NTSB Factual Report

HISTORY OF FLIGHT

On May 19, 2000, about 0912 eastern daylight time, a Piper PA-23-160, N3492P, registered to Merkado Holdings, Inc., dba Walkwitz Aviation, operating as a Title 14 CFR Part 91 checkout flight, crashed in the vicinity of the Space Coast Regional Airport, (TIX), Titusville, Florida. Visual meteorological conditions prevailed and no flight plan was filed. The airplane was destroyed, the commercially rated pilot received fatal injuries, and the certified flight instructor received serious injuries. The flight originated from Titusville's Arthur Dunn Airpark about 0730.

According to the CFI, in a statement given to two FAA inspectors at about 1630 on the day of the accident in the emergency room of Orlando Regional Medical Center, Orlando, Florida, he was giving dual check-out in MEL single engine failure procedures and simulated failed engine landings at the TIX airport. Once he was satisfied with the pilot's identification and response to a simulated failed engine, he set the right engine power controls to a zero thrust setting for engine-out approaches and landings. The pilot felt his first single engine approach was too high and too fast and a two engine go-around was conducted. During the downwind turn for the second approach, after the CFI zero-thrusted the right engine, the pilot allowed the airplane to decelerate below single engine minimum control speed, (Vmc) at which time the CFI took control and affected a recovery. A second control transfer from CFI back to the pilot resulted in a similar deceleration below Vmc and a right roll and dive that resulted in terrain collision. The NTSB 6120.1/2 form submitted by the CFI on June 9, 2000, stated that the airplane entered a left roll and dive that resulted in the ground collision.

During a telephone interview with the NTSB, on December 13, 2000, the CFI requested that certain changes be made to his previous statements. He reiterated that their TIX landing pattern work the day of the accident began with a low approach to runway 27 followed by a go-around and an entry to a left downwind to runway 09 due to tower controlled runway change from 27 to 09. The pilot's landing resulted in an extended flare because he was too fast. On the climb out and upwind right turn for a right pattern to runway 09, the pilot stated he was determined to control his airspeed more precisely the next time. It was on the downwind segment that the CFI zero-thrusted the right engine, the flight was straight and level at 800 to 900 feet, agl, and they had not started their base turn to final approach. The airspeed was not below Vmc but probably a little below Vyse, (single engine best rate of climb speed, or more commonly, the blue line on the indicator) when they entered a "1/2 snap roll to the left and the nose dropped below the horizon". He maintains that the puzzling thing to him is that the airplane rolled into the operating engine, and thus the mishap could not have been a Vmc roll. He states that he was not riding or feeling the control inputs being applied by the pilot at the instant they departed from normal flight, and that the pilot may have been cross controlling the flight controls. He stated he waited an instant to see how the pilot would react, but lacking any reaction, he took control, but ran out of altitude to recover. The CFI added that the TIX landing pattern is exposed to smoke stack outflow from a power generating plant about 3 miles southeast of the field. He maintains that the accident had to be the result of the wind change or the smoke stack outflow, or a combination of the two.

According to the tower controller on duty at the time of the accident, following a few practice touch and go landings to runway 09, N3492P entered a right downwind pattern for another approach to 09. N3492P was just past the abeam position for a landing when he observed the airplane abruptly roll left and dive for the ground where he lost sight behind the trees. The controller added that no other aircraft in the landing pattern, before, during, or after the accident, reported turbulence or unstable air. There was no radio call to indicate a problem preceding the accident. All radio transmissions from the accident airplane, including the initial call up, the go-around call, and the abeam position call for the last approach seemed routine.

PERSONNEL INFORMATION

The instructor is an Irish national aviation college student who had been authorized employment as a CFI to enhance practical training in the student's field of study. He held a Flight Instructor certificate with ratings for airplane single engine land, multiengine land, instrument airplane, and advanced and instrument ground instructor. His most recent FAA first-class medical certificate was dated October 2, 1998, with no limitations. His total flight time was 1180 hours, with 234 hours flown in multiengine aircraft. Multiengine instructor time was 192 hours.

The pilot/student was a Swedish national who had arrived in the U.S. on May 16, 2000, reportedly to work on his multiengine currency and build MEL flight time. He held a Commercial Pilot certificate with ratings for airplane single engine land, single engine sea, multiengine land, and instrument airplane. His most recent FAA first-class medical certificate was dated June 6, 1999, with no limitations. No pilot logbook was supplied to the NTSB, but the flight school application form completed by the pilot listed his flight time as of May 17, 2000 as 600 hours SEL, and 30 hours MEL. He had flown a 1.6-hour dual checkout flight on May 18, 2000, with the same CFI, which included seven or eight landings at TIX.

AIRCRAFT INFORMATION

The airplane had undergone a 100-hour inspection and its logbook signed by an FAA licensed mechanic on May 9, 2000, at an aircraft total time of 7765.8 hours and Hobbs time of 4095.0 hours. The Hobbs read 4146.5 at the wreckage site. According to engine records, the left engine had been rebuilt to new parts specifications in July, 1999, at a Hobbs time of 2507.7 hours. The left engine logbook entry indicated that engine "TTSPO" to zero time was accomplished on July, 1999. The right engine records revealed a time since overhaul of 2843 hours. Zero time left and right propellers had been installed on January 6, 2000, and both had accumulated 934 hours. The propellers were a modification per STC SA00721HC whereby the existing Hartzell HC-82YL-2C propellers, spinners and bulkheads were replaced with Hartzell HC-C2YL-2CUF propellers, spinners, and bulkheads. The aircraft records contained an STC for automotive fuel use; however, evidence at the accident site revealed use of 100LL aviation fuel. The static system was tested and inspected on April 26, 2000, and found to meet the requirements of FAR 91.411 and 91.413.

METEOROLOGICAL INFORMATION

The TIX tower personnel recorded a special METAR immediately following the accident at 0912. Visibility was 7 miles, cloud cover was scattered at 4,000 feet and at 20,000 feet, barometric pressure was 30.20 inches Hg., and the winds were from 120 degrees at 6 knots. WRECKAGE AND IMPACT INFORMATION

The airplane impacted dense 2-inch to 12-inch diameter scrub oak, gum, and palmetto growth at about 1.5 miles southwest of the TIX airport center at coordinates, N28 degrees, 29.92 minutes by W80 degrees, 48.72 minutes, which corresponds to the abeam-of-touchdown point for a right landing pattern to TIX's runway 09. The wreckage path was oriented about 070 degrees magnetic, measured about 65 feet in length, and began with tree collision about 40 feet above the surface in a wings level, nose down attitude. Tree foliage and palmetto fronds situated along the wreckage path exhibited evidence of fuel spewage, and the site smelled of 100LL fuel spill. The aircraft came to rest upright, heading about 125 degrees, in about a 15 degree left bank, having shed pieces of the right wing and the outer left wing panel in the trees. Pieces of wing, aileron, aileron trim tab, control linkage, and fuel cell bladder remained in the tree branches. The empennage had separated due to tree impact, was adjacent to the fuselage at 3 o'clock to its normal position, and was resting on its elevator and rudder trailing edges. The nose section received heavy inward crushing that encroached into the left front seat area due to tree collision. The right front seat track had fractured and the seat and occupant had been ejected frontward through the windshield. The left front seat and occupant remained in the aircraft, and the seat frame had sustained forward and downward deformation. The left seat belt was found buckled, but had been cut by rescue personnel. Shoulder harnesses were not installed. The configuration of the airplane was landing gear down, flaps in the retracted position, rudder trim neutral, and slight nose down trim. The cockpit fuel controls were selected to left and right main fuel tanks and crossfeed on.

Examination of the wreckage revealed flight control continuity was functional from cockpit to surface in all three axes, precrash. Flaps were found slightly extended and symmetrical, postcrash, but examination of the actuator revealed they were selected to the up position and the CFI confirmed that the flaps had not been selected down, precrash. All airframe components were located in the immediate area and showed no signs of precrash failure or malfunction. Both propellers exhibited "S"-shaped bending and numerous chordwise wood stained markings and scratches. One 4-inch diameter tree stump exhibited two clean, helix shaped slices, one at 11 inches and the other 18 inches above ground level. Both spinners revealed rotational shaped indentations. The left cowling revealed rotational scoring from contact with the alternator pulley. There was no evidence of fire.

The engines and attached propellers were removed from their respective mounts at the wreckage site and relocated to a flat bed trailer for partial disassembly inspection. Both engine assemblies were rotated and continuity was established with the crankshaft, camshaft, valve train, and accessory drive gears. Each cylinder produced compression, and magneto timing appeared consistent with piston position. Both engine induction and exhaust systems revealed no precrash obstructions. Both engine induction inlet and filter assemblies, carburetors, and exhaust systems were heavily impact damaged. The carburetor inlet screens were found to be clean. Some fuel was collected from both carburetors and revealed clean, uncontaminated, 100LL octane aviation fuel, and tested negatively for water content. Both engine fuel pumps revealed functional pumping action. The propeller governors were removed to reveal both drive couplings were intact, the units rotated freely, and both gasket screens were free of contamination. Both engine oil suction screens and filters revealed clean, proper viscosity lube oil. All four magnetos revealed good spark when field tested. Of the eight spark plugs for the left engine, six had severely worn electrodes. All spark plugs showed electrode coloration characterized as "normal" per Champion Spark Plugs Check-a-Plug chart AV-27. According to the Textron Lycoming Air Safety Investigator, on scene, "At the conclusion of the left engine examination, no evidence of any pre-impact mechanical failure or malfunction was found which would have prevented the engine from developing power prior to the mishap." An identical quote from the investigator regarding the right engine was also made.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examination of the pilot was conducted by Dr. Paulino O. Vasallo, District Medical Examiner, District 18, Brevard County, Florida, on May 20, 2000. The cause of death was attributed to multiple blunt force injuries. No findings that could be considered causal were noted. Toxicological tests on the pilot were conducted by the Federal Aviation Administration Research Laboratory, Oklahoma City, Oklahoma. The tests were negative for ethanol, basic, acidic, and neutral drugs.

The CFI was airlifted immediately after the crash, admitted to Orlando Regional Medical Center, Orlando, Florida, and was discharged on May 22, 2000. Toxicological tests on the CFI upon his admission to the medical center were conducted. The tests were negative for alcohol ethanol, amphetamine, benzodiazepine, barbiturate, opiate, cannabinoid, and cocaine.

TEST AND RESEARCH

According to the pilots who flew the aircraft for 4.5 hours the day before the accident, it flew without any problems except for the illumination of the right alternator warning light. They stated that after their return to base the evening before the accident flight, the aircraft was fully fuelled with 100 LL. The maintenance record revealed that the warning light write-up had not been cleared before the accident flight.

Follow-up telephone communication with two TIX tower controllers on December 14, 2000, revealed that neither the one, 23 years experience as a TIX tower controller, nor the other, 19 years experience as a TIX tower controller, could remember an instance where traffic pattern aircraft complained of turbulence or unstable air due to the outflow from nearby smoke stacks.

ADDITIONAL INFORMATION

The airplane wreckage, minus maintenance records, was released to a representative of the owner/operator on May 20, 2000. The completion of the return of the maintenance records and related aircraft rental records to the owner/operator occurred on January 3, 2001.

NTSB Probable Cause

The failure of the PIC to maintain control of the aircraft while in the simulated engine inoperative configuration in the landing pattern during a checkout flight resulting in an uncontrolled descent and collision with trees. A factor in the accident is the inadequate monitoring of aircraft control by the checkout pilot.