NTSB Factual Report

HISTORY OF FLIGHT

On April 21, 1995, about 1703 eastern daylight time, a Piper PA-28-180, N3995R, crashed shortly after takeoff from the Quincy Municipal Airport, Quincy, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was destroyed and the commercial-rated pilot and four passengers were fatally injured. The flight originated about 1700 from the Quincy Municipal Airport, Quincy, Florida.

According to a witness, the pilot, who was by himself, landed about 1200 and at the pilot's request, both fuel tanks were filled with 100 Low Lead fuel. A fuel receipt indicated that 23.1 gallons of fuel were added. The airplane was then parked. Review of recorded transcriptions from the Gainesville, Florida, Federal Aviation Administration Automated Flight Service Station (AFSS) revealed that the pilot called twice and obtained weather briefings for a proposed flight to the Arlington Municipal Airport, Arlington, Tennessee. The pilot and his family were then observed before departure around the airplane and before takeoff from runway 14, a witness heard run-up of the engine with no unusual sounds noted. The flight was observed to rotate about 1,584 feet down the 2,963-foot asphalt runway and during the initial climb on the upwind leg, the airplane was observed to roll left and right about the longitudinal axis. The airplane turned left crosswind and a witness who was about 1 mile east of the airport observed the airplane flying "slow" northbound about 100 feet above ground level (agl). The witness reported that the engine sounded normal and there was no smoke trailing the airplane.

Another witness who was about 1/4 mile south of the crash site observed the airplane flying northbound about 200-300 feet above ground level with "dark black smoke" trailing from the engine area. He stated that because of distance from the airplane he couldn't hear the engine operating and he did not observe the airplane crash. He did hear an explosion and stated he did not observe anything fall from the airplane during the 5- 10 seconds he observed the airplane flying.

According to a witness who lives about 1/4 mile north- northeast from the crash site she reported hearing the engine "backfiring & sputtering." She did not witness the accident and reported that the weather at the time of the accident included good visibility beneath the clouds with light drizzle. At the time of the accident the wind was from the south at about 8-10 miles per hour. She heard an explosion and then saw the postcrash fire.

A relative of the pilot's wife stated that the pilot had earlier in the week briefly stayed at a farm which is located about 1/4 mile east of the Quincy Airport.

PERSONNEL INFORMATION

Information pertaining to the pilot is contained in the NTSB Factual Report-Aviation. According to the owner of the airplane, the pilot had flown the accident airplane about 200 hours.

AIRCRAFT INFORMATION

Information pertaining to the airplane is contained in the NTSB Factual Report-Aviation. Review of airplane records revealed that Supplemental Type Certificates (STC Numbers SA2660CE & SE2563CE) were issued to the airplane. The STC's in part indicate removal of the single auxiliary fuel pump and installation of two auxiliary fuel pumps. This allows for the operation of the airplane on leaded and unleaded automotive gasoline or a mixture of automotive gasoline and 100 Low Lead fuel. The airplane owner stated that the fuel pumps are activated by a single, three position rocker-type switch in the cockpit. The STC instructions indicate that aluminum tubing connects the fuel pumps to the gascolator.

The airplane owner also stated that in 1990 or 1991 during an annual inspection of the airplane, the baffle tube weld at the end plate of the muffler for the right forward cylinder was found cracked circumferentially about 90 degrees. The owner stated that the muffler was removed and repaired then reinstalled. Review of the engine logbook revealed an entry dated June 15, 1989, which indicated in part "...removed exhaust and repaired...." Additionally, the airplane owner stated that he flew the airplane about 50-55 minutes on April 13, 1995, and about 50-55 minutes the following day. No discrepancies with the engine were noted. He also stated that there was no reported rough engine at low throttle settings, or inconsistent engine shutdown when he last flew the airplane. After landing on April 14, 1995, he changed the engine oil and then operated the engine checking for leaks; none were found. He also observed that there were no fuel leaks. An entry in the aircraft logbook associated with an annual inspection dated August 10, 1994, indicates in part that the gascolator was cleaned. There were no other fuel related entries in the aircraft logbook. An entry in the engine logbook associated with an annual inspection of the engine was dated August 10, 1994. There were no other entries in the engine logbook.

According to the airplane flight manual and equipment list, two individual rear seats and seatbelts were installed when the airplane was manufactured.

METEOROLOGICAL INFORMATION

Information pertaining to the weather is contained in the NTSB Factual Report-Aviation. Additionally, a pilot who departed on a flight about 10 minutes after the accident airplane departed reported the ceiling was about 5,000 feet with 15 miles visibility beneath the ceiling. He also stated that during the initial climb on the upwind leg, he did not experience the left and right rolls about the longitudinal axis in his airplane that he observed the accident airplane experience.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site area revealed that the left wing of the airplane forward of the fuel tank collided with an approximately 80-foot-tall tree. The magnetic heading of the airplane at the time of impact was determined to be about 340 degrees. Numerous tree branches, a tree trunk, and dead leaves were observed along the wreckage path. The airplane came to rest upright adjacent to a pond in a wooded area about 308 feet from the initial impact point on a magnetic heading of about 060 degrees. Located near the wreckage were several tree trunks severed by the propeller. The crash site was located about 009 degrees and 2.41 nautical miles from the departure airport.

Examination of the airplane at the accident site revealed all components necessary to sustain flight were in the immediate vicinity. The right horizontal stabilator was found separated and impact damage was noted near the outboard portion on the leading edge. Pieces of tree were found imbedded in creases of the left wing fuel tank skin and heat damage was noted adjacent to the fuel tank. Additionally, the left wing jack pad was located adjacent to the first impact point with the tree. No heat damage was noted to the jack pad. The right wing was examined and the top and bottom skin sections were displaced up and down respectively. Heat damage to the right wing was observed adjacent to the fuel tank. Both fuel tank caps were found secured and examination of the remaining sections of the fuel supply lines and outlet screens from each tank revealed no obstructions. The aileron, elevator, and rudder flight controls were also examined with no evidence of preimpact failure or malfunction. The cockpit, engine compartment and fuselage were damaged by the post crash fire. Soot was not observed on the horizontal stabilator or vertical stabilizer and the firewall was found to be upright, nearly vertical.

Examination of the engine compartment revealed that the gascolator was nearly destroyed by heat but the drain was closed and safety wire was found attached from the gascolator bowl set screw to the gascolator bowl drain fitting. Aluminum was observed adhering to the engine side of the firewall above the gascolator adjacent to the two auxiliary fuel pumps. Additionally, non-uniform shaped holes were observed in the firewall adjacent to the brake cylinder reservoir assembly and a section of firewall was extensively heat damaged adjacent to the gascolator attach bracket. The auxiliary fuel pumps were found secured to the firewall and threaded section of aluminum fittings were observed at the inlet and outlet of each auxiliary fuel pump which were heat damaged. Two sections of aluminum tubing were located in the engine compartment area both of which had one end connected to a steel fitting. The opposite ends of both were not connected to fittings and displayed heat damage.

Additionally, a copper fuel line which connects the fuel selector to the bulkhead tee fitting at the firewall was intact along its length. The line was connected to the bulkhead fitting aft of the firewall but was found separated at the fuel selector, which was heat damaged. Examination of the flexible fuel and oil hoses in the engine compartment revealed no evidence of preimpact failure or malfunction.

Examination of the carburetor which was found secured to the engine revealed that a nut with associated nipple and portion of a socket from a flexible hose was found to be tightly secured to the tee fitting at the inlet for the carburetor. The fuel pressure hose nut with associated nipple and portion of the flexible hose socket was also found to be secured to the tee fitting at the carburetor. Heat damage to the carburetor was observed.

Located adjacent to the gascolator attach area was a 90-degree steel fitting. The non-flared end of the fitting was not connected. The flared end of the fitting was observed to have a nut and associated sleeve with approximate 2-inch long aluminum tubing extending beyond the nut. According to the installation instructions of the STC, the steel 90-degree fitting was threaded into the inlet of the gascolator. Additionally, the primer line end fitting and line were found near the gascolator area.

Examination of the accessory case revealed that the engine driven fuel pump was found to be secured to the accessory case by two internal hex screws which were found to be safety wired. The engine, and fuel selector valve were removed for further examination.

Examination of the engine revealed crankshaft and camshaft continuity. Valve train continuity was verified by thumb compression for cylinders Nos. 1 and 3. Thumb compression for cylinder Nos. 2 and 4 was not verified due to heat damage to the intake and exhaust valve springs. The No. 2 and 4 cylinders were removed from the engine which revealed no evidence of preimpact failure or malfunction. Each magneto was tight against the accessory case; however both were heat damaged which precluded testing. Examination of the oil suction screen and oil filter element revealed no evidence of metal particles. The carburetor was removed for examination which revealed that the idle adjustment screw was set to provide a slightly enrichened fuel/air mixture at idle. Additionally, the air metering pin was adjusted to provide a slightly leaner fuel/air mixture at full throttle. The air metering pin jet plug was observed to safety wired to the throttle body assembly. The composite float, synthetic rubber material on the float valve, and throttle body to bowl gasket were heat damaged which precluded bench testing. The nozzle assembly was found to flow within specification and the carburetor was found to contain a one-piece venturi. The engine-driven fuel pump was heat damaged which precluded testing but the spring of the diaphragm assembly and operating lever were not failed. Examination of the spark plugs revealed that cylinder Nos. 1 and 4 top plugs were black in color and dry and the No. 2 cylinder bottom spark plug was dark brown in color and also dry. The remaining spark plugs were found to be wet with oil. According to a report prepared by a representative of the engine manufacturer, all of the spark plugs were "worn out-severe."

MEDICAL AND PATHOLOGICAL

Post-mortem examinations of the pilot and four passengers were conducted by Lynn H. Dolson, M.D., Acting Associate Medical Examiner of the District Two Medical Examiners Office, Tallahassee, Florida. Significant autopsy findings of the pilot were in descending order, small aircraft accident, skull fracture, basilar portion of the occipital bone, severely charred body, with no evidence of soot deposition or burning of the larynx or trachea. Hypertensive cardiovascular disease with interstitial fibrosis was noted. The results of post-mortem examinations of all passengers indicate that significant findings indicate small aircraft accident with blunt force injury. No soot deposition or charring of the larynx and trachea was identified for all the passengers. The carboxyhemoglobin level was determined for the pilot seated in the left front seat, the 11-year-old passenger seated in the right rear seat, and the 42- year-old passenger seated in the left rear seat. The results were recorded as 10-11 percent (non-smoker by history), 15 percent, and 39 percent respectively.

Toxicological analysis was performed on specimens of the pilot by the FAA Toxicology and Accident Research Laboratory and the District Two Office of the Medical Examiner. The results of analysis by the FAA was negative for cyanide and volatiles and positive for carbon monoxide (11 percent). Verapamil and Norverapamil were detected in the blood and urine. The results of analysis by District Two was positive for Verapamil. No other drugs or volatiles were detected.

TESTS AND RESEARCH

During the examination of the engine it was noted that the No. 1 cylinder baffle tube was failed circumferentially along a weld at the end plate of the muffler. The baffle and muffler were metallurgically examined which revealed evidence of stress corrosion cracking. The metallurgy report is an attachment to this report.

ADDITIONAL DATA/INFORMATION

The day after the accident about 0800, a fuel sample was obtained by an FAA inspector from the fuel pump nozzle under pressure, and the fuel filter housing drain. Visual examination of the samples revealed a color and odor of 100 Low Lead fuel. No contaminants were noted. According to the president of the fueling facility, on April 9, 1995, 7,979 gallons of 100 Low Lead fuel were added to the above ground storage tank. He also stated that between April 9-21, 1995, fuel was dispensed to 97 aircraft, several of which were operated by the fueling facility. Fuel contamination was not noted.

The fuel selector was removed from the wreckage and sent to the airplane manufacturer for examination which revealed that it was in either the "off" position or partially aligned between the right tank and the engine ports. Review of the STC instructions revealed that the fuel selector is to be positioned to the right tank on takeoff and landing when operating on auto gas or when auto gas is intermixed with aviation fuel. Additionally, the aircraft logbook indicates that Airworthiness Directive (AD) 71-21-8 was complied with on November 9, 1971. The AD indicates replacement of the fuel selector valve cover assembly and mating handle to prevent inadvertent selection to the "off" position.

The brother of the pilot indicated that the pilot was a non- smoker and in good health. The pilot's wife occasionally smoked and exercised by playing tennis.

The mechanic who performed the last annual inspection of the airplane stated that he tightened the gascolator "jam nut" with pliers then safetied the jam nut using safety wire.

The wreckage and all retained components were released to Mr. Don Huntington, Quality Aircraft Salvage, on December 5, 1995.

NTSB Probable Cause

AN UNDETERMINED FUEL SYSTEM PROBLEM THAT RESULTED IN A FUEL LEAK, AN ENGINE COMPARTMENT FIRE, AND A PARTIAL LOSS OF ENGINE POWER. A FACTOR RELATING TO THE ACCIDENT WAS: THE LACK OF SUITABLE TERRAIN FOR A FORCED LANDING. AN EXHAUST LEAK FROM THE FRACTURE OF AN IMPROPERLY WELDED BAFFLE TUBE MAY HAVE BEEN THE SOURCE OF IGNITION FOR THE ENGINE COMPARTMENT FIRE.