N200RAPiper PA-31P · 1974

On July 20, 2023, about 0934 central daylight time, a Piper PA-31P airplane, N200RA, was destroyed when it was involved in an accident near Kearney, Missouri. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 maintenance ferry flight.

The flight departed runway 36 at the Midwest National Air Center Airport (GPH), Mosby, Missouri, on a one-time maintenance ferry flight to Clyde Cessna Field (9K8), Kingman, Kansas. Before the accident flight, the owner requested an airport lineman to fuel the airplane. During the fueling of 18.53 gallons of avgas, an unknown amount of fuel leaked from the right-wing inboard fuel tank (see figure 1). According to the mechanic, the airplane had 140 gallons onboard divided between both 50-gallon inboard wing fuel tanks and 40 gallons in the right-wing auxiliary fuel tank. The lineman was unable to fuel the left-wing auxiliary fuel tank due to a known leak of the nipple at the bottom of the tank.

Figure 1. Video screen capture of the fuel leak provided by the lineman.

Witnesses reported that the pilot did not perform an engine run-up before takeoff, and during the takeoff roll the pilot had to bring the airplane back to the centerline with a power reduction as it yawed to the right. Cellphone video recordings of the takeoff sequence showed the airplane veer to the right and attempt to rotate before the airplane settled back to the runway. The recordings showed the airplane become airborne near the end of the runway and initially yaw to the right before it entered a shallow climb. It barely cleared a line of trees past the departure end of the runway and made a left turn before it disappeared behind the trees.

A witness about 1.6 nautical miles to the north of the airport stated he heard a loud airplane that appeared from behind trees headed toward his residence. He observed the airplane strike two static wires on a power transmission line before it impacted the canopy of a large tree in his front yard (see figure 2). The airplane continued in a left bank toward a nearby soybean field and impacted the terrain in a nose-low, left-bank attitude. The airplane slid several hundred feet and a postcrash fire ensued.

Figure 2. Transmission line and tree impact

All flight history and hours were obtained through the pilot’s FAA medical certificate applications due to his pilot logbook not being located. The pilot’s recent and make/model experience was not available.

Multiple witnesses reported that the airplane was chained to a tree in an agricultural field adjacent to GPH from August 2021 until December 2022 due to its previous owner being evicted from the airport. Before the eviction, the airplane’s last recorded annual inspection was on August 15, 2015, with a tachometer (tach) time of 1182.2 hours. A propeller inspection record on May 19, 2019, still reported a tach time of 1182 hours.

According to the same witnesses, the owner and a mechanic with airframe and powerplant ratings worked on the airplane for about six months; the most recent annual inspection was completed in 2015. Two witnesses reported that during an engine ground run about two weeks before the accident, the right engine was difficult to start and would not produce full power. The witnesses also stated that the inboard fuel tanks leaked “horribly” when the airplane was fueled.

About two weeks before the accident, the owner received a Special Airworthiness Certificate: Special Flight Permit to ferry the airplane from Mosby, Missouri, to Kingman, Kansas, to complete an annual inspection. Witnesses and the mechanic reported that two or three pilots declined to perform the ferry flight for the owner before the accident pilot agreed to take the flight.

An interview of the mechanic was performed via telephone on July 26, 2023. During the interview, the mechanic stated that the only work performed before the accident flight was replacing the nose and one main landing gear tire, servicing the brakes, a landing gear swing, replacement of burnt wiring in the right engine, and several maintenance engine runs. The Special Flight Permit was requested so the airplane could be ferried back to the mechanic’s hangar in Kingman, Kansas, for maintenance. The mechanic stated that he knew about the fuel leaks coming from the various tanks and further stated that it was an item to be fixed once the ferry flight was complete. Additionally, he and the owner spent several days vacuuming out various bird nests and debris from the airplane. During engine start, the mechanic stated that the pilot contacted him several times to ask about various issues, such as the location of the radio master switch, how to transfer fuel between fuel tanks, and the left vacuum pressure gauge being inoperative.

The Special Airworthiness Certificate: Special Flight Permit for a one-time maintenance ferry flight between GPH to Clyde Cessna Field (9K8) was issued by a Kansas City Federal Aviation Administration (FAA) Flight Standards District Office inspector on June 29, 2023, and then reissued on July 11, 2023, with an expiration date of July 23, 2023. The airplane was inspected, and a logbook entry was recorded with a tach time of 1192.2 hours by the mechanic on June 28, 2023, for the one-time ferry flight. Part of the logbook entry stated that the mechanic removed the emergency locator beacon (ELT) for repair during his inspection. However, postaccident examination showed that the ELT was in the airframe cradle with an undisturbed animal nest in the antenna wiring. The animal nest had to be removed by investigators to disconnect the antenna from the ELT (See Figure 3.)

Figure 3. ELT as found during the postaccident examination.

Additionally, the mechanic stated that he reviewed the applicable airworthiness directives (AD) and part of the ferry flight logbook entry stated that he “checked the Ads.” Paperwork provided as part of the application for the permit showed that the ADs were signed off by an apprentice and not the mechanic as stated in the logbook entry.

The FAA Inspector who issued the Special Airworthiness Certificate, when asked what actions he performed while issuing the permit, stated that he assisted the owner’s wife in completing the application electronically in the FAA Airworthiness Certification (AWC) tool web portal and reviewed the application via the same portal. He also stated that he did not physically inspect the airplane or logbooks due to no “indication that there was something wrong with the airplane [or] that it wasn’t safe for the flight.” When asked if he had reviewed the AD Compliance Report provided with the application, he stated that he was not sure he saw a specific AD report. He stated that, “the log entry said that the ADs had been checked. I didn’t see an actual itemized report except from the previous inspection.”

Multiple witnesses reported that the airplane was chained to a tree in an agricultural field adjacent to GPH from August 2021 until December 2022 due to its previous owner being evicted from the airport. Before the eviction, the airplane’s last recorded annual inspection was on August 15, 2015, with a tachometer (tach) time of 1182.2 hours. A propeller inspection record on May 19, 2019, still reported a tach time of 1182 hours.

According to the same witnesses, the owner and a mechanic with airframe and powerplant ratings worked on the airplane for about six months; the most recent annual inspection was completed in 2015. Two witnesses reported that during an engine ground run about two weeks before the accident, the right engine was difficult to start and would not produce full power. The witnesses also stated that the inboard fuel tanks leaked “horribly” when the airplane was fueled.

About two weeks before the accident, the owner received a Special Airworthiness Certificate: Special Flight Permit to ferry the airplane from Mosby, Missouri, to Kingman, Kansas, to complete an annual inspection. Witnesses and the mechanic reported that two or three pilots declined to perform the ferry flight for the owner before the accident pilot agreed to take the flight.

An interview of the mechanic was performed via telephone on July 26, 2023. During the interview, the mechanic stated that the only work performed before the accident flight was replacing the nose and one main landing gear tire, servicing the brakes, a landing gear swing, replacement of burnt wiring in the right engine, and several maintenance engine runs. The Special Flight Permit was requested so the airplane could be ferried back to the mechanic’s hangar in Kingman, Kansas, for maintenance. The mechanic stated that he knew about the fuel leaks coming from the various tanks and further stated that it was an item to be fixed once the ferry flight was complete. Additionally, he and the owner spent several days vacuuming out various bird nests and debris from the airplane. During engine start, the mechanic stated that the pilot contacted him several times to ask about various issues, such as the location of the radio master switch, how to transfer fuel between fuel tanks, and the left vacuum pressure gauge being inoperative.

The Special Airworthiness Certificate: Special Flight Permit for a one-time maintenance ferry flight between GPH to Clyde Cessna Field (9K8) was issued by a Kansas City Federal Aviation Administration (FAA) Flight Standards District Office inspector on June 29, 2023, and then reissued on July 11, 2023, with an expiration date of July 23, 2023. The airplane was inspected, and a logbook entry was recorded with a tach time of 1192.2 hours by the mechanic on June 28, 2023, for the one-time ferry flight. Part of the logbook entry stated that the mechanic removed the emergency locator beacon (ELT) for repair during his inspection. However, postaccident examination showed that the ELT was in the airframe cradle with an undisturbed animal nest in the antenna wiring. The animal nest had to be removed by investigators to disconnect the antenna from the ELT (See Figure 3.)

Figure 3. ELT as found during the postaccident examination.

Additionally, the mechanic stated that he reviewed the applicable airworthiness directives (AD) and part of the ferry flight logbook entry stated that he “checked the Ads.” Paperwork provided as part of the application for the permit showed that the ADs were signed off by an apprentice and not the mechanic as stated in the logbook entry.

The FAA Inspector who issued the Special Airworthiness Certificate, when asked what actions he performed while issuing the permit, stated that he assisted the owner’s wife in completing the application electronically in the FAA Airworthiness Certification (AWC) tool web portal and reviewed the application via the same portal. He also stated that he did not physically inspect the airplane or logbooks due to no “indication that there was something wrong with the airplane [or] that it wasn’t safe for the flight.” When asked if he had reviewed the AD Compliance Report provided with the application, he stated that he was not sure he saw a specific AD report. He stated that, “the log entry said that the ADs had been checked. I didn’t see an actual itemized report except from the previous inspection.”

Postaccident examination of the accident site revealed that the airplane impacted terrain in a relatively flat agricultural field about 1.6 nautical miles north of the runway. The first impact point consisted of struck electrical wires that were located about 735 ft before the main wreckage and were about 65 ft above ground level (agl). The second identified point of contact was a tree canopy impact about 60 ft agl and 150 ft after the wire strike. The airplane then impacted the ground, and a debris path extended into the field about 313 ft on a heading of 254°, to where the main wreckage came to rest.

The main wreckage consisted of the fuselage, empennage, left wing, and the inboard portion of the right wing. The outboard 4 ft of the right wing was found separated about 210 ft from the first ground impact point. The left propeller and gear reduction drive were found separated and located on the right side of the debris path about 30 ft from the airplane (See figure 4)

Figure 4. Accident Site

Examination of the airplane revealed the main landing gear assemblies were retracted in the wing and nose wheel wells. The cockpit flight and engine instruments were destroyed with thermal damage. The cockpit throttle quadrant control levers were found all full forward with thermal damage. Thermal damage occurred along the length of the fuselage to the aft pressure bulkhead. The empennage was intact with no thermal damage from the aft pressure bulkhead rearward. The left horizontal stabilizer and elevator had upward deformation of the structure with crush damage. The elevator outboard of the outboard hinge was separated and was located in the debris path. The vertical stabilizer was intact with no accident damage noted. The rudder above the upper hinge was displaced to the left about 45° degrees with no impact damage noted. The empennage contained numerous pre-accident vegetation debris, bird and insect nests, tree sap, and bird droppings were located on and in the empennage (See Figure 5).

Figure 5. Preaccident vegetation and animal debris inside the empennage.

Elevator, rudder, and trim flight control continuity was established to their respective cockpit controls. Both fuel selector levers in the cockpit were found in the Main (inboard) positions. The rudder trim tab jackscrew was found in the neutral position with a preaccident insect nest surrounding the entire jackscrew protruding forward of the drum. The elevator trim was found in the full nose-up position. The right wing was found separated from the fuselage at the wing root with thermal damage outboard to the right engine nacelle. The left wing was found attached to the fuselage with thermal damage to the auxiliary fuel tank filler cap outboard of the left engine nacelle. Aileron flight control continuity for both wings was established to the fuselage. Fuselage to cockpit control continuity could not be established due to impact and thermal damage.

Both engines and propellers were examined and partially dissembled at a follow-up examination. Both engines had postimpact crush and thermal damage to the entire engine with the crankshaft unable to be rotated by hand to verify internal continuity due to damage.

Examination of the left engine revealed no preaccident mechanical malfunctions or failures with the engine that would have precluded normal operation. The turbocharger, waste gate, and waste gate controller were removed, and a teardown inspection was performed. The waste gate was in the fully closed position and moved freely through the entire range when actuated by hand. The turbocharger had continuity between the compressor and exhaust section, with rotational witness marks observed in the compressor section and burring and bending of the blades. Additionally, the turbocharger had numerous areas of rust present both externally and internally with no oil present in any bearing oil galleries.

Examination of the right engine revealed two blocked fuel injectors, corrosion along with rust, and other debris in the induction housing section and all fuel injectors (see figure 6). Additionally, an oil filter installed in 2012 was not changed during the recent maintenance.

Figure 6. Right Engine No. 4 Fuel Injector with Magnesium Oxide corrosion.

The fuel injectors and a sample of the white deposit was sent to the NTSB Materials Laboratory for identification. The white deposits on the surface were analyzed using energy-dispersive x-ray spectroscopy (EDS). The EDS spectrum showed high peaks of magnesium and oxygen consistent with magnesium oxide. The fuel manifold housing is primarily a magnesium alloy; magnesium oxide is consistent with galvanic corrosion between the brass fuel injectors and the induction housing.

The right engine turbocharger, waste gate, and waste gate controller were removed, and a teardown inspection was performed. The waste gate was in the fully open position and moved freely through the entire range when actuated by hand. The turbocharger had continuity between the compressor and exhaust section with no rotational signatures on the turbocharger compressor blades or housing. The turbocharger had numerous areas of rust present both externally and internally with no oil present in any bearing oil galleries. All oil galleries were clear of debris when visually examined with a handheld flashlight.

Examination of both propeller assemblies revealed no indications of any type of propeller failure or malfunction before impact. However, there was extensive rust present on the blade bearings and pitch change components of both propellers. The right propeller low pitch stop had an impact mark consistent with the propeller rotating in the low pitch range and not feathered. Wire strike damage on the leading edge of the right blades was also consistent with rotation at a low pitch range.

An airplane performance study was conducted using video from several witness cellphones. Based on the visual and sound information in two submitted videos, the airplane’s speed during its ground roll, the ground speed at the time of rotation, the location of rotation, and the speed of the two airplane engines and propellers were estimated. Analysis was based on the visual and sound information in the two videos. Analysis showed that the left propeller was operating at the rated speed, and the right propeller was operating at about 100 rpm below the rated speed. Airplane rotation was at a ground speed of about 70.8 knots, corresponding to an estimated air speed of about 74.8 knots, which was below the recommended rotation speed of 85 knots.

Forensic Medical of Kansas performed the pilot’s autopsy for Clay County, Missouri. According to the pilot’s autopsy report, his cause of death was inhalation of the products of combustion and thermal injuries, and his manner of death was accident. His autopsy identified evidence of hypertensive cardiovascular disease, with an enlarged heart and dilated cardiac ventricles. His cardiac pacemaker was identified and recovered.

The pilot’s pacemaker interrogation summary report provided no clear evidence of a potentially impairing arrhythmia leading up to the time of the crash. Episodes of elevated atrial rate lasting seconds to minutes, without rapid ventricular rate, were recorded hours before the crash.

The FAA Forensic Sciences Laboratory also performed toxicological testing of postmortem specimens from the pilot. Carboxyhemoglobin was measured at 20% in femoral blood. Warfarin, carvedilol, and valsartan were detected in femoral blood and liver tissue.

Carboxyhemoglobin is formed when carbon monoxide binds to hemoglobin in blood, diminishing the blood’s ability to deliver oxygen to body tissues. Carbon monoxide is an odorless, tasteless, colorless, nonirritating gas that can be produced during hydrocarbon combustion. Exposure to carbon monoxide usually occurs by inhalation of smoke or exhaust fumes. Nonsmokers normally have carboxyhemoglobin levels of less than 1-3%, while heavy smokers may have levels as high as 10-15%.

Warfarin is a prescription blood thinning medication with a variety of uses, including to help prevent stroke in people who have atrial fibrillation/flutter. Warfarin is not typically impairing, although the medication and the conditions it treats may convey some medical risks. According to the FAA medical case review for this accident, warfarin is conditionally acceptable for pilots, requiring case-by-case Authorization for Special Issuance for medical certification.

Caffeine is a central nervous system stimulant that is commonly ingested, including in coffee, tea, soft drinks, and chocolate; caffeine also is an ingredient in certain anti-drowsiness medications and headache medications. Carvedilol and valsartan are prescription medications that can be used to treat high blood pressure and heart failure. Caffeine, valsartan, and valsartan are not generally considered impairing.

Based on the interviews with the mechanic and FAA personnel, a review of FAA policy and procedures was performed for issuing Special Flight Permits (SFP). Review of FAA Order 8900.1 Flight Standards Information Management System found no policy or procedures available to FAA personnel on how to issue a Part 91 Special Flight Permit. The only policy and procedure found was contained within Chapter 18 of the FAA Order 8130.2J Airworthiness Certification of Aircraft, last revised in 2017. However, this order had not been updated to include the use of the Airworthiness Certification Tool (AWC) released in 2019. No policy or procedures for issuing a Special Flight Permit using AWC could be located.

During the video conference interview with the issuing inspector, the inspector was asked if there was a Job Task Analysis (JTA) for issuing an SFP. FAA Order 3140.20 Flight Standard Service National Training Program defines a JTA as “the process of making a complete task inventory of a job which results in accurate and descriptive task statements and other job-specific information.” The inspector stated that the issuing of an SFP “was a local task, so there wasn’t a JTA code associated with it.” He further stated that he used the 8130.2J along with conversations with his management to issue the SFP.

A follow-up interview with the FAA Kansas City Flight Standards District Office Front Line Manager was conducted via video conference on September 30, 2023. The manager was also asked about any JTAs, policy, or procedures to issue a SFP. The manager stated that there is no JTA code and the only policy and procedures are in the 8130.2J.

Both the inspector and front-line manager stated that SFP specific training is completed locally, as there is no national standardization of that process. Additionally, the front-line manager stated that AWC-specific training was given via a PowerPoint presentation and that a user guide was always available for use. When asked on what constituted a completed SFP, the inspector stated that all green checkmarks displayed in the AWC application “means I can issue the special flight permit.” A review of the system and application process showed that the green checkmarks are only data entry validation and not data analysis validation.