N422HP

HISTORY OF FLIGHT

On October 21, 2011, about 0415 Pacific daylight time (PDT), N422HP, a Piper PA-46R-350T airplane, sustained substantial damage as a result of a forced landing following a loss of engine power near Paso Robles Municipal Airport (PRB), Paso Robles, California. The pilot, the sole occupant of the airplane, suffered minor injuries. The airplane is registered to Central Valley Mortgage Services of Porterville, California. The cross-country business flight was being operated in accordance with Title 14 Code of Federal Regulations (CFR) Part 91, and an instrument flight rules (IFR) flight plan was filed and activated. The flight departed the Porterville Municipal Airport (PTV), Porterville, California about 0300, with PRB as its destination.

In a written report submitted to the National Transportation Safety Board investigator-in-charge (IIC), the pilot reported that after missing the first instrument approach he was cleared by air traffic approach control for a second approach. The pilot stated that when he was on course [inbound] the engine began to make a sound similar to that of fuel starvation. The pilot further stated that he made sure that the fuel mixture was “full rich” and turned on the fuel pump, but there was no change in the sound coming from the engine. The pilot reported that he then changed fuel tanks but there was still no change in the engine sound, and as he was losing altitude fast he needed to set up for a glassy water [type] landing due to the fog, the dark night condition, and the hilly terrain. The pilot stated that he now had the throttle full forward, and while the engine was running it was not making full power. The airplane subsequently impacted an open field in the landing configuration, coming to rest in an upright position.

An onsite postaccident examination performed by a Federal Aviation Administration (FAA) aviation safety inspector revealed that the airplane sustained substantial damage to both wings. It was also revealed that both main landing gear and the flaps were extended and that the nose landing gear was bent aft from the extended position. There was no observable damage to the empennage. The airplane was recovered to a secured location for further examination.

PERSONNEL INFORMATION

The pilot, age 65, held an airline transport pilot certificate. He possessed ratings for airplane single-engine land and sea, airplane multiengine land and sea, and instrument airplane. The pilot also held a flight instructor certificate for airplane single-engine, multiengine, and instrument airplane. The pilot reported a total time of 32,476.7 total hours of flight time, 23,061.7 hours in single-engine airplanes, and 9,415 hour in multiengine airplanes. The pilot reported 243.9 hours flown in the past 90 days, 109 hours in the last 30 days, and 4.1 hours in the last 24 hours. The pilot reported 420 hours in the make and model as the accident airplane, with 75.3 hours as an instructor in make and model. His most recent flight review was conducted on September 21, 2010. The pilot held a second-class medical certificate issued on July 29, 2011, with the restriction that he “must have glasses available for near vision.”

AIRCRAFT INFORMATION

The 2009 fixed wing single-engine airplane, serial number 4692122, received a FAA airworthiness certificate on May 29, 2009. The airplane was equipped with a Lycoming TIO-540-AE2A , turbocharged, fuel injected, reciprocating engine, serial number L-13354-61A, and was rated at 350 horsepower. The engine was equipped with a composite three-blade Hartzell constant speed propeller.

A review of aircraft maintenance records indicated that the most recent annual inspection was performed on May 4, 2011, at a total aircraft time of 281.1 hours. A review of the engine logbooks revealed that a left magneto, part number 6363, serial number 09020514, was removed and reinstalled after repairs had been completed by Ly-Con Rebuilding Co. of Visalia, California, on October 18, 2011, at a total aircraft time of 336.6 hours.

The airplane was equipped with an Avidyne Flightmax Entegra EX5000 R8.1 Multi-function Display unit (MFD). The engine page provides the pilot with engine parameters depicted on simulated gauges and electrical system parameters located in dedicated regions within the MFD display.

The most recent fueling of the airplane was recorded to have taken place at the Visalia Municipal Airport, Visalia, California, on October 7, 2011, two weeks prior to the accident. At that time the airplane was topped off with 69.4 gallons of 100LL aviation fuel. The only flight reported to have taken place during the two week period preceding the accident flight was the reposition flight from Visalia to Porterville, a distance of about 23 nautical miles.

METEOROLOGICAL INFORMATION

At 0403, the PRB weather reporting facility located about 3 nautical miles (nm) south of the accident site reported wind 310 degrees at 6 knots, visibility 1 ¾ miles, mist, overcast clouds at 200 feet mean sea level (msl), temperature 12 degrees Celsius (C), dew point 11 degrees C, and an altimeter setting of 30.08 inches of mercury.

At 0414, the PRB weather reporting facility indicated wind 300 degrees at 4 knots, visibility 2 ½ miles, mist, overcast clouds at 200 feet msl, temperature 12 degrees C, dew point 11 degrees C, and an altimeter setting of 30.09 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest upright in an open field surrounded by gentle rolling terrain about 3.07 nm north and slightly west of the extended centerline of runway 19 at PRB. The measured geographical coordinates at the accident site were 35 degrees 43.862 minutes north latitude and 120 degrees 36.905 minutes west longitude, and the elevation was measured at 927 feet msl.

An examination of the airplane at the accident site revealed that both wings had sustained substantial damage, all three propeller blades were damaged, and that the flaps and landing gear were configured in the extended position. The airplane’s cabin section and aft fuselage, inclusive of the empennage, were intact and appeared undamaged.

TESTS AND RESEARCH

On November 9th and 10th, 2011, under the supervision of the National Transportation Safety Board IIC, representatives from the FAA, Lycoming Engines and Piper Aircraft, Inc. examined the airplane at the facilities of Plain Parts, located in Pleasant Grove, California.

Multi-Function Display (MFD) examination

During the examination the airplane’s Avidyne Multi-Function Display (MFD) yielded a CF memory card, which provides GPS position, time and track data, as well as information from the airplane concerning altitude, engine and electrical system parameters, and outside air temperature. Under the supervision of the IIC, the MFD memory card was downloaded on site using a portable laptop computer. This data was then sent to the NTSB Vehicle Recorders Laboratory in Washington, D.C., who processed the recorded flight data. (Refer to the NTSB Vehicle Recorder’s Specialist’s Factual Report, which is located in the docket.)

The downloaded MFD data resulted in 3 plots and corresponding tabular data being generated, which were then provided in graphical format to the IIC. The plots covered a time period from 03:15:00 to 04:15:00 (PDT), which is the entire flight. The last recorded data point occurred at 04:14:06. Plot one contains basic engine parameters, including engine speed, oil pressure, oil temperature, and cylinder temperatures. Plot two contains fuel system and gear weight on wheels information. Plot three contains electrical system parameters.

A review and analysis of the Avidyne MFD data was conducted by a Lycoming Electronic Engine Controls Lead Engineer and a Piper Aircraft Powerplant and Mechanical Systems Engineer. This information was subsequently reviewed by an NTSB powerplant engineer, who concurred with both assessments. Their reviews revealed the following:

Lycoming Engines engineer’s review: (all times referred to are Pacific daylight time)

When the pilot did his missed approach procedure at 04:01, he did not return the engine to a full rich condition. The pilot’s climb back to about 6,000 feet pressure altitude was performed at something less than full rich.

At 04:06, the [engine] was making full power with about 42 in-Hg manifold pressure and 2,500 RPM. However, he was running a fuel flow which put him in the 0.43 Brake Specific Fuel Consumption (BSFC) range (so he was not at 350 horsepower). This is very lean, and his cylinder head temperature (CHT) peaked around 450 degrees Fahrenheit (F), while the Turbine Inlet Temperature (TIT) was running [between] 1,700 to 1,800 degrees F for about 5 minutes. One of these two elevated temperatures likely tripped a red annunciator on the panel, prompting the pilot to go to the full rich condition at 04:06:30.

Once at full rich, the pilot was leveling off, so we see the CHTs started a steady drop, along with oil temperature. The TIT did an immediate drop to a more normal 1,400 degrees F when the pilot went to full rich.

At 04:09:30, the manifold pressure makes a nice drop to about 18 in-Hg, which is below the International Civil Aviation Organization (ICAO) standard atmospheric pressure for 6,000 feet, which makes us think that he closed the throttle. As he descends, the manifold pressure should decrease, but it does not, suggesting the throttle was not opened.

If there was an un-commanded loss of power, say from both turbo[chargers] dying, I would expect the engine to perform as a normally aspirated engine, which should have been sufficient to land the aircraft. Seems he closed the throttle.

Piper Aircraft engineer’s review: (all times referred to are Pacific daylight time)

In summary, it appears the data ends during a second approach attempt. At 04:09:30, there was a large drop in MAP consistent with closing of the throttle to a low power setting. At 04:10:15, the aircraft ...