NTSB Factual Report

HISTORY OF FLIGHT

On October 11, 1997, at 1040 eastern daylight time, a Piper PA-28R-180, N3981T, owned and operated by the Monmouth Area Flying Club (MAFC), was destroyed when it collided with trees in Morganville, New Jersey, during the climb after takeoff from the Marlboro Airport, Marlboro, New Jersey. The certificated private pilot and three passengers were fatally injured. Visual meteorological conditions prevailed for the personal flight that originated at the Marlboro Airport (2N8), about 1038, destined for Lebanon, New Hampshire. No flight plan had been filed for the flight conducted under 14 CFR Part 91.

The pilot was a member of the flying club, and had signed the airplane out to depart 2N8, at 1000. The listed destination was "Lebanon," with a return time of 1830 the same day. The pilot received a weather briefing from the Millville Automated Flight Service Station, for a flight to Lebanon, New Hampshire.

According to witnesses at 2N8, the pilot fueled the airplane, and then boarded the passengers. The pilot then taxied out and took off on runway 09. Witnesses observed the airplane lift off from the runway, "just beyond mid-field." None of the witnesses could recall if the flaps were extended. One witness described the rotation as abrupt and to a "high" pitch attitude. This was followed by a shallow climb and the wings rocking back and forth. Another witness described the pitch attitude as low, followed by a shallow climb angle. Both witnesses lost sight of the airplane as it flew past trees at the departure end of the runway, and observed the retractable landing gear was still extended.

Witnesses near the accident site observed the airplane flying in a southeast direction. They stated that the airplane was at a "low" altitude, wings level, with "normal" engine sounds. They also observed that the landing gear was extended. A witness observed the nose of the airplane pitch-up, followed by the airplane entering a right turn and descent.

A witness inside of her residence reported that she heard a "loud airplane." When the airplane was overhead, "the house vibrated." She then looked out a rear window and observed the airplane descending, "like it was on a landing approach," and collide with trees about 50 feet from her window.

The airplane came to rest in a ravine at the base of a tree about 40 feet below the terrain elevation of the residence. The accident site was about 1/2 mile from the departure end of runway 09, on a magnetic bearing of 117 degrees.

The accident occurred during the hours of daylight, approximately 40 degrees, 22 minutes north latitude, and 74 degrees, 15 minutes west longitude.

PILOT INFORMATION

The pilot held a Private Pilot Certificate with a rating for airplane single engine land. His most recent FAA Third Class Medical Certificate was issued during October 1995.

A review of the pilot's logbook revealed the he had accumulated about 486 total flight hours, of which about 79 hours were in the PA-28R-180.

WRECKAGE INFORMATION

The airplane wreckage was examined at the accident site on October 11 and 12, 1997. The examination revealed that all major components of the airplane were accounted for at the scene.

The initial impact scars were observed about 30 feet east of the wreckage, at the tops of trees about roof level of the nearby residence. The airplane came to rest inverted, at the base of a 45 inch diameter tree.

Examination of the wreckage revealed that the landing gear was extended, and the main fuselage and center wing sections were consumed by a post crash fire. The outer wing sections and the tail section were partially burned. The manual flap handle was found in the last, upper notch, which related to a full flaps position according to the airplane owner's manual. The right flap torque tube control rod was in the vicinity of the second notch position. The left flap torque tube control rod was deformed and past the fully extended flap position.

Control continuity was established from the pilot's controls to the rudder, stabilator, and to the left and right ailerons. The stabilator trim was measured to be 7 degrees tab down. The throttle, mixture and propeller cables were all stretched.

Both propeller blades displayed "S" bending, chordwise scratches, and leading edge nicks. The outboard 7 to 8 inches of one blade tip was missing.

The engine and electric fuel boost pump were removed from the wreckage and examined at the Allaire Airport, Farmingdale, New Jersey. The boost pump was connected to an electrical source and fluid pumped freely.

The engine was rotated by hand, and valve train continuity and compression was confirmed on all cylinders. The engine oil sump screen and the fuel servo inlet filter screens were absent of debris. The inside of the muffler was examined and observed to be unrestricted. The alternate air door was in the closed position and the screen was not clogged. The propeller hub, blades, and the governor were removed and shipped to Hartzell Propeller Inc. The engine was shipped to Textron-Lycoming.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot, on October 13, 1997, by Dr. Jay A. Peacock, of the Monmouth County Medical Examiners office, Monmouth County, New Jersey.

Toxicological testing of the pilot and front seat passenger was conducted by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated the following:

0.347 (ug/ml, ug/g) Oxycodone detected in Urine 0.401 (ug/ml, ug/g) Oxymorphone detected in Urine Pseudoephedrine was detected in Urine PhenylpropanoLamine was detected in Urine 43.8 (ug/ml, ug/g) Salicylate detected in Urine No Drugs detected in Blood.

TESTS AND RESEARCH

Propeller and Governor

The propeller and propeller governor were examined at Hartzell Propeller Inc. Piqua, Ohio, on January 8, 1998. The examination was conducted under the supervision of an FAA Inspector from the MIDO, Vandalia, Ohio.

Examination of the propeller blades and hub did not reveal any preimpact failures.

The propeller governor, A Hartzell model F-2-7A, bearing serial number 872W, was placed on a governor test bench, and performed satisfactorily. The following settings were obtained: Specification High RPM Stop setting (RPM): 2455 2330+/- 10 Pressure relief setting (psi): 265 275 - 300 Internal leakage (Oz/minute): 10.0 8.0 or less Capacity (Qts/minute): 7.8 8 - 12

Engine

On December 10, 1997, the engine was examined at the Textron-Lycoming Facility, Williamsport, Pennsylvania, under the supervision of the Safety Board Investigator. The examination revealed the fuel servo contained about 1/2 ounce of clear fluid that was absent of water when tested with water finding paste.

The left and right magneto spark plug wires were replaced due to impact damage. The left magneto timing was determined to be set correctly by the use of a timing light. When the right magneto timing was checked, it had an open circuit and could not be timed. The starter motor was replaced due to impact damage.

The engine was placed in a test cell and fuel pressure was applied to the fuel system. The fuel inlet fitting to the fuel pump was not damaged, but leaked fuel at the "O" ring gasket. The "O" ring was replaced and the fitting no longer leaked. The number 2 fuel manifold line was bent at the injector fitting. The line was disconnected and flow checked normally.

The engine was started and ran rough on the left magneto only. The right magneto did not produce spark. The engine was shut down and the fuel injector nozzles were removed, then reconnected to the manifold lines for a flow check. Fuel pressure was applied for less than a minute, which resulted in the following fuel flow into measured containers:

Number 1 injector nozzle - 104 ml Number 2 injector nozzle - 101 ml (line was partially crimped) Number 3 injector nozzle - 107 ml Number 4 injector nozzle - 58 ml

The four nozzles were removed and visually checked. Light could be seen through the numbers 1, 2, and 3 nozzles, but the number 4 nozzle was restricted. The number 4 cylinder intake tube was also observed to have impact damage, and it was dented inward blocking over 50 percent of the passage. After part of the dent was removed, and the number 4 nozzle replaced, the engine was started and ran slightly rough. When the dead right magneto was replaced, the engine was run again and produced factory rated power.

Fuel Selector

The fuel selector was removed from the fuselage as found. The Safety Board Investigator flow checked the valve at the Lycoming-Textron Facility on December 10, 1997. The valve was determined to be in the full open position selecting the left tank.

Magneto at Mattituck

On January 22, 1998, a Safety Board Investigator tested the right magneto at Mattituck Aviation, Mattituck, New York. When the magneto was placed on a magneto test bench and rotated, it produced spark at all towers. Examination of the cam and breaker point assembly revealed a slight discoloration of the breaker points, similar to a water stain.

ADDITIONAL INFORMATION

Trim

The stabilator trim was measured to be 7 degrees tab down. According to Piper Aircraft, that equated to a nose up trim position, half way between neutral and full nose up trim.

Landing Gear Operation

The airplane was equipped with a pressure sensing device in the system, which lowered the gear regardless of gear selector position, depending upon airspeed and engine power. Gear extension was designed to occur, even if the selector was in the up position, at airspeeds below approximately 105 mph with the power off. The device also prevented the gear from retracting at airspeeds below approximately 85 mph with full power, though the selector switch may be in the up position. The speed increased with reduced power and or increased altitude.

The sensing device operation was controlled by differential air pressure across a flexible diaphragm, which was mechanically linked to a hydraulic valve and an electrical switch which actuated the pump motor.

A high pressure and static air source for actuating the diaphragm was provided in a mast mounted on the left side of the fuselage above the wing. According to a Piper Aircraft manual, any obstruction of the holes in the mast would cause the gear to extend.

Landing Gear Malfunctions

A review of the flying club's "Old Squawks" and Usage records, revealed that on six previous occasions, the landing gear was unable to be retract after takeoff. The Usage log stated that the gear did not retract on February 9, 1997. The next notation available was from the "Old Squawks" records.

On July 16, 1997, the "Old Squawks" records stated, "landing gear will not come up, Plane grounded." The airplane was flown for 26 hours on 13 flights after the write-up, and a second write-up was placed on the same sheet that stated, "...landing gear will not operate properly, plane grounded." At the bottom of the page was checked: "operating OK now." This write-up was dated August 1, 1997.

On August 7, 1997, the "Old Squawks" records stated, "Gear did not retract on trip home." The airplane had been flown for a total of 3.2 hours that day. Another entry on the same "Old Squawks" page dated August 8, 1997, stated, "...gear works best when over-ride/extension lever is in neutral (middle) position." The bottom of the page was also checked: "operating OK now," and dated August 8, 1997.

On September 1, 1997, the "Old Squawks" records stated, "Gear did not retract! (tried everything)." This write-up was entered by the pilot who had signed off the August 7 write-up. The airplane was flown for 10.9 hours on 6 flight after the write-up, when on September 7, 1997, the bottom of the page was checked: "operating OK now, and signed by a pilot who's name did not appear in the Usage records between September 1 and 7, 1997.

On October 4, 1997, the current "Squawks" records stated, "Landing gear don't go up." This was an open entry and was not signed-off. The airplane was flown for 9.7 hours on 9 flights after the write-up, until the departure of the accident flight.

The accident pilot had last flown N3891T on July 16,1997, for 3/10 of an hour. This was the flight before the series of write-ups about the landing gear not retracting, which began on July 16, 1997.

Landing Gear Maintenance

According to the airplane's maintenance records:

April 10, 1997, the airplane was stripped of its paint and repainted. Also a landing gear operation check was performed.

April 29, 1997, a landing gear "retraction and free fall" test was performed.

May 2, 1997, the logbook stated, "trouble shoot landing gear retraction problem...perform retraction and landing gear freefall OK..."

June 24, 1997, "adjusted nose gear doors...gear retraction & free fall."

August 14, 1997, "...retraction and gear free fall checked."

This was the last entry in the airframe logbook.

An FAA Inspector interviewed personnel at a maintenance facility located at the Marlboro Airport. The Inspector was informed by the maintenance personnel that the pitot line for the auto gear extension system was "blown out" after the October 4, 1997, write-up in the "Squawk" log. He said that the line had been clogged with debris. The airplane was jacked up and the landing gear was cycled "OK." The FAA Inspector was also informed that the maintenance had not been entered into the airplane's logbooks.

Airframe and Engine Maintenance

The airplane was maintained through an annual maintenance inspection. The airplane was not maintained under a "100 hour" maintenance inspection program. According to the engine maintenance logbooks, the engine was overhauled during July 1994. The engine received an annual inspection on December 9, 1994, about 134.7 hours since overhaul. The next annual inspection was on January 17, 1996, about 423.7 hours since overhaul. The last annual inspection was signed off on February 1, 1997, about 644.1 hours since overhaul.

According to the airplane's maintenance records, during June 1994, the engine was removed and received a major overhaul. During September 1994, about 40.2 hours since overhaul, the number 4 cylinder was removed and replaced with a "serviceable" cylinder. During May 1995, the number 2 cylinder was replaced about 220 hours since overhaul.

On September 5, 1996, about 586 hours since overhaul, the number 4 cylinder was removed due to low compression. The intake valve was refaced and the exhaust valve was replaced. On August 12, 1997, about 805 hours since overhaul, the number 4 cylinder was again removed due to low compression. The exhaust valve guide was replaced, and the intake and exhaust valves and seats were refaced.

Pilot Training

The pilot joined the MAFC during November 1991. During his membership, he was "signed-off" in the PA-28R-180 and the PA-28-181. According to the manuals for both airplanes, both were equipped with 180 horsepower engines. However, the 28-181 had a wing span about 5 feet wider and a maximum gross weight of 2,550 pounds. The 28R-180 had a maximum gross weight of 2,500 pounds, and had retractable landing gear.

A review of the pilot's training records provided by the MAFC revealed that he had completed a "Meet Your Aircraft" quiz for the PA-28-181. Question 29 stated:

"What take-off distance is required to clear a 50 ft. obstacle with a gross weight at a pressure altitude of 5,000 ft. and 75 degrees (F)? (Assume no wind and a hard surface runway.)"

However, the question did not specify a weight or flap setting. The pilot's answer was 3,156 feet.

The Safety Board Investigator computed takeoff distances using PA-28-181 climb charts, which used pressure altitude and temperature. At a maximum gross weight of 2,550 pounds, the required takeoff distance was 4,300 feet with a zero flap setting. A flaps 25 degree takeoff could not be computed due to chart limitations.

The pilot's answer of 3,156 feet would have been the result of a 2,250 pound takeoff weight at zero flaps.

Question 30 stated: "What would the answer to

NTSB Probable Cause

The inadequate maintenance by the flying club and maintenance facility, which resulted in a takeoff with a partially blocked fuel injector nozzle and the failure of the landing gear to retract after takeoff. This resulted in the pilot's diverted attention and the subsequent stall.