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NTSB Report

August 19, 1994 · Piper PA-32R-300 · N4316X

Roanoke, VA

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
August 19, 1994
Injury Outcomes
3 injuries (2 fatalities, 1 serious injury)
Location
Roanoke, VA
Aircraft
Piper PA-32R-300
Tail Number
N4316X
Operator
Kulwicki Joseph F
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
BFO94FA140

DURING TAKEOFF CLIMB, THE AIRPLANE'S ENGINE LOST POWER. DURING A TURN TO THE EMERGENCY LANDING AREA, THE AIRPLANE STRUCK TREES AND FELL TO THE GROUND. POSTACCIDENT EXAMINATION OF THE AIRFRAME AND FUEL SYSTEM DID NOT REVEAL ANY ANOMALIES. EXAMINATION OF THE ENGINE REVEALED THE THROTTLE CABLE WAS FULL FORWARD (MAXIMUM FUEL FLOW) BUT DISCONNECTED FROM THE THROTTLE ARM ON THE FUEL INJECTOR SERVO. THE THROTTLE ARM WAS IN THE IDLE POSITION. THE HARDWARE CONNECTING THE THROTTLE CABLE ROD END TO THE THROTTLE ARM WAS NOT LOCATED. EXAMINATION OF THE THROTTLE CABLE ROD END AND THROTTLE ARM REVEALED WEAR AROUND THE CIRCUMFERENCE OF THEIR ATTACHMENT HOLES. THE WEAR AROUND THE CIRCUMFERENCE OF THE ATTACHMENT HOLE ON THE THROTTLE ARM WAS CONSISTENT WITH INSTALLATION OF THE ROD END AT A SKEWED ANGLE. THE AIRPLANE RECEIVED AN ANNUAL INSPECTION ABOUT 99 HOURS PRIOR TO THE ACCIDENT.

NTSB Probable Cause

THE DISCONNECTION OF THE THROTTLE CABLE FROM THE THROTTLE ARM ON THE FUEL INJECTOR SERVO.

Full Narrative

HISTORY OF FLIGHT On August 19, 1994, at 1515 eastern daylight time, a Piper PA-32R-300, N4316X, lost engine power shortly after takeoff from the Roanoke Regional Airport, Roanoke, Virginia. The pilot was maneuvering the airplane to make an emergency landing on a golf course when the airplane struck trees on the golf course. The pilot was seriously injured and the two passengers were fatally injured. The airplane was destroyed. The visual flight rules flight had originated from Nassau, Bahamas, landed at the Fort Pierce Airport, Fort Pierce, Florida, and then continued to Roanoke where the airplane was refueled. The flight was destined for Meadville, Pennsylvania, and was operated under 14 CFR Part 91. According to the pilot, shortly after takeoff the airplane's engine started to lose power. He stated that the engine's revolutions per minute slowly declined until the engine was not producing enough power to maintain flight. The pilot stated that when he figured the airplane could not make the airport, he decided to make an emergency landing on a golf course. He stated as he was maneuvering to land on the golf course, he saw trees but thought the airplane had enough altitude and airspeed to fly over them. He stated when he input elevator to get over the trees, the airplane did not respond and started to descend. He stated at that time he turned the airplane to the left in attempt to miss the trees. The airplane struck the trees and continued to the ground. PERSONNEL INFORMATION The pilot held a private pilot certificate with a single engine land rating. According to the pilot's records, at the time of the accident, he had accumulated about 2,259 total flight hours, of which, 867 hours were in the same make and model as the accident airplane. AIRCRAFT INFORMATION According to the airplane's Aircraft and Engine Log books, the airplane and engine received an Annual Inspection on December 12, 1993, at a tachometer time of 3,591.87 hours, 99 hours prior to the accident. The engine's time since major overhaul was 814.8 hours at the annual inspection. Since the annual inspection, the only maintenance logged was an engine oil and filter change on March 15, 1994, at a tachometer time of 3,634 hours. The entry also stated, "...Lyc Engine additive & operational check completed...." At the time of the Annual Inspection, the log books indicated that all Airworthiness Directives (ADs) applicable to the airplane were accomplished. Two AD's applicable to the throttle cable control rod end were visually checked. AD 77-23-03, published in 1977, was accomplished on the accident airplane. AD 80-14-02, published in 1980, could not be verified. AD 80-14-02 requires that the throttle linkage connecting hardware be replaced. This hardware was not recovered at the accident site. (See attached ADs for further information.) The mechanic who accomplished the Annual Inspection and subsequent oil and filter change wrote on the Safety Board's Statement of Witness Form, "[The airplane] Had appropriate AN Hardware installed when last inspected." WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the accident site on August 19 and 20, 1994. Examination of the wreckage revealed the airplane came to rest on a golf course about 1/2 mile west of the approach end of runway 6 at the Roanoke Airport. Examination of the accident site revealed a large broken tree with an airplane seat track lodged in it. The airplane came to rest about 100 feet beyond the broken tree on a magnetic heading of about 300 degrees. The left and right wing were separated from the airplane and came to rest next to the fuselage. Both of the fuel tanks contained fuel and no contaminants were found. Examination of the engine revealed the throttle cable was full forward (maximum fuel flow) but disconnected from the throttle arm on the fuel injector servo. The throttle arm was in the idle position. The hardware connecting the throttle cable rod end to the throttle arm was not located. The engine was removed from the airplane and transported to Lycoming located in Williamsport, Pennsylvania, for further examination and test run. The throttle cable was reconnected to the throttle arm and the engine was tested. The engine started and performed with no anomalies noted. ADDITIONAL INFORMATION The Throttle Control Cable Rod End and the Throttle Arm were removed from the airplane and sent to the Safety Board's Materials Laboratory in Washington, D.C. Examination of the Throttle Control Cable Rod end and Throttle Arm revealed "wear" around the circumference of their attachment holes. (See attached Metallurgist's Factual Report for details.) The Metallurgist's Factual Report states, "Wear around the circumference of the attachment hole on the arm was consistent with installation of the rod end at a skewed angle...." The airplane wreckage was released to Robert P. Porter, Assistant Vise President, AIG Aviation, on August 20, 1994. The engine was retained and released to Mr. Porter on October 6, 1994.

Flight

Event TypeAccident
Event Time15:15 EDT
Nearest Airport0nm
Runway0
Flight Plan FiledNone
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-32R-300
Tail NumberN4316X
Aircraft CategoryAir
DamageDestroyed
OperatorKulwicki Joseph F
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · IO-540-K1A5D · Reciprocating · 300
Seats6

People & Injuries

Injury Summary3 injuries (2 fatalities, 1 serious injury)
Fatal2
Serious1
Minor0
Uninjured0
Total3
Crew 1Age 55 · Third Class

Conditions

ConditionsVMC
LightDaylight
Wind150° @ 7 kt
Visibility15 sm
CeilingBroken clouds 25000 ft
Temperature / Dew Point64 F
Altimeter30.00 inHg
Observation Time19:27
Weather SourceWFAC

Appendix: Source Data