N400JM

HISTORY OF FLIGHT

On March 12, 2019, at 1516 eastern daylight time, a Piper PA-31-350, N400JM, was substantially damaged when it impacted terrain in Madeira, Ohio. The commercial pilot was fatally injured. The airplane was operated by Marc, Inc. under the provisions of Title 14 Code of Federal Regulations Part 91 as a commercial aerial observation flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight that originated from Cincinnati Municipal Airport-Lunken Field (LUK), Cincinnati, Ohio, at 1051.

Federal Aviation Administration (FAA) radar data revealed that, after departure LUK, the airplane flew several survey tracks near Cincinnati, Ohio, before proceeding north to fly survey tracks near Dayton, Ohio. According to air traffic control (ATC) voice communications, the pilot contacted ATC at 1503 to request direct routing to LUK due to a fuel problem. The air traffic controller advised the pilot to proceed as requested and offered Dayton-Wright Brothers Airport (MGY), which was 8 miles ahead, as a landing alternative. The pilot responded that he had MGY in sight but wanted to continue to LUK, which was 30 miles away. The controller then asked the pilot if he wanted to declare an emergency, and the pilot responded "negative."

About 1505, when the airplane was at 5,000 ft mean sea level (msl), the controller asked the pilot if he required any assistance with the fuel issue, and the pilot responded that he should be "okay." The controller then advised the pilot that "multiple airports" were available between his location and LUK, and the pilot informed the controller that he would advise if the fuel issue developed again.

About 1513, the pilot established radio contact with the LUK ATC tower and advised the controller that the airplane had a fuel problem and that he was hoping to reach the airport. At that time, the airplane was at an altitude of 1,850 ft msl and was about 8 miles north of LUK. Shortly thereafter, the pilot advised the controller that he was unsure if the airplane would reach the airport. No further communications were received from the pilot. Radar data showed that, between 1513 and 1516, the ground track of the airplane was about 200°, the airplane descended to an altitude of 1,275 ft msl, and its estimated groundspeed decreased from about 140 to 98 knots. At 1516, the radar data depicted a right turn to a heading of about 250° and a ground track that aligned with a golf course fairway (which had an elevation of 865 ft msl). At 1516:27, radar data indicated that the airplane was about 180 ft from the fairway at an altitude of 1,050 ft msl and an estimated groundspeed of about 82 knots. The airplane's last radar-recorded position was located about 550 feet from the accident site. No additional radar data were recorded.

According to witnesses, the airplane engine sputtered before making two loud "pop" or "back-fire" sounds. One witness reported that, after sputtering, the airplane "was on its left side flying crooked." Another witness reported that the "unusual banking" made the airplane appear to be flying "like a 'stunt' in an air show."

Two additional witnesses reported that the airplane was flying low when it turned to the left and "nose-dived" into their neighborhood. The airplane then impacted a tree and the backyard of a residence.

A witness from an adjacent residence heard the impact, approached the wreckage immediately after the accident, and noted a "whitish gray smoke coming from the left engine." He reported that "a small flame began rising from that same area." Video recorded on the witness' mobile phone about 1522 showed the area around the left engine engulfed in flames. The witness stated that the airplane was fully engulfed in flames about 3 minutes later.

PERSONNEL INFORMATION

According to FAA records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. He also held a flight instructor certificate with ratings for airplane single-engine, and instrument airplane, and a ground instructor certificate. His most recent FAA first-class medical certificate was issued November 8, 2018.

According to the operator (Marc, Inc.), the pilot was contracted to work for them about 1 month before the accident. Examination of the pilot's logbook revealed that as of February 19, 2019, he had accrued 6,392 total hours of flight experience. The logbook included seven entries for Marc, Inc., all of which were in the Cessna 310. The pilot had logged 1,364 hours of flight time in the accident airplane make and model, all of which had been accumulated prior to 2010. The logbook also showed no piston multiengine airplane flight time between that time and his employment with the operator; all of the pilot's logged flights during that time were in turbine and/or single-engine airplanes. The available evidence did not indicate if the pilot received any training or a flight check in the PA-31-350. Review of daily flight logs submitted to the company showed that the pilot flew the accident airplane for 2.5 hours the day prior to the accident.

AIRCRAFT INFORMATION

A review of the airplane's maintenance logs revealed that the airplane's most recent annual inspection was completed on July 1, 2018, at 19,094 total hours of operation. The left engine had accumulated 453.5 hours of operation since its most recent inspection and 2,991.5 hours of operation since overhaul. The right engine had accumulated 448.5 hours since its last inspection. The time since overhaul for the right engine could not be determined based on the information contained within the logs. Additionally, several entries logging maintenance had been added to the records as loose, unbound sheets; several entries within the logs documented maintenance that had been performed to other airplanes; and the right propeller logbook documented maintenance to a propeller whose serial number did not match the propeller installed on the accident airplane's right engine.

A company pilot reported that the accident airplane had a fuel leak in the left wing and provided a photograph of the fuel on the hangar floor, taken about a week before the accident. The company pilot also reported that the accident airplane was due to be exchanged with another company PA-31-350 the week before the accident so that the fuel leak could be isolated and repaired but that the airplane remained parked for a few days and was not exchanged. The accident pilot was then assigned to fly the airplane. One of the pilot's relatives reported that the pilot told him that the accident airplane had airplane fuel leak about 1 week before the accident. Review of the maintenance records revealed no entries in the 2 weeks preceding the accident.

The accident airplane was flown by another company pilot about 1 month before the accident, and he had to perform an unscheduled single-engine landing at Smyrna Airport (MQY), Smyrna, Tennessee, The pilot stated that he secured the right engine after an indication of low oil pressure and that maintenance work to address "external oil leaks" was performed at a fixed-base operator at MQY. Review of the airplane's maintenance records revealed no entries associated any repairs following this event. The company owner/manager stated that he knew "of no single engine landings" involving the accident airplane.

Fuel System

Each wing contained an inboard (main) and an outboard (auxiliary) fuel tank, which were standard components. Fuel for each engine was routed from either the main or auxiliary fuel tank to the selector valve, fuel filter, fuel boost pump, emergency fuel pump, firewall shutoff, engine-driven fuel pump, and fuel injectors. The engine-driven fuel pumps ran continuously and were not controllable by the pilot. Two electric fuel quantity gauges indicated the fuel quantity in the respective (left or right wing) selected fuel system tank (main or auxiliary). During normal operation, each engine was supplied with fuel from its respective fuel system. In an emergency, fuel from one system could supply the other engine through a crossfeed.

Each wing also had a nacelle fuel tank that was located aft of the respective engine. According to the airplane's maintenance records, the nacelle fuel tanks were installed in the airplane in accordance with a supplemental type certificate in June 2017. The airplane flight manual supplement for PA-31-350 airplanes equipped with nacelle fuel tanks included the following operating limitation: "Do not transfer fuel until main tanks are at least one-half full or less." The manual also included the following normal operating procedure: "Approximately 55 minutes are required to transfer all the fuel out of the nacelle tanks."

Postaccident interviews with company pilots revealed that there was no way to directly monitor the quantity of fuel in the nacelle tanks during flight, nor was there any direct indication that the fuel pumps were operating. Company pilots reported using various methods of managing fuel in airplanes equipped with nacelle fuel tanks. Some pilots used fuel from the main tanks until they were empty, whereas others used fuel from the main tanks for 1.5 to 2 hours and then switched to the auxiliary tanks. After switching to the auxiliary tanks, these pilots turned on the nacelle fuel transfer pumps and used the auxiliary tanks until they were empty to allow time for fuel to transfer from the nacelle tanks to the main tanks. One of the pilots used the auxiliary fuel tanks and switched to the main tanks every 30 minutes so that he could check the fuel gauges and ensure that the fuel was transferring from the nacelle to the main tanks. After all of the fuel from the auxiliary tanks was used, the pilot would switch back to the main tanks, which then contained the fuel from the nacelle tanks, to complete the flight. The available evidence showed no standardized p...