NTSB Factual Report

HISTORY OF FLIGHT

On October 31, 1997, about 1015 eastern standard time, a Piper PA-23-150, N3EV, operated by Fitchburg Colonial Aviation, struck the ground during a go-around from the Fitchburg Municipal Airport (FIT), Fitchburg, Massachusetts. The airplane was destroyed, and the certificated flight instructor and multi-engine pilot trainee were fatally injured. Visual meteorological conditions prevailed for dual instructional flight that departed from Fitchburg about 0915. No flight plan had been filed for the flight that was conducted under 14 CFR Part 91.

The accident flight was the second multi-engine training flight for the trainee. After departure from Fitchburg, the airplane was not observed until it entered the traffic pattern at Fitchburg. Two witnesses, in airplanes awaiting departure at the approach end of runway 32, observed the accident airplane in the traffic pattern for runway 32.

One witness stated, "...the twin turned final and reported...'Single Engine'. I watched him on final and observed his left...[prop] stopped and, I think feathered. I noted he seemed low over the fence. At about 100 feet over the numbers the twin called 'go-around'...the twin seemed to be climbing at a very shallow attitude and banking very slightly left...."

Another witness stated, "...The twin was now on final, and as he arrived on short final, I noted that his left prop was feathered...He announced that he was 'going around' his voice was normal...He was high over the threshold for a normal approach...He looked slow to me...."

According to both witnesses, the runway was clear and there was nothing to prevent a landing.

The airplane continued in a northwesterly direction; however, neither witness saw the airplane descend to the ground. Both pilots reported that they saw a column of smoke.

Several witnesses in the area of the ground impact reported seeing a low flying airplane, and hearing an engine operating. The witnesses observed the airplane descend in a steep nose down attitude with the left wing low. It then impacted the ground, passed through a chain link fence, and came to rest upright in the back yard of a residence. A post-crash fire consumed the wings and cabin.

The accident occurred during the hours of daylight at 42 degrees, 33.61 minutes north latitude, and 71 degrees, 46.72 minutes west longitude.

OTHER DAMAGE

During the descent, the airplane struck a television antenna mounted on the roof of a residence. Two fences were damaged during the ground impact.

PERSONNEL INFORMATION

The flight instructor held an airline transport pilot certificate for single engine airplanes, and a commercial pilot certificate for multi-engine airplanes. He also held a flight instructor certificate for single and multi-engine airplanes, and instrument airplane. According to his pilot logbook, he had logged a total time of 5,407 hours.

He was issued a First Class FAA Airman Medical Certificate on June 2, 1997, with a limitation to wear corrective lenses for near and distant vision. He also had a vision waiver for amblyopia in the right eye.

The multi-engine pilot trainee held a commercial pilot certificate with single engine land and instrument airplane ratings. According to his pilot logbook, he had logged a total time of 1,108 hours, with 1.3 hours of multi-engine training. He was issued a Second Class FAA Airman Medical Certificate on June 10, 1997, with a limitation to wear corrective lenses.

AIRCRAFT INFORMATION

The airplane was a 1957 Piper PA-23-150. It was maintained under an annual inspection program. The airplane was delivered with 150 horsepower engines and they had been upgraded to 160 horsepower. The propellers were not equipped with unfeathering accumulators.

The airframe had been modified with Supplemental Type Certificates (STCs), known as the Geronimo conversion, and included a aerodynamic nose, a shortened rudder, and aerodynamic fairings. The wing flaps and landing gear were hydraulically operated. The left engine was equipped with an engine driven hydraulic pump. There was no hydraulic pump on the right engine. In addition, there was a hydraulic hand pump, located below the landing gear and wing flap control levers, on the center pedestal, which could be used to pressurize the hydraulic system.

According to the Owner's Handbook, "...If the engine driven hydraulic pump fails, or the left engine driving the pump, extension of the landing gear or flaps is accomplished by supplying hydraulic pressure with the manual hydraulic pump. With the gear or flaps control in the desired position, 30-40 strokes of the pump handle will raise or lower the landing gear, and 12 strokes will raise or extend the flaps.

AIRDROME INFORMATION

According to FAA data, Fitchburg airport had an elevation of 348 feet. Runway 32 had a left handed traffic pattern, was 4,511 feet long, 100 feet wide, and had an asphalt surface. The airport did not have an air traffic control tower. Pilots communicated their intentions on a common frequency that was not recorded.

WRECKAGE AND IMPACT INFORMATION

The accident site was located about 3,500 feet beyond the departure end of runway 32, and about 1,500 feet left of extended runway centerline. The airplane was examined at the accident site on October 31, 1997.

The airplane had impacted in the back yard of a residence, and came to rest upright, near the intersection of 4 back yards. A chain link fence, and wooden fence, located on the east side, and south side respectively of the initial ground impact were damaged.

The airplane was resting on the main landing gear and nose. The fuselage cabin and wings were destroyed by fire. Both main landing gear were found in a down and locked position. The nose landing gear down lock was broken, and the landing gear had collapsed. Flight control continuity was verified between the rudder pedals, and the rudder. The elevator was actuated by a pushrod. The pushrod was attached at the elevator, but was melted in the center section of the airplane. The ailerons used control cables to the outboard wing panels, and then a pushrod to the aileron. The aileron cables were intact. Remnants of the pushrods were identified.

The rudder trim was found at tab left (nose right) 10-12 degrees. Total travel was 25 degrees each way. The elevator trim was found with the leading edge horizontal stabilizer down, (nose up) 14 threads visible, which corresponds to 55% of available nose up travel.

The wing flap extension cylinder corresponded to a trailing edge flap position of 30 to 35 degrees. The flap system had been compromised with burned hydraulic lines.

The left propeller was found in a feathered condition.

The right propeller was on the low pitch stops, and a chain link fence was wrapped around the blades. Pieces of cut steel posts were found near where the right engine propeller impacted the ground, and where a chain link fence had been located. Several indention's were found on the leading edge of one propeller blade, similar in size to the diameter of the chain link fence links.

Both engines were rotated, and valve train continuity was confirmed. Compression was observed in all cylinders. The oil suction screen on both engines was free of debris. Sparkplugs from both engines were gray in appearance, and there was no impact damage to the electrodes. Both magnetos on the left engine, and the right magneto of the right engine produced spark. The internal gears of the left magneto in the right engine, were melted and could not be rotated.

FIRE

Soot was found on the upper and lower surfaces of the horizontal stabilizer and elevator. There were no soot patterns on any of the surfaces from the front of the airplane to the rear. No pieces of melted metal were found on the horizontal stabilizers.

MEDICAL AND PATHOLOGICAL INFORMATION

The toxicological testing report from the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, was negative for drugs and alcohol for both pilots.

Autopsies were conducted on the flight instructor, and multi-engine trainee on November 1, by Dr. Stanton Kessler, and Dr. Jennie Duval, respectively, of the Medical Examiners Office, Boston, Massachusetts.

TESTS AND RESEARCH

The three landing gear light bulbs, and the landing gear in transit bulb were forwarded to the NTSB Metallurgical Laboratory in Washington, DC for examination. According to the NTSB Technician's Factual Report, electrical continuity was found in the three landing gear bulbs. Filament stretch was found in the right main landing gear, and nose landing gear bulbs. No distinctive stretching was found in the filament of the left main landing gear; however, there was some filament bowing between the posts and supports, typical of aged filaments in the left main landing gear bulb. The landing gear in transit light had a fractured filament, with no distinctive filament stretch.

The hydraulic hand pump was examined at Airight Inc, in Wichita, Kansas. A representative of the FAA was in attendance and reported:

"...The pump was then affixed to the test stand and serviced with hydraulic fluid. The pump handle was operated twice obtaining a indicated pressure of 1,000 psi. The pressure decayed to 900 psi and then held for the duration of the test. With the results of this test it could be suggested that the pump was capable of producing sufficient pressure to raise the landing gear."

ADDITIONAL INFORMATION

The airplane was certified under Civil Air Regulation (CAR) 3. There were no certification requirements for a single engine climb on multi-engine airplanes that weigh less than 6,000 pounds, and have stall speeds less than 70 miles per hour.

The minimum single engine speed was published in the owner's manual as 85 mph. The stall speed at maximum gross weight was 59 mph.

According to the checklist in the owner's manual, unfeathering of a propeller was accomplished by placing the propeller control in the cruise setting, and then starting the engine. After starting, engine oil pressure would unfeather the propeller. The engine starter switches were located on the lower left instrument panel, in front of the left seat pilot.

According to the FAA publication FLYING LIGHT TWINS SAFELY, FAA-P-8740-19:

"...Climb performance depends on an excess of power over that required for level flight. Loss of power from one engine obviously represents a 50% loss of power but, in virtually all light twins, climb performance is reduced by at least 80%...If you do find yourself in a position of not being able to climb, it's much better to pull the power on the good engine and landing straight ahead than try to force a climb and lose control...."

The following was excerpted from the AOPA publication, FLYING LIGHT-TWIN ENGINE AIRPLANES, CO23-109-12/95:

"...When it is time to start single-engine activities, do so at a safe altitude (allowing for a recovery from all maneuvers above 3,000' [feet] (AGL) and near a suitable airport...some twins have little or no single-engine climb performance, which means no go-around capability...Practicing single-engine landings and go-arounds should only be done simulating engine failure by using zero thrust techniques. If you are unable to maintain altitude or climb, the zero-thrust engine can be used immediately...."

The flight instructor was checked out in N3EV, by another pilot. The flight instructor's log book reflected 3 flights over 3 days which totaled 10.1 hours. However, in written and oral statements, the person that conducted the check out indicated that it was done in one flight of 2 to 3 hours.

A student who had received multi-engine training in N3EV from the accident flight instructor, reported that on September 25, 1997, the flight instructor gave him a single engine go-around from about 500 feet above the ground with the left engine shut down and the propeller feathered. The landing gear was retracted when the go-around was initiated, and the student remembered the airplane climbed between 50 and 200 feet per minute.

According to the flight instructor's logbook, the flight instructor's total multi-engine time was 393.8 hours. He had logged 69.1 hour as a multi-engine instructor. His logbook did not reflect one flight, October 24, 1997, in N3EV, which totaled 1.3 hours. That flight was the initial training flight for the accident multi-engine pilot trainee.

A check of the flight instructor's logbook revealed that the preponderance of his multi-engine instruction flights, 53.6 hours, had been conducted in a Piper PA-23-250. The remainder, 15.5 hours, were spread through the following aircraft: Cessna 310, Beech 58P, and Piper PA-23-160.

The pilot received his multi-engine flight instructor rating on February 4, 1994. A breakdown of his multi-engine flight time following the issuance of his multi-engine flight instructor rating by year follows:

Year Total Multi-engine Time Multi-engine Instruction

1994 42.5 hours 30.5 hours 1995 28.7 hours 10.4 hours 1996 23.5 hours 20.1 hours 1997 17.8 hours 8.1 hours

The flight instructor had logged a total time of total time of 22 hours in the PA-23-150.

Wreckage Release

The aircraft wreckage was released to Lieutenant Peter Bergeron of the Fitchburg Police Department on November 2, 1997. He in turn released the airplane to the insurance adjuster, Mr. Alan Ryan of Alan Ryan Insurance Company, of Scarborough, Maine.

NTSB Probable Cause

The flight instructor's inadequate in-flight decision and his failure to maintain adequate airspeed which resulted in a loss of control. Contributing was the flight instructor's failure to follow standard practices while simulating and practicing emergency procedures which resulted in his initiating of a single-engine go around and reduced climb performance.