NTSB Factual Report

HISTORY OF FLIGHT

On May 13, 2004, about 0700 mountain standard time, a Piper PA-44-180, N4144C, collided with terrain under unknown circumstances near Whittman, Arizona. Westwind Aviation, Inc., was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI), the private pilot undergoing instruction (PUI) and one passenger sustained fatal injuries; the airplane was destroyed. The local instructional flight departed Deer Valley Airport, Phoenix, Arizona, about 0645. Visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 33 degrees 47.453 minutes north latitude and 112 degrees 28.997 minutes west longitude.

A National Transportation Safety Board specialist plotted recorded radar data. A target appeared just north of Phoenix Deer Valley Airport around 0645 climbing out of 4,400 feet. The track made a climbing left turn, and headed in a westerly direction. It climbed to 6,000 feet, but didn't maintain that altitude. The altitude varied (climbing and descending) about 500 feet for the next several minutes. About 20 miles west-northwest of the airport, the target began a figure-eight type of track, and then went into a descending 360-degree turn before the last radar contact. The last radar return was at 0706:53 just abeam the main wreckage area at a mode C reported altitude of 3,900 feet. The preceding target was 18 seconds earlier at a mode C altitude of 5,200 feet.

A witness saw the airplane spinning as it headed toward the ground in a nose low attitude.

PERSONNEL INFORMATION

The operator submitted a Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2).

CFI

A review of Federal Aviation Administration (FAA) airman records revealed that the CFI held a commercial pilot certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. The pilot had a CFI certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. He had a first-class medical issued on June 18, 2002.

The operator reported that the CFI had about 480 hours total flight time, and 173 hours as a flight instructor. He had about 76 hours in multiengine airplanes, and all of them were in this make and model. He had about 10 hours in the last 30 days.

PUI

A review of FAA airman records revealed that the PUI held a private pilot certificate with ratings for airplane single engine land and instrument airplane. He had a second-class medical certificate issued on March 15, 2003, which had no limitations or waivers.

The operator reported that the PUI had 230 hours total flight time. He logged about 60 hours in the last 90 days, and 25 in the last 30 days. He had about 21 hours in this make and model.

AIRCRAFT INFORMATION

The airplane was a Piper PA-44-180, serial number 4496020. A review of the airplane's logbooks revealed a total airframe time of 3,643 hours at the last annual inspection. The logbooks had an entry for an annual inspection dated May 11, 2004. The Hobbs hour meter read 3,643.7 at the last inspection. The Hobbs hour meter read 3,647.3 at the accident site.

The left engine was a Textron Lycoming O-360-A1H6, serial number L-25704-36A. Engine total time recorded at the last annual inspection was 3,825 hours, and time since major overhaul was 1,522 hours.

The right engine was a Textron Lycoming LO-360-A1H6, serial number L-600-71A. Engine total time recorded at the last annual inspection was 3,643 hours, and time since major overhaul was 2,609 hours.

Fueling records at Deer Valley established that the airplane was last fueled on May 13 with the addition of 50.0 gallons of 100-octane aviation fuel.

WRECKAGE AND IMPACT INFORMATION

Investigators from the Safety Board, the FAA, Piper, and Textron Lycoming examined the wreckage at the accident scene. The airplane came to rest in rough desert terrain.

The first identified points of contact (FIPC) were 2 ground scars about 7 feet apart. The larger ground scar was about 1-foot wide, 3-feet long, and 6-inches deep. The orientation of these scars was 154/334 degrees. The second scar was about 1-foot in diameter. The pilot's operating handbook for the airplane indicated that the distance from the center of the propeller to the nose gear was about 6.5 feet.

The debris path from the center of the FIPC to the center of the cockpit was along 280 degrees. The center of the cockpit came to rest about 40 feet from the FIPC. The orientation of the fuselage was 114 degrees. The engines and forward part of fuselage were on a 45-degree slope that was about 20 feet long. The aft cabin and empennage were in a gravel road oriented 180/360 degrees. The trailing edge of the left wing lay against the base of a tree. None of the branches on the tree appeared to have been disturbed. Shrubs between the fuselage and the FIPC had broken branches.

The left wing tip fairing, with the red lens cap in place, separated and was 70 feet north of the FIPC. The right wing tip fairing separated, and was about 10 feet from the outboard edge of the right wing. The navigation light was still in its fixture, but only fragments of green lens remained in the fixture.

The wings and fuselage exhibited vertical crush damage. The nose section exhibited vertical and some aft crush damage. The cabin roof fractured along the forward edge of the cabin area and bent aft. The crush angle was 15-20 degrees.

The right side of the horizontal stabilator was undamaged. The outboard third of the left horizontal stabilator buckled along the trailing edge. The portion of the trim tab on the left side bent up. Both the horizontal stabilator and trim tab sustained upward crush damage, and exhibited scrape marks in a concave, circular pattern.

The vertical stabilizer and rudder were undamaged.

All control surfaces remained with the main wreckage. The outboard left aileron hinge was the only control surface separation point. Its hinge was bent outboard, and the bolt hole where it attached was oblong.

MEDICAL AND PATHOLOGICAL INFORMATION

The Maricopa County Coroner completed an autopsy. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilots. Analysis of the specimens contained no findings for carbon monoxide, cyanide, volatiles, or tested drugs.

TESTS AND RESEARCH

The FAA, New Piper Aircraft Corporation, and Textron Lycoming were parties to the investigation.

Investigators examined the wreckage at Air Transport, Phoenix, Arizona, on May 14, 2004.

Right Propeller

One blade of the propeller appeared undamaged. The other blade exhibited leading edge gouges.

Right Engine

Investigators kept the right engine on the airframe, and removed the top spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.

A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head.

Investigators manually rotated the engine with the propeller. The engine rotated freely, and the valves moved approximately the same amount of lift in firing order. The gears in the accessory case turned freely. Investigators obtained thumb compression on all cylinders in firing order.

Investigators manually rotated the magnetos, and both magnetos produced spark at all posts.

The vacuum pump drive gear remained unbroken, and the vacuum pump turned freely.

The oil filter was clean.

The engine driven fuel pump's rubber diaphragm was unbroken. A blue fluid that smelled like aviation fuel drained from the pump after removal. The carburetor sustained mechanical damage near the throat; however, the butterfly valve moved freely. After removal of the float, the float chamber was half full of a blue fluid that smelled like aviation fuel.

Left Propeller

One blade of the propeller appeared undamaged. The other blade exhibited gouges on the leading edge, tip, and trailing edge. The cambered side had angled chordwise striations.

Left Engine

Investigators removed the propeller to aid examination of the engine. They slung the engine from a hoist, and removed the top spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.

A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder heads.

The crankshaft was bent. It fractured around 270 degrees of its circumference, and the fracture surface was a 45-degree shear lip. Investigators manually rotated the engine with a tool in an accessory drive gear. The engine rotated freely, and the valves moved approximately the same amount of lift in firing order. The gears in the accessory case turned freely. Investigators obtained thumb compression on all cylinders in firing order.

Investigators manually rotated the magnetos, and both magnetos produced spark at all posts.

The vacuum pump drive gear remained unbroken, and the vacuum pump turned freely.

The oil filter was clean.

The engine driven fuel pump's rubber diaphragm was unbroken. A blue fluid that smelled like aviation fuel drained from the pump after removal. The carburetor sustained mechanical damage near the throat; however, the butterfly valve moved freely. After removal of the float, the float chamber was half full of a blue fluid that smelled like aviation fuel.

The forward position of the cockpit fuel levers selects fuel on. The center position is fuel off, and the aft position is the cross-feed position. The cockpit fuel levers were in an area that sustained mechanical damage, and they were in the middle of the slots. The fuel selector valves physical locations were in the aft center cabin area. They were in the cross-feed position.

All three landing gear sustained mechanical damage. The nose gear mechanism separated in several places. The nose gear was crushed up into the fuselage. The right main gear downlock engaged its locking plate. The operating arm of the right gear actuator was extended. The right strut bent aft. The left main gear downlock engaged its locking plate. The left strut separated about 2 inches from the wheel. The fracture surface was jagged around the circumference, and angled about 45 degrees to the vertical plane of the shaft. The left strut stub bent aft. The operating arm of the left gear actuator was extended. The manufacturer's representative said that main gear actuators extended corresponded to the gear down position.

The airframe representative reported that the flaps are mechanically actuated. The flaps sustained upward mechanical crush damage. The flap handle was in the 10-degree detent; however, the torque tube for the flap was in the up position.

The stabilator trim measured 0.8125 inches. The airframe representative determined that this equated to the trailing edge of the stabilator down (0.9 inches is neutral). The rudder trim tab measured 1.3 inches trailing edge tab left (nose right); the neutral position is 1.4 inches).

ADDITIONAL INFORMATION

Safety Board investigators interviewed several students, instructors, and Westwind staff personnel that knew the pilots. They noted that Westwind did not have a designated pilot examiner (DPE) on staff; they used several examiners. Westwind reported that the CFI had done multiple check rides with a DPE who would simulate loss of engine power during stall recovery and slow flight at airspeeds about 60 mph. They indicated that if CFIs knew that a maneuver might be tested, then CFIs would teach the maneuver.

The Piper Seminole Pilot Operating Handbook notes symbols, abbreviations, and terminology in Section 1.19. It indicates that Vsse is the intentional one engine inoperative speed. This is a minimum airspeed selected by the manufacturer for intentionally rendering one engine inoperative in flight for pilot training. Section 4 (normal procedures) points out that Vsse is not a limitation; however, it provides the margin that the manufacturer recommends for use during training in the particular airplane. Vsse for the Seminole is 82 KIAS.

Westwind made immediate changes to their operating procedures including no rear seat observers during multiengine training, practicing power-on stalls at no more than 20 inches of manifold pressure, and prohibition of practicing single engine operations below Vsse.

One DPE interviewed noted that there were differences in the Practical Test Standards (PTS) between the commercial and private certificates. The private PTS requires recognition and recovery after the stall occurs. The commercial PTS requires recognition and recovery as the stall occurs. This DPE feels that the ATP PTS is the preferred method; it requires recognition and recovery at the approach to stall. Candidates do a stall, and recognize the stall. They do this by hearing the sounds of the airstream, and feel the airplane buffet. This provides a bigger margin for error, by letting the candidate recognize the onset without actually going into the stall. This avoids possible loss of control in a multiengine airplane.

The IIC released the wreckage to the owner's representative at the conclusion of the on-scene examination.

NTSB Probable Cause

The flight instructor's failure to maintain sufficient airspeed to avoid a stall/spin while maneuvering the airplane with a dual student.