NTSB Factual Report

HISTORY OF FLIGHT

On October 13, 2003, at 1957 eastern daylight time, a Piper PA-23-250, N63942, registered to Air Mango, Ltd., and operated by the commercial pilot, collided into trees and terrain and caught fire in the Francis Marion National Forest, Cordesville, South Carolina. The personal flight was operated under the provisions of Title 14 CFR Part 91 with an instrument flight plan filed. Visual meteorological conditions prevailed. The pilot received fatal injuries, and the airplane sustained substantial damage. The flight departed East Hampton Airport, East Hampton, New York, about 1549 on October 13, 2003.

The flight was en route to Charleston International Airport, Charleston, South Carolina. According to air traffic control records, about 1942, the pilot contacted the Myrtle Beach approach controller while transitioning the airspace at 8,000 feet above mean sea level (MSL) and requested to begin a descent as soon as possible. The pilot was cleared to descend to 6,000 feet MSL, and was instructed to contact Charleston Approach. At 1948:37, the pilot established contact with the Charleston West Radar approach controller. A review of recorded radar data revealed the flight was approximately 40 miles from the airport descending through 7,000 feet MSL. At 1950:13, the pilot stated, "charleston six three nine four two would like to keep it coming down if you can arrange that." The controller cleared the pilot to descend and maintain 3,000 feet MSL, the pilot acknowledged, and no further radio communication was received from the pilot. A review of recorded radar data showed the flight began its descent, and the last recorded position for the flight was approximately 20 miles northeast of the airport at 2,900 feet MSL. The air traffic controller stated the airplane's target on the radar screen disappeared, and neither a primary nor a secondary return was observed.

Two witnesses approximately two nautical miles east of the accident site reported their observations. One witness stated she was in her yard, and she heard what sounded like "a normal plane," then she heard "something that sounded like fireworks." She stated she looked up and saw only the lights of the airplane and heard "crackling" noises. A second witness stated he was on his porch and he heard an airplane engine noise that sounded like "back fire." He looked for the airplane and saw it directly overhead flying west, then he heard it back fire again, and five or ten seconds later he heard the sound of an impact. The witness telephoned the local 911 operator to report the accident.

PERSONNEL INFORMATION

The pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. The pilot also held a flight instructor certificate for airplane single-engine land issued February 13, 1991, and expired February 28, 1993. The pilot held a second class medical certificate issued November 13, 2002, with the restriction "must wear corrective lenses." The pilot's log book was not recovered for examination. The pilot reported 5,500 civilian flight hours on his most recent application for airman medical certificate.

AIRCRAFT INFORMATION

The Piper PA-23-250 was manufactured in 1978 and was powered by two Lycoming IO-540-C4B5, 250-horsepower engines. The maintenance logbooks were not recovered for examination. Work orders provided by a maintenance facility revealed an annual inspection was completed November 20, 2002, at an airframe total time of 4760.3 hours, right engine time since major overhaul of 857.8 hours, and left engine time not recorded.

The airplane's fuel tanks were topped off with 97.7 gallons of fuel prior to departure from East Hampton, New York.

WRECKAGE AND IMPACT INFORMATION

The wreckage was found in a heavily wooded area, and wreckage debris was scattered approximately 70 feet along a path heading approximately 250 degrees magnetic from a tree freshly broken 50 feet above the ground. The fuselage, wings, and engines were found amid charred trees and burned pine straw approximately 25 to 35 feet west of the broken tree, and the empennage was separated and found approximately 35 feet west of the fuselage.

The fuselage, including the cockpit, instrument panel, and cabin were crushed and fire-damaged. The rudder bar was damaged and separated, and the left rudder cable was attached to the rudder bar. The right rudder cable was separated from the rudder bar, and the right rudder cable with the attachment was found near the rudder bar. The aileron chain was separated, and control cables in the center fuselage were encased in melted metal and not identified. The left fuel valve and the right fuel valve were fire-damaged; examination revealed the valves could be positioned to all ports and no obstructions were observed.

The left wing was crushed and fire-damaged. Approximately six feet of the inboard wing, including the engine nacelle, was embedded in the ground on the left side of the fuselage area. The chordline of the wing was approximately perpendicular to the ground. The inboard section of the wing was crushed from the leading edge aft to the main spar, the middle section of the wing was crushed, fragmented, and fire-damaged, and the outboard wing was crushed and separated. The fuel tanks were breached. The main landing gear was damaged and partially extended, and the actuator measurement was consistent with the stowed position. The flap was separated and on the ground adjacent to the trailing edge of the wing. The aileron was separated from its attachments and in two pieces. The aileron cables were separated from the bellcrank arm and separated near the wing root. The bellcrank was damaged and attached to a separated section of wing.

The right wing was crushed and fire-damaged. Approximately eight feet of the inboard right wing, including the engine nacelle, was embedded in the ground on the right side of the fuselage area. The chordline of the wing was approximately perpendicular to the ground. The inboard section of the wing was crushed from the leading edge aft to the main spar, and the outboard section of the wing was crushed, fragmented, and fire damaged. The fuel tanks were breached. The main landing gear was damaged and partially extended, the actuator was separated, and its measurement was consistent with the stowed position. The flap was crushed and fire-damaged and was partially attached to the trailing edge of the wing at the outboard hinge. The aileron was separated from its attachments and in two pieces; the inboard section was crushed around a tree near the right wing, and the outboard section was approximately 35 feet west of the fuselage. The aileron control cable and balance cable were separated outboard of the engine mount, and the bellcrank was not located.

The vertical stabilizer was crushed, and approximately three feet of the upper section was separated. The rudder was crushed and fire-damaged, and approximately 40 inches of the upper section was separated. The lower section of the rudder was attached to the rudder horn, and the rudder stops were in place. The left rudder cable was attached to the rudder horn, and the right rudder cable was attached to a separated arm of the rudder horn; rudder control cable continuity was established from the horn attachments to a fire-damaged area at the fuselage center. The left inboard section of the stabilator was crushed aft to the spar, and the outboard stabilator with the trim tab was crushed and separated. The right stabilator was crushed and separated at the root with the trim tab attached. Stabilator control cable continuity was established from the balance weight to a fire-damaged area at the fuselage center.

The left engine was embedded approximately five feet in the ground. The propeller, hub, and spinner were separated from the crankshaft flange and were found on the ground along the wreckage debris path. Both propeller blades showed twist deformation, s-shaped forward bending, and tip damage. The left engine crankcase was fractured at the front, the oil cooler was crushed, and the cylinders were damaged. The induction tubes and exhaust system were separated. The pushrods were damaged. The crankshaft was rotated at the propeller flange, crankshaft and camshaft continuity was observed to the accessory drive gears, and compression developed on all cylinders. Borescope examination of the piston domes and the valves revealed no evidence of mechanical anomaly. The oil suction screen was free of contaminants, and the oil filter was fire-damaged and free of metallic contaminants. The fuel servo housing was fractured and fire-damaged, the control rod ends were attached to the lever arms, and the control cables were separated. The fuel pump was fire-damaged. The fuel flow divider contained fine, light-colored, sand-like debris on top of the diaphragm, and the internal side of the diaphragm was free of debris. The ignition harness was damaged. The left magneto was crushed, fire-damaged, and could not be rotated; the right magneto was fire-damaged and rotated when turned by hand. The spark plugs recovered for examination exhibited "normal" wear as defined on the Champion AV-27 comparison chart for massive electrode plugs. The vacuum pump rotor and vanes were intact, and the shear coupling was fire-damaged.

The right engine was embedded approximately five feet in the ground. The propeller assembly was attached to the crankshaft flange, and the propeller blades were separated from the hub. Both propeller blades showed leading edge gouges and tip damage; one blade showed s-shaped bending, and the other blade was bent forward approximately 25 degrees. The right engine oil sump was fragmented, the oil cooler was crushed, and the cylinders were damaged. The induction tubes and exhaust system were separated. The pushrods were damaged. The crankshaft was rotated at the propeller flange, crankshaft and camshaft continuity was observed to the accessory drive gears, and compression developed on all cylinders. Borescope examination of the piston domes and the valves revealed no evidence of mechanical anomaly. The oil suction screen was free of contaminants, and the oil filter was fire-damaged and free of metallic contaminants. The fuel servo was not located, and the fuel pump was separated and fire-damaged. The fuel flow divider contained fine, light-colored, sand-like debris on top of the diaphragm, and the internal side of the diaphragm was free of debris. The ignition harness was damaged. Both magnetos were fire-damaged and could not be rotated. The spark plugs recovered for examination exhibited "normal" wear as defined on the Champion AV-27 comparison chart for massive electrode plugs. The vacuum pump rotor and vanes were intact, and the shear coupling was fire-damaged.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Medical University of South Carolina, Department of Pathology, Charleston, South Carolina, on October 15, 2003. The report stated the cause of death was "... blunt force trauma ... ."

Forensic toxicology was performed on specimens from the pilot by the Federal Aviation Administration (FAA), Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The report stated no ethanol was detected in the liver, 32 (mg/dL, mg/hg) acetaldehyde was detected in the liver, and 19 (mg/dL, mg/hg) ethanol and 1 (mg/dL, mg/hg) n-butanol were detected in the muscle. The report stated, "The ethanol found in this case is from postmortem ethanol formation and not from the ingestion of ethanol." The report stated bupropion, bupropion metabolite, sertraline, and desmethylsertraline were detected in the liver, and bupropion metabolite and sertraline were detected in the kidney.

A review of medical records maintained by the pilot's primary care physician revealed the pilot had been prescribed medications containing bupropion (Wellbutrin) and sertraline (Zoloft) to treat symptoms of depression. The records revealed the pilot sought treatment for symptoms of depression in August 1990, and a physician's note dated December 13, 1990, stated the pilot, "... has never been suicidal." The records showed the pilot had been prescribed various treatment medications throughout the years during follow-up visits. The pilot stated to the physician in a letter dated January 10, 2003, that the Wellbutrin and Zoloft treatment was working well for him, and a physician's note dated July 14, 2003, stated, "Doing very well on Zoloft ... and Wellbutrin ... . Depression - stable."

The records revealed in a physician's note dated November 1, 2002, the pilot was "... treated for atrial fibrillation since last office visit. Had negative heart catheterization ... one 30 percent ... artery blockage. Cardioverted. Recurred January 2002. ... Paroxysmal atrial fibrillation ... . Wishes therapy due to upcoming stress." A physician's note dated July 14, 2003, stated, "Atrial fibrillation January 02 - no recurrence ... . Sotalol increased to 60 mg twice a day."

An acquaintance of the pilot stated the pilot had been vacationing in Europe since late August 2003, and that the pilot returned to the United States four days before the accident. Another acquaintance of the pilot who dropped the pilot off at the airport prior to the accident flight reported the pilot showed no signs of fatigue or illness.

A review of airman medical records on file with the FAA Aerospace Medical Certification Division, Oklahoma City, Oklahoma, revealed that, on all applications for Airman Medical Certificate dated from August 30, 1974, to November 13, 2002, the pilot did not report any of his medical diagnoses or prescription medications.

ADDITIONAL INFORMATION

A mechanic at a maintenance facility provided a copy of a hand-written list of maintenance items for the airplane prepared by the pilot and dated July 15, 2003. Included on the pilot's list of items to be repaired were, "autopilot doesn't work, trim runs nose-down, dives when engaged," and "remount compas[s], check," and "check on a place to o/h HSI (sticking)." According to a statement obtained by an FAA inspector, the mechanic stated the pilot mentioned he would have the autopilot examined in Charleston, South Carolina, and that he would not use the autopilot and would keep the autopilot circuit breaker pulled in the meantime.

A mechanic at a maintenance facility in Charleston, South Carolina, stated the pilot called the facility the evening of October 12, 2003, and asked about having the autopilot examined. According to the mechanic, the pilot stated he would bring the airplane to the facility the following day, but the airplane did not arrive.

The wreckage was released to the general manager of Atlanta Air Recovery & Storage, Griffin, Georgia, on August 26, 2004.

NTSB Probable Cause

The pilot's failure to maintain adequate airspeed, which resulted in an inadvertent stall and subsequent uncontrolled descent into trees and the ground. A factor was physical impairment.