NTSB Factual Report

HISTORY OF THE FLIGHT

On Friday, September 10, 1993, at 1545 eastern daylight time, a Piper PA-32RT-300T, N2207B, operated by Air Spirit Aviation of St. Louis, Missouri, and piloted by Steven Dickson of Topeka, Kansas, had a in-flight engine fire and collided with objects during the emergency descent and landing roll. The pilot and passenger were fatally injured. The airplane was destroyed. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed for the flight. The cross country flight departed Dulles International Airport in Chantilly, Virginia, at 1527, and was destined for Cahokia, Illinois. The flight was conducted under 14 CFR Part 91.

According to the Dulles Air Traffic Control Tower tape transcripts, the pilot of N2207B was cleared for takeoff from runway 30 at 1526:47. After takeoff, the pilot received visual flight rules advisories and routing from the Dulles Air Traffic controllers. About 14 minutes and 13 seconds after N2207B departed the airport, at 1541:00, the pilot stated to the North Departure controller, "Dulles approach two two zero seven bravo need to get down real fast..." and requested vectors to the nearest airport.

The North Departure controller advised the pilot of nearby airports and vectored the flight toward the Upperville Airport which was seven miles from the airplane's position. At 1541:48, the pilot stated to the North Departure controller, "...we've got a fire on board somewhere." At 1543:00, radar contact with N2207B was lost 20 miles west of the Dulles International Airport and no further transmissions were received from the pilot.

A witness located about two miles from the accident site stated that he heard the airplane overhead and looked up. He said he "...saw a glow by the engine compartment, underneath by the nose wheel area." He stated that flames were coming from the nose wheel area and went to the trailing edge of the wings. He said as he watched the airplane, the flames "...died down and turned to smoke." The witness stated the airplane was about 2,500 to 3,000 feet above the ground when the airplane's nose dropped and the airplane started to descend "...rapidly in a continuous left turn." He stated the airplane disappeared behind a tree line. The witness also stated that the airplane's engine was running the entire time it was in his view.

At 1545, the Virginia State Police reported that an airplane had crashed on Route 710 in Marshall, Virginia. The accident occurred during the hours of daylight at 38 degrees and 57 minutes North latitude and 77 degrees 52 minutes West longitude.

PILOT INFORMATION

The commercial pilot's log books were not recovered. According to FAA records, at the time of the pilot's last medical on January 8, 1992, the pilot reported that he had accrued about 1,600 total flying hours.

AIRPLANE INFORMATION

N2207B was a low wing, seven seat, Piper PA-32RT-300T, single engine airplane. It had a Lycoming engine, model TIO-540-S1AD, installed.

The engine was last overhauled on June 1, 1992, at a tachometer time of 1950.3 hours. During the overhaul, Federal Aviation Administration Airworthiness Directive (AD) 91-21-01, effective November 4, 1991, was complied with by inspection of the exhaust system. The AD required repetitive exhaust system inspections at intervals not to exceed 25 hours or until a new One Piece Riser Kit was installed. The AD also specified that the airplane was never to exceed 75 flight hours from the AD effective date without the installation of the One Piece Riser Kit.

An annual inspection was completed on the engine on July 30, 1993, at a tachometer time of 2429.0 hours, about 3 flight hours prior to the accident. There is no record in the airplane's log books of an exhaust system inspection at the time of the last annual nor was there a record of a One Piece Riser Kit installation.

Review of the airplane's maintenance records revealed that numerous ADs were not complied with. See attached FAA report, N2207B AIRCRAFT MAINTENANCE RECORDS REVIEW, for a complete listing of applicable ADs for this airplane and maintenance information.

WRECKAGE AND IMPACT INFORMATION

The airplane wreckage and accident site were examined on September 10, 1993. Examination of the accident site revealed broken tree limbs about 600 feet from the airplane's final resting spot with airplane debris strewn between the two points. The wreckage path followed a northwesterly heading. (See attached wreckage diagram.)

Both of the airplane's wings were fire damaged and torn away from the fuselage. The cabin and cockpit area were consumed by fire. The airplane's tail section was intact and had some scorch marks on the tailcone.

The engine was inspected at the accident site and again at the wreckage storage facility in Wilmington, Delaware, on September 15, 1993. Examination of the engine revealed that the top left cross-over exhaust pipe was disengaged from the left intermediate exhaust pipe and the left intermediate exhaust pipe flange was broken (see photographs). Markings on the left intermediate exhaust pipe and the left cross-over exhaust pipe showed that the engagement between the two pipes was less than the required 1.5 inches. A required bracket securing the exhaust pipe clamp to the top left hydraulic pump pad stud was missing as was the bracket securing the exhaust pipe clamp to the accessory housing.

Further, the One Piece Riser Kit (O5K21503), required by AD 91-21-01, was not installed on the engine. The exhaust gasket which should be between the number five cylinder exhaust pipe flange and the left intermediate exhaust pipe flange was missing and the exhaust gasket between the exhaust manifold flange and the right intermediate exhaust pipe flange was also missing. Fuel injection lines for the number three and four cylinders were not clamped as required by AD 93-05-22.

The magnetos were fire damaged and the turbocharger was rotated by hand and turned freely. Continuity was confirmed through the engine including the accessory drive train. (See attached Textron Lycoming Accident Investigation Report for detailed information on the engine inspection.)

MEDICAL AND PATHOLOGICAL INFORMATION

The autopsy was performed by Dr. Field, Assistant Chief Medical Examiner, at the Medical Examiner's office located in Fairfax, Virginia, on September 12, 1993. The autopsy revealed no evidence of physical incapacitation or impairment.

The toxicology was performed by Dr. Canfield at the Civil Aeromedical Institute in Oklahoma City, Oklahoma. Negative results were reported for all screened drugs and volatiles.

ADDITIONAL INFORMATION

The airplane wreckage was released to Mike Hansen of Home Insurance Company in Dallas, Texas, on January 7, 1994.

NTSB Probable Cause

AN INADEQUATE ANNUAL INSPECTION OF THE AIRPLANE AND NON-COMPLIANCE WITH AIRWORTHINESS DIRECTIVES BY COMPANY MAINTENANCE PERSONNEL.