NTSB Factual Report

HISTORY OF FLIGHT

On April 19, 2001, about 1633 eastern daylight time, a Piper PA-32-300, N4103R, registered to Skobin Import and Export, Inc., crashed in a wooded area near warehouses shortly after takeoff from the Fort Lauderdale/Hollywood International Airport, Fort Lauderdale, Florida. Visual meteorological conditions prevailed at the time and a visual flight rules (VFR) flight plan was filed for the international passenger/cargo flight. The airplane was destroyed by impact and a postcrash fire, and the private-rated pilot, sustained serious injuries. Four passengers were fatally injured. The flight originated about 4 minutes earlier.

The airplane was fueled before departure; during fueling a witness noted postal crates and miscellaneous packages next to the airplane. The person who fueled the airplane reported seeing the pilot load the last of the cargo into the airplane. Sometime after fueling, the passengers were taken to the airplane; a person who escorted them reported seeing cargo in the left rear portion of the cabin. A copy of the statement from the person who observed the cargo location in the airplane and from the person who noted the postal crates are an attachment to this report.

According to a transcription of communications with the Fort Lauderdale Air Traffic Control Tower, the pilot contacted flight data/clearance delivery at 1615:07, then ground control at 1625:14, and was cleared to taxi to runway 9L, which was acknowledged. At 1627:05, the pilot contacted local control (tower), and advised that the flight was holding short in sequence for runway 9L. The controller advised the pilot that a twin engine general aviation airplane would be departing first, then she would be departing. At 1628:42, the controller advised the accident pilot to taxi into position and hold, which was acknowledged. At 1629:15, the controller advised the pilot to maintain visual separation with the previously departed airplane, gave the wind as 070 degrees at 14 knots, and cleared the flight for takeoff. At 1629:25, the pilot acknowledged the takeoff clearance and advised the controller that the flight was "...rolling." Review of a certified copy of the voice tape revealed the flightcrew of a U.S. Airways flight was advised by the tower controller to position and hold immediately after the accident pilot advised the tower controller that the flight was rolling. The transcription of communications further indicates that at 1630:51, the controller stated, "cherokee zero three romeo tower are you experiencing any difficulty", to which the pilot replied at 1631:03, "...slightly uh i may have to circle." There were no further recorded transmissions from the accident pilot. The controller then advised the U.S. Airways flightcrew, "...i'm not going to get you out that cherokees having a little bit of difficulty", to which one of the flightcrew members responded, "yeah we noticed...."

A flightcrew member of the U.S. Airways flight reported that the takeoff roll seemed to be unusually long and was longer than expected for an airplane of that type. The flightcrew members did not notice the point of rotation but both reported the airplane was climbing "slowly" and never climb higher than 300 feet above ground level (agl). Both flightcrew members also reported that during the climbout, the airplane was observed to drift to the left, and one reported the airplane was noted to then begin a nose level descent before losing sight of the airplane. Both reported there was no smoke trailing the airplane during the takeoff roll or during the climbout. One of the flightcrew members reported seeing the wings rocking during the climbout. Copies of NTSB Record of Conversation forms are an attachment to this report.

The tower controller in contact with the accident pilot reported to the Federal Aviation Administration inspector-in-charge (FAA-IIC) that the accident flight's takeoff roll began from the beginning of runway 9L. The airplane became airborne at approximately the "Delta" intersection, and the aircraft was porpoising and the wings rocking at the "Quebec" intersection. The controller reported that the airplane never climbed higher than 100 feet, and he contacted the pilot after he saw the aircraft was having "difficulty." The controller reported that at that point, there was runway remaining. A copy of the FAA Record of conversation with the controller and a copy of the controller's "Personnel Statement" are attachments to this report.

A Federal Aviation Administration (FAA) employee who was located in a building on the airport reported he first noticed the airplane when it was 6,000 feet down the 9,000-foot runway, and estimated that the airplane was 80-100 feet agl. He stated, "The aircraft was flying with unusual characteristics. It was much slower [than] what I would have considered normal. It also was maintaining a high angle of attack and was slowly pitching up and down. The aircraft was not gaining altitude rapidly." He further stated the flight continued eastbound and when it cleared the east end of the runway, the airplane was at an estimated 230 feet. He noted that the airplane was in a left bank and lost sight of the airplane. A copy of his statement and diagram are an attachment to this report.

Several witnesses who were located near the departure end of the runway reported the airplane was only between 100-200 feet agl when it passed their position. One witness reported that the engine sound was steady but didn't sound "fast." Another witnesses who was at gate 101 (located east and north of the runway), reported the airplane appeared to be having trouble gaining altitude and was fishtailing left to right. He also reported the airplane seemed to "porpoise" up and down, and the engine sounded like it was at full throttle. He did not perceive of an engine malfunction. Several witnesses near the accident site reported hearing an engine indication described as, "stall out", or "sputtering noise" immediately before the airplane was observed to pitch nose down. One witness who was inside a building located about 100 yards south of the crash site and who has 35 years experience as an automobile mechanic reported he never saw the airplane but heard an airplane flying low; the engine sounded as if it were operating at full throttle. He reported he did not hear the engine missing or sputtering. Another witness also located approximately 100 yards from the accident site observed the airplane pitch nose-up, and the airplane banked to the left in an approximate 45-degree angle of bank. The airplane then pitched nose down and left wing low. He reported hearing the engine revving up and down (surging) immediately before the crash. Personnel from the warehouses rescued the pilot and attempted to rescue the passengers, but were unable. A postcrash fire was extinguished by local fire departments. The witness statements are an attachment to this report.

PERSONNEL INFORMATION

The pilot is the holder of a private pilot certificate with airplane single and multi-engine land ratings. According to FAA Integrated Safety Information System (ISIS) database records, she was issued a warning notice for cited Federal Aviation Regulation violations pertaining to operation of a U.S. registered airplane on May 4, 2000, in Nassau, Bahamas. The records indicate that an FAA inspector performed a ramp inspection of the airplane and noted it was full of unsecured cargo, and the pilot was unable to produce an aircraft flight manual. The records indicate the pilot had no previous accidents or incidents. Excerpts from her airman's file and the ISIS database records are attachments to this report.

She was issued a third class medical certificate with no limitations on November 4, 1999. On the application for that certificate she indicated a total flight time of 1,008.1 hours and listed her occupation as manager with Van Tran Aviation Ltc.

The pilot did not provide flight time or recency of experience information. According to United States Customs Service Private Aircraft Enforcement System Arrival Report records, the accident pilot flew 27 times as pilot-in-command into the Fort Lauderdale/Hollywood International Airport between January 1, 2001, and the accident date.

AIRCRAFT INFORMATION

The airplane was last inspected in accordance with an annual inspection on November 14, 2000. At that time, the recorded total time in service was 8,499.9 hours. The engine was last overhauled on September 19, 1997, and installed in the airplane on October 17, 1997. The engine received a, "Continued Time Repair/Propeller Strike" inspection on May 18, 1999; the engine was approved for return to service and installed in the airplane on November 13, 1999. The engine received a second, "Propeller Strike/Continued Time Repair" inspection on May 23, 2000. The engine again was approved for return to service and was installed in the airplane with a zero time propeller on August 14, 2000. The engine oil and oil filter were changed the day before the accident. At the time of the accident the engine had accumulated approximately 1,347.6 hours since overhaul. A copy of the engine logbook is an attachment to this report.

METEOROLOGICAL INFORMATION

A special weather observation taken at the Fort Lauderdale/Hollywood International Airport about 1 minute after the accident indicates that the wind was from 080 degrees at 13 knots with gusts to 19 knots. The visibility was 10 statute miles, few clouds existed at 4,700 feet, broken clouds existed at 6,000 feet, the temperature and dew point were 24 and 12 degrees Celsius respectively, and the altimeter setting was 30.23 inHg.

COMMUNICATIONS

The pilot was in contact with the Fort Lauderdale/Hollywood International Air Traffic Control Tower (ATCT); a transcription of communications is an attachment to this report.

AIRPORT INFORMATION

The runway used by the pilot is 9,000 feet long by 150 feet wide, and is grooved asphalt.

As discussed in the "History of Flight" section of this report, the tower controller reported the airplane began the takeoff roll at the beginning of runway 9L, and became airborne about the "Delta" intersection. Review of an airport chart revealed the "Delta" intersection is located approximately 2,625 feet from the approach threshold of runway 9L. The calculations do not include the length of displaced runway surface. The distance from the "Quebec" intersection (point where the tower controller noted that the airplane appeared to have "difficulty") to the departure threshold was calculated to be approximately 3,312 feet.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed into a wooded area adjacent to warehouses (see photographs 1 and 2); the crash site was located at 26 degrees 04.919 minutes North latitude and 080 degrees, 07.959 minutes West longitude. That location when plotted was located 045 degrees and .47 nautical mile from the departure end of runway 9L.

Examination of the accident site revealed that the airplane collided with trees then the ground and came to rest 61 feet from the first observed tree impact point. A segment of left wing remained elevated in a tree near the initial tree impact point. The energy path through the trees was oriented on a magnetic heading of 020 degrees. The airplane came to rest nearly inverted on a magnetic heading of 039 degrees; all components necessary to sustain flight were found in the immediate vicinity of the accident site (see photograph 3). Fire damage to an area of trees measuring approximately 20 by 30 feet was noted to the left of the energy path beginning approximately 20 feet from the initial tree impact point. Fire damage was also noted in the area where the airplane came to rest, and forward of where the airplane came to rest. Browning of tree leaves was noted forward of the left wing segment in the tree. Fallen trees were noted in the cockpit area of the airplane. Examination of the forward baggage compartment revealed no evidence of a placard; extensive fire damage in the area was noted. Cargo that was found either inside or outside the airplane was documented as to description and location then retained for further investigation (see photographs 5, 6, 7, 10, 11 and 16, and Tests and Research section of this report). Several tree limbs exhibiting 45-degree cuts were located (see photograph 9). One of the tree limbs approximately 5.5 inches in diameter exhibited a 45-degree cut approximately 3 inches deep; red colored paint was noted on the cut surface. The cut was located approximately 18 feet 5 inches agl. Fifteen discharged portable fire extinguishers were noted at the accident site. During recovery of the airplane, an estimated 5 gallons of fuel leaked from the left main fuel tank into the ground.

Examination of the airplane revealed both wings were separated and exhibited fire damage; the left wing major structure was comprised of two sections; the inboard section consisting of the main landing gear and flap segment was separated near the wing root (see photograph 4). The leading edge of the left wing exhibited two semi-circular indentations located approximately 7 feet and 11.5 feet outboard from the wing root, respectively. The auxiliary fuel tank of the left wing was separated. The left main fuel tank cap and both auxiliary fuel tank caps were of the vented type; the right main fuel tank cap was not located. No obstructions were noted in the recovered fuel caps. No obstructions were noted in the primary fuel vent of the left main fuel tank. The right main fuel tank was consumed by fire; the auxiliary fuel tank was separated. The cockpit and cabin areas were damaged by fire. Fire consumed the fuselage bottom skin from the firewall aft to approximately 6.5 feet forward of the tailcone bulkhead assembly. Impact damage to the left horizontal stabilator was noted. Examination of the flight control cables for roll revealed no evidence of preimpact failure or malfunction. Stabilator and rudder flight control continuity was confirmed from near each control surface to the cockpit. The fuel selector was found in the "off" position; the rod between the valve and the selector handle was bent. The fuel selector valve was retained for further examination. The auxiliary fuel pump was electrically checked and found to operate (see photograph 12). The mixture and throttle controls were connected at the servo fuel injector. The engine that remained attached to the firewall was removed for further examination.

Examination of the engine revealed crankshaft, camshaft, and valve train continuity. Suction and compression was noted in all cylinders during rotation of the crankshaft though the No. 5 cylinder appeared weaker than the rest. Examination of the area surrounding the No. 5 cylinder revealed evidence of high heat damage to the oil sump beneath that cylinder. Removal of the No. 5 cylinder from the engine revealed normal combustion deposits on the piston dome; the rings were not failed and the ring gaps were not aligned. Leak check of the intake and exhaust valves revealed slight leakage from the exhaust valve and very slight leakage from the intake valve. Both magnetos were destroyed by fire, the hold down clamps of both magnetos were in place and secured; the coils of both magnetos were separated but recovered. The rotating magnet of the left magneto was noted to rotate with rotation of the propeller; the rotating magnet of the right magneto would intermittently rotated with rotation of the propeller. The engine-driven fuel pump could not be rotated by hand, the driven shaft was not failed. The snap ring that secures the shaft to the pump body was partially out of position. Examination of the muffler revealed no obstructions of the outlet; the internal baffle exhibited damage inline with the exterior damage. The servo fuel injector, distributor valve, injector lines, fuel injector nozzles, engine-driven fuel pump, propeller governor, and spark plugs were removed for further examination or testing.

Visual examination of the three-bladed propeller revealed all blades were in position but loose in the hub. The leading edge of the No. 1 propeller blade

NTSB Probable Cause

The pilot's exceeding the forward center of gravity (CG) ) limits at the time of engine start, the inability of the pilot to control the airplane due to the exceeded CG limits, the failure of the pilot to abort the takeoff with sufficient runway remaining, and the inadvertent stall by the pilot while maneuvering shortly after takeoff.