Accident Details
Probable Cause and Findings
Fatigue fracture of an engine cylinder resulting in a loss of power on the left engine. Additional causes were the pilot's failure to maintain minimum control airspeed (Vmc), the resulting loss of aircraft control, and an inadvertent stall/spin. Contributing factors were the pilot's failure to feather the propeller on the failed engine and his decision to turn toward the inoperative engine during the circling maneuver. Additional factors were the inoperative hydraulic system pump and the emergency landing gear actuation which caused the pilot to circle prior to landing.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On December 28, 2004, at 1135 central standard time, a Piper PA-23-250 (Aztec), N5398M, piloted by a commercial pilot, was substantially damaged during an in-flight collision with terrain at the Gogebic-Iron County Airport (IWD), Ironwood, Michigan. The pilot had reported an engine problem about 20 minutes before the accident while en route to IWD. The personal flight was operating under the provisions of 14 CFR Part 91. The flight was on an instrument flight rules (IFR) flight plan until the pilot canceled IFR on approach to IWD and proceeded under visual flight rules (VFR). Visual meteorological conditions prevailed at IWD. The pilot and four passengers sustained fatal injuries. The flight departed Menominee-Marinette Twin County Airport (MNM), Menominee, Michigan, about 1010.
An individual representing the accident aircraft contacted Green Bay Automated Flight Service Station (AFSS) at 0814 and obtained a pre-flight weather briefing from MNM to IWD. The pilot called Green Bay AFSS again at 0903 and requested an updated weather briefing. At the conclusion of that briefing the pilot filed an IFR flight plan from MNM to IWD.
The Federal Aviation Administration (FAA) provided transcripts of air traffic control (ATC) transmissions with the accident aircraft and radar track data for the flight. Radar track data was processed and plotted by the NTSB. The transcripts and plot of the radar track data are included with the docket information associated with the accident file.
The pilot established contact with Minneapolis Air Route Traffic Control Center (ARTCC) at 1021. The flight was approximately 10 nautical miles (nm) northwest of MNM and climbing through 5,000 feet mean sea level (msl) at the time. The flight climbed to 8,000 feet msl en route to IWD. Communications were routine during this portion of the flight. The pilot was informed that he could expect radar vectors for the Instrument Landing System (ILS) approach to runway 27 at IWD
At 1104, ATC instructed the flight to descend at pilot's discretion and maintain 3,500 feet msl. The pilot acknowledged this clearance.
At 1114:58 (HHMM:SS) the pilot transmitted: "I've got single engine problems here mayday mayday." The controller replied that the closest airport was IWD, the intended destination, and advised a heading of 310 degrees from the aircraft's present position.
At 1119:36 the controller instructed the pilot to turn left to 290 degrees to intercept the localizer on the ILS approach. Twenty-seven seconds later the pilot inquired about the aircraft's heading. The controller replied "you just took a hard left again on that twenty degree turn" and provided a 310-degree heading for the localizer intercept. The pilot stated that he had a "vacuum failure," however, he noted that he was able to maintain a heading. The aircraft subsequently descended below the level of radar coverage at 1120:35.
The pilot reported intercepting the ILS localizer at 1122:04. The pilot also stated, "[I] am single engine and one propeller feathered." At 1127:07, the pilot reported that the runway was in sight. At 1128:00, he reported a "complete loss of hydraulics" to the center controller. The pilot added that he was planning to circle to the left and hand pump the landing gear down. No further transmissions were received from the accident aircraft.
The plot of radar track data for the accident flight depicted the airplane approaching IWD from the southeast. The plot showed the airplane on a northwest ground track passing 6,700 feet msl at 1106:45 and descending until it reached 3,500 feet msl at 1113:46.
At 1114:58, when the pilot initially indicated that he had an engine problem, the radar track indicated that the aircraft was at 3,500 feet msl on an approximate magnetic course of 317 degrees. The aircraft then entered a descending left turn, reaching an altitude of 2,500 feet msl on a 169-degree magnetic course at 1115:22, 24 seconds later. The calculated average descent rate during this time frame was 2,500 feet-per-minute. The calculated average rate of course change during this time was approximately 7 degrees-per-second. A standard rate turn is defined at 3 degrees-per-second.
The track data indicated that the aircraft then entered a climbing right turn, reaching 3,500 feet msl at 1118:10 on an approximate course of 316 degrees. The aircraft subsequently turned left and descended again. Final radar contact was at 1120:35, 10.8 nm east of IWD at 2,400 feet msl.
The accident site was located in the side yard of a residence south of the IWD airport. The owner was home at the time. He reported hearing a loud noise and looked out a window to investigate. When he saw the accident site he contacted the sheriff's department.
PERSONNEL INFORMATION
The pilot held a commercial pilot certificate with airplane single and multi-engine land and instrument airplane ratings. He also held a flight instructor certificate with an airplane single-engine rating and a ground instructor certificate with advanced and instrument ratings.
The pilot was issued a second class airman medical certificate on October 9, 2004, with a restriction that corrective lenses must be worn.
The pilot's logbook was reviewed. The last logged flight was on November 30, 2004. According to the logbook, the pilot had accumulated 950.4 hours total flight time. He had logged 313.7 hours in multi-engine airplanes, with 11.5 hours logged within the previous 90 days. The pilot's most recent flight review was completed on February 26, 2003.
Within the previous 6 months, the pilot had logged 8.0 hours actual instrument flight time and 5.7 hours simulated instrument flight time. He had logged 20 approaches on flights where actual or simulated instrument flight time was also noted. An additional 24 approaches were logged without any corresponding instrument time for the particular flight.
AIRCRAFT INFORMATION
The accident airplane was a twin-engine 1977 Piper PA-23-250 Aztec, serial number 27-7754135. The airplane was a six-place, low-wing configuration with retractable tricycle landing gear. The airplane was powered by Lycoming IO-540-C4B5 six-cylinder, fuel-injected, reciprocating engines. Each engine was rated at 250 horsepower.
The engines provided power through Hartzell HC-E2YK-2RBS two-bladed propeller assemblies. The propellers were a hydraulically operated, constant speed design with feathering capability. The propeller blades were moved to lower pitch settings by oil pressure from the propeller governor. The blades were moved to a higher pitch setting by spring and air charge in the hub.
The maintenance logbooks were reviewed. The most recent annual inspection was completed on December 11, 2004, at a total airframe time of 7,210.5 hours. The engine and propeller logbooks noted a recording hour meter of 41.9 hours at that inspection. The hour meter read 48.6 hours at the accident site, indicating 6.7 hours had accumulated since the annual inspection.
The right engine assembly, serial number RL-9402-48, was overhauled on April 24, 1997, and installed on the accident aircraft on December 7, 1997. The logbook noted that 6 "CermiNil" remanufactured cylinders had been installed on the engine. At the time of the last annual inspection, the engine had accumulated 343.8 hours since overhaul. Total time for the engine was not noted.
The left engine assembly, serial number RL-11740-48, was overhauled on April 24, 1997, and installed on the accident aircraft on December 7, 1997. According to the logbook, 6 "CermiNil" remanufactured cylinders were also installed on this engine during the overhaul. Time since overhaul was 343.8 hours and total engine time was not noted in the log.
METEOROLOGICAL INFORMATION
The IWD Automated Weather Observing System (AWOS) recorded at 1135: Wind from 260 degrees at 12 knots; visibility 5 statute miles; overcast clouds at 1,100 feet above ground level (agl); temperature -04 degrees Celsius; dew point -08 degrees Celsius; and altimeter 29.89 inches of mercury.
WRECKAGE AND IMPACT INFORMATION
The accident site was located in the side yard of a residence adjacent to the IWD airport. Coordinates of the site were determined to be 46 degrees 31 minutes 17 seconds north latitude, 090 degrees 07 minutes 42 seconds west longitude using a handheld global positioning system (GPS) receiver. A line of trees about 40 feet in height was located approximately 19 feet west of the accident site. The tree line was oriented in a north-south direction and extended from the roadway south of the site to a point west of the accident site. No evidence of a tree strike was observed. Snow on the tree branches also appeared undisturbed.
A ground impact mark was located about 30 feet south of the wreckage location. The mark consisted of an elliptical depression in the snow about 20 feet long and 5 feet wide. Within the boundary of the depression, there were two gouges extending about 2 feet into the ground. They were 12 feet apart and measured approximately 4 feet by 4 feet in length and width. They were centered on the width of the depression and located symmetrically to the length.
The airplane came to rest on an approximate heading of 170 degrees magnetic. The wreckage was resting on the nose and the wings. The empennage was oriented vertically, approximately 65 degrees relative to the terrain.
The nose structure and engines were dislocated upward relative to the airframe. The wings exhibited leading edge crushing along the entire length. The empennage was buckled forward of the vertical stabilizer. Ice accretion was present on the leading edges of the wings, stabilator, vertical stabilizer, and antennas.
The flight control surfaces remained attached to the airframe. Control continuity was verified from the rudder and stabilator to the cabin area and from the ailerons to the cabin area. Stabilator trim cont...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CHI05FA049