NTSB Factual Report

HISTORY OF FLIGHT

On March 11, 1996, at 1329 eastern standard time, a Piper PA-23-250, N222WR, struck terrain in Bridgeport, West Virginia. The airplane, which had departed from the Benedum Airport, Clarksburg, West Virginia, and was maneuvering to return for a landing, was destroyed. The Airline Transport Pilot was fatally injured. No flight plan had been filed for the ferry flight, which was conducted in visual meteorological conditions, and under 14 CFR Part 91.

Earlier in the day, with two pilots and a passenger onboard, there was an inadvertent main landing gear retraction. This event occurred while the airplane was in the runup area for runway 21, about 0948. According to the left seat pilot

"...Prior to beginning taxi I attempted gear pressure check. I believe that I pushed handle down, but with ensuing events, I am not positive. I may have either moved selector to up position or, may have caught gear handle in coat sleeve and thereby raised the selector. In any event, the landing gear partially retracted with the aircraft slowly sinking in a left side lower but nearly level attitude until it dropped approximately the last 10 to 12 inches...During the retraction there was no gear warning horn nor were there any gear unsafe lights...The only visible damage was to small pieces of fiberglass from the rear of the outboard door of each of the main gears, the loran antenna located forward of the down hook [tail tie down ring] was bent and the skin around the base was slightly dented, the tail hook [tail tie down ring] was pushed upward from its normal position approximately 1 1/2 inches and the skin forward of the hook was dented with a crack in the sheet metal skin just forward of the hook. One screw was pulled from the tail cone assembly...."

Maintenance personal examined the airplane and reported:

"The airplane had a main gear retraction on taxi way Alpha. Nose gear did not retract. Pilot shut engines down. Damage to tail tie down area. No side skin damage to tail. Tail tie down attach area skin damage. No aft bulkhead damage at stabilator attach point. Visually inspect landing gear for down lock. Down lock O.K. Safety valve arm broken. No visible defects with landing gear control system. Aircraft tail assembly visually inspected...Visually inspected and operated all flight controls, no defects found. Applied duct tape to damaged skin area tail tie down. Obtained ferry permit for ferry flight from Clarksburg (CKB) to Hagerstown, MD (HGR) for sheet metal repair. Limitations for permit - gear down and placards [Landing Gear] INOP."

In a telephone interview, the mechanic who signed the ferry permit reported that he placed a placard in the cockpit that the landing gear was inoperative; however, the landing gear was still operative, and had not been disabled. He also reported that he had removed both the left side panel and tail cone to inspect the airplane, and that after the inspection, he prepared the airplane for the ferry flight. Upon completion of the work, the pilot took the airplane for the ferry flight. The accident pilot had been the right seat pilot on the earlier event with the inadvertent landing gear retraction.

At 1321, the pilot called the Clarksburg tower and reported that he was ready to taxi for an eastbound departure. He was cleared to taxi to runway 3.

At 1326, the pilot reported he was ready for takeoff. The flight was cleared into position and hold on runway 3., and the pilot replied, "Position and hold runway three...and for your information [this] will be a ferry flight with the gear down so don't look for retraction on takeoff."

The flight was cleared for an on-course departure at 1327:10, which was acknowledged by the pilot.

At 1328:21, the local controller transmitted, "Aztec two whiskey romeo did you want advisories from approach control sir."

At 1328:30, the pilot replied, "Whiskey romeo negative we need to come back in for a landing." The local controller replied, "Aztec two whiskey romeo roger enter on ah right down wind for runway three wind three five zero at seven cleared to land."

At 1328:37, the pilot replied, "Cleared to land two whiskey romeo." No further radio calls were received from the pilot.

At 1329:15, the local controller transmitted, "Two whiskey romeo check altitude."

A witness who landed on runway 3 after the pilot departed reported:

"...N222WR climbed out which appeared to be normal. After turning east, he called the tower stating he needed to return and land. N222WR started a turn south (for down wind). In this direction, he was descending at a constant rate (He maintained directional/level flight attitude). As he descended below the horizon (in my view from the taxi-way) the tower called N222WR check altitude and then he disappeared and a mushroom cloud of smoke appeared."

The flight was observed by other witnesses who described; seeing the airplane flying and hearing the engines out of sync; observed the airplane through a window and saw the nose pitching up and down; and saw something trailing from the left wing tip which was described as smoke. Another witness located near the accident site heard the airplane engine(s) and impact, but did not see it. He reported that the engine(s) sounded like it was at high power, but he could not distinguish if it was a single engine or a twin engine airplane.

The accident occurred during the hours of daylight at location 39 degrees, 16 minutes North and 80 degrees, 10 minutes West.

PERSONNEL INFORMATION

The pilot was the holder of an Airline Transport Pilot Certificate for single and multi-engine land airplanes. In addition, he held a flight instructor certificate for single and multi-engine land airplanes and instrument airplanes. He was issued an FAA 2nd class Airman Medical Certificate on May 15, 1995, with a limitation to wear corrective lenses.

The pilot's last flight review was conducted in a Cessna 172, on November 5, 1995. The same flight instructor had conducted the last three flight reviews, all in single engine airplanes, and when interviewed reported no problems with the pilot.

According to his pilot log book which was current through October 10, 1995, he had a total time of 5348.5 hours. In addition he was estimated to have flown at least 50 additional hours between the date of his last flight in the log book, and the date of the accident for a total time of about 5400 hours, and about 30 hours in the preceding 90 days.

AIRCRAFT INFORMATION

The airplane was a 1976 Piper PA-23-250. The engines were Lycoming TIO-540-C1A which developed 250 horse power at takeoff. The flight control system was cable actuated from the cockpit with functioning dual controls installed. The wing flaps and landing gear were hydraulically actuated from cockpit controls. There were four fuel tanks, two in each wing. The fuel tanks were identified as left and right, and inboard and outboard.

WRECKAGE AND IMPACT INFORMATION

The airplane was examined at the accident site on March 12 and 13, 1996. The examination revealed that the airplane had impacted the side of a hill. The debris path was scattered along a heading of 180 degrees, for a distance of 267 feet.

In the initial impact area, the ground was burned black. Impact marks from the right wing and right wing landing gear, and nose gear, and left engine were visible. Small pieces of green navigation light lens were found at the origin of the mark identified as the right wing impact mark. The center of the right engine and right landing gear impact marks measured 16 feet from the right wing tip impact mark. The nose impact crater measured 25 feet, and the nose wheel 26 feet from the ring wing tip impact mark. The left engine impact crater measured 31 feet from the right wing tip impact mark.

The wings were fragmented and separated from the fuselage.

The left engine was separated from the engine mounts and wing center section which was nearby. The left propeller was separated from the engine behind the propeller flange, and found about four feet down in the left engine impact crater. The fracture face on the crankshaft was at a 45 degree angle to the shaft, with a granular surface, with no discoloration. The propeller blades were bent rearward, and exhibited "S" curves.

The right propeller remained attached to the engine which was still attached to its mounts, and the wing section behind the engine. Both blades were bent rearward and one blade exhibited "S" curves near the tip.

The fuselage was found 207 feet from the initial impact point. The cabin forward of the wing spar was distorted and crushed. The roof had been bent rearward, the sidewall were separated from the fuselage, and the floorboard in the vicinity of the crew seats had been bent downward and rearward.

Flight control continuity between the stabilator and rudder, and the crushed area was verified. Flight control cables were visible forward of the crushed area; however, attach points were either distorted, or missing, and operation was not verified. Aileron continuity was not verified due to cable separation and wing fragmentation. The rudder trim jackscrew was found with seven thread visible. A representative of Piper Aircraft reported that this jackscrew position correspond to neutral rudder trim.

The airplane was equipped with both the manual overhead crank for elevator trim, and electric trim, operable from both the auto-pilot control head, and a thumb switch on the control yoke. Examination of the elevator trim jack screw found zero threads visible on the top. A representative of Piper Aircraft reported that his corresponded to a full nose down elevator trim position.

The manual elevator trim and rudder trims were colocated on the overhead in the cockpit, between the seats. This area was opened up and pealed back from the cockpit. Tree branches were found mixed in both of the trim cables.

The hydraulic cylinder for flap extension measured 6 inches; however, the hydraulic system had been compromised with broken lines, and it is unknown if the extension was representative of a pre-impact flap setting. A representative from Piper Aircraft said the extension corresponds to about 13 degrees of flap extension.

The fuel selector was located between the two pilot seats and had been deformed. The crossfeed lever was on. The locking fuel levers were found with the left positioned to the left outboard tank, and the right side broken off. The remaining stub from the lever pointed to the middle position which is fuel off.

The fuel selector valves which were cable actuated, and located in the wheel wells were recovered. Tension on the cable between the selector valves and the fuselage will move the valves to the inboard tank position. Both valves were found selected to the inboard tanks.

The three landing gear were identified; however, impact damage prevented a determination of locked or unlocked. Filament stretch was found in the landing gear down bulbs. Impact marks were found at the main impact crater that corresponded to the position of extended landing gear for the nose and right main landing gear. Disturbance of the ground in the vicinity of the left main landing gear obscured any evidence of a left main wheel impact mark.

Examination of the rudder and stabilator mechanism found tape placed over the torn metal as described in statements. The bulkhead that the stabilator attached to was distorted, but not fractured. The elevator counterbalance weight was rubbing against the right side of the fuselage and restricted elevator movement. When the weight was straightened, the stabilator could be moved between the stops with no binding or hesitation. The rudder was able to be moved between its stops with no binding or hesitation.

Soot was visible on the vertical and horizontal stabilizer of the airplane. There were no soot patterns in the direction of flight or metal splatters visible.

The engines and propellers were examined at the request of the NTSB Investigator-In-Charge, and under the supervision of the Federal Aviation Administration (FAA). According to the FAA report, heavy earth ingestion was found on cylinders from both engines. According to the report from Hartzell Propellers, "...The impact angles noted are well above the low pitch stop setting of 15.2 degrees."

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was conducted in Morgantown, West Virginia, by Dr. James L. Frost, Deputy Medical Examiner for the State of West Virginia.

Toxicological testing conducted by the FAA Civil Aeromedical Institute (CAMI), in Oklahoma City, Oklahoma. The drug Chlorpheniramine, a antihistamine, was detected in the blood at .027 ug/ml, and Detromethorphan, a cough suppressant was detected in the blood at trace levels. Additionally the drug acetaminophen (the active ingredient of Tylenol) was detected in the blood. According to the Laboratory Manager for CAMI, the level of Chlorpheniramine was mid-range for therapeutic doses, and all the drugs listed above are found either singly or together in several over the counter cold remedies.

ADDITIONAL DATA / INFORMATION

The pilot who was involved in the landing gear retraction incident reported:

"...[The accident pilot] had a head cold the previous week and still did not sound like himself. During the events [described] above he periodically made noises which sounded like a motor by pursing his lips while emitting low guttural sound. I kidded him about it asking what motor he was running. He shrugged it off...."

The airplane was refueled with 54 gallons of 100LL aviation gasoline from an underground 10,000 gallon tank prior to departure. A check of the filter revealed no contaminants. The airplane was released to the insurance adjuster, Mr. John Cooley on March 13, 1996.

NTSB Probable Cause

The pilot's inablility to maintain aircraft control due to a full nose down trim condition, which resulted in a loss of control and collision with terrain.