NTSB Factual Report

HISTORY OF FLIGHT

On June 25, 2012, at 0421 eastern daylight time, a Socata TB21, N2528N, was substantially damaged when it impacted terrain shortly after takeoff from Gold Hill Airport (NC25), Gold Hill, North Carolina. The certificated private pilot was fatally injured. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan had been filed for the personal flight destined for Lancaster Airport (LNS), Lancaster, Pennsylvania. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

According to the pilot's wife, he intended to fly the airplane from his home airport (NC25), to Germany, where he had another residence. He planned to make several stops along the way for fueling. On the morning of the accident, she assisted him in pulling the airplane from the hangar and observed the pilot load the airplane and taxi toward the runway. She reported it was a "little foggy" when the pilot departed, but did not observe the airplane depart due to her viewpoint on the field.

A witness who was driving toward NC25 observed what he described as a "bright spotlight" which appeared to be on an airplane flying away from NC25. Shortly afterward, he observed white and gray smoke coming from the airplane, which turned to an orange color. He also observed the airplane's wings rocking back and forth, and the airplane veered to the right just prior to impacting the trees. The witness also reported fog in the area when he observed the airplane.

According to information provided by the Lockheed Martin Washington Contracted Flight Service Station (FSS), the pilot called the FSS at 0347 to obtain his IFR clearance. He stated he intended to depart approximately 10-15 minutes later, and was given the clearance with a void time of 0410.

The pilot did not contact any air traffic facilities, and a subsequent search and rescue effort was initiated. At 0421, the Rowan County Sheriff's Department received a telephone call regarding a possible airplane accident in Gold Hill. Department personnel located the airplane in a field about 1/2 mile north of NC25 at 0557.

PILOT INFORMATION

The pilot held a private pilot certificate with an instrument rating. His most recent FAA third-class medical certificate was issued on December 16, 2011. At that time, he reported 2,200 hours of total flight experience.

A pilot flight log was provided by the pilot's wife after the accident. It contained entries from August 23, 2007 to October 31, 2010. During that period, the pilot logged 1,917 hours of total flight experience. A more recent logbook could not be located by the pilot's wife.

Documentation provided by the insurance company revealed the pilot's most recent BFR was completed on May 4, 2012.

AIRCRAFT INFORMATION

The airplane was manufactured in 1989, and received its first airworthiness certificate from the FAA the same year. According to the pilot's wife, he had owned the airplane since approximately 2005.

The logbooks for the airplane could not be located by the pilot's wife.

An interview with a mechanic at the local airport revealed he completed the most recent annual inspection on March 4, 2012. However, he did not have a copy of the logbook signoff and did not recall how many hours the airplane had accumulated at the time of the inspection. The mechanic did remember that the engine was past the recommended TBO time, which he mentioned to the pilot. He did not recall any other anomalies with the airplane or engine.

According to interviews with friends and family of the pilot, he routinely performed his own maintenance on the airplane. Several friends and the pilot's wife confirmed that he installed an auxiliary fuel tank in the cabin of the airplane during the weeks prior to the accident.

One friend, who observed the installation, described the fuel tank as a plastic white tank in the backseat, which was not aviation-approved. It appeared to be an "herbicide-type tank, similar to a tank you would see on a riding lawnmower." In addition, the fuel line installed was too small (1/4 inch in diameter, compared to 3/8 or 1/2 inch), and the system was vented into the cabin.

Maintenance personnel at Stanly County Airport (VUJ) reported that the pilot arrived at their facility on June 22, 2012 and requested an oxygen fill. The system was "topped off" with 1800 psi. The mechanic reported that when he added the oxygen, he noticed water coming out of the valve. The pilot had been in about 2 weeks prior to this visit, at which time the oxygen system was also topped off with 1800 psi. Between these visits, the pilot reportedly had trouble breathing when he took the airplane to an altitude of 25,000 feet.

While at VUJ, the pilot also requested maintenance personnel examine the turbocharger, as he had been experiencing a lack of power at altitude. The pilot informed the mechanic that he had made adjustments to the turbocharger himself. The mechanic stated he could not work on the turbocharger as he was not familiar with the system.

According to records obtained from a local maintenance facility (at Burlington-Alamance Regional Airport), the pilot arrived at their facility on June 21, 2012, and requested expedited maintenance be performed on the airplane. He stated the engine was losing manifold pressure at altitude. Maintenance personnel found an excessive exhaust leak at the turbocharger and the exhaust system was misaligned. They repositioned the exhaust system and installed new gaskets. The engine was run on the ground and no leaks or other anomalies were noted. Maintenance personnel also adjusted the controller, which the pilot had previously adjusted improperly.

The tach time during this maintenance was recorded as 2,197 hours.

The pilot's wife reported to several people that she thought the airplane was overweight at the time of departure. She reported to investigators that the pilot departed with the following items: (1) a life raft; (2) two briefcase/duffel bags; (3) aircraft manual and logs (estimated to weigh 50-60 pounds); and (4) the auxiliary fuel tank in the rear of the airplane.

A weight and balance calculation was performed which included the information provided by the pilot's wife, and assumed full fuel and oil. According to the calculation, the estimated takeoff weight may have been approximately 2,889 pounds with a moment arm of 123203. The maximum takeoff weight, according to the Pilot's Operating Handbook (POH) was 3086 pounds. Due to several unknown factors, a more precise weight and balance could not be performed.

METEOROLOGICAL INFORMATION

The weather recorded at 0355, at Rowan County Airport (RUQ), 13 miles to the northwest, included calm winds, and ½ mile visibility in fog, with an indefinite cloud ceiling at 500 feet. The temperature was 20 degrees C, the dew point was 18 degrees C, and the altimeter setting was 29.89 inches Hg.

The weather recorded at 0355, at Stanly County Airport (VUJ), Albemarle, North Carolina, 10 nm to the southeast, included calm winds, 10 miles visibility, overcast clouds at 900 feet, temperature 22 degrees C, dew point 21 degrees C, and altimeter setting of 29.93 inches Hg.

The pilot called FSS on the morning of the accident at 0341 and requested an abbreviated weather briefing for the flight. He was informed by the briefer that an icing AIRMET had been issued for the part of his flight over Maryland and Pennsylvania. The freezing level was predicted between 9,000 and 11,000 feet. There were several convective SIGMETS issued for the route of flight as well as IFR AIRMETs for ceilings below 1,000 feet and visibility below 3 miles with mist, in the vicinity of the route.

WRECKAGE INFORMATION

The initial impact point was at the top of an approximately 60-foot-tall tree, where a portion of the left wing was wrapped around the tree. At the base of the tree, the left flap was observed, separated into two sections. The wreckage path continued on a heading of about 270 degrees magnetic for approximately 150 feet to the main wreckage. Several pieces of 90-degree cut wood, with black paint transfer were located along the wreckage path.

The main wreckage was oriented on an approximate heading of 090 degrees magnetic and nearly completely consumed by fire. The flight control tubes were all accounted for at the accident site. The tubes to the tail section were separated in several sections and melted in the cockpit area. Both aileron tubes were separated from their respective wing sections. The trim and flap settings could not be determined to due impact and fire damage.

The engine came to rest separated from the firewall and resting nose-down against a tree (the number 1 cylinder being the lowest point). The propeller remained attached to the engine; one blade was relatively straight and one blade was bent forward about 10 degrees at mid-span. Located in the vicinity of the engine was a non-approved fuel line and valve. Additionally, about 15 feet from the engine, an aluminum can was observed, which was safety-wired to the outlet of the air-oil separator.

After removal from the accident site, the engine was further examined. It was rotated at the propeller flange, and valve train continuity was confirmed on all cylinders. Thumb compression was also confirmed on all cylinders, with the exception of the No. 2 cylinder, which displayed severe heat damage.

The turbocharger was separated from the engine. The compressor shaft rotated freely by hand, the hoses were burned, and the controllers were separated and fire damaged. Additionally, the exhaust bypass valve was in the "open" position, and displayed impact damage.

The dual-magneto ignition system was separated and consumed by fire.

Examination of the spark plugs exhibited a "worn, but normal condition."

The vacuum pump remained attached to the engine. The drive coupling was melted; however, the vanes remained intact.

The fuel flow divider remained attached to the engine. The diaphragm was charred; however, examination of the fuel nozzles revealed Nos. 2, 3, 5, and 6 were unobstructed, and Nos. 1 and 4 contained some particulates.

The engine-driven fuel pump remained attached to the engine and could not be rotated by hand due to severe fire damage. The spline remained intact (not fractured).

No fuel was observed in any of the fuel system components.

MEDICAL AND PATHOLOGICAL INFORMATION

The North Carolina Department of Health and Human Services, Office of the Chief Medical Examiner, performed an autopsy on the pilot on June 26, 2012. The cause of death was listed as blunt force trauma.

The FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma conducted toxicological testing on the pilot. Following were the results of the toxicological testing:

104.7 (ug/ml, ug/g) Acetaminophen detected in Urine

The NTSB Chief Medical Officer reviewed the autopsy results, toxicology results, FAA blue ribbon medical file, FAA medical review, and had a conversation with the reviewing pathologist from the medical examiner's office. Her review of the information revealed the following:

The autopsy also identified coronary artery disease and a mass in the abdomen. The heart was enlarged, weighing 380 grams. There was moderate to high grade atherosclerotic stenosis of the proximal and middle aspects of the right coronary artery and middle and distal aspects of the left anterior descending artery. The examining pathologist did not further quantify the degree of stenosis but according to a pathologist from the same office who reviewed the slides, the stenosis within the left anterior descending measured at least 80%.

ADDITIONAL INFORMATION

Fueling info

According to fueling records provided by RUQ, the pilot purchased 51 gallons of 100LL aviation fuel on June 19, 2012. He additionally purchased 41 gallons of 100LL aviation fuel on June 23, 2012.

Additionally, examination of a security video from RUQ recorded the pilot servicing the airplane from the self-serve fuel station on the above-documented dates. The video showed the pilot fueling both wing tanks and placing the fuel hose inside the cabin of the airplane.

NTSB Probable Cause

An inflight fire, the origin of which could not be determined because of postaccident fire damage. Contributing to the accident was the pilot's improper modifications to the airplane.