N4319P

HISTORY OF FLIGHT

On November 9, 2005, at 2059 central standard time, a Piper PA-23-160, N4319P, operated by Blackstone Rotorcraft Inc., received substantial damage on impact with terrain about one mile southeast of Central Illinois Regional Airport (BMI), Bloomington, Illinois, during a visual approach to runway 29. Night visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 135 on-demand cargo flight was operating on an instrument rules flight plan. The pilot was fatally injured. The flight departed from Greater Peoria Regional Airport (PIA), Peoria, Illinois, en route to Johnston County Airport (JNX), Smithfield, North Carolina, at 2021 and returned to PIA without incident after the pilot reported that the airplane door came open. The flight then departed at 2031 and diverted back to PIA due to a reported rough right engine, but while diverting back to PIA, the pilot diverted to BMI. The pilot did not declare an emergency.

N4319P was fueled by a PIA fixed base operator's (FBO's) line service technician who stated that the pilot of N4319P told him to fuel the airplane's main and auxiliary fuel tanks. The line service technician stated that he fueled everything with 100 low lead and he did not fuel the tip tanks. The line service technician stated that the pilot was present when he fueled the airplane, and the pilot "seemed happy." The line service technician stated that the pilot "verified" the fuel and oil, but he did not see the pilot sump the fuel tanks after the airplane was fueled and added that "maybe" he was not present "at the exact" time when the pilot sumped the fuel tanks.

The line service technician stated that another airplane that was fueled from the same truck did not report any problems.

An FBO front desk employee stated that the pilot of N4319P came into the FBO to pay for fuel and cargo and at that time he "seemed fine."

Fuel and credit card receipts show that 59 gallons of fuel was purchased at 2004 and 104 lbs of freight on/off loaded.

The following is a partial transcription of air traffic control recordings of transmissions made by Champaign (CMI) Approach Control (APCH), PIA APCH, BMI air traffic control tower (ATCT), PIA ATCT Combined APCH (CAP), and N4319P.

2011, N4319P called PIA ground control and obtained an instrument clearance to JNX.

2016, N4319P advised PIA that he was ready to taxi and was given taxi instructions to runway 31

2020, N4319P called PIA ATCT ready to depart runway 31 and was issued a takeoff clearance with an assigned departure heading of 360

2022, N4319P advised PIA ATCT a need to return to the airport because a door on the aircraft opened. The ATCT controller cleared N4319P to land on runway 31

2031, N4319P advised PIA ATCT ready to depart runway 31. PAI ATCT issued takeoff clearance and assigned a departure heading of 360 degrees

2032, PIA ATCT instructed N4319P to contact the departure controller

2033, N4319P contacted PIA Departure and was issued a climb clearance to 9,000 feet

2035, N4319P was issued on course

2048, N4319P was instructed to contact CMI APCH.

2051, CMI APCH requested a heading from PIA to assign N4319P to return to PIA and informed PIA APCH the aircraft right engine is not developing full power and wanted to return to PIA

2052:59, PIA ATC/APP, (unintelligible) four three one niner papa peoria approach ah expect visual approach runway three one and ah are you declaring an emergency

2053:14, N4319P, ah negative its just ah just developing partial power i'm in good shape

2053:14, PIA ATC/APP, ya i was gonna say ah right now i show you doing seventy knots for the ground speed ah if you'd like bloomington airport's about seven miles northeast of your position

2053:26, N4319P, all right give me a vector to bloomington

2053:28, CAP, okay one niner papa descend and maintain three thousand and you can turn back right heading of about let's make the heading one five zero and we'll set you up for runway two nine

2056:49, N4319P, bloomington tower four three one niner papa

2056:53, LC, apache four three one niner papa bloomington tower good evening report the midfield downwind runway two nine

2056:59, N4319P, one niner papa

2057:20, LC, apache one niner papa just verify you do have the airport in sight

2057:26, N4319P, that's affirmative in my ah about ten o clock right now

2057:30, LC, affirm

2057:32, LC, are you requiring any assistance at this time

2057:34, N4319P, a negative I just need to see if I can find out whats the problem with that engine

2057:38, LC, roger

2058:24, N4319P, one niner papas midfield downwind runway two nine

2058:31, LC, apache one nine papa runway two nine cleared to land

2059:19, N4319P, *(breathing) [expletive]

2059:32, N4319P, *(breathing) aw [expletive] me

2059:48, LC, apache one niner papa can you make it

2059:50, N4319P, aw

2100:59, LC, apache four three one niner papa bloomington tower

There were no further recorded transmissions from N4319P.

The BMI ATCT controller stated that he saw N4319P make a base turn when it started losing altitude. The airplane made a "sharp turn" to the south and continued to lose altitude. The airplane impacted the ground and exploded "shortly" after impact.

PERSONNEL INFORMATION

The pilot was issued a second class medical certificate on May 5, 2005 with the following limitation: "Holder shall wear lenses that correct for distant vision and possess glasses that correct for near and intermediate vision. Certificate not valid after May 31, 2006."

AIRCRAFT INFORMATION

The 1959 PA-23-160, serial number 23-1820, was powered by two Lycoming O-320-B3B engines with left and right engine serial numbers of L-3948-39 and L-4052-39, respectively. Aircraft logbook entries stated that an annual inspection of the airplane and engines was completed on October 15, 2005, at a left tachometer time of 493 hours.

The airplane was configured and operated as an on-demand cargo airplane at the time of the accident.

AIRPORT INFORMATION

BMI is a controlled airport located about 37 nautical miles east of PIA. BMI is served by runway 02-20 (8,000 feet by 150 feet, grooved concrete) and runway 11-29 (6,529 feet by 150 feet, asphalt, grooved concrete). Runway 02-20 was equipped with high intensity runway lights and centerline lights. Runway 02 was equipped with a precision approach path indicator with 4 identical light units on the right side of the runway and runway 20 was equipped with a medium intensity approach lighting system with runway alignment indicator lights. Runway 11-29 was equipped with high intensity runway lights. Runway 11 was equipped with runway end identifier lights and a 4-box visual approach slope indicator on the right side of the runway. Runway 29 was equipped with lead-in lighting system.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located approximately one nautical mile southeast of BMI in an agricultural field. The main wreckage exhibited fire damage along the wings, fuselage, and engines.

The left propeller was attached to the engine with one blade deformed aft approximately 10 degrees and twisted towards the low pitch. The other blade of the left propeller was deformed aft about 90 degrees near mid span and twisted towards low pitch. The left propeller was not in the feathered position.

The right propeller was attached to the engine with one blade deformed aft about 10 degrees near the root. The propeller was not in the feathered position.

Flight control continuity was confirmed. The rudder trim actuator extension was approximately 1 inch, which equates to a neutral position. The horizontal trim actuator was extended 1 5/8 inch, which equates to a neutral position. The flap control handle was partially melted and in the mid travel position.

The landing gear control handle was partially melted and in the down position.

Magnetos from both engines were rotated by hand and a spark noted from each magneto terminal.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot's toxicological test results performed by the Federal Aviation Administration were as follows:

No carbon monoxide detected in blood, no cyanide detected in blood, no ethanol detected in blood, 61.6 (ug/ml, ug/g) acetaminophen, amlodipine present in urine, and amplodipine not detected in blood.

The following information was extracted from the pilot's medical records maintained by the FAA Aerospace Medical Certification Division:

April 20, 2004, A letter to the FAA from the pilot's Aviation Medical Examiner notes, in part, [The pilot] was in the office 4-20-04 for his annual second class medical certification. I have been his personal physician for the past two years.

He is being treated for diabetes, hypertension, and hyperlipidemia.

Current medications include Crestor [rosuvastatin] 10 mg daily, Norvasc [amlodipine] 10 mg daily, Lotensin [benazepril] 20 mg twice a day, HCTZ [hydrochlorothiazide] 25 mg daily, Glucophage [metformin] XR 500 mg daily, and aspirin 5 grains daily.

His blood pressure has been well controlled. Today it is 128/82, on 4-5-04 it was 126/80, and on 2-9-04 it was 134/80.

His diabetes is well controlled. On 4-5-04 he had lab work done that revealed a hemoglobin A1C of 5.9. Remainder of his chemistry panel and lipid profile is attached. He has had no hypoglycemic episodes, no side effects from his medication, and he has no evidence of end organ damage.

He was hospitalized briefly in May of 2003 with "indigestion." He had a cardiology consultation and a surgical consultation and was found to have biliary colic and cholecystitis. He subsequently had an uneventful laparoscopic cholecystectomy from which he made a complete recovery. As a precaution he also had coronary arteriograms done and he had no evidence of significant coronary artery disease and his ejection fraction was normal. Copies of relevant notes are attached as well.

The remainder of his examination today meets...