NTSB Factual Report

HISTORY OF FLIGHT

On November 9, 2005, at 2059 central standard time, a Piper PA-23-160, N4319P, operated by Blackstone Rotorcraft Inc., received substantial damage on impact with terrain about one mile southeast of Central Illinois Regional Airport (BMI), Bloomington, Illinois, during a visual approach to runway 29. Night visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 135 on-demand cargo flight was operating on an instrument rules flight plan. The pilot was fatally injured. The flight departed from Greater Peoria Regional Airport (PIA), Peoria, Illinois, en route to Johnston County Airport (JNX), Smithfield, North Carolina, at 2021 and returned to PIA without incident after the pilot reported that the airplane door came open. The flight then departed at 2031 and diverted back to PIA due to a reported rough right engine, but while diverting back to PIA, the pilot diverted to BMI. The pilot did not declare an emergency.

N4319P was fueled by a PIA fixed base operator's (FBO's) line service technician who stated that the pilot of N4319P told him to fuel the airplane's main and auxiliary fuel tanks. The line service technician stated that he fueled everything with 100 low lead and he did not fuel the tip tanks. The line service technician stated that the pilot was present when he fueled the airplane, and the pilot "seemed happy." The line service technician stated that the pilot "verified" the fuel and oil, but he did not see the pilot sump the fuel tanks after the airplane was fueled and added that "maybe" he was not present "at the exact" time when the pilot sumped the fuel tanks.

The line service technician stated that another airplane that was fueled from the same truck did not report any problems.

An FBO front desk employee stated that the pilot of N4319P came into the FBO to pay for fuel and cargo and at that time he "seemed fine."

Fuel and credit card receipts show that 59 gallons of fuel was purchased at 2004 and 104 lbs of freight on/off loaded.

The following is a partial transcription of air traffic control recordings of transmissions made by Champaign (CMI) Approach Control (APCH), PIA APCH, BMI air traffic control tower (ATCT), PIA ATCT Combined APCH (CAP), and N4319P.

2011, N4319P called PIA ground control and obtained an instrument clearance to JNX.

2016, N4319P advised PIA that he was ready to taxi and was given taxi instructions to runway 31

2020, N4319P called PIA ATCT ready to depart runway 31 and was issued a takeoff clearance with an assigned departure heading of 360

2022, N4319P advised PIA ATCT a need to return to the airport because a door on the aircraft opened. The ATCT controller cleared N4319P to land on runway 31

2031, N4319P advised PIA ATCT ready to depart runway 31. PAI ATCT issued takeoff clearance and assigned a departure heading of 360 degrees

2032, PIA ATCT instructed N4319P to contact the departure controller

2033, N4319P contacted PIA Departure and was issued a climb clearance to 9,000 feet

2035, N4319P was issued on course

2048, N4319P was instructed to contact CMI APCH.

2051, CMI APCH requested a heading from PIA to assign N4319P to return to PIA and informed PIA APCH the aircraft right engine is not developing full power and wanted to return to PIA

2052:59, PIA ATC/APP, (unintelligible) four three one niner papa peoria approach ah expect visual approach runway three one and ah are you declaring an emergency

2053:14, N4319P, ah negative its just ah just developing partial power i'm in good shape

2053:14, PIA ATC/APP, ya i was gonna say ah right now i show you doing seventy knots for the ground speed ah if you'd like bloomington airport's about seven miles northeast of your position

2053:26, N4319P, all right give me a vector to bloomington

2053:28, CAP, okay one niner papa descend and maintain three thousand and you can turn back right heading of about let's make the heading one five zero and we'll set you up for runway two nine

2056:49, N4319P, bloomington tower four three one niner papa

2056:53, LC, apache four three one niner papa bloomington tower good evening report the midfield downwind runway two nine

2056:59, N4319P, one niner papa

2057:20, LC, apache one niner papa just verify you do have the airport in sight

2057:26, N4319P, that's affirmative in my ah about ten o clock right now

2057:30, LC, affirm

2057:32, LC, are you requiring any assistance at this time

2057:34, N4319P, a negative I just need to see if I can find out whats the problem with that engine

2057:38, LC, roger

2058:24, N4319P, one niner papas midfield downwind runway two nine

2058:31, LC, apache one nine papa runway two nine cleared to land

2059:19, N4319P, *(breathing) [expletive]

2059:32, N4319P, *(breathing) aw [expletive] me

2059:48, LC, apache one niner papa can you make it

2059:50, N4319P, aw

2100:59, LC, apache four three one niner papa bloomington tower

There were no further recorded transmissions from N4319P.

The BMI ATCT controller stated that he saw N4319P make a base turn when it started losing altitude. The airplane made a "sharp turn" to the south and continued to lose altitude. The airplane impacted the ground and exploded "shortly" after impact.

PERSONNEL INFORMATION

The pilot was issued a second class medical certificate on May 5, 2005 with the following limitation: "Holder shall wear lenses that correct for distant vision and possess glasses that correct for near and intermediate vision. Certificate not valid after May 31, 2006."

AIRCRAFT INFORMATION

The 1959 PA-23-160, serial number 23-1820, was powered by two Lycoming O-320-B3B engines with left and right engine serial numbers of L-3948-39 and L-4052-39, respectively. Aircraft logbook entries stated that an annual inspection of the airplane and engines was completed on October 15, 2005, at a left tachometer time of 493 hours.

The airplane was configured and operated as an on-demand cargo airplane at the time of the accident.

AIRPORT INFORMATION

BMI is a controlled airport located about 37 nautical miles east of PIA. BMI is served by runway 02-20 (8,000 feet by 150 feet, grooved concrete) and runway 11-29 (6,529 feet by 150 feet, asphalt, grooved concrete). Runway 02-20 was equipped with high intensity runway lights and centerline lights. Runway 02 was equipped with a precision approach path indicator with 4 identical light units on the right side of the runway and runway 20 was equipped with a medium intensity approach lighting system with runway alignment indicator lights. Runway 11-29 was equipped with high intensity runway lights. Runway 11 was equipped with runway end identifier lights and a 4-box visual approach slope indicator on the right side of the runway. Runway 29 was equipped with lead-in lighting system.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located approximately one nautical mile southeast of BMI in an agricultural field. The main wreckage exhibited fire damage along the wings, fuselage, and engines.

The left propeller was attached to the engine with one blade deformed aft approximately 10 degrees and twisted towards the low pitch. The other blade of the left propeller was deformed aft about 90 degrees near mid span and twisted towards low pitch. The left propeller was not in the feathered position.

The right propeller was attached to the engine with one blade deformed aft about 10 degrees near the root. The propeller was not in the feathered position.

Flight control continuity was confirmed. The rudder trim actuator extension was approximately 1 inch, which equates to a neutral position. The horizontal trim actuator was extended 1 5/8 inch, which equates to a neutral position. The flap control handle was partially melted and in the mid travel position.

The landing gear control handle was partially melted and in the down position.

Magnetos from both engines were rotated by hand and a spark noted from each magneto terminal.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot's toxicological test results performed by the Federal Aviation Administration were as follows:

No carbon monoxide detected in blood, no cyanide detected in blood, no ethanol detected in blood, 61.6 (ug/ml, ug/g) acetaminophen, amlodipine present in urine, and amplodipine not detected in blood.

The following information was extracted from the pilot's medical records maintained by the FAA Aerospace Medical Certification Division:

April 20, 2004, A letter to the FAA from the pilot's Aviation Medical Examiner notes, in part, [The pilot] was in the office 4-20-04 for his annual second class medical certification. I have been his personal physician for the past two years.

He is being treated for diabetes, hypertension, and hyperlipidemia.

Current medications include Crestor [rosuvastatin] 10 mg daily, Norvasc [amlodipine] 10 mg daily, Lotensin [benazepril] 20 mg twice a day, HCTZ [hydrochlorothiazide] 25 mg daily, Glucophage [metformin] XR 500 mg daily, and aspirin 5 grains daily.

His blood pressure has been well controlled. Today it is 128/82, on 4-5-04 it was 126/80, and on 2-9-04 it was 134/80.

His diabetes is well controlled. On 4-5-04 he had lab work done that revealed a hemoglobin A1C of 5.9. Remainder of his chemistry panel and lipid profile is attached. He has had no hypoglycemic episodes, no side effects from his medication, and he has no evidence of end organ damage.

He was hospitalized briefly in May of 2003 with "indigestion." He had a cardiology consultation and a surgical consultation and was found to have biliary colic and cholecystitis. He subsequently had an uneventful laparoscopic cholecystectomy from which he made a complete recovery. As a precaution he also had coronary arteriograms done and he had no evidence of significant coronary artery disease and his ejection fraction was normal. Copies of relevant notes are attached as well.

The remainder of his examination today meets the standards for a second class certification.

May 14, 2004, A letter to the pilot from an FAA Deputy Regional Flight Surgeon notes, in part: I have reviewed the information submitted by you in support of your request for an airman medical certificate. The medical evidence reveals a history of diabetes mellitus requiring oral hypoglycemic medication and hypertension requiring medication. You are ineligible for medical certification. However, based on the complete review of the available medical evidence, I have determined that you may be granted Authorization for special issuance of a second-class airman medical certificate

May, 3, 2005, A letter to the FAA from the pilot's Aviation Medical Examiner notes, in part: [The pilot's] blood pressure has been well controlled, today 138/82, on 4-4-05 140/80, and on 12-20-04 130/84. His diabetes is well controlled. Lab work done on 4-4-05 revealed a hemoglobin A1C of 6.5.

June 24, 2005, A letter to the pilot from an FAA Deputy Regional Flight Surgeon notes, in part: I have reviewed the information submitted by you in support of your request for an airman medical certificate. The medical evidence reveals a history of diabetes mellitus requiring oral hypoglycemic medication and hypertension requiring medication. You are ineligible for medical certification. I have determined, however, that you may be granted an Authorization for special issuance of a second-class airman medical certificate

The following information was extracted by Dr. Mitchell A. Garber, NTSB Medical Officer, from the report of autopsy performed on the pilot for the McLean County (Missouri) Coroner: Under Body Cavities is noted, in part: In the pericardial sac, there is 250 cc of liquid hemorrhage. Under Cardiovascular System is noted, in part: 1.0 cm above the aortic leaflets, there is a 5.0 cm, horizontal, transmural defect with tracking hemorrhage extending from the intima into the adventitia and, subsequently, into the pericardial sac. The defect is in the atheromatous plaque. The remainder of the intima of the aorta is covered with raised, yellow-tan, atheromatous plaque material. There is outpouching of the distal aorta, consistent with early aneurysm formation. Patchy calcification is seen, predominantly in the distal aorta. Under Diagnoses is noted, in part:

1. Hemopericardium, 250 cc.

2. Dissecting aortic aneurysm, Type A. a 5.0 cm defect at the root in an atheromatous plaque tracking hemorrhage extending from the intima to adventitial wall and into the pericardial sac.

3. Moderate aortic atherosclerosis.

4. Severe arterionephrosclerosis.

Under "Opinion" is noted: "In consideration of the circumstances surrounding his death, the available medical history, and autopsy findings, the death of [the pilot] is ascribed to Blunt Head and Chest Trauma sustained as a pilot involved in an airplane mishap. A factor significantly contributing to his death is Hemopericardium due to Dissecting Aortic Aneurysm due to Hypertensive and Atherosclerotic Cardiovascular Disease.

TESTS AND RESEARCH

The radio transmissions from the accident aircraft were examined to document any engine or propeller sounds that might be present. There were several radio transmissions identified as originating from the accident aircraft recorded after the aircraft notified the departure controller that he had a rough running engine and wanted to return to BMI.

The radio transmissions were examined on an audio spectrum analyzer to identify any background sound signatures that could be associated with either the aircraft's engines or the attached propellers. This aircraft was equipped with two wing-mounted reciprocating engines that are each equipped with a 2-blade variable pitch propeller. The propellers normally rotate at a certificated maximum rotation speed of 2,700 revolutions per minute (RPM). During several of the longer radio transmissions originating from the accident aircraft sounds were identified that could be associated with the rotating propellers of the aircraft. During the radio transmissions that were recorded on the radar control frequency only the 4th and 5th harmonic of the primary blade passing frequency of the rotating propellers could be identified. During the radio transmissions that were recorded on the tower frequency only the second and third harmonics of the rotating propellers could be identified.

The sound signatures that were identified during the various radio transmissions were converted to propeller rotating speed in RPM and listed in the following table. It should be noted that the exact radio transmission phrase as spoken by the accident pilot was not transcribed. Only a paraphrased portion of the pilot's transmission is shown in the following table, enough to adequately identify them as originating from the accident aircraft. Not all radio transmissions originating from the accident aircraft contained identifiable propeller and/or engine sounds.

The following radio transmissions were examined:

2050:06, 4319P return to airport, propeller A 2,688 RPM, propeller B 2,400 RPM

2050:18, right engine running rough, propeller A, 2,670 RPM, propeller B 2,364 RPM

2052:38 eighteen point zero five 19Papa, propeller A 2,565 RPM, propeller B 2,328 RPM

(Changed to Bloomington Tower frequency)

2057:24, have airport in sight, propeller A 2,670 RPM, propeller B 2,350 RPM

2057:34, Need to find out whats wrong, propeller A 2,670 RPM, 2,350 RPM

2058:25, 19Papa mid field downwind, propeller A 2,670 RPM, propeller B 2,419 RPM

2059:19, (33 second long transmission), propeller A 2,670 RPM, propeller B 1,800 RPM

The right engine was shipped to Textron Lycoming, Williamsport, Pennsylvania, where it underwent a disassembly examination because of accident damage that precluded a test run of the engine. The examination was conducted under the supervision of the National Transportation Safety Board. There were no engine component anomalies noted.

The carburetor was sent to Precision Airmotive, LLC, and examined under the supervision of an FAA inspector from the Seattle Flight Standards District Office. Damage to the carburetor precluded functional flow testing and a disassembly

NTSB Probable Cause

The aircraft control not possible by the pilot during a visual approach to the runway due to the physical impairment of the pilot.