Four Fatally Injured When PA-44 Went Down Just After
Takeoff
The NTSB's factual report in an accident involving a Florida
Institute of Technology (FIT) Piper PA-44 on an instruction flight
indicates that a checklist item may have been missed. Investigators
found the fuel select lever set to "off" during the post-accident
inspection. There was also no fuel found between the fuel selector
valve and the engine's fuel pump. On board the airplane were the
student pilot, an instructor, and two passengers.
The flight originated November 11, 2010, at 1805 eastern
standard time. The airplane, a Piper PA44-180, N883FT, registered
to and operated by the Florida Institute of Technology (FIT)
Aviation LLC, collided with the ground after an engine failure,
shortly after takeoff from runway 10R at the Palm Beach
International Airport (PBI), West Palm Beach, Florida. The
instructional flight was operated under the provisions of Title 14
Code of Federal Regulations (CFR) Part 91, with a night visual
flight rules (VFR) flight plan filed. The certificated flight
instructor (CFI), a certificated commercial pilot and two
passengers were killed, and the airplane was substantially damaged.
There was a postcrash fire. The airplane was departing at the time
of the accident, enroute to Melbourne, Florida (MLB).
According to information from the FAA air traffic control tower
at PBI, a female voice, later determined to be the CFI, transmitted
during initial climb that they had an engine failure and "needed to
turn-around and land." The controller cleared the flight to land
"any runway" and there was no further communications with the
flight.
A security video, provided by Galaxy Aviation located at PBI,
showed the accident airplane taking off from runway 10R. The video
was of poor quality due to the lights glaring into the camera from
the main terminal. All that was viewable was the airplane's
rotating beacon as it climbed and then started a slow turn to the
left. The accident airplane continued to turn left until a large
explosion was observed.
According to the FIT flight training department, this flight was
being conducted as a supervised solo cross-country training flight
for familiarization on international operations.
PILOT INFORMATION
The pilot, age 22, held a commercial pilot certificate, with
ratings for airplane single-engine land, airplane multiengine land,
and instrument airplane, which was last issued on December 16,
2009, and a first-class airman medical certificate issued on August
14, 2007, with a restriction that he must wear corrective lenses. A
review of the pilot's logbook indicated that he had accumulated a
total time in all aircraft of 298.2 hours. The pilot's total
multiengine time prior to the accident flight was 46.7 hours. The
pilot's most recent flight in a multiengine airplane was November
15, 2009.
The CFI, age 26, held a commercial pilot certificate, with
ratings for airplane single-engine land, airplane multiengine land,
and instrument airplane, which was last issued on September 16,
2010, and a first-class airman medical certificate issued on May
22, 2008, with a restriction that she must wear corrective lenses.
The CFI held a certificated flight instructor certificate, with
ratings for airplane single-engine, airplane multiengine, and
instrument airplane. A review of the CFI's flight records indicated
that she had accumulated a total flight time in all aircraft of
2,278 hours, and 492 hours in multiengine airplanes.
AIRPLANE INFORMATION
The airplane was a four-seat, low-wing, retractable gear, twin
engine airplane, serial number (S/N) 4496249, manufactured on July
2, 2008. It was powered by two Lycoming O/LO-360-A1 H6 (counter
rotating), 180-horsepower engines. A review of the aircraft's most
recent 100-hour inspection record found that the inspection had
been performed on October 25, 2010, at an airframe/engines total
time of 1,638.3 hours.
METEOROLOGICAL INFORMATION
A review of recorded weather data from the PBI automated weather
observation station, elevation 19 feet, revealed at 1753,
conditions were winds 200 degrees at 9 knots, visibility 10 statute
miles, clouds scattered 6,000 feet above ground lever (agl),
temperature 24 degrees Celsius, dew-point temperature 13 degrees
Celsius, altimeter 30.12 inches of mercury.
WRECKAGE/IMPACT INFORMATION
Examination of the crash site revealed the airplane impacted
taxiway hotel (H) in a nose-down, right wing low attitude. The
airplane impacted the taxiway on a heading of 340 degrees magnetic
and slid 80 feet before coming to rest upright on a 060-degree
heading.
The left wing remained attached to the fuselage. The inboard
side of the engine nacelle received fire damage. The outboard side
of the engine nacelle had no major damage. The main gear was down
and locked and had impact and fire damage. The fuel cap was in
place and fuel, blue in color, remained in the fuel tank. The left
fuel system fuel lines were all free from blockage. No fuel was
found from the fuel selector valve forward to the engine driven
fuel pump. The fuel selector lever and fuel selector valve were
found in the off position. The electric fuel pump was removed and
inspected. The screen was free from blockage and no fuel was
observed. The pump was field tested by applying battery power and
water in the inlet. The pump operated and the water placed in the
inlet was observed pumping out of the outlet.
The left aileron remained attached to the wing and had no major
damage. Control continuity was established from the left aileron to
the main cabin area. The outboard section of the left flap remained
attached to the outboard hinge. The inboard section of the flap was
destroyed by fire.
The right wing was destroyed by impact and postimpact fire. The
outboard fiberglass wing tip was separated and found along the
debris path. The fuel cap was in place and the fuel tank was
destroyed by fire. The main gear was down and locked and had impact
and fire damage. The electric fuel pump was removed. The outlet
fitting was separated from the pump. Damage was noted in this area.
The screen was free from blockage and residual fuel was observed on
the bottom of the fuel pump. The pump was field tested by applying
battery power and water in the inlet. The pump operated and the
water placed in the inlet was observed pumping out of the
outlet.
The right aileron and flap were destroyed and consumed in the
postimpact fire. The aileron bell crank was separated from the
wing. Both aileron cables remained attached to the bell crank.
Aileron control continuity was established from the bell crank to
the main cabin area.
The empennage was destroyed in the postimpact fire. The stabilator
and rudder cables were strung over the right wing. Both rudder
cables remained attached to the rudder. The rudder trim drum was
separated and destroyed. The top section of the empennage,
including the stabilator, was separated from the aircraft and
located along the debris path. The stabilator trim drum displayed
3.5 threads, which is constant with a neutral trim position.
The fuselage received impact damage and was consumed in the
postimpact fire. The cabin roof was separated and destroyed.
Forward of the instrument panel was crushed aft and to the left.
Aft of the rear seats, the fuselage was destroyed and consumed in
the postimpact fire. The interior cabin furnishings were consumed
in the fire. All seats were found in place.
The landing gear lever was in the down position. The left fuel
selector was found in the off position, 1 inch aft of the forward
stop, and the right fuel selector was found in the on position. The
fuel selector valves remained attached. The left fuel selector
valve was found in the off position and the right fuel selector
valve was found in the on position. Both valves were field tested
by applying low pressure air and were operational in all positions.
Both fuel gascolator filters were free from blockage. Fuel control
continuity was established from the fuel levers in the cockpit to
the fuel selector valves.
All engine control levers were forward and found approximately 1
inch aft of the forward quadrant stop, except the right throttle
lever, which was found approximately 2 inches aft of the forward
quadrant stop. Throttle quadrant continuity was established from
the throttle quadrant to the respective engine controls. The flap
handle was bent over to the side. The left engine magnetos were on.
The overhead panel and electrical switches were destroyed. The left
carburetor heat lever was in the off position and the right was in
the on position. The rudder trim indicator was in the neutral
position. The pilot's primary flight display (PFD) and the multi
function display (MFD) and all radios had impact and fire damage.
The standby instruments, airspeed, altimeter, and attitude, were
all damaged. No airframe anomalies were found during the on-site
examination.
Both propellers separated from each engine, consistent with
impact. The crankshafts were broken aft of the propeller flange.
The right propeller spinner was crushed and the propeller hub,
piston dome, piston, spring, and counterweights were separated and
displaced. Both blades of the right propeller exhibited torsion
twisting damage and chordwise scoring.
The left propeller spinner was partially crushed on one side.
Both propeller blades remained attached to the hub. One blade had
rotated from the normal pitch position; the internal pitch change
mechanism was broken. The other blade remained in normal pitch
position. Both blades were only slightly damaged. Neither propeller
was in the feathered position.
Piper Seminole File Photo
The right engine remained attached to the airframe firewall
assembly and was displaced aft and to the left, heavy fire damage
was noted; the wing nacelle was essentially destroyed. The engine
mount assembly was buckled. Impact damage was noted on the outboard
side and the exhaust pipes were crushed. The engine accessories
remained attached and secured to the engine and were scorched by
fire. Except for the propeller control which was melted, the engine
control cables remained attached to each respective control arm.
The throttle was in full open position. The mixture control was
full rich. The carburetor heat control was in the cold or off
position. Initial examination of the engine revealed no outward
indication of any mechanical malfunction. The spark plugs were
removed and exhibited tan color combustion deposits. Electrode wear
was moderate and gap settings were normal. Borescope examination of
the top end components was unremarkable. The carburetor bowl drain
plug was removed and clean blue fuel was observed.
The right engine was removed from the airframe and the valve
covers, governor, rear mounted components and carburetor were
removed. The engine was rotated using a drive tool adapter inserted
into the governor spline. Rotation of the crankshaft established
internal gear and valve train continuity. All four cylinders
produced compression. Internal gear timing was confirmed. The
magnetos were fire damaged, which precluded field testing. The fuel
pump was intact and scorched by fire. The pump contained clean blue
fuel and pumping action was noted when the pump was actuated by
hand. The pump was opened, which revealed no internal anomalies.
The accelerator pump was checked and found to operate normally and
expelled fuel. The carburetor fuel inlet screen was removed and
found clean. The carburetor bowl screws were found secured with
safety tabs. The safety tabs were opened and the screws were found
to be tight. The carburetor bowl was opened. A residual amount of
blue fuel was found remaining in the carburetor bowl. The
carburetor venturi was intact. The needle valve was checked and
found to operate normally when low pressure air was applied to the
unit, the float height measured approximately .187 inch. The
carburetor float was composite type. The mixture control valve
operated normally and was removed; the valve components were intact
and secure. The governor oil screen was found clean. The engine oil
filter element and oil suction screen were both found clean. At the
conclusion of the engine examination, no evidence of any preimpact
mechanical failure or malfunction was found.
The left engine remained attached to the airframe firewall and
was displaced aft, upward, and to the left. Slight fire damage was
noted and the wing nacelle was not heavily damaged. The engine
mount assembly was buckled. Impact damage was noted on the inboard
side. The engine accessories remained attached and secured to the
engine and were slightly scorched by fire. The engine control
cables remained attached to each respective control arm. The
governor arm was approximately .250 inch from the high rpm stop.
The throttle was in full open position. The mixture control was
full rich. The carburetor heat control was in off or cold
position.
Initial examination of the left engine revealed no outward
indication of any mechanical malfunction. The spark plugs were
removed and exhibited light gray color combustion deposits.
Electrode wear was moderate and gap settings were normal. Borescope
examination of the top end components was unremarkable. The
carburetor bowl drain plug was removed and was found to be void of
fuel.
The left engine was removed from the airframe and the valve
covers, governor, rear mounted components and carburetor were
removed. The engine was rotated using a drive tool adapter inserted
into the governor spline. Rotation of the crankshaft established
internal gear and valve train continuity. All four cylinders
produced compression. Internal gear timing was confirmed. The
magnetos were field tested and produced spark from all towers. The
fuel pump was intact and contained a residual amount of clean blue
fuel and pumping action was noted when the pump was actuated by
hand. The pump was opened, which revealed no internal anomalies.
The accelerator pump was checked and found to operate normally;
however, no fuel was expelled. The carburetor fuel inlet screen was
removed and found clean. The carburetor bowl screws were found
secured with safety tabs. The safety tabs were opened and the
screws were found to be tight. The carburetor bowl was opened. No
fuel was found remaining in the carburetor bowl. Blue stains were
observed at the low point of the bowl. The carburetor venturi was
intact. The needle valve was checked and found to operate normally
when low-pressure air was applied to the unit. The float height
measured approximately .187 inch. The carburetor float was metal
type. The mixture control valve operated normally and was removed
for inspection. The valve components were intact and secure. The
governor oil screen was found clean. The engine oil filter element
and oil suction screen were both found clean. At the conclusion of
the engine examination, no evidence of any preimpact mechanical
failure or malfunction was found.
MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed on the commercial pilot on November 11,
2010, by the Office of the District Medical Examiner, District
15-State of Florida, Palm Beach County, West Palm Beach, Florida.
The autopsy findings included "Thermal injuries." Forensic
toxicology was performed on specimens from the commercial pilot by
the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma
City, Oklahoma. The toxicology report indicated that there was no
carbon monoxide or cyanide detected in blood, no ethanol detected
in vitreous, and no drugs detected in urine.
An autopsy was performed on the CFI on November 11, 2010, by the
Office of the District Medical Examiner, District 15-State of
Florida, Palm Beach County, West Palm Beach, Florida. The autopsy
findings included "multiple blunt force injuries." Forensic
toxicology was performed on specimens from the CFI by the FAA
Bioaeronautical Sciences Research Laboratory, Oklahoma City,
Oklahoma. The toxicology report indicated that there was no carbon
monoxide or cyanide detected in blood, no ethanol detected in
vitreous, however, 25.43 (ug/ml, ug/g) Acetaminophen and
Salicylamide was detected in urine.
ADDITIONAL INFORMATION
The MFD and PFD received fire damage. The NTSB retained the PFD
and MFD flash cards for further examination. Examination and data
download revealed that at 18:00:50, Eng1 rpm and Eng 2 rpm began to
increase. At 18:01:08, Eng1 rpm and Eng2 rpm both reached 2,650
rpm. At 18:01:08, the recorded Eng1 fuel flow began to decrease,
followed by a drop in Eng1 rpm. At 18:01:38, the recorded Eng1 fuel
flow was approximately 1 gph and Eng1 rpm was approximately 1,270
rpm. The last recorded engine data was at 18:01:50, when the Eng1
fuel flow was approximately 4 gph and Eng1 rpm was 1,480 rpm. From
approximately 18:01:08 to the end of the recorded engine data, Eng
2 rpm remained at 2,650 rpm and Eng2 fuel flow remained between 15
and 16 gph.
POH Checklists
A review of the pilot operating handbook (POH) found that during
the taxi checklist (paragraph 4.5e), the fuel selector was to be
switched from the on position to the cross feed position, to ensure
that the crossfeeds were working properly. Once the airplane was in
the run-up area and prior to takeoff (paragraph 4.5g), the pilot
was to move the fuel selector from the crossfeed position to the on
position. During both of these procedures, the fuel selector must
pass through the off position before reaching on/crossfeed
position.