N14A

HISTORY OF FLIGHT

On April 4, 2004, about 1606 eastern daylight time, a Piper PA-30, N14A, registered to Light Wing, LLC, crashed onto airport property shortly after takeoff from Fernandina Beach Municipal Airport, Fernandina Beach, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 personal flight from Fernandina Beach Municipal Airport, to Burlington-Alamance Regional Airport, Burlington, North Carolina. The airplane was substantially damaged and the commercial-rated pilot and one passenger were fatally injured. The flight originated about 5 minutes earlier from Fernandina Beach Municipal Airport.

One witness who is an airplane mechanic and was outside a hangar located north of runway 08/26, near the midfield of the runway, reported hearing the accident airplane's engines start, and based on the time from the engine start to the time he saw and heard the airplane during takeoff, he thought the pilot had time to perform an engine run-up before takeoff. The airplane departed from runway 26, and after becoming airborne, the gear retracted. The flight climbed to approximately 200 feet and at that time, the airplane banked to the left then quickly back to the right. After that, the airplane then appeared to be flying stabilized. The airplane then flew past the hangar where he was located and he lost sight of the airplane.

Another witness who was located east of the previous witness and who is a private-rated pilot reported he did not see the point where the airplane became airborne. He reported the airplane was airborne with the landing gear retracted before reaching the intersection of runway 04/22 and 08/26. He believed the airplane climbed to approximately 250-300 feet during climb out which initially appeared normal. Just before the airplane flew past the hangar, he heard a brief sputtering sound, and then observed the airplane bank to the left. He lost sight of the airplane for a short time and when he saw it again, the airplane was south of runway 08/26 and was in a 25-30 degree left wing low and nose-low attitude, which continued until the airplane impacted the ground. He described the sputtering sound as being similar to a sound he has heard in the past when power is reduced. He also reported that he did not see any smoke trailing the airplane.

NTSB review of recorded radar data from Whitehouse ARSR-4, Naval Air Station (NAS) Jacksonville ASR-8, and NAS Mayport ASR-8 radar facilities revealed all targets in the vicinity of the airport were transmitting "VFR 1200 code." A radar target at 1605:58, was located southeast of the departure end of runway 26, or northwest of the accident site location. The radar target was noted to be at 200 feet, with a speed of 105 knots, and the location was consistent with the witness reported position of the accident airplane.

Readout of the on-board, portable global positioning system (GPS) receiver at the manufacturer's facility revealed the unit retained data from the beginning of the taxi, to near the accident site location. The retained data (coordinates), is correlated with time received directly from satellites' signals. A review of the data and a plot of it revealed the airplane started taxiing at approximately 1600:27. The airplane taxied to runway 26, and a gap in data was noted between 1602:45, and 1604:46. At 1605:04, the airplane was plotted to be on the runway heading 266 degrees. The airplane continued on the runway heading from 1605:04, to 1605:21, at which time the ground speed was recorded to be 77 knots. The plotted data indicates the airplane began a left turn, accelerated to 92 knots groundspeed, and was on a heading of 144 degrees magnetic at 1605:50. The last recorded coordinates occurred at 1605:53, in which the groundspeed was 84 knots, and the heading was 122 degrees magnetic. The initial impact site was located approximately 97 feet and 71 degrees magnetic from the last recorded coordinates.

PERSONNEL INFORMATION

According to FAA records, the pilot was the holder of a commercial pilot certificate with ratings airplane multiengine land, and instrument airplane; he had a DC-3 type rating. He was also the holder of a private pilot certificate with a airplane single engine land rating. The pilot held a second-class medical certificate that was issued on January 15, 2003, with the restriction "must wear corrective lenses."

A review of the pilot's pilot logbook that contained entries from November 18, 1995, to November 23, 2003, and a computer flight log which contained entries from September 1, 2003, to December 28, 2003, some of which are duplicate entries from the pilot logbook, revealed his total logged flight time was approximately 643 hours. His first logged flight in the accident airplane occurred on December 21, 2001; since that date he logged a total time of 150.9 hours in the accident airplane. His last flight review in accordance with federal regulations occurred on September 9, 2003; the flight duration was 3.6 hours, and was flown in a Piper PA-39. At the time of the accident, the airplane had been operated approximately 43 hours since the date of the last logged flight in the computer flight log.

AIRCRAFT INFORMATION

The airplane was manufactured on July 13, 1966, by Piper Aircraft Corporation, as model PA-30, and designated serial number 30-1208. The airplane was certificated in the normal category, and Brittain Industries model TT-5 tip tanks were installed when the airplane was manufactured under Delegation Option Authorization. With the installed tip tanks, the design gross weight was 3,725 pounds. Robertson Aircraft Corporation modified the airplane on March 3, 1973, in accordance with Supplemental Type Certificate (STC) SA2312WE, and SA1113SW. Supplemental Type Certificate SA2312WE, incorporated leading edge cuffs, stall fences, stall strips, drooped ailerons, flap actuated stabilator trim system, and dorsal fin. The STC (SA2312WE), allowed the gross weight to be increased to 3,800 pounds, and lowered the velocity minimum control (Vmc) speed to 80 miles-per-hour. The limitations and conditions section of the STC indicated, "When Brittain Model TT-5 wing tip tanks are installed, all weight in excess of 3,650 lbs. must consist of symmetrically loaded fuel in the tip tanks." Supplemental Type Certificate SA1113SW incorporated a nose extension. Two 200-horsepower, Lycoming IO-360-C1C engines, and two Hartzell HC-C2YR-2CFU constant-speed, manual-feathering propellers were installed on August 15, 1974, in accordance with STC SA 1151SW. The airplane was also equipped with a JPI Instruments EDM 760 engine monitor that was installed on March 24, 2003, in accordance with STC SA00729SE. The engine monitor was programmed to record in part the exhaust gas temperature (EGT) and cylinder head temperature (CHT) readings from both engines every 6 seconds.

Light Wing LLC (owner at time of accident), purchased the airplane on December 21, 2001; the pilot and passenger were each listed as a co-owner of the airplane on the "Aircraft Registration Application." Both engines were removed from the airplane and overhauled on March 21, 2002; the overhauled engines were installed in the airplane on April 17, 2002. At the time of each engine overhaul, both servo fuel injectors and manifold valves were overhauled, and new engine-driven fuel pumps were installed on each engine. At the time of the accident, the airplane had accumulated approximately 161 hours since the overhauled engines were installed.

A review of the maintenance records revealed on June 26, 2002, or approximately 6 months after the pilot and passenger purchased the airplane, and approximately 2 months after the overhauled engines were installed, an entry in the airframe logbook indicates, "Troubleshot both engines running rough. Cleaned all fuel injectors and spark plugs. Reinstalled cowlings. Removed small amount of water from fuel tanks during sumping." The airplane was approved for return to service. There was no entry in the airframe logbook between June 26, 2002, and March 26, 2004, indicating repairs or work performed to the airplane's fuel tanks, or fuel caps.

A review of the pilot's computer flight log revealed two entries describing discrepancies relating to the fuel injector systems of both engines. The first entry was dated October 18, 2003, and the remark was "clogged L3 injector." The next entry was dated October 19, 2003, and the remark was "L4 & R4 injector clogs." Review of the airframe and both engine maintenance records revealed no entry on or immediately following those dates indicating the above referenced fuel injectors were removed and inspected.

Further review of the airframe logbook revealed the airplane was last inspected on March 26, 2004, in accordance with an annual inspection. The inspection of the airplane was performed using Piper Aircraft Corporation Inspection Report, and additional inspection items prepared by the facility. During the inspection, the fuel caps were removed, and the fuel cap seals were inspected and lubricated. Airworthiness Directive (AD) 83-10-01, which requires inspection every 50 hours to prevent retention of water and deterioration of fuel system, was complied with. The AD requires in part removal of the fuel strainers, and to inspect the screen. An individual of the facility that performed the inspection later reported that during the inspection, "When we removed the filter bowls we found water and a little rust. We discussed the importance of draining the fuel bowls and for how long. During the demonstration, we found a small amount of water in the fuel. We drained until clean fuel was present." Also during the inspection, standing water was noted on top of the left main and auxiliary fuel quantity senders. They were removed, corrosion on both was removed, the cleaned area on b...