrees. A Cessna T210 aircraft was stored in the hangar and was also destroyed.

The fuselage was oriented with the nose in the northwest corner of the hangar and the skeletal remains of the empennage about 25 feet southeast near the center of the hangar door. The aluminum components of the fuselage were consumed by fire except for the area under the cabin floor in proximity of the wing center section structure. The instrument panel, switches, and radios were destroyed by impact damage and fire. The cabin area was identifiable by the steel tube truss cabin structure, seat frames, and lower fuselage in proximity of the wing center section. The cabin floor beneath the pilot's seat was buckled. The pilot's seat remained attached to the right rail and was detached from the left rail. The aft travel seat stop was in place on the left rail and the seat was positioned forward of the stop. The engine power levers were bent to the right side. The throttle and propeller controls were approximately in the mid-range position with the left-hand engine controls forward of the right hand engine.

The nose baggage door latch handle and recess assembly, and the latch operating shafts were located in the nose area of the wreckage. The handle was approximately 1/4-inch open at the locking end and solidified molten metal had filled the cavity between the handle and the recess fixture. The track for the nose baggage door ...