N14181

Substantial
Fatal

Piper PA23S/N: 27-4746

Accident Details

Date
Tuesday, June 2, 2020
NTSB Number
ERA20LA202
Location
San Juan, PR
Event ID
20200602X42557
Coordinates
18.458889, -66.091941
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
2
Serious Injuries
1
Minor Injuries
0
Uninjured
0
Total Aboard
3

Probable Cause and Findings

The pilot’s intentional operation of the airplane with known deficiencies of the left engine and subsequent in-flight loss of control after takeoff. Contributing to the loss of engine power was internal contamination of the left servo fuel injector. Contributing to the loss of control was the pilot’s intentional operation below the single engine rate of climb airspeed, and his failure to feather the left propeller.

Aircraft Information

Registration
N14181
Make
PIPER
Serial Number
27-4746
Engine Type
Reciprocating
Year Built
1971
Model / ICAO
PA23PA23
Aircraft Type
Fixed Wing Multi Engine
No. of Engines
2

Registered Owner (Historical)

Name
BLUE WATERS AIR CHARTERS LLC
Address
1225 AVE PONCE DE LEON PH 4
Status
Deregistered
City
SAN JUAN
State / Zip Code
PR 00907-3921
Country
United States

Analysis

HISTORY OF FLIGHTOn June 2, 2020, about 1333 Atlantic standard time, a Piper PA-23-250, N14181, was substantially damaged when it was involved in an accident during takeoff from Fernando Luis Ribas Dominicci Airport (TJIG), San Juan, Puerto Rico. The airline transport pilot and one passenger were fatally injured and a pilot-rated passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 post-maintenance flight test.

The pilot-rated passenger, who occupied the right front seat and also held a mechanic certificate with airframe and powerplant ratings, reported the pilot taxied to runway 9 where an engine run-up was performed and that no discrepancies were noted. The airplane was cleared for takeoff, the pilot applied takeoff power, and the airplane immediately yawed to the left as if the left engine was not producing power. The pilot aborted the takeoff and was able to control the airplane, which, according to the pilot-rated passenger, was “almost sideways.”

The pilot-rated passenger later reported that he attributed the yaw to a loss of power from the left engine but at the time asked the pilot what would have caused the yaw, and the pilot responded that the left landing gear strut had less nitrogen than the right strut. However, according to a partial transcript of the pilot’s communications with air traffic control, he replied “…I think it’s a low tire” when asked if he needed any assistance. The pilot-rated passenger reported that the left engine quit while at idle power as they exited the runway. The pilot was able to restart it with some difficulty then taxied to the ramp.

While at the ramp, the pilot directed the pilot-rated passenger to inspect the landing gear. He informed the pilot that the left strut had more extension than the right, which was opposite the pilot’s expectation. The pilot directed the passenger to get back in the airplane and performed an engine run-up, which included a check of the magnetos and cycling the propellers. The pilot-rated passenger did not detect any discrepancies though he did state that he was wearing a noise-cancelling headset.

The pilot then contacted the air traffic control tower and requested taxi clearance to runway 09. After taxiing to the runway, the airplane was cleared for takeoff. The pilot-rated passenger stated that the airplane again immediately yawed to the left when the pilot applied full power for takeoff. The pilot immediately applied “right rudder, yoke to the right and back pressure like in a crosswind soft field takeoff.” During takeoff, the pilot was "fighting" the airplane as it drifted left of the runway centerline with the left engine not producing full power. The pilot-rated passenger reported the pilot raised the landing gear selector to retract the landing gear but did not recall seeing a green light. The pilot-rated passenger noticed that the airplane was not climbing normally; he estimated the climb rate at 100 feet-per-minute.

Security video from a nearby marina captured the final portion of the flight and depicted the airplane during the upwind leg flying in a near wings-level, slight nose-up attitude. As the flight continued, one of the landing gear was visible. The video depicted the airplane rolling left into an inverted and nose-low attitude. It remained in that position until impacting the water. No parts were seen separating from the airplane.

After impact, the passenger was knocked unconscious then regained consciousness. He initially had difficulty opening the door but was able to exit the airplane after it was fully submerged.

An in-flight video taken by the middle row passenger’s portable electronic device (PED) was provided to the National Transportation Safety Board (NTSB) for review and analysis. A view of the full instrument panel was captured at 03 seconds and frame 21 at which time the airplane was noted to be in a climb pitch attitude, both of the pilot’s hands were on the control yoke, and he was inputting a right roll command. The left throttle, propeller, and mixture controls appeared to be in the full forward position. During that same time and frame, the airspeed indicator appeared to be between 90 and 100 mph. The JPI engine monitor depicted the fuel flow for the left and right engines near zero and top of the indicator bar, respectively. The fuel pressure for the left engine was lower than the fuel pressure for the right engine, and the rpm for the left engine was between 1,000 and 1,500, while the rpm for the right engine was near the top of the green arc.

PERSONNEL INFORMATIONThe pilot also held an mechanic certificate with airframe and powerplant ratings issued September 18, 2008.

AIRCRAFT INFORMATIONThe landing gear and flaps were hydraulically controlled by an engine-driven hydraulic pump installed on the left engine. According to the Federal Aviation Administration (FAA)-approved Airplane Flight Manual, in the event of failure of the left engine, the landing gear and flaps should be retracted by utilizing the emergency hydraulic hand pump. The Pilot’s Operating Manual (POM) specified about 50 strokes of the hand pump were required to retract the landing gear.

The published minimum controllable single-engine airspeed and best single engine rate of climb airspeed were 80 and 102 mph, respectively.

The airplane was equipped with a Garmin GTN 650, a Garmin GPSMay 696 and a JPI EDM 960 engine monitor. The devices were submitted to the NTSB Vehicle Recorder Division for read-out. The GTN 650 had no data recording capability and the last recorded flight in the Garmin GPSMap 696 was April 4, 2019.

The JPI engine monitor recorded two sessions on the accident date; the last being associated with the accident flight. The data from the engine monitor indicated that for the accident flight, the left and right engine rpm values were between 1,000 and 1,300, and 600 to 800 rpm, respectively; thus, no data were recorded during takeoff for the accident flight. A review of prior flights revealed the recorded engine rpm for both engines were about 2,300. The last recorded fuel level in the left outboard fuel tank was 9.9 gallons.

AIRPORT INFORMATIONThe landing gear and flaps were hydraulically controlled by an engine-driven hydraulic pump installed on the left engine. According to the Federal Aviation Administration (FAA)-approved Airplane Flight Manual, in the event of failure of the left engine, the landing gear and flaps should be retracted by utilizing the emergency hydraulic hand pump. The Pilot’s Operating Manual (POM) specified about 50 strokes of the hand pump were required to retract the landing gear.

The published minimum controllable single-engine airspeed and best single engine rate of climb airspeed were 80 and 102 mph, respectively.

The airplane was equipped with a Garmin GTN 650, a Garmin GPSMay 696 and a JPI EDM 960 engine monitor. The devices were submitted to the NTSB Vehicle Recorder Division for read-out. The GTN 650 had no data recording capability and the last recorded flight in the Garmin GPSMap 696 was April 4, 2019.

The JPI engine monitor recorded two sessions on the accident date; the last being associated with the accident flight. The data from the engine monitor indicated that for the accident flight, the left and right engine rpm values were between 1,000 and 1,300, and 600 to 800 rpm, respectively; thus, no data were recorded during takeoff for the accident flight. A review of prior flights revealed the recorded engine rpm for both engines were about 2,300. The last recorded fuel level in the left outboard fuel tank was 9.9 gallons.

WRECKAGE AND IMPACT INFORMATIONThe wreckage was recovered the following day. As part of the recovery the fuel tanks were drained; the FAA was not present when the tanks were drained. Examination of the wreckage by a representative of the airframe manufacture with oversight from the FAA revealed extensive impact damage to the airframe and wings; the left wing was separated at the wing root. All landing gears were extended.

A postaccident examination of the flight controls revealed no evidence of preimpact failure or malfunction. The hydraulic flap actuating cylinder piston was extended about 7 inches which corresponded to flaps retracted. The rudder trim jackscrew was extended aft from the drum about 5/8 inch or about 5 threads, which corresponded to a neutral to slight aircraft nose right trim setting. The stabilator jackscrew was extended above the drum about 1/2 inch or about 10 threads, which corresponded to a full aircraft nose up trim setting.

A postaccident examination of the left-wing fuel supply system to include the fuel selector, supply hoses, fuel strainer bowl, fuel tank, and electric fuel pump did not reveal any preimpact failures or malfunctions which would have precluded normal operation.

Examination of the left engine propeller and mixture controls revealed that except for cuts at the left-wing root consistent with recovery, control cable continuity was confirmed from the cockpit to their respective attach points in the engine compartment. Throttle control cable continuity was confirmed from the cockpit to the left-wing root area where cut for recovery, then from there to the ball screw which was fractured; the ball screw connected the throttle cable to the fuel servo throttle arm. Examination of the fractured ball screw by the NTSB Materials Laboratory revealed the fracture features were consistent with fracture from overstress in bending.

During manual rotation of the left propeller, crankshaft, camshaft, and valve train continuity were confirmed to the valves and to the accessory section. Thumb section and compression were felt at each of the top spark plug openings of each cylinder. The magnetos appeared secure on their mounts and undamaged. The magnetos were mechanically rotated and both produced spark at all towers of the distributor cap. Examination of the engine-driven fue...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA20LA202