NTSB Factual Report

HISTORY OF FLIGHT

On July 25, 2002, at 1259 central daylight time, a Piper PA-30, N8563Y, owned and piloted by a private pilot, was destroyed when it impacted a 40 acre grass field near Marble Hill, Missouri. The pilot reported a loss of engine power and that he was landing in a field. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 personal flight was not operating on a flight plan. The pilot was fatally injured. The flight departed from the Whiteside County Airport, Rock Falls, Illinois, en route to Newport, Arkansas.

The pilot departed from Appleton, Wisconsin, where he purchased 18 gallons of 100 Low Lead (LL) aviation fuel at 0838. He made a stop and subsequently departed from Whiteside County Airport where he purchased 43.3 gallons of 100 LL fuel at 1039.

The following is a transcription of recorded conversations with St. Louis Automated Flight Service Station (STL AFSS) and the accident airplane:

At 1251:17, N8563Y transmitted, "mayday mayday eight five six three yankee anybody hear me."

At 1251:23, STL AFSS transmitted, "eight five six three yankee saint louis radio read *(you) loud and clear."

At 1251:26, N8563Y transmitted, " *(yeah) six three yankees gonna have to put it down in a field somewhere *(now) I just lost my other engine."

At 1251:31, STL AFSS transmitted, "rodger uh are you near...do you know your position."

At 1251:35, N8563Y transmitted, "five six three yankee."

At 1251:50, N8563Y transmitted, "that's affirmative we're goin' into a field down here somewhere i don't---."

The * indicated that the portion of the re-recording is not entirely clear, but this represent the best interpretation possible under the circumstances.

There were no further radio transmissions by N8563Y were recorded.

A witness stated that he was outside his home when he heard the engine of the airplane sputter like it was out of fuel. It then became silent and just gliding. Then it sputtered again and became silent. The airplane was flying low over the trees toward an open field, made a turn towards the left and then "went to an angle." He could see the top of the airplane.

A second witness said that he first noticed the airplane because it was low. The airplane sounded all right as it came in from the east. The airplane began a circle over his hayfield which he described as "it came in smooth" and it "was gradually descending." The airplane "fluttered and backfired" about 1/2 way through the circle while heading towards the south. After it backfired, the engine noise went silent. The landing gear was not extended. He said that it was 100 degrees outside and humid.

PERSONNEL INFORMATION

The pilot, age 59, held a private pilot certificate with a single engine land and instrument rating and a multiengine land rating for visual flight rules only. He was issued a third class airman medical certificate on June 22, 2000 with the following limitation: "holder must wear corrective lenses."

AIRPLANE INFORMATION

The 1967 airplane, serial number (S/N) 30-1679, was powered by two Lycoming fuel injected IO-320-B1A engines rated at 160 horsepower at 2,700 rpm The airplane was last inspected during an annual inspection dated July 27, 2001, at a tachometer time of 3,487.8 hours and a total time in service (TTIS) of 3,487.8 hours. The left engine, serial number L-3601-55A, received its last inspection during a annual inspection dated July 27, 2001, at a tachometer 3,487.8 and a TTIS of 3,487.8 hours. The right engine, serial number L-3566-55A, received its last inspection during an annual inspection dated July 27, 2001, at a tachometer time of 3,662.6 and a TTIS of 3,662.6 hours.

The airplane was equipped with a Vision Microsystems Inc., VM1000 graphic engine monitoring system which was sent to the manufacturer in order to download the units nonvolatile memory.

WRECKAGE AND IMPACT INFORMATION

The airplane was upright and oriented on a tail to nose heading of about 200 degrees on a 40 acre grass field. The wings and their control surfaces, empennage, and engines were attached to the fuselage. Both propellers and pieces from the nose of the airplane were located about 60 feet to the southeast of the airplane. The propellers were about 1-1 1/2 feet under ground. A wreckage diagram is included in the public docket of this accident.

Flight control continuity to the control surfaces to their respective control surfaces was confirmed. The rudder trim jack screw was 11 threads which equated to about half nose left trim travel and the elevator jack screw extension was about 5/8 inches which equated to about 3-4 degrees nose up trim. The flaps and landing gear were retracted.

The left engine throttle was in the idle position. The left engine mixture control was in the full rich position. The left propeller control was in the "decrease" position. The right engine throttle control was in the forward position. The right engine mixture control was retarded about one inch behind the left engine mixture control. The right propeller control was in the forward position. Both cowl flaps were closed. Both left engine magneto switches were in the off position. The right engine magneto switches were on for the right magneto and off for the left magneto. The master switch was in the on position.

The right main fuel tank, left main, and left auxiliary fuel tank contained a liquid consistent with 100 LL which was about 2-3 inches below the filler neck. The right auxiliary fuel tank was empty. The left fuel selector was in the left main position and the right fuel selector was in the right auxiliary position.

On-site examination of the engines revealed that the left engine driven fuel pump contained about a 1/4 cup of fuel and the right engine driven fuel pump contained less than a 1/2 teaspoon of fuel.

Both fuel selector were disassembled and examined and noted to contain a brown colored contaminant which was also found on the fuel servo screens for both engines.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was performed at the Mineral Area Regional Medical Center, Farmington, Missouri.

The Federal Aviation Administration’s Final Toxicology Fatal Accident Report of the pilot reported the following:

0.231 (ug/mL, ug/g) norpropoxyphene detected in blood

0.743 (ug/mL, ug/g) norpropoxyphene detected in urine

ranitidine present in blood

ranitidine present in urine

77.23 (ug/ml, ug/g) salicylate detected in urine

14.23 (ug/ml, ug/g) acetaminophen detected in urine

TESTS AND RESEARCH

Airworthiness Directive (AD) 83-10-01 applicable to Piper models PA-24-400 (S/Ns 26-2 through 26-148); PA-30 (S/Ns 30-2 through 30-2000); and PA-39 (S/Ns 39-1 through 39-155) was issued to prevent retention of water contamination and deterioration of the fuel system, accomplish the following:

(A) Within the next 50 hours time-in-service after the effective date of this AD and at intervals not exceeding 50 hours time-in-service thereafter, clean and inspect the fuel selector valve strainer filter on all airplanes listed in the applicability statement for water accumulation, contamination, and corrosion of the fuel strainer filter components...

(B) Within the next 100 hours time-in-service after the effective date of this AD, replace the existing fuel selector strainer filter housing on the Model PA-30 (S/Ns 30-2 through 30-1744) airplanes with Piper P/N 757187 conical-shaped stainless steel strainer housing in accordance with Piper Service Letter No. 589, dated August 18, 1971. NOTE: This may have been previously accomplished per Piper Service Spares Letter No. SP-289 or Service Letter No. 589.

(C) Within the next 50 hours time-in-service after the effective date of this AD, fabricate and install a permanent placard as described below having letters with 1/8 inch minimum height on the inside of the hinged access door or adjacent location clearly visible to the pilot during his preflight check.

(2) On Model PA-30 and PA-39 airplanes, the placard must read as follows:

"THE FUEL SYSTEM SHALL BE DRAINED DAILY PRIOR TO FIRST FLIGHT AND AFTER REFUELING TO AVOID THE ACCUMULATION OF WATER OR SEDIMENT USING THE FOLLOWING PROCEDURE:

a. Pull up on the knob located in the center of the selector valves to open the strainer quick drain for a few seconds with the fuel tank selector on the main tank, then change the tank selector to each auxiliary tank and repeat the process. Allow enough fuel to flow to clear the lines as well as the strainer. Positive fuel flow shut-off can be observed through the clear plastic tube which carries the fuel overboard.

b. Ensure that the drain valve positively closes.

c. If it is not possible to observe fuel draining through the clear plastic tube because of a loss in its transparency, replace with a new tube.

The Advanced Pilot's Flight Manual (Kershner) states under Emergency Procedures:

"The nonpilot may feel that a loss of an engine on a multiengine airplane is either a terrifying disaster or nothing to be concerned about. Experienced pilots know that the multiengine airplane, if properly flown with an engine out, has a strong safety factor. They also know that at certain times the airplane must be flown precisely, and in some cases it is safer to chop the other engine(s) than try to continue. New pilots have been killed by the loss of an engine on takeoff or approach when they believed they could go around. Ironically enough, they might have survived had the engine quit at the same place in a single-engine airplane. They would have landed straight ahead in the single-engine airplane but instead attempted the impossible because of overconfidence or ignorance of the single-engine performance of their twin."

The VM1000 nonvolatile memory download indicated that the left engine exhaust gas temperatures ranged from 78-90 degrees Fahrenheit (F) and the right engine EGT parameters ranged from 458-588 degree F. The left engine cylinder head temperatures (CHTs) ranged from 84-94 degrees and the right CHTs ranged from 298-380 degrees F. The left engine hours were 3,517.7 hours and the right engine hours were 3,491.3 hours. The system on time or power on time of the VM1000 was 3 minutes and 28 seconds.

Disassembly of the left fuel servo did not reveal the brown colored contaminant beyond the filer screen. The right fuel servo was bench tested and noted to have met in-service specifications.

ADDITIONAL INFORMATION

The FAA, The New Piper, Inc. and Textron Lycoming were parties to the investigation.

The wreckage was released and all retained components were released to the registered owner's insurance representative.

NTSB Probable Cause

The solid fuel system contamination resulting in a loss of engine power. The inadequate emergency procedures, and the airspeed not maintained by the pilot were additional causes.