NTSB Factual Report

HISTORY OF FLIGHT

May 5, 1993, at 1645 eastern standard time, a Piper PA-28-140, N2487T, registered to Stanley J. Kososki of Taylor, Michigan, and piloted by a student pilot, experienced a loss of engine power during initial climb from runway 2 (2,773' X 50' dry/asphalt) at Paoli, Indiana. During the forced landing the airplane departed controlled flight and impacted the terrain. The airplane was destroyed and the pilot sustained fatal injuries. The solo instructional flight was being conducted under provisions of 14 CFR Part 91, in visual meteorological conditions. No flight plan was on file. The flight was departing, with an intended destination of Salem, Indiana, at the time of the accident.

According to the pilot's instructor during a face to face interview, the student pilot purchased the accident airplane in October, 1992. At that time the instructor picked up the airplane from the previous owner in Taylor, Michigan, and returned the airplane to Paoli, Indiana. At the time the instructor pre- flighted the airplane in preparation for flying it to Indiana, he reported checking the fuel tanks and sumps for water or contamination and found none. The instructor indicated that this was the last time he checked the fuel and that subsequent to his delivery of the airplane to the student pilot, he never observed the student pilot or anyone else check the fuel sumps.

The instructor indicated during the above interview that he was the only instructor for the student pilot. He stated that flight training was started in another type of airplane; however the student decided to purchase his own airplane shortly after commencing training. The instructor stated that the student lived in Paoli, Indiana, and he lived in Salem, Indiana. When the student originally purchased the airplane, the instructor traveled from Salem to Paoli to give the instruction; however, after checking the student out in the airplane, the instructor allowed the student to fly from the Paoli Municipal Airport to the Salem airport to pick him up for dual instruction.

According to the instructor and a non-rated mechanic, both of Salem, sometime prior to April 27, 1993, the airplane began to sustain a rough running engine. On April 27th the carburetor was removed from the accident airplane and the mechanic replaced the venturi and float. The repair resulted in a temporary restoration of power; however prior to May 1, 1993, the airplane again sustained a rough running engine. This time the mechanic removed the carburetor and replaced it with the carburetor from another airplane on which he was working. Again he reported that the airplane flight checked satisfactorily and the student pilot continued to fly the airplane. According to both of these people, at no time did anyone drain the fuel tank sumps.

On the accident date, the student pilot had an appointment to meet his instructor in Salem. On departure the airplane was observed to lose engine power and a forced landing was initiated to a farm field north of the airport. A witness near the farm said he saw the airplane approaching the field and then heard the engine RPM return and the airplane to turn left and initiate a climb. A few seconds later he heard the engine power reduce and the airplane impacted the terrain in an adjacent farm field.

PERSONNEL INFORMATION

The 31 year old pilot was the holder of a student pilot certificate number DD0167995, issued September, 25, 1992. He held a third class medical certificate issued on the same date, with the restriction for "Must wear corrective lenses." His total flight experience consisted of 30 hours of which eight hours were as sole manipulator of the controls (solo), and 25 hours were in the accident airplane.

AIRCRAFT INFORMATION

The airplane was a Piper PA-28-140, N2487T, serial number 28- 7125537. The airplane had accumulated 3,265 hours time in service at the time of the accident. The airplane had received an annual inspection on September 26, 1992, and had accumulated 38 hours since the inspection. The engine had accumulated 715 hours time in service since a major overhaul.

WRECKAGE AND IMPACT INFORMATION

The airplane was observed by witnesses to be heading on a north heading when engine power was lost and the airplane descended into a farm field. One wing was observed to strike the ground and the airplane nosed into the ground and "cartwheeled" to a stop reversing direction, coming to rest facing south.

When the airplane was examined it was found to have lost both wings during the ground impact. The right wing was folded back and the fuselage was lying on its left side atop the left wing which remained upright. The nose of the airplane was approximately 20 feet north of a small crater in the ground which was consistent with the marks on the engine, cowling and propeller.

One propeller blade was bent back slightly and the other blade was bent slightly forward. Dirt adhered to the cambered side of the propeller and no polishing or gouging of the propeller leading edge was visible.

The carburetor was removed from the engine while on-scene. When opened water contamination was found the bottom the float bowl and in the accelerator pump cavity. The electric fuel pump was disassembled. Water and dirt contamination were found in the pump and filter. The interior housing of the fuel pump was rusted. The gascolator was removed and water contamination was found in the bottom of the bowl.

The fuel selector was found in the position for the left tank. Samples of fuel were taken from the left tank and were found to contain water and dirt. Samples were also taken from the right tank using a sampling tube which is clear plastic to observe and measure contents. Ten samples were taken filling the tube with dirty water until Av-gas was found.

The magnetos were checked and found to spark. Sample spark plugs were examined and found to contain combustion deposits.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on May 6, 1993, by James M Jacobi, M.D., at the request of the Orange County Coroner. Post mortem toxicological examination was made on specimens from the pilot. No preexisting anomalies or positive toxicological findings were determined that would have been a factor in the accident.

TESTS AND RESEARCH

During the investigation the flight instructor told investigators that all the fuel for the accident airplane was purchased at the Salem airport. The manager of the airport was approached and he confirmed that the pilot had regularly purchased fuel from his facility. A check of the filters in the dispersing pump for fuel was examined and no dirt or water was found although a small amount of rust was found. A random check of airplanes parked on the ramp at the Salem airport failed to reveal any water or dirt contamination in their fuel sumps.

ADDITIONAL DATA/INFORMATION

Parties to the investigation were the Federal Aviation Administration, Flight Standards District Office, Indianapolis, Indiana, and Lycoming of Williamsport, Pennsylvania. All parties were briefed on findings prior to departure from the on scene investigation. The airplane wreckage was released to a representative of the pilot/owner's insurance company on May 10, 1993.

NTSB Probable Cause

THE PILOT-IN-COMMAND'S INADEQUATE PREFLIGHT PREPARATIONS AND HIS FAILURE TO MAINTAIN AIRSPEED. FACTORS WERE THE INSTRUCTOR'S INADEQUATE TRAINING OF THE PILOT-IN-COMMAND, UNQUALIFIED MAINTENANCE PERSONNEL'S INADEQUATE INSPECTION OF THE AIRCRAFT AND THE CONTAMINATED FUEL.