NTSB Factual Report

HISTORY OF FLIGHT

On August 29, 2012, about 1800 central daylight time, a Piper PA-23-150, N1486P, sustained substantial damage during a forced landing after a partial loss of power when it impacted trees and terrain about 3 miles southwest of Canton, Missouri. The pilot and passenger received fatal injuries. The airplane was registered to and operated by the pilot under the provisions of the 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident. The flight, which was not on a flight plan, departed from Pinckneyville-DuQuoin Airport (PJY), Pinckneyville, Illinois, about 1600, and was en route to the Antique Airfield, a private airstrip near Blakesburg, Iowa.

A witness reported that the route of flight that the pilot commonly traveled from PJY to Blakesburg was direct from PJY to the airport at Litchfield, Illinois, and then west to the Mississippi River, while staying clear of the St. Louis Class B airspace, and then north following the Mississippi River to Blakesburg. Using that route of flight, the distance from PJY to the accident site was about 187 nautical miles. At an average airspeed of 120 knots, the time en route was calculated to be about one hour and thirty-five minutes. The airplane was flying under visual flight rules and the transponder code was 1200. There was no radar track data available that identified the airplane or its actual route of flight. There were no witnesses to the airplane's impact with terrain.

A witness, who was a 75-hour private pilot, stated that he was in the parking lot at the Wakonda State Park around 1800 to 1830 when he observed a twin-engine airplane flying overhead on a northerly heading. He reported that the airplane was about 2,000 feet in level flight, and that the left propeller blades were not rotating. The accident site was about 6.5 miles north of the parking lot.

A witness, who lived about a quarter mile from the accident site, reported that about 1745 he observed a low flying airplane and heard a "crunching" sound, but there was no smoke or other evidence to indicate the airplane crashed. He later observed the airplane wreckage in a field when he was driving by and he notified local authorities of the accident.

PERSONNEL INFORMATION

The 74-year-old commercial pilot held single-engine land, single-engine sea, and multi-engine land ratings. He held a third-class medical certificate that was issued September 10, 2010. The pilot's logbook was destroyed in a hangar fire in August 2011. Remaining pilot records indicated that the pilot had about 6,459 total flight hours and 809 multi-engine hours. It is unknown how many hours he had flown in the make and model of the accident airplane. The pilot also held an airframe and powerplant (A&P) mechanic's rating and had inspection authorization (IA). The airplane was purchased by the pilot on October 15, 2011. He performed the last annual maintenance inspection of the airplane and subsequent aircraft maintenance.

AIRCRAFT INFORMATION

The airplane was a twin-engine Piper PA-23-150, serial number 23-255, manufactured in 1956, powered by 150-horsepower Lycoming O-320 engines. It was manufactured with a "Super Custom" configuration which included two 18-gallon auxiliary fuel tanks and a fifth passenger seat, and it had a maximum gross weight of 3,500 pounds. The airplane's original logbooks were lost or destroyed in 1995, and the first entry in the current logbooks was dated October 1, 1995. The available airplane records indicated that the airplane total time was 5,724 hours; and the left engine total time was 3,609 hours, with 1,773 hours since major overhaul (SMOH); and the right engine total time was 3,624 hours, with 1,567 hours SMOH. The last annual inspection was completed on October 15, 2011, but no total airplane time or engine time was shown on the logbook entry. The logbook entry was made by the accident pilot/IA. The airplane had flown about 21 hours since March 10, 2010.

The last available weight and balance found for the airplane dated back to 1962, and the empty weight listed was 2,348 pounds. A witness reported that the airplane was topped off before the flight. A fuel receipt showed that 62.23 gallons of fuel were purchased by the pilot about 1508 on the day of the accident at the Sparta Community Airport (SAR), Sparta, Illinois, located about 19 nautical miles northwest of PJY. The airplane's main fuel tanks held 72 gallons of fuel which weighed 432 pounds. It is not known if the auxiliary fuel tanks contained any fuel. The total weight of the pilot and passenger was about 410 pounds. The baggage found at the accident site was weighed and it totaled about 320 pounds. The 4 gallons of oil weighed 30 pounds. The estimated takeoff weight of the airplane was about 3,540 pounds, not including any fuel that might have been in the outboard auxiliary fuel tanks. If the auxiliary fuel tanks were topped off, the takeoff weight of the airplane was about 3,756 pounds.

METEOROLOGICAL CONDITIONS

At 1754, the surface weather observation at the Quincy Regional Airport-Baldwin Field (UIN), Quincy, Illinois, located about 20 miles southeast of the accident, was: wind calm; visibility 10 miles; sky clear; temperature 33 degrees Celsius; dew point 15 degrees Celsius; altimeter 30.02 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted trees and terrain in an area of rolling hills, woods, and open fields. A tree about 60-70 feet in height was initially impacted. An 8-foot outboard section of the left wing was found about 30 feet from the tree in the debris field that was on a 100 degree magnetic heading. The leading edge of the wing section exhibited a semi-circular indentation, which was consistent with a wings level impact with the tree. The left propeller was found along the tree line stuck in the ground in a near vertical position. The initial ground scar from the airplane impacting the ground was found about 93 feet from the initial tree strike. The main wreckage came to rest about 40 feet from the initial ground scar with the wreckage facing in the opposite direction of the debris field. There was no post impact fire, although there was evidence of fuel blight in the vegetation and trees. A tree branch about 6 inches in diameter was found with a diagonal slash through it that was consistent with a propeller slash with paint transfer.

The fuselage was found on its right side on top of the right wing in the field. The nose section was compressed back to the instrument panel, and the cockpit sustained significant structural deformation. The avionics and instruments were impact damaged. The right engine's oil temperature, oil pressure, and fuel pressure gauge needles were all found in the operating range; the left engine's oil temperature, oil pressure, and fuel pressure gauge needles were all found at low or zero readings. The engine power lever quadrant was separated from the instrument panel mounting. The controls were impact damaged, but there was very little movement of the levers when they were manipulated. The right engine's throttle, mixture, and propeller controls were found positioned forward; and the left engine's throttle, mixture, and propeller controls were found pulled back relative to the right engine's control levers. The fuel control panel, which was mounted between the front seats, exhibited light impact damage. Both left and right engine fuel primers were found in the locked position. The fuel tank selector levers were found in the main tank position for both wings with the levers mechanical detent locking guards in place. The cross feed lever was in the off position. The landing gear control lever and the flap control lever were found in the up position. The pilot seats remained attached to their seat tracks, but the seat tracks were partially separated from the cabin floor. About 320 pounds of cargo, consisting mostly of camping equipment, food, clothing, and tools, were found in the aft cabin. Flight control continuity from the airplane's controls to their respective control surfaces was not established due to the extensive impact damage to the wings, fuselage, and empennage; however, all separations were consistent with overload failures.

The empennage remained loosely connected to the fuselage, but was found lying at an approximately 90 degree angle to the fuselage. The horizontal stabilizer and vertical stabilizer remained attached together, and the elevator and rudder remained attached at their hinge points.

The right wing was partially attached to the fuselage. The leading edge exhibited accordion type aft crushing. The flap and aileron remained attached to the wing. The landing gear was found in the retracted position. Both the inboard and outboard fuel tanks were breached. Their fuel caps were loose in the fuel tank filler neck and could be removed without loosening the caps adjuster lever. The outboard tank cap had a vent hole drilled through it. The right wing gascolator bowl was missing from impact damage. The engine nacelle was impact damaged. The engine was loosely attached to the wing, but the propeller was separated from the engine.

The left wing was separated from the fuselage. The 8-foot outboard section contained the outboard fuel tank, the aileron with the balance weight attached, and the outboard flap section. The fuel cap was located in the outboard fuel tank filler neck. It could be removed without lifting the expansion lever, and it had a vent hole drilled through it. The outboard and inboard section of the wing exhibited accordion type aft crushing. The landing gear was attached to the inboard section of the wing. The left engine was separated from the left wing, and the propeller was separated from the engine.

The left wing gascolator bowl was removed and found to contain a blue silicon jell type of sealant that covered about two-thirds of the area of the bowl's circumference, and the area where a gasket is typically placed. No propagation of the blue jell substance was found in the adjacent fuel pump screens or fuel lines. No gasket was found in the gascolator. The blue silicon jell found in the gascolator was observed to deteriorate gradually after it was removed from the airplane wreckage. The amount of jell was substantially less than what was first observed after a two day period. Fuel was found in the bowl and Kolor Kut was used to check for water with only a trace amount found.

The engines were inspected at the Canton R-V Fire Protection District fire house. The right engine was rotated by hand using a tool inserted at the vacuum pump drive pad. The crankshaft and camshaft rotated, all accessory gears rotated, and the valves and rocker arms were observed rotating. Thumb suction and compression was observed on all cylinders. Both magnetos were rotated and spark was observed on all outlet points. The carburetor was broken by impact and separated at the throttle plate. The composite floats were destroyed by impact, and the fuel inlet screen was not recovered. The engine driven fuel pump was actuated and it displaced fuel. The captured fuel was tested for water and none was observed. The spark plugs exhibited a color consistent with normal combustion when compared to the Champion Spark Plug Wear Guide.

The left engine was rotated by hand using a tool inserted at the vacuum pump drive pad. The crankshaft and camshaft rotated, all accessory gears rotated, and the valves and rocker arms were observed rotating. Thumb suction and compression was observed on all cylinders. Both magnetos were rotated and spark was observed on all outlet points. The carburetor was broken by impact and separated at the throttle plate, and the composite floats were destroyed by impact. The fuel inlet screen was examined and it displayed no contaminants. The engine driven fuel pump was actuated and it displaced fuel. The captured fuel was tested for water and none was observed. All of the spark plugs were observed carbon fouled except for the No. 3 cylinder spark plugs, which exhibited a color consistent with normal combustion when compared to the Champion Spark Plug Wear Guide. The Nos. 1, 2, and 4 cylinders had fuel primer lines attached to the cylinders; the No. 3 cylinder did not have a fuel primer line attached.

The right propeller marked "A" exhibited gouges along its leading and aft edges. The blade exhibited chordwise scratching and tip curl. The blade marked "B" had about the outboard 8 inches of the blade tip missing. The inboard section of the blade was bent forward at the fracture and red paint transfer was present on the fracture surface.

The left propeller blades exhibited much less impact damage than the right propeller blades. The blade marked "A" did not exhibited leading edge gouges, but it did have two gouges on the trailing edge. The blade marked "B" exhibited no chordwise scratching, or leading or trailing edge nicks or gouges. Both blades exhibited some blade twist or bending to the low pitch setting. The blade hub fractures did not exhibit fractures consistent with torsional signatures, and both blades were loose in the propeller hub.

The NTSB retained the fuel primers and spark plugs from both engines for further testing. An iFly GPS unit was found in the airplane and it was retained for examination.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was conducted on August 31, 2012, at the Boone/Callaway County Missouri Medical Examiner's office. The "Cause of Death" was noted as "blunt trauma to the head, trunk, and extremities secondary to an airplane crash." A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aerospace Medical Institute. The results were negative for carbon monoxide and cyanide. 15 (mg/dL, mg/hg) ethanol was detected in the urine, but none in the blood. N-propanol was detected in the urine. 0.018 (ug/mL, ug/g) of cetirizine was detected in the blood and it was detected in the urine. Glucose was not detected in vitreous. 171 (mg/dl) glucose was detected in urine. 8.6(%) hemoglobin A1C was detected in blood.

Cetirizine is an over-the-counter sedating antihistamine used to control allergies. The therapeutic low level is 0.1900 ug/mL, and the high therapeutic level is 1.4500 ug/mL.

Postmortem urine levels of glucose above 100 mg/dL are considered abnormal. Hemoglobin A1C blood levels above 6% are considered abnormal.

TESTS AND RESEARCH

The iFly GPS unit was sent to the NTSB Vehicle Records Laboratory for examination. The unit still operated; however, the Scan disk flash card that stored the non-volatile memory was not in the GPS unit's flash card slot, and it was not found at the accident site.

The fuel primers for both engines were examined for leaks by testing them on a fuel bench and applying vacuum pressure to the primers. No leaks or other anomalies were observed.

The eight spark plugs from the left engine were examined. Both spark plugs from the Nos. 1, 2, and 4 cylinders exhibited carbon fouling. All eight spark plugs from the left engine were installed in a Piper Cherokee with a 160-horsepower Lycoming O-320 engine. The engine started immediately and operated normally at all power settings.

On June 18, 2013, an exemplary Piper gascolator was filled with Permatex Blue RTV Silicone Gasket Maker in the area where a normal gasket sits. The gascolater bowl was secured to the base of the gascolator and was filled with 100 low lead aviation fuel for a 24-hour period. The gascolator was opened and the blue RTV silicone was observed to have expanded inside the gascolator bowl, which was similar to the blue silicone jell observed in the accident airplane's left wing's gascolator. The directions for using Permatex Blue RTV Silicon Gasket Maker states: "NOTE: Not recommended for use on head gaskets or parts in contact with gasoline."

Aircraft Performance

Total Empty Weight 2,348 2,348

Oil 30 30

Fuel (Main – 72 gal) 432 432

Aux Fuel (36 gal)

NTSB Probable Cause

The pilot's improper decision to attempt to execute a forced landing to an open field with obstacles. Contributing to the accident was the left engine’s total loss of power due to fuel starvation as a result of the introduction of air into the fuel system through a gascolator seal breach and the pilot’s use of an improper substance on the left wing gascolator bowl during maintenance operations, which led to the gascolator seal breach.