Pilot Debrief

Piper PA23 near San Juan, PR — 2020-06-02

Final reportERA20LA202
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Date
2020-06-02
Location
San Juan, PR, USA
Airport
SIG
Aircraft
Piper PA23
Registration
N14181
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

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.

Contributing factors

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.

NTSB narrative

The pilot-rated passenger reported that before takeoff, the pilot performed an engine run-up with no discrepancies noted. During takeoff, when full power was applied, the airplane yawed abruptly to the left and the left engine was not producing full power. The pilot elected to continue the takeoff and immediately applied right rudder, right aileron and back pressure, similar to a crosswind soft field takeoff. The airplane climbed about 100 ft-per-minute at an indicated airspeed below the published single engine rate of climb airspeed. When the pilot reached to retract the hydraulically controlled landing gear, it failed to retract. The airplane then rolled left and impacted the water adjacent to the airport in an inverted nose-low attitude. The pilot-rated passenger, who was also a mechanic, stated that during a previous takeoff attempt, the pilot aborted the takeoff when the airplane yawed left after takeoff power was applied. While taxiing off the runway, the left engine quit. The pilot restarted the engine and taxied to the ramp. Following a visual inspection that revealed the left strut extension was more than the right, the pilot decided to attempt the takeoff again; it was during this subsequent takeoff that the accident occurred. Postaccident examination of the flight controls, right engine and its systems, and the left engine powertrain, fuel supply, and ignition systems revealed no evidence of preimpact failure or malfunction. A missing nylon throttle stop of the left servo fuel injector (fuel servo) was the likely reason why the left engine quit at idle, and internal contamination of it resulted in a decreased fuel flow of about 31% of the minimum required value at full throttle and full rich mixture. Once the contamination was removed the left fuel servo flowed within limits at full throttle and full rich mixture; the contaminant was not analyzed.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have aborted takeoff after first yaw indication.

NTSB coding

Evidence available

  • ATC audio
  • Video
  • Photos
  • 22 docket documents
View NTSB final reportView NTSB docket

Docket documents22

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