N8155C

HISTORY OF FLIGHT

On October 27, 2007, about 2012 eastern daylight time, a Piper PA-28-181, N8155C, operated by Rohan Aviation, Incorporated, doing business as Kemper Aviation, was substantially damaged when it impacted trees and terrain in Boynton Beach, Florida following a loss of engine power. The certificated flight instructor (CFI) and the certificated private pilot receiving instrument instruction were fatally injured, and the passenger was seriously injured. Night visual meteorological conditions prevailed, and no flight plan had been filed for the instructional flight, which was operating under the provisions of 14 Code of Federal Regulations Part 91.

According to Federal Aviation Administration (FAA) air traffic control (ATC) information, radar contact with the accident airplane was initially established about 1813, shortly after the airplane departed its base at Palm Beach County Park Airport (LNA), Lantana, Florida. The pilots then conducted four practice instrument approaches at four different airports in Florida. These included Kendall-Tamiami Executive Airport (TMB), Miami, Opa-Locka Executive Airport (OPF), Miami, Ft. Lauderdale Executive Airport (FXE), Ft. Lauderdale, and Pompano Beach Airpark (PMP), Pompano Beach.

Communications between the PMP air traffic control tower (ATCT) and the airplane indicated that the pilots planned to conduct a low approach to runway 15 at PMP, followed by the missed approach and then the very high frequency omnidirectional radio range (VOR) approach to return to LNA. About 1956, the pilots initiated the missed approach. The ground track derived from ATC radar data initially depicted the airplane when it was approximately 4 1/2 miles northwest of PMP, and proceeding to the northwest. The airplane maintained this track at an altitude of 2,700 feet for approximately 4 miles, and then flew in a more northerly direction for another 4 miles. About 1957, PMP ATCT instructed the pilots to contact Palm Beach Approach once they were "established northeast bound." About 2001, the pilots contacted Palm Beach Approach, and were initially cleared "direct Lantana." The pilots responded that they wanted the "full VOR" approach, and about 2002 the Palm Beach Approach controller instructed the pilots to "proceed direct [to the] Palm Beach" VOR, and to "maintain VFR at two thousand five hundred for now."

About 2003, the airplane turned to the northeast, towards the VOR. About the same time, the pilots radioed that they needed to descend to 2,000 feet to remain in visual meteorological conditions, and were approved to do so by the controller. About 2006, the ground radar data indicated that the airplane departed 2,000 feet and began a descent of approximately 300 feet per minute (fpm). There were no communications from the airplane regarding this descent. About 2009, when the airplane was at an altitude of approximately 1,000 feet, the pilots reported to the controller that "we have engine problems, we need to land as soon as possible." The controller first responded with a query as to whether the pilots preferred to "come to Palm Beach or go to Lantana?" After 10 seconds and two unsuccessful attempts to communicate their preference, the pilots radioed that they were "unable to maintain altitude" and that they did "not know how long the engine is gonna hold for us." The controller advised the pilots that "Lantana airport is twelve o'clock and four miles you just want to land there?" There was no response, and eight seconds later the controller repeated the transmission. The pilots responded, but the transmissions were only partially intelligible. The final transmission from the airplane was received 1 minute and 35 seconds after the initial declaration of the engine problem, and appeared to indicate that the pilots intended to land on a road. Radar data indicated that during this period, the airplane flew to the northeast, then turned north, and then turned to the east, all while it was in a continuous descent. The final four radar data points depicted a flight path that nearly reversed course to the west in a sharp right turn, and descended from an altitude of 500 feet. The last radar data point indicated an airplane altitude of 100 feet, at a time of 2011.

Several persons on the ground either heard or saw an airplane in the area with engine problems. Most of these witnesses reported that unusual engine noises drew their attention to the airplane; almost uniformly, the witnesses described the engine as "sputtering." Two individuals who were located in a house approximately 300 feet from the impact point heard the impact, but when they stepped outside and visually scanned the area, they did not see the wreckage.

According to FAA communications transcripts, about 2010 the Palm Beach controller solicited the assistance of another airplane in the area to locate the accident airplane. About 2014, another airplane contacted the controller and offered search assistance, and about 2017 the pilot of that airplane reported receiving an emergency locator transmitter (ELT) signal. In the ensuing hour, several other airplanes assisted in the search, and were able to determine the general location of the ELT signal. About 2129, a Palm Beach County Sheriff's Office helicopter reported to the controller that it had located the wreckage.

Several months after the accident, the surviving passenger was interviewed about the accident flight. The passenger had approximately 23 total hours of flight experience, all in Cessna 152 airplanes, and he had been invited along on the flight as an observer by the pilot. He was seated in the rear seat, on the right side of the airplane, and could hear and communicate with the two pilots in the front via his headset. He could also hear the ATC communications. According to the passenger, the airplane was headed back to LNA when "the engine quit." He said that the pilots immediately notified ATC that they had an engine problem, and that both pilots were focused exclusively on looking for a place to land, but that it was difficult due to the darkness. He could not recall either pilot making any attempt to diagnose the reason for the engine failure, or taking any actions to restart the engine. The passenger recalled that at some point, the pilot pointed out a road on the left side of the airplane as a suitable landing area, but that the CFI countered the suggestion with a decision to have the pilot land on a golf course. The passenger said that the airplane hit trees and "cartwheeled" during the attempted landing on the golf course. When he was asked about it in the interview, the passenger could not recall any in-flight discussion by the pilots regarding fuel management, and was he not aware of the pilot switching fuel tanks during the flight.

PERSONNEL INFORMATION

The pilot in the left seat held a private pilot certificate with airplane single engine land (ASEL) rating. His most recent first-class medical was dated November 15, 2006. He began his flight training in December 2006. According to his logbook, the pilot had approximately 360 hours of flight experience, including 42 hours of night experience, and received 180 hours of flight instruction. The pilot had accrued approximately 17 hours of flight time in the 30 days prior to the accident. The accident flight was the pilot's first flight since October 22, 2007. The pilot's toxicology report noted that no screened compounds were detected.

The CFI in the right seat began instructing at the flight school in June 2007. His most recent second-class medical was dated April 24, 2007. He held an Airline Transport Pilot certificate with ASEL and airplane multiengine land (AMEL) ratings, a Flight Instructor certificate with ASEL, AMEL and instrument airplane ratings, and a Ground Instructor certificate with advanced and instrument ratings. He reported approximately 12,500 hours of total flight experience on his last medical application. A summary sheet provided to the flight school by the CFI indicated that, as of April 2007, he had provided approximately 1,300 hours of flight instruction in single engine airplanes.

The CFI's toxicology report noted the presence of labetalol, amlodipine, and irbesartan. The CFI’s most recent application for his FAA first-class medical certificate, dated October 18, 2007, indicated the use of these three medications, which are used to control blood pressure, and was approved by the FAA.

AIRCRAFT INFORMATION

According to FAA records, the airplane was manufactured in 1980. It was equipped with a Lycoming O-360-A4M engine, and two fuel tanks. Each tank had a maximum capacity of 25 gallons, including 1 gallon of unusable fuel. The fuel selector valve control was located on the left cockpit sidewall panel, forward of the pilot’s seat. Fuel selector positions were "Off," "Left Main," and "Right Main."

Each fuel tank was equipped with an individual drain at the bottom, inboard aft corner. A fuel strainer, located on the lower left front of the firewall, had a drain which was accessible from outside the nose section. According to the Pilot's Operating Handbook (POH), the fuel drains "should be opened daily prior to first flight to check for water or sediment" and the strainer "should also be drained before the first flight of the day." Fuel quantity and pressure were indicated on gauges located on the left side of the instrument panel. An auxiliary electric fuel pump was provided "in case of failure of the engine driven pump. The electric pump should be on for all takeoffs and landings, and when switching tanks."

According to the POH, the flaps were manually operated, and spring-loaded to return to the up/retracted position.

According to FAA and maintenance records, the airplane had accumulated approximately 5,200 hours total time in service, and the engine had accumulated approximately 3,300 hours since the previous major overhaul. The airplane had accumulated approx...