NTSB Factual Report

HISTORY OF FLIGHT

On October 8, 2002, at 1845 central daylight time, a Piper PA-28-140 single-engine airplane, N4344J, was destroyed when it impacted a bluff while maneuvering near Lakeview, Arkansas. The airplane was registered to and operated by the pilot. The commercial pilot, and two pilot-rated passengers sustained fatal injuries. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The cross-country flight originated from Gastons Airport, Lakeview, Arkansas, and was destined for the Springdale-Branson Regional Airport, Springdale, Arkansas.

According to witnesses, the airplane arrived at Gastons Airport approximately 1730. The three occupants ate dinner at the restaurant located at the airport. Restaurant staff reported that when the main course was finished the occupants were offered dessert; however, declined and stated that they needed to depart before dark because the airport was not equipped with runway lights. The occupant's meal ticket was closed at 1836.

Four witnesses reported approximately 1840, they observed the airplane's engine start and the airplane takeoff. One witness stated, he observed the airplane hold prior to runway 6 for landing traffic; however, he did not hear the pilot perform a pre-takeoff engine run-up. The four witnesses commented the airplane was slow to accelerate and the airplane used most of the 3,200 foot-long turf runway before becoming airborne. One witness stated that he was "surprised to see him lift off." Another witness reported that after airborne the airplane's attitude was "nose high," and it appeared as if the airplane "wasn't climbing or accelerating normally." One witness reported that most airplanes that size become airborne around cottage 20, and the accident airplane did not lift off until cottage 68. The cottages are oriented along the south side of the runway, between the runway and the White River.

Three witnesses along the White River stated that the airplane was flying at a low altitude. One witness observed the airplane approach power lines and then make a climbing left turn away from the power lines. She stated, she thought the airplane would have contacted the wires if it had continued straight ahead. Subsequently, the airplane impacted a bluff and a fire erupted.

A witness in the restaurant stated that he did not see the airplane depart; however, he did notice the fire. He stated that the fire appeared approximately 10 minutes after the 3 three gentlemen left the restaurant.

PERSONNEL INFORMATION

One pilot held a commercial pilot certificate, with single- and multi-engine land airplane ratings and an instrument-airplane rating. He also held an FAA issued flight instructor certificate for single-engine land airplanes and instrument-airplanes. He was issued a second-class medical certificate on May 1, 2002, with a limitation to wear corrective lenses. According to records provided by Proflite, a flight school where the pilot was employed, the pilot accumulated a total of 4,033.7 hours. He underwent his last biennial flight review on February 1, 2002.

One of the other occupants held a private pilot certificate with an airplane single-engine land rating. He held a third class medical certificate that was issued on March 21, 2003, with the limitation he must wear corrective lenses. Additionally, he held airframe and powerplant mechanic certificates.

The third occupant had recently started flying again (after 20 years) and had recently received instruction including one ground instruction unit and one flight instruction unit. The instructor who was on board the accident airplane provided the instruction.

The NTSB could not determine where each occupant was seated at the time of the accident.

AIRCRAFT INFORMATION

The 1967 model airplane (serial number 28-22720) was equipped with a 150 horsepower Lycoming O-320-E2A engine, and a 2- bladed, fixed pitch, Sensenich propeller. The airplane underwent its most recent annual inspection on October 1, 2001, at an airframe total time of 5,232.52 hours. The next entry, which was also the last entry in the airframe logbook, was dated May 12, 2002, and the entry stated that a new G-35 Gill battery was installed. A total airframe time was not listed on the May 12, 2002 entry.

The last entry in the engine logbook, dated August 12, 2002, revealed that an oil and filter change was performed, at a tachometer time of 5,448 hours, 1,777.9 hours since its last overhaul. During this oil and filter change, and the previous four engine oil changes (spaced approximately 50 hours apart), one pint of "AVBLEND oil additive" was added to the engine oil. AVBLEND is purported to restore and maintain used aircraft engines to improved performance levels and "provides protection against rust, corrosion, dry start damage and premature wear." According to AVBLEND's website, it "slowly dissolves carbon and helps to improve valve and ring sealing in the combustion chamber. This provides better cylinder combustion (peak pressure) efficiency resulting in improved engine horsepower. Engines must be at least dimensionally correct within service limits to restore performance."

Personnel at Proflite reported the flight instructor/aircraft owner had mentioned he was trying to "troubleshoot a low power problem." The instructor pilot reported to Proflite, he had the intake gaskets replaced and the "power problem was fixed." There was no record in the engine (or airframe) logbook that this maintenance had been performed; however, parts sales sheets from Springfield Aircraft & Charter Sales, Inc., indicated that on September 18, 2002, the flight instructor purchased two intake gaskets (part number 71973), and then on October 4, 2002, four more of the same gaskets were purchased.

METEOROLOGICAL INFORMATION

At 1853, the weather observation facility located at the Baxter County Regional Airport, which is approximately 3 miles east of the accident site, reported the wind from 080 degrees at 3 knots, visibility 10 statute miles, a few clouds at 8,500 feet, scattered clouds at 25,000 feet, temperature 61 degrees Fahrenheit, dew point 30 degrees Fahrenheit, and an altimeter setting of 30.08 inches of mercury.

AERODROME INFORMATION

According to the FAA's Airport/Facility Directory (A/FD), the Gastons Airport is located at North 036.55.243 latitude and West 092.25.587 longitude, and at an altitude of 479 feet msl. The airport has one turf-covered runway, 06-24, and is 3,200 feet long and 55 feet wide. All aircraft are required to land on runway 24 and depart runway 06. Obstructions to runway 06 include a road and obstructions to runway 24 include trees.

WRECKAGE AND IMPACT INFORMATION

The accident site was located 1.3 miles southeast of the departure airport, at an elevation of 709 feet msl (166 feet above the Gastons Airport elevation). A global positioning system recorded the location at North 036 degrees 21.131 latitude and West 092 degrees 31.882 longitude. The airplane came to rest along a bluff with a 60-degree slope. Witness marks at the accident site revealed that the airplane impacted a solid rock cliff, which was oriented 90 degrees to ground level, in a near wings level attitude. The airplane came to rest 25 feet below the initial impact area. A post-accident fire consumed the cockpit, fuselage, both inboard wing sections, and a portion of the empennage.

Flight control continuity was established from the left aileron to the T-bar; the control cables for the right aileron were destroyed. The left rudder control cable was destroyed and the right rudder control cable was destroyed. Control continuity was established for the stabilator trim. The horizontal stabilator trim tab was found in the full nose up position (13/4 shaft extension with 16 threads exposed). The stabilator nose down control cable was destroyed and the nose up cable was found intact from the stabilator to the T-bar. The flap handle in the cockpit was found positioned to the 25-degree extended selection. The cockpit fuel selector arm was found positioned to the right fuel tank.

The engine came to rest inverted on top of the left wing. The accessory section displayed impact and fire damage and the oil sump was burned away. The carburetor, including its main fuel screen, displayed impact and fire damage. The throttle and mixture control cables were both attached to the cockpit panel; however, they were separated from the carburetor housing. The carburetor heat control cable was intact and connected between the cockpit and carburetor heat housing. The vacuum pump rotor was found intact and displayed rotational scoring. The gasculator displayed impact and fire damage. Both magnetos sustained fire damage. The oil suction screen was clean. The exhaust tubes were found flattened and displayed ductile deformation.

The propeller assembly remained attached to the engine. Both of the propeller blade tips were separated and the blade's leading edges displayed heavy gouge marks. One blade was twisted in the direction of low pitch and its outboard 12 inches was broken off. The other blade was separated approximately 10 inches from its tip and displayed a polished appearance near its tip. The propeller blades also exhibited chordwise scratches.

The cockpit was consumed by fire; however, the tachometer was located and the tachometer needle was found pointing at 3,500 rpm. One seatbelt buckle was found latched, and another buckle and one tab portion of another belt were located; however, they were not latched. Two seatbelt assemblies were not recovered.

The engine was again examined at the facilities of Air Salvage of Dallas in Lancaster, Texas, on October 23, 2002. Closer examination of the engine revealed that the engine crankcase was burned away in many places, and the camshaft and crankshaft were visible through the missing areas. The camshaft was jutting out of the crankcase at a 45-degree angle through the area where the oil sump would normally be. All of the accessories sustained heat damage beyond a testable condition.

Cylinder compression could not be verified by rotating the crankshaft due to the impact and heat damage sustained by the valve cases, pushrods, camshaft, and accessory section. A visual examination of the crankshaft, camshaft, connecting rods, valve assemblies, and piston assemblies was conducted and no pre-impact defects were observed. The accessory gears appeared to be intact and positioned in their respective places.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed on all three occupants of the airplane by the Arkansas State Crime Laboratory, Little Rock, Arkansas. The autopsies did not reveal any preexisting disease in any of the three occupants that contributed to the accident. Toxicological testing was performed by the FAA's Civil Aeromedical Institute of Oklahoma City, Oklahoma.

Toxicological test results revealed the flight instructor tested negative for ethanol; however, unquantified amounts of the following were detected in the pilot's liver and kidney: chlorpheniramine, ephedrine, phenylpropanolamine, phenyltoloxamine, and pseudoephedrine. According to an FAA Acting Regional Flight Surgeon, "Chlorpheniramine and Phenyltoloxamine (i.e. Nalex) are antihistamines used in the symptomatic management of allergic symptoms and decongestion, and may have sedative effects. Ephedrine is found in some nasal drops and several diet preparations. Phenylpropanolamine is a decongestant. Pseudoephedrine is a decongestant (i.e. Sudafed plain)."

Toxicological test results for the private pilot tested negative for alcohol and drugs.

The non-pilot rated occupant tested negative for ethanol; however, unquantified amounts of Amlodipine were detected in the kidney and liver. According to the FAA Regional Flight Surgeon, "Amlodipine is a anti-hypertensive medication." Review of this occupant's last FAA medical application revealed he reported the use of medication for high blood pressure and hypertension.

ADDITIONAL INFORMATION

According to the A/FD, pilots are instructed to land on runway 24 and to takeoff on runway 6. Local pilots told investigators that the normal departure procedure is to takeoff from runway 6, then turn northeast and fly down a valley that paralleled the runway, instead of flying along the White River, which has steep bluffs along the river edge and high power lines that cross the river. Review of comments placed on AirNav's website (www.airnav.com) revealed two cautions regarding the airport area. One of the cautions warned of the "high wires on left base when landing on [runway] 24." The other caution recommended studying the airport area because there is steep hill on the east side of the airport and power lines. According to acquaintances with the instructor pilot, he had flown into and out of that airport before.

The wreckage was released to the owner's representative on February 24, 2003.

NTSB Probable Cause

the pilot's failure to maintain clearance with the terrain while maneuvering.