NTSB Factual Report

HISTORY OF FLIGHT

On August 3, 2002, about 1539 eastern daylight time, a Piper PA-28-180, N3450R, listed with FAA records as "Registration Pending", collided with trees then terrain approximately .25 nautical mile west-southwest of the approach end of runway 07 at Cheraw Municipal/Lynch Bellinger Field Airport, Cheraw, South Carolina. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was substantially damaged and the private-rated pilot was fatally injured, a passenger sustained serious injuries. The flight originated about 5 minutes earlier from the Cheraw Municipal/Lynch Bellinger Field Airport.

The pilot was observed performing a preflight inspection of the airplane, and after the engine was started, the pilot taxied to runway 07. The flight departed runway 07, and remained in the traffic pattern where one witness noted the airplane appeared to be at traffic pattern altitude while flying on the downwind leg. Another witness on the airport reported he observed the airplane flying on the downwind leg for runway 07, and when the flight was about 3/4 down the length of the runway, the engine lost power. He further stated that the engine sounded as if it, "...wanted to start once more but than did not refire." A witness located off the airport reported hearing the engine and stated, "It was [sputtering] then it cut back on; then it went back off", and, "It sounded like it ran out of gas." Several witnesses on the airport reported that from the point the engine lost power, the flight path was similar to an airplane flying a normal traffic pattern. The airplane was observed on final approach where it appeared to be low; the airplane went out of sight behind trees.

A pilot who was waiting to takeoff was advised on the UNICOM frequency that the accident airplane, "...went down below the trees", and, the accident pilot was, "...having engine trouble." He departed, spotted the wreckage in a clearing, and reported on the UNICOM frequency directions on how to get to the accident site. He returned and landed, then proceeded via vehicle to the accident site; he departed the site after law enforcement arrived.

PERSONNEL INFORMATION

The pilot was issued a private pilot certificate with airplane single engine land rating on May 1, 2002. He was the holder of a third- class medical certificate with no limitations that was issued on October 5, 2001.

Review of the pilot logbook that begins with an entry dated August 25, 2001, and ends with an entry dated March 20, of an unmarked year, revealed he logged a total flight time of 61.5 hours, of which all but 1.0 hour were in the same make and model airplane as the accident airplane. He had logged a total of 19.3 hours as pilot-in-command, all of which were in the same make and model airplane as the accident airplane.

AIRCRAFT INFORMATION

The airplane was a Piper Aircraft Corporation model PA-28-180, manufactured in 1969, as serial number 28-5684. It was equipped with a Lycoming O-360-A3A engine, and a Sensenich 76EM-8-0-60 propeller. The airplane was certificated in the normal and utility categories. Review of the maintenance records revealed the airplane was last inspected in accordance with an annual inspection on July 19, 2002. The entry contained in the aircraft logbook indicates in part that the wings were installed, and fuel lines were connected and tested for fuel leaks. The airplane had been operated for 1.82 hours since completion of the inspection at the time of the accident.

METEOROLOGICAL INFORMATION

A METAR weather observation taken at the Darlington County Jetport, Darlington, South Carolina, on the day of the accident at 1539 indicates the wind was from 070 degrees at 10 knots with gusts to 18 knots, the visibility was 10 statute miles, clear skies existed, the temperature and dew point were 34 and 16 degrees Celsius respectively, and the altimeter setting was 30.10 inHg. The Darlington County Jetport was located approximately 162 degrees and 16 nautical miles from the accident site.

COMMUNICATIONS

The UNICOM frequency on the airport was not recorded though a speaker located outside the terminal building on the airport broadcast transmission(s) of the UNICOM frequency. Several individuals located on the airport outside the terminal building reported hearing the accident pilot broadcast on the UNICOM frequency, "Mr. Ralph" just before the airplane disappeared behind a line of trees.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed in a sparsely wooded area located at position 34 degrees 42.554 minutes north latitude and 079 degrees 58.171 minutes west longitude, or 247 degrees and .25 nautical mile from the approach end of runway 07.

Examination of the accident site revealed damage to a tree approximately 55 feet above ground level. A ground scar was located approximately 107 feet from the tree impact location; browning of leaves were noted near the first ground impact location. The airplane came to rest upright on a heading of 246 degrees, approximately 46 feet from the ground scar location. A straight line heading of 070 degrees was noted from the tree impact location to the main wreckage.

Examination of the airplane revealed all components necessary to sustain flight were attached or partially attached to the airplane. Flight control cable continuity was confirmed for roll, pitch, and yaw. The airplane was not equipped with shoulder harnesses. The propeller was attached to the engine, which was displaced up. The left wing remained attached only by the aileron flight control cables; the wing was in close proximity to the fuselage with the leading edge rotated up approximately 90 degrees. The leading edge skin approximately 14 inches outboard of the wing root exhibited a semi-circular indentation. An aluminum fuel line that routed fuel from the left fuel tank to the aft side of the fuel selector valve was damaged in the left wing root area; the line remained connected and was leaking fuel post accident. The left wing fuel tank was drained and found to contain approximately 13 gallons of blue colored fuel that was consistent with 100 low lead; no fuel stains were noted aft of the fuel filler cap.

The right wing remained attached; the outboard section of the wing from the wingtip inboard about 2 feet, was displaced up. An aluminum fuel line that routed fuel from the right fuel tank to the forward side of the fuel selector valve was bent and fractured in the left wing root area. The right wing fuel tank was drained and found to contain approximately 20 ounces of blue colored fuel that was consistent with 100 low lead; the tank was not compromised and there was no evidence of fuel stains aft of the fuel filler cap or of the sump drain. No obstructions of the fuel delivery or fuel vent system were noted. The fuel selector was found positioned near the right fuel tank detent; impact damage was noted to the fuel selector valve attach structure. No fuel was noted at the lines at the fuel selector valve, and there were no fuel stains in the area of the fuel selector valve. The electric fuel pump switch was found in the off position.

Examination of the engine revealed only residual fuel remained in the fuel hoses located in the engine compartment area; the fuel hoses were not failed. Approximately 1 ounce of fuel consistent with 100 low lead was drained from the carburetor bowl. The engine was removed from the airplane, the impact-damaged propeller was removed, and a serviceable propeller (Sensenich model 76EM8S5-0-62) was installed. The engine was temporarily mounted on a forklift for an engine run, was started and operated to approximately 2,250 rpm using only the engine driven fuel pump, no discrepancies were noted during the engine run.

Examination of the propeller revealed blade No. 1 was bent aft approximately 60 degrees, and blade No. 2 exhibited "S" type bending.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination of the pilot was performed by Inas Z. Yacoub, M.D., Forensic Pathologist, authorized by the Chesterfield County Coroner. The cause of death was attributed to blunt force trauma to the torso.

The FAA, Toxicology and Accident Research Laboratory (CAMI), located in Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. The results were negative for carbon monoxide, cyanide, volatiles, and tested drugs.

TESTS AND RESEARCH

According to personnel from the AIG insurance company, the airplane was involved in an occurrence on November 23, 2000, in which the pilot reported landing first on the nose landing gear, then becoming airborne. The airplane then bounced three times and came to rest. The airplane sustained minor damage; the occurrence was not investigated by the National Transportation Safety Board. The airplane was considered a constructive total loss by the insurance company, and sold, "as is/where is" to Wentworth Aircraft, Inc., located in Minneapolis, Minnesota.

According to the chief executive officer (CEO) of Wentworth Aircraft, Inc., his company bought the airplane from AIG insurance on March 15, 2001, and personnel at the occurrence airport disassembled the airplane. The airplane was then transported to Minneapolis, Minnesota, where it remained for approximately 1 year before being sold to AKN, Inc., a subsidiary of Wentworth Aircraft, Inc. The airplane was then transported from Minneapolis, Minnesota, to Cheraw, South Carolina, and purchased by the accident pilot on May 10, 2002.

According to a mechanic who repaired the airplane and performed the last annual inspection following purchase by the accident pilot, 14 CFR Part 43 Appendix D, and the Piper inspection guide were used as references when performing the inspection. When he began working on the airplane, the wings and horizontal stabilator were previously removed, and the aluminum fuel lines aft of the fuel selector valve were bent and damaged to the point that he could not determine routing of the lines to the fuel tanks. A person under his supervision repaired the damaged lines, and the wings were installed. He looked on microfiche at the Piper Parts Catalog for the fuel system illustration and later reported, "...it appeared that the forward line out of the fuel selector valve stayed routed on the lower side, then turned right toward the right wing." Additionally, it appeared to him that the fuel selector handle pointed to the forward port of the fuel selector valve when the right fuel tank was selected. Based on his perception of the illustration in the Piper Parts Catalog, and his belief of the fuel selector handle position, he routed and connected the aluminum fuel line from the right fuel tank to the forward port of the fuel selector valve, and routed and connected the aluminum fuel line from the left fuel tank to the aft port of the fuel selector valve. On the first page of the Introduction Section of the PA-28 parts catalog, there is a note, in bold letters, which states, "UNDER NO CIRCUMSTANCES SHALL THIS CATALOG BE USED FOR RIGGING AND INSTALLATION PURPOSES." Following repairs to the airplane, he added 10 gallons of fuel to each fuel tank to run the engine and check for leaks; the fuel tanks were filled before completion of the annual inspection. Following the annual inspection he test flew the airplane checking rigging of the flight controls, and for any other problems; no discrepancies were reported. The mechanic also reported flying with the airplane owner on a 15-minute flight after the annual inspection was completed so the pilot would feel comfortable in the airplane.

Review of Piper Parts Catalog pertaining to the fuel system installation which had an effective date of May 1980, revealed the illustration for the accident make and model airplane was difficult to ascertain the routing of fuel lines from the fuel selector valve to each tank. Further review of the illustration and index revealed the aluminum fuel line from the forward side of the fuel selector valve connected with the left fuel tank, and the aluminum fuel line from the aft side of the fuel selector valve connected with the right fuel tank.

Review of the airplane maintenance manual with respect to removal of the wings revealed a note indicating that to facilitate reinstallation of the wings, to mark fuel line ends. With respect to installation of the wing, the manual indicates to connect the fuel line to the fitting located aft of the spar at the wing butt line.

Review of the Inspection Report found in the Piper Cherokee Service Manual revealed that during an annual inspection, the fuel lines, valves, and gauges are designated to be inspected for damage and operation. Additionally, the fuel selector valve is operationally checked. Review of 14 CFR Part 43 Appendix D revealed that with respect to the cabin and cockpit group, all systems are to be checked for improper installation.

The airplane was reportedly flown by the accident pilot three or four times after completion of the annual inspection. A pilot other than the accident pilot/owner flew the airplane on a 30-minute flight the day before the accident. According to the pilot, during his preflight he noted the left fuel tank contained approximately 15 gallons of fuel and the right fuel tank contained 5-6 gallons of fuel. The left fuel gauge indicated 10 gallons of fuel or above, and the right fuel gauge indicated less than 10 gallons of fuel. When he entered the airplane to begin his flight, the fuel selector was positioned to the "right" tank position. Based on his preflight, he switched the fuel selector to the "left" tank position where it remained for the entire flight duration. He did not visually check the fuel tanks after landing but the left fuel gauge indicated approximately 10 gallons of fuel; he did not pay attention to the right fuel gauge after landing. He further reported that during the flight, the engine hesitated slightly when full throttle was applied, there were no other discrepancies related to the engine noted during his flight.

The owner's handbook indicates to visually check fuel supply and replace the fuel caps during the preflight check. The takeoff checklist of the handbook indicates, "Fuel-on proper tank." The procedure for loss of engine power indicates that, "The most common cause of engine power loss is mismanagement of the fuel. Therefore, the first step to take after engine power loss is to move the fuel selector valve to the tank not being used."

Inspection of the fuel selector valve at the manufacturer's facility with FAA oversight revealed the shaft indexing was correct.

ADDITIONAL INFORMATION

The airplane minus the retained components was released to Richard Carnes, Director of Chesterfield County Emergency Services, on August 6, 2002. The retained components were released to Mr. Les Sychak, Sr. Claims Representative for AIG Aviation, Inc., on January 14, 2003.

NTSB Probable Cause

The misrouting of the fuel lines to the fuel selector, which resulted in the use of a fuel tank with inadequate fuel supply, fuel starvation, and the loss of engine power. Contributing was the pilot's inadequate remedial action for conducting an emergency landing.