NTSB Factual Report

HISTORY OF FLIGHT

On July 3, 2008, at 1931 eastern daylight time, a Piper PA 28-161, N9888K, sustained substantial damage when it impacted trees, during the initial climb from Newport State Airport (UUU), Middletown, Rhode Island. The certificated flight instructor and a passenger were killed. The third occupant, a student pilot, was seriously injured and succumbed to his injuries on September 15, 2008. Visual meteorological conditions prevailed and no flight plan was filed for the local instructional flight conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to the airplane owner and fueling records, the airplane was "topped-off" with 25.1 gallons of 100 low-lead aviation fuel, and departed on runway 22, a 2,999-foot-long, 75-foot-wide, asphalt runway. Several witnesses, who lived near the airport, reported hearing the engine noise cease, immediately followed by the sound of an impact. One of the witnesses approached the wreckage from the right side, and was able to extricate the student pilot before the airplane was consumed by fire.

Another witness was a professional pilot, who held an airline transport pilot certificate and reported 12,670 total hours of flight experience. The witness stated that he was approaching UUU in a Socata TBM 700, with the intent to land and drop-off a passenger. During the approach, the witness was behind a "PA 28 aircraft" in the traffic pattern (but could not positively identify it as the accident airplane). A pilot in the PA 28 reported that he was on a downwind leg for runway 22, with the intention to touch-and-go. The witness thought it was odd that the PA 28 was "quite high" on final approach, landed about mid-field, and the performed a touch-and-go.

The professional pilot witness then landed, dropped-off his passenger, and prepared to depart about 10 minutes later. During engine start-up, the witness noticed that the accident airplane (but could not positively identify it as the previous PA 28) landed about 2,000 feet beyond the approach end of runway 22. It was slow, but the witness thought that the accident airplane might not be able to stop on the remaining runway. The witness was then "shocked" that the pilot attempted to perform a touch-and-go as the airplane rotated and began a "slow laborious climb." The witness further stated:

"The nose was too high to permit any gain in airspeed and it mushed along with the wings occasionally rocking. It was basically in a slow left turn never rising above the tree line until it impacted the trees more or less wings level."

Radar data was obtained from the Federal Aviation Administration (FAA). Review of the radar plot revealed targets with a 1200-transponder code, oriented along a path consistent with a left-hand traffic pattern for runway 22 at UUU. The last target was recorded at 1931:04, near the threshold of runway 22, indicating an altitude of 100 feet above mean sea level. No subsequent corresponding radar targets were recorded near the departure end of runway 22.

PILOT INFORMATION

The pilots' logbooks were not recovered. The flight instructor, age 63, held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He also held a flight instructor certificate, with ratings for airplane single-engine and instrument airplane. The flight instructor's most recent third-class medical certificate was issued on January 14, 2008. At that time, he reported a total flight experience of 2,650 hours. According to the airplane owner, UUU was the flight instructor's home airport, and he frequently instructed in the accident airplane. The flight instructor was seated in the left front seat at the time of the accident.

The student pilot, age 38, obtained his most recent third-class medical certificate on December 4, 2007. At that time, he reported a total flight experience of 12 hours. According to the airport manager at UUU, the student pilot completed his first solo flight during June 2008. The student pilot was seated in the right front seat, and his wife was seated in a rear passenger seat.

AIRCRAFT INFORMATION

The four-seat, low-wing, fixed-gear airplane, serial number 28-7816207, was manufactured in 1977. It was powered by a Lycoming O-320, 160-horsepower engine and equipped with a Sensenich propeller.

Review of the airplane's logbooks revealed that a 100-hour inspection was completed on June 23, 2008, at a total airframe time of 4,405.1 hours. At the time of the inspection, the engine had accumulated 1,081.8 hours of operation since major overhaul.

METEOROLOGICAL INFORMATION

The reported weather at UUU, at 1953, was: wind variable at 4 knots; visibility 5 miles in haze; broken ceiling at 8,000 feet, overcast ceiling at 9,000 feet; temperature 22 degrees Celsius (C); dew point 18 degrees C; altimeter 29.97 inches of mercury.

WRECKAGE INFORMATION

The airplane came to rest in trees on a residential property, about 1,000 feet beyond the departure end of runway 22. An approximate 30-foot debris path was observed, which consisted of damaged trees. The debris path was oriented along a magnetic course of approximately 180 degrees. The wreckage was also oriented on a heading about 180 degrees. The aft portion of the wreckage remained upright, while the engine was inverted. The cockpit and cabin area were consumed by fire; however, all major portions of the airplane were accounted for at the scene.

The wreckage was examined at the accident site on July 4 and 5, 2008. The right wing separated near the wing root and about mid-span. The middle section of the right wing, including the right flap and inboard right aileron, was consumed by fire. Crush damage was noted on the leading edge of the right wing, and approximately two-thirds of the aileron remained attached to the right wing. The inboard section of the left wing, including the left flap, had also been consumed by fire. two-thirds (outboard) of the left wing remained intact, with the left aileron attached. The empennage also remained intact. Stabilator and rudder control continuity were confirmed from the control surfaces to the control column in the cockpit. Aileron control continuity was confirmed from their respective bellcranks to the control column in the cockpit. The stabilator trim jackscrew was measured, revealing four visible threads, which equated to an approximate neutral position. The left aileron bellcrank remained attached to the airframe, and the right aileron bellcrank had separated from the right wing, consistent with impact forces. Both aileron cables were intact and traced from their respective bellcranks, to the sprocket and chain assembly at the cockpit control column. The aileron balance cable had separated and exhibited features consistent with tensile overload.

The remnants of the throttle and mixture cable were found in the aft position, and the remnant of the carburetor heat control was found in the midrange position. The flap handle was in the 10-degree flap extended position, and the fuel selector was destroyed. Only two readable cockpit instruments were recovered. The vertical speed indicator displayed an approximate 500-foot-per-minute descent, and the attitude indicator was tumbled.

The propeller remained attached to the engine, and exhibited little damage. The engine exhibited fire damage to the accessory section and carburetor. The engine was removed from the airframe, and the propeller was rotated by hand. Crankshaft, camshaft, and valve train continuity were confirmed, and thumb compression was attained on all four cylinders. The magnetos sustained fire damage and could not be tested; however, when the No. 1 cylinder was placed to top-dead-center, internal timing of the engine was verified via rocker arm oscillation on the No 2. cylinder. When the oil filter was opened, no metallic contamination was observed. Disassembly of the carburetor revealed that the floats and needle were intact. The mechanical fuel pump was destroyed, and could not be tested. All eight spark plugs were removed and inspected. Their electrodes were intact and light gray in color, except for the No. 1, No. 2, and No. 3 top spark plugs, which were oil soaked.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the flight instructor by the Rhode Island Department of Health, Office of the State Medical Examiner, Providence, Rhode Island, on July 4, 2008. According to the autopsy report, the cause of death was listed as "thermal injuries and smoke inhalation."

Toxicological testing was performed on the flight instructor by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. The testing revealed:

"HYDROXYCHLOROQUINE detected in Blood

HYDROXYCHLOROQUINE detected in Urine

IBUPROFEN detected in Urine."

According to the flight instructor's wife, and review of his medical records by a National Transportation Safety Board medical officer, he had a recent history, beginning about 9 months prior to the accident, of severe joint pain of the hands, wrists, knees, ankles, and feet. The flight instructor had been diagnosed with rheumatoid arthritis and had been treated with ibuprofen, prednisone, hydroxychloroquine, and methotrexate. During a doctor's visit 2 weeks prior to the accident, it was noted that the flight instructor "still has some pain and stiffness of his hands and wrists...significant morning stiffness lasting several hours." He was noted at that time to be taking 800 mg of ibuprofen twice a day and 400 mg of hydroxychloroquine once a day, and methotrexate was increased to 15 mg, once per week. He had been referred to an ophthalmologist for visual field testing "before he begins taking hydroxychloroquine," but the hydroxychloroquine was started on February 12, 2008, and visual field testing had not been accomplished as of the time of the accident. The flight instructor's most recent application for airman medical certificate, dated January 14, 2008, noted "No" to "Do You Currently Use Any Medication," to all items under "Medical History," and to "Visits to Health Professional Within Last 3 Years."

NTSB Probable Cause

The flight instructor's failure to initiate a go-around during a high approach, and his inadequate remedial action during an attempted touch-and-go.