NTSB Factual Report

HISTORY OF FLIGHT

On March 6, 2005, at 1413 eastern standard time, a Piper PA-23-250, N2343Z, was substantially damaged when it impacted a cornfield during an approach to the Chester County Airport (40N), Coatesville, Pennsylvania. The certificated airline transport pilot and passenger were fatally injured. Visual meteorological conditions prevailed and no flight plan was filed for the flight that originated at the York Airport (THV), York, Pennsylvania, about 1330. The personal flight was conducted under 14 CFR Part 91.

According to radar data provided by the Federal Aviation Administration (FAA), a target that correlated to be the accident airplane was first observed on radar about 2 miles east of the York Airport, at 1345, at an altitude of 2,800 feet. The target flew a direct path to the Coatesville area, and approached the Chester County Airport from the south. The target then flew to the east of the airport (passing to the east of the approach end of runway 29), and continued in a circular pattern above the airport, gradually descending from 2,600 feet. The target continued to circle back toward the south and passed through the final approach for runway 11, on a southeasterly heading, at an altitude of 1,900 feet. Fourteen seconds later, the target was observed at an altitude of 1,500 feet, continuing on a southeasterly heading. The last radar return was observed 14 seconds later, at 1402, at an altitude of 500 feet, about 1 mile to the south of the airport.

A witness, who was sitting in his car at the Coatesville Airport, observed the accident airplane enter the traffic pattern on a "normal" 45-degree angle to the downwind leg. Shortly thereafter, he observed the airplane's landing gear extend. The airplane was on final approach (approximately 1/4 mile from the runway), when it made a "hard left turn" and then descended behind a tree line. The witness heard the airplane for several more seconds, "like it was running at a very high rpm", and then heard the sound of an impact.

Another witness, who had just gotten out of his car in the driveway of his residence, heard the sound of a "failing engine," coming from overhead. He noticed the twin-engine airplane flying in a westerly direction, which was unusual for the Coatesville traffic pattern (the airport was in a north/northwest direction from the witness's residence). The witness then observed the airplane in a 35-40-degree left bank, and heard "the engine throttle, and then not throttle, and finally throttle again as it flew west."

A third witness reported observing the airplane on short final for runway 29. The witness looked away momentarily and when he looked back, he observed the airplane, wings level, on a heading 90 degrees perpendicular to the runway (heading approximately 200 degrees). The airplane then dropped below the tree line; however, the witness heard "at least one engine running strong." He then heard the sound of an impact 20-30 seconds later.

A pilot flying on the downwind leg of the traffic pattern for runway 29, at Chester County, stated that he heard another pilot report on the UNICOM frequency that he was "on the cross wind leg for runway 29." As the (witness) pilot was on short final, the same pilot reported he was "clear of the pattern to the south." The (witness) pilot stated the other airplane did not land, and he could not recall the registration number or type of aircraft making the transmissions.

PILOT INFORMATION

The pilot held an airline transport pilot certificate with a rating for airplane multi-engine land. He also held a commercial pilot certificate with a rating for airplane single-engine land. His most recent Federal Aviation Administration (FAA) second-class medical was issued on October 14, 2004.

According to an insurance form submitted by the pilot on February 28, 2005, he reported 12,783 total hours of flight experience. He also reported 72 total hours of flight experience in the make and model of the accident airplane, 2 of which were accumulated in the past 12 months.

AIRCRAFT INFORMATION

Examination of the airplane maintenance records revealed the most recent annual inspection was completed on March 1, 2004, with no anomalies noted.

METEOROLOGICAL INFORMATION

Weather reported at an airport 22 miles to the southeast, at 1351, included wind from 220 degrees at 21 knots, gusting to 27 knots, visibility 10 statute miles, a broken cloud layer at 11,000 feet, temperature 46 degrees Fahrenheit, dew point 27 degrees Fahrenheit, and altimeter setting of 29.73 inches Mercury.

COMMUNICATIONS

The pilot contacted the Williamsport Flight Service Station on March 6, 2005, at 0929, and requested a weather briefing for a visual flight rules (VFR) flight from York Airport to Chester County Airport. The weather briefer provided the pilot with the current and forecasted weather conditions, as well as an AIRMET for occasional moderate turbulence. The briefing was concluded at 0934.

Information provided by the FAA revealed the pilot did not file a flight plan. Additionally, there was no record of air traffic control communication with the pilot.

WRECKAGE INFORMATION

The airplane came to rest in a cornfield, approximately 1 mile to the south of the airport. The wreckage was examined on March 7, 2005, at the accident site. All major components of the airplane were accounted for at the accident site, and were contained in close proximity to the main wreckage. A row of 80-foot trees, located along the airplane's flight path, approximately 75 feet from the main wreckage, was undisturbed.

The main fuselage was oriented on an approximate heading of 243 degrees. Both wings remained attached to the fuselage. The right wingtip was separated from the wing, and located approximately 3 feet to the right rear of the wing. The right aileron and flap remained attached to the wing, and displayed minimal damage. Both the inboard and outboard fuel tanks were ruptured; however, more than 15 gallons of fuel was drained from the right wing. The right fuel selector valve (located in the engine nacelle) was selected to the inboard tank, and the fuel selector handle in the cockpit was selected to the "inboard" position. The right engine remained attached to the wing, and observation of the propeller blades revealed they were S-bent, and displayed chordwise scratching.

The left wingtip was also separated from the wing, and located about 1 foot to the left of the wing. The left aileron and flap remained attached to the wing; however, the left flap was observed folded under the inboard section of the wing. Both the inboard and outboard fuel tanks remained intact. The fuel tanks were drained, and the outboard tank contained a "trace" amount of fuel, and the inboard tank contained about 10 gallons of fuel. The left engine fuel selector valve (located in the engine nacelle) was selected to the outboard tank, and the left fuel selector handle (located in the cockpit) was selected to the "off" position; however, the handle was impact damaged. The cross-feed selector was in the "off" position. The left engine remained attached to the wing and observation of the propeller blades revealed no signatures of chordwise scratching or rotational bending. The propeller did not appear to be in the feathered position.

Flight control continuity was confirmed from all control surfaces to the cockpit controls. A measurement of the flap actuator revealed the flaps were in the full-extended position (50-degrees), and the flap handle in the cockpit was selected to the "down" position; however, the handle was impact damaged. The landing gear was observed in the retracted position. Measurements of the actuators for the horizontal stabilator and rudder trim were consistent with trim settings in the neutral position.

The left engine tachometer gauge in the cockpit displayed a reading of 400 rpm and the right engine tachometer gauge indicated 2,700 rpm. Both throttle levers and both propeller levers appeared to be in the aft position, and both mixture control levers appeared to be in the full rich position; however, the control column was impact damaged.

Both engines were removed from the airplane and examined at a salvage facility on March 8, 2005.

The left and right engines were rotated by hand at their respective propeller flanges. Valve train and crankshaft continuity was confirmed to the rear accessory drive on both engines, and thumb compression and suction, was obtained on all cylinders. Both magnetos, on both engines, were rotated by hand, and produced spark at all terminal leads. Examination of the top and bottom spark plugs, on both engines, revealed their electrodes were intact and light gray in color.

No fuel was observed in the fuel line from the left engine fuel pump to the fuel servo. A "trace" amount of fuel was observed in the left engine fuel distributor. Additionally, a "trace" amount of fuel was observed in the regulator section of the fuel servo.

Fuel was observed in the fuel line from the right engine fuel pump to the fuel servo. Fuel was also observed in the right engine fuel distributor, and was absent of contamination or debris.

The left propeller was disassembled and further examined. The examination revealed that the propeller was not in the feathered position at the time of impact.

MEDICAL AND PATHOLOGICAL INFORMATION

The Chester County Coroner's Office performed an autopsy on the pilot on March 7, 2005.

The FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma conducted toxicological testing on the pilot. According to the pilot's toxicology test results, metoprolol was detected in the pilot's blood and urine.

A review of the pilot's FAA medical file revealed that the pilot was taking Toprol (metoprolol) for a history of coronary artery disease.

ADDITIONAL INFORMATION

Fueling Info

According to fuel receipts provided by personnel at the Coatesville and York Airports, the airplane was fueled at the Coatesville Airport on February 25, 2005, with 26.6 gallons of fuel. The airplane was fueled at the York Airport on March 6, 2005, at 1254, with 20 gallons of fuel. The fixed base operator (FBO) employee who fueled the airplane reported that the 20 gallons of fuel added to the airplane, included 10 gallons added to each outboard fuel tank.

Examination of a flight log for the airplane revealed the airplane was last flown on February 25, 2005 for 2.5 hours.

According to the Piper Aztec Pilot's Operating Manual, the airplane fuel system consisted of two 36-gallon fuel tanks in each wing, totaling 144 gallons of fuel (140 gallons useable). During normal operation, it was recommended that fuel be pumped directly from the tanks to their respective engines, using the fuel selectors located on the fuel control panel between the front seats.

Examination of the Aztec Fuel Consumption Performance Chart, revealed at a power setting of 23 inches of manifold pressure and 2300 rpm, each engine burned approximately 12 gallons of fuel per hour.

According to the Airplane Flying Handbook (FAA-H-8083-3), Transition to a Multiengine Airplanes,

"When one engine fails on a multiengine airplane, performance is not halved, but is reduced by approximately 80 percent.

When one engine fails, however, it not only loses power, but the drag increases considerably because of asymmetric thrust, and the operating engine then carries the full burden alone. This leaves very little excess power for climb performance.

Since the failed engine is no longer delivering power to the propeller to produce thrust, but instead is absorbing energy to overcome friction and compression of the engine, the drag of the windmilling propeller is significant and causes the airplane to yaw toward the failed engine."

The procedure outlined in the Aztec Pilot Operating Handbook, for an engine failure in flight, instructed the pilot to feather the propeller of the dead engine, to reduce the yaw which will occur in the direction of the dead engine.

Wreckage Release

The wreckage was released to a representative of the owner's insurance company on November 22, 2005.

NTSB Probable Cause

The pilot's inadequate remedial action during an engine failure, which resulted in a loss of airplane control. A factor was the pilot's improper fuel management, which resulted in fuel starvation to one engine, and its subsequent loss of engine power.