NTSB Factual Report

HISTORY OF FLIGHT

On September 9, 2001, at 1911 Pacific daylight time, a Piper PA-23-150, N2268P, experienced a partial loss of engine power during takeoff from the Chico Municipal Airport, Chico, California. The airplane impacted terrain on airport property and collided with a berm. Thereafter, a fire erupted, which destroyed the airplane. The commercial certificated pilot owned and operated the airplane, and he was fatally injured. Visual meteorological conditions prevailed. The flight was performed under the provisions of 14 CFR Part 91. At the time of the accident, the planned local area personal flight was originating, and no flight plan had been filed.

An eyewitness, located on the airport's ramp, reported observing the airplane near the approach end of runway 13L. He saw the airplane accelerate and liftoff at a location about 75 yards south of taxiway E. This location was about 3,000 feet from the beginning of the runway. As the airplane flew past the midfield position it had climbed between 125 and 200 feet above the runway. This was the maximum altitude the witness observed the airplane to obtain during its flight. As it passed the witness, he noted that its engines sounded normal, its wings were not rocking, and it looked okay. The witness turned away from the runway and did not see the airplane for several seconds, but he heard a transmission on the local airplane radio frequency that is broadcast over a loudspeaker. The transmission was a one-syllable word that was either "help" or something similar. There were no other airplanes in the area, and the witness believed the transmission came from the accident airplane. He turned back toward the airplane and heard the "pop" sound of an impact that was immediately followed by smoke and fire.

Two witnesses, who were located in an open field just west of the airport, reported that a "pop pop pop pop" sound was coming from the airplane. The noise sounded like a backfiring rather than an engine sputtering. The engine(s) sounded like a "radial engine that was poorly tuned and misfiring." When the airplane was flying just past the south end of the airport it was a lot lower to the ground than other airplanes these witnesses had seen. About 2 seconds before the crash, the airplane was only about 40 feet above the ground. No smoke was coming from the airplane during flight. The popping sound stopped just before impact. The airplane appeared to be in a 45-degree right wing low bank angle as it descended into the ground. The airplane hit the ground and then rotated clockwise. A fire erupted as soon as the airplane came to a stop.

Another witness, sitting at a location south of the airport, observed the airplane flying in a southerly direction and descending. He heard an engine or engines running, and he did not hear any sputtering sounds. Just before the crash he observed the airplane initiate a right turn, and it crashed during the turn. The airplane was not on fire while it was airborne, but a fire started immediately following the impact.

According to the responding emergency medical personnel, the pilot made a statement regarding the flight. The medical personnel reported that the pilot stated, "my engine failed and I was trying to turn around."

PERSONNEL INFORMATION

The pilot held a commercial pilot certificate, and he was rated to fly single and multiengine land airplanes. He also held an instrument rating and was certified as an advanced and instrument ground instructor. Additionally he was certificated as an airframe and powerplant mechanic.

A review of the pilot's personal flight record logbook indicated that he had a total of about 1,782 flight hours including over 1,000 hours as pilot-in-command. During the 90 days preceding the accident the pilot had flown at least 130 hours combined flight time as a pilot and copilot.

According to his logbook, the pilot had satisfactorily completed his last biennial flight review on June 30, 2000. However, a flight instructor where he was employed reported that he gave the pilot a biennial flight review on May 4, 2001.

The pilot's wife reported that she believed the pilot had last flown the accident airplane in May 2001. According to the pilot's logbook, he had not flown the airplane between May 23 and the accident date.

The flight times listed above and in the "Flight Time Matrix" box of this report are estimates. The flight times consist of a combination of data complied from the pilot's flight logbook, family and employer information, and data listed on a United States Forest Service form, dated May 14, 2001.

AIRPLANE INFORMATION

The accident airplane, serial number 23-878, was manufactured in 1957. The airplane's Piper data plate lists the airplane as being a model "PA-23." In various Federal Aviation Administration (FAA) documents it is subsequently referred to as being a model "PA-23-150."

The airplane had undergone several modifications. In pertinent part, its Lycoming O-320 engines (rated at 150 horsepower each) were equipped with Rajay turbochargers (referred to in associated literature as turbosuperchargers). The airplane's flight manual was supplemented to reflect this modification. Affixed on top of the airplane's serial number identification plate was a metal band indicating that the airplane's model was a "PA 23TS."

According to the pilot's wife, her husband was a professional airplane mechanic and pilot. He performed the maintenance on the airplane, which he had owned for about 2 years.

Based upon a review of incomplete records, on May 30, 2000, the pilot had performed an annual inspection on his airplane. On this date the listed airframe total time was 4,288.2 hours. The time since the engines had received a major overhaul was 1,293.0 hours. Since this date, the airplane had been operated for between 42 and 91 hours.

About 1500 on the accident day, a witness observed the pilot at the Chico Airport. The pilot was standing by his airplane with the right engine cowling removed. The witness reported that he asked the pilot, "Are you working on it today?" The pilot replied he would "see if we can get her to go," at which point the witness departed the area.

METEOROLOGICAL INFORMATION

In part, Chico Airport reported its weather conditions at 1910 as follows: Sky condition clear, surface wind from 120 degrees at 7 knots, and visibility 10 miles. The ambient temperature at the airport was 27 degrees Celsius. The calculated density altitude was approximately 1,900 feet.

AIRPORT AND GROUND FACILITIES

Chico Municipal Airport runway 13L is 6,724 feet long. The air traffic control tower was closed at the time of the accident.

The airport's elevation is 238 feet mean sea level. The terrain is nearly level between the runway end and the initial point of ground impact (IPI). Between the IPI and the main wreckage, the terrain slopes upward about a 5-degree angle. All vegetation between the runway end and the IPI was less than 2 feet tall.

WRECKAGE AND IMPACT INFORMATION

The accident site is located adjacent to the Chico Municipal Airport's southern perimeter fence, at the following approximate global positioning satellite coordinates: 39 degrees 47.055 minutes north latitude by 121 degrees 50.935 minutes west longitude. The initial point of impact was about 1,400 feet south of runway 13L's departure end, and about 150 feet west of the runway's extended centerline. The crash site elevation is about 200 feet mean sea level.

The initial point of impact was noted by the presence of a 17-foot-long shallow ground scar swath that was oriented in a southerly (176 degree, magnetic) direction toward the main wreckage. At the end of the swath, an oval shaped depression in the hard-packed ground was apparent that was about 3 feet wide by 9 feet long and 6 inches deep. Adjacent to the crater, green lens fragments were located which resembled the right wing's missing navigation light lens.

The main wreckage was found about 46 feet farther south, or a total of 72 feet from the IPI. The airplane was on top of a dirt berm, and was in an upright attitude on a 065-degree heading. The right wing and the engine were upside down. All other components were connected and right side up. With the exception of the aft portion of the empennage, the entire airplane was consumed by fire. The wings were fire damaged in the areas of both the inboard and outboard fuel tanks.

All flight controls were attached to the airframe, and the continuity of the flight control system was confirmed. The landing gear was extended. The rudder trim tab was positioned to its maximum 25-degree design limit in a trailing edge right setting (left rudder trim).

The right wing main spar separated from its fuselage attachment point. The left wing's main spar was attached to the fuselage. The left wing tip was bent upward about a 45-degree angle. No evidence of cargo was found in the airplane.

FIRE

A review of the Chico Fire Department's fire incident report indicates that the airport based fire station number 3 received the Alert 3 (fire alarm) at 1912. The station's first engine arrived at the crashed airplane at 1915:15.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot was initially airlifted to a local hospital, and subsequently flown to the University of California Davis Hospital's burn center, where he succumbed to his thermal injuries. The FAA's toxicology tests on the pilot did not reveal evidence of carbon monoxide, cyanide, or ethanol. Morphine was found in his blood.

TESTS AND RESEARCH

The airplane was examined under the supervision of the National Transportation Safety Board investigator.

Airframe Examination.

The airframe and engine assemblies were initially examined on scene. No baggage was found in the airplane wreckage. Following recovery, the airplane was examined at the storage facility of Plain Parts, Pleasant Grove, California. No current airframe logbook was located.

The engines' fuel tank selectors were set to the main tank positions, and the crossfeed control was in the off position. The turbocharger controls were both in the off position.

The wing flaps were partially extended. The fire-damaged flight control system was examined in conjunction with the airplane manufacturer participant. The participant opined that all of the observed structural damage evidence was consistent with the damage having occurred during the impact sequence. No evidence of any preimpact separations was found.

Propeller Blade Examination.

The left engine propeller governor was at the low pitch (high rpm) stop. The right engine propeller governor was broken, and its position was not determined.

The left engine's two propeller blades were torsionally twisted. One of the blades bent into an "S" shape and it bore numerous 1/8-inch deep leading edge nicks and scratches in a chordwise direction over its cambered surface. The tips of both blades fractured off.

One of the right engine's two propeller blades was nearly straight. The second blade was bent about 30 degrees aft. Both blades bore scratches in a chordwise direction. No leading edge nicks greater than 1/32-inch deep were in one blade, and no leading edge nicks were in the second blade. The tips of both blades were intact.

Engine and Accessory Examination.

No current engine logbooks were located. The engines and accessories were fire damaged. They were initially examined on scene. Thereafter, a partial teardown examination was performed during which all cylinders, pistons, and accessories were removed and inspected.

The engines' internal mechanical continuity was established during rotation of the crankshafts and upon attainment of thumb compression in all cylinders. Thereafter, the engines were partially disassembled. The continuity of the valves and gear train was confirmed. The valves and guides were examined and no evidence of material transfer was visually apparent. There were carbon deposits on top of all pistons. No evidence of detonation was noted on the piston domes or cylinder heads. The spark plugs exhibited coloration consistent with their manufacturer's guide for normal operation and wear, according to the Lycoming engine participant. Spark was noted from all terminals upon manual rotation of both magnetos' drive shafts. Evidence of oil and lubrication was found in the engines. No foreign objects were in the oil pans and screens. The induction and exhaustion systems were examined, and no evidence of blockage was found. The push rods were removed and were not bent. There was no evidence of exhaust leakage.

The fire-damaged turbine sections of the turbochargers rotated freely. The turbochargers' exhaust gas wastegate controls on the fuel valve selector console were in the off position.

Carburetor Examination.

The fire-damaged carburetors' fuel inlet screens were mostly clear. Under the supervision of the FAA, the carburetors were examined at the facilities of Precision Airmotive Corporation. In pertinent part, the FAA reported that the carburetors were fire damaged and could not be functionally tested.

Climb Performance Data.

According to airplane documents, on October 15, 1992, the airplane's empty weight was 2,468 pounds, and its maximum certificated gross weight was 3,800 pounds. The estimated weight during the accident flight was 3,090 pounds.

In the Piper PA-23 Owners' Handbook, at a weight of 3,090 pounds, and under the atmospheric conditions that existed on the accident date at Chico, the airplane's maximum single-engine rate of climb is nearly 250 feet per minute. However, this climb rate is achievable with the operative engine producing full rated power, with the inoperative engine's propeller blades feathered, and with the landing gear retracted. According to the Piper Owner's Handbook, in this configuration the airplane should have been able to sustain flight in the specified "clean" configuration.

WRECKAGE RELEASE

The airplane wreckage was released to the wreckage recovery agent on September 14, 2001.

NTSB Probable Cause

The loss of right engine power for undetermined reasons, and the pilot's failure to maintain control of the aircraft due to his improper single engine emergency procedures.