Pilot Debrief

PIPER PA-28R-180 near Roanoke, TX — 2012-09-22

Final reportCEN12FA654
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Date
2012-09-22
Location
Roanoke, TX, USA
Airport
52F
Aircraft
PIPER PA-28R-180
Registration
N4567J
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The loss of engine power during takeoff due to fuel contamination. Contributing to the accident was maintenance personnel's failure to adequately correct the water contamination effects. Contributing to the severity of the occupants' injuries was the lack of shoulder restraints.

Contributing factors

Contributing to the accident was maintenance personnel's failure to adequately correct the water contamination effects. Contributing to the severity of the occupants' injuries was the lack of shoulder restraints.

NTSB narrative

The pilot, who had purchased the airplane about 2 months earlier, and the flight instructor departed on an instructional flight. Two witnesses reported that the airplane's engine did not sound right during the takeoff and the ground roll was longer than normal. Just beyond the runway, the airplane turned slightly left and then impacted the top of several trees. Both wings separated and remained lodged in the treetops; first responders noted fuel running from the wings. The emergency locater transmitter (ELT) was in found in the off position. Examination of the engine revealed water and contaminants in the fuel system, especially in the injection servo and fuel pump, which would have resulted in the rough-running engine and loss of engine power. A review of the airplane's maintenance records did not reveal any entries since the pilot had purchased the airplane. The airplane's last maintenance entry was at the annual inspection, which was about the time the airplane was purchased. The entry stated "found water in tanks - sumped tanks, cleaned flow divider, fuel screens and lines." The log also had the entry that stated "c/w FAR 91.207 ELT insp by installing new batteries, due March 2017." The airport manager had witnessed the same pilot depart in the accident airplane about a month earlier; however, the airplane's engine did not sound right, and the pilot returned to the airport. A review of the pilot's logbook revealed an entry "aborted X-country, lost engine power, so landed" on that date. About 2 weeks later, an e-mail from the pilot to family members stated that a clogged fuel injection system was found after the aborted flight. Two days after that, the pilot's logbook reflected 1.1 flight hours with a note that stated "test flight, perfect." On that same date, the pilot wrote a check to a maintenance company at the airport on which the airplane's registration number and "Maint" were written in the memo field. It is likely that either at the annual inspection and/or 2 weeks before the accident, maintenance personnel did not appropriately address the fuel contamination issues that persisted at the time of the accident. The airplane was not equipped with shoulder belts. During the impact sequence, the pilot likely rotated about his lap belt, braced himself with his arms and fractured his shoulders, but his head struck the instrument panel, resulting in his fatal skull injury. The flight instructor similarly rotated forward about his lap belt; his chest and abdomen struck the instrument panel resulting in his fatal injuries. Had the airplane been equipped with single or double shoulder restraints, the pilots' injuries likely would have been less severe and they might have survived.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have aborted takeoff due to rough engine sound and long takeoff roll.

NTSB coding

Evidence available

  • Photos
  • 21 docket documents
View NTSB final reportView NTSB docket

Docket documents21

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