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NTSB Report

June 25, 2023 · Piper PA-30 · N7240Y

Claxton, GA

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
June 25, 2023
Injury Outcomes
3 injuries (3 fatalities)
Location
Claxton, GA
Aircraft
Piper PA-30 (1964)
Tail Number
N7240Y
Operator
Midcoast Aviation Services
Injuries
Fatal
Aircraft Damage
Substantial
NTSB Number
ERA23FA274

The pilot, flight instructor, and a pilot-rated passenger had planned an instructional flight in the multiengine airplane to prepare the pilot for a proficiency check with an FAA inspector the following day. They were not able to fuel the airplane before departure and flew to a nearby airport to obtain fuel before the instructional flight; however, while refueling the airplane, the fueling equipment malfunctioned and they obtained less than 1 gallon of fuel. They subsequently departed, and the airplane impacted trees and terrain less than ½ mile from the end of the runway. ADS-B data showed that, during the accident flight, the airplane was in close proximity to the ground just beyond the departure end of the runway for about 8 seconds. The altitude data did not depict an appreciable climbing trend during that time. The distance between the final ADS-B position and the accident site was less than 700 feet, and the track line between these two points was about 30 degrees right of the departure runway’s heading. The results of toxicological testing revealed the pilot had used alprazolam and methadone. Both medications have the potential to impair cognitive and motor function. However, because measured levels of the drugs in cavity blood cannot be used reliably to predict effects, whether the pilot was experiencing impairing effects from alprazolam and methadone use could not be determined. The results of toxicological testing revealed the flight instructor had used warfarin. Reviewed records did not indicate the reason for the flight instructor’s warfarin use. Warfarin itself is not typically impairing; however, some underlying conditions for which it is used increase the risk of sudden impairing medical events such as stroke or unstable arrhythmia. There was no autopsy evidence that such an event occurred, but such an event may not leave reliable autopsy evidence. Examination of the wreckage revealed that, while some fuel was present in the right wing’s auxiliary fuel tank, no quantifiable fuel was found in the right main fuel tank. Some fuel was observed draining from the left-wing fuel tanks during recovery from the accident site. The left engine fuel selector was found set to the left main tank, while the right fuel selector was found positioned between the auxiliary and off positions. Additional examination of the fuel system revealed that the components associated with the right engine and its fuel supply were generally absent of fuel, while the left engine’s fuel system components contained trace amounts of fuel. The left engine’s propeller displayed signatures that were consistent with powered rotation at impact, while the right engine’s propeller displayed no evidence of powered rotation at impact. Neither engine displayed evidence of a preimpact mechanical malfunction or failure. The landing gear were found extended. While there was not sufficient evidence available to determine the airplane’s fuel state before the accident takeoff, given that the flight crew’s attempt to fuel the airplane was unsuccessful, it is likely that they departed with less fuel than anticipated, and that they may have been attempting to use fuel from the auxiliary fuel tank during the takeoff, contrary to the manufacturer’s guidance. It is also possible that the pilots were manipulating the fuel selector in response to a loss of engine power, which resulted in the fuel selector’s as-found position. Regardless, the lack of fuel found in the right engine fuel system components downstream of the fuel selector suggest that the right engine lost engine power due to fuel starvation. Additionally, because the airplane had been flying for fewer than 10 seconds before impact, and given that the landing gear remained extended and the right propeller remained unfeathered, the flight crew likely did not configure the airplane quickly enough for successful, sustained single-engine flight before it impacted trees and terrain.

NTSB Probable Cause

The flight crew’s improper fuel management, which resulted in the airplane’s right engine being starved of fuel and its subsequent total loss of power.

Full Narrative

On June 25, 2023, at 1232 eastern daylight time, a Piper PA-30, N7240Y, was substantially damaged when it was involved in an accident near Claxton, Georgia. The pilot, flight instructor, and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. The airplane was operated by a flight school. According to the flight school’s assistant chief flight instructor, the purpose of the flight was for the flight instructor to prepare the pilot (who was the chief pilot and owner of a flight school) for a 14 CFR Part 141 proficiency check with an FAA examiner that was scheduled for the following day. The pilot-rated passenger owned the airplane and was onboard to observe and familiarize himself with the airplane. The planned activities for the flight included standard multiengine maneuvers, to include a single-engine minimum control speed (Vmc) demonstration and an instrument approach with a simulated loss of engine power. The assistant chief flight instructor also stated that the fuel payment cards in their airplanes did not work with new fuel pumps that had recently been installed at Swinton Smith Field - Reidsville Municipal Airport (RVJ), Reidsville, Georgia, so the pilot planned to get fuel at Claxton - Evans County Airport (CWV), Claxton, Georgia. According to ADS-B data provided by the FAA, the airplane departed RVJ about 1140 and flew to CWV, where it landed at 1151. According to the airport manager at CWV, while the flight crew was refueling the airplane there, the motor for the airport’s fuel pump failed and only about 3/4 of a gallon of fuel was dispensed. ADS-B data showed that the airplane departed CWV about 1231 on the accident flight. Five ADS-B targets were recorded, with the first target observed at 1231:21 at a reported altitude of 100 ft agl. Over the next 3 seconds, the reported altitude was 100 ft agl, 125 ft agl, and 25 ft agl. The airplane’s final target was observed at 1231:29, at a reported altitude of 125 ft agl. The accident site was located in a wooded area about 2,100 ft from the departure end of runway 10 at CWV, and about 680 ft from the airplane’s final ADS-B-observed location (figure 1). The bearing between these two points was about 30° right of the runway heading. The elevation at the accident site was about 135 ft mean sea level. Figure 1 - Plot showing the first and last ADS-B targets, as well as the accident site, in relation to the departure runway. Examination of the accident site and wreckage revealed that the airplane impacted the ground in a nose-down, left-wing-low attitude. The left wingtip was located at the initial ground impact location, which was about 30 ft from the main wreckage. There was no evidence of fire or impact with the surrounding trees. The airplane came to rest upright with the fuselage aligned on a magnetic heading of approximately 013°. Significant compression damage was visible to the nose and cockpit floor, along with the top of the fuselage above the baggage door location. The left side of the aft fuselage was buckled. The empennage revealed little damage. Both engine nacelles sustained compression damage on their respective top surfaces and were bent upward. The leading edge of the left wing was compressed and torn. The left wingtip was separated at the point of initial ground impact. The left wing exhibited compression damage along the entire leading edge. The left aileron was separated at the outboard attach hinge and remained attached at the inboard hinge. The outboard end of the left wing was torn at a position even with the inboard end of the aileron. The right wing was bent upward outboard of the flap/aileron juncture and buckling was noted on the top surface of the wing. The right aileron was also bent upward. The right wingtip was lodged against a pine tree, deforming the tip. The wing flaps were in the retracted position. Flight control continuity was established from the ailerons, stabilator, and rudder to the base of the control column and rudder bar. The rudder trim actuator was found with 5 threads exposed, which corresponded to a nose-right setting, with 0 threads being full nose right and 7-8 threads being neutral. The stabilator trim actuator was found with an exposed dimension of 0.35 inches, which corresponded to a slight nose down setting. Examination of the instrument panel revealed that the tachometer displayed approximately 3,100 rpm for the left engine and 890 rpm for the right engine. The exhaust gas temperature gauge indicated about 200° for the left engine, and off-scale-low for the right engine. The fuel quantity indicator displayed below empty for the right-wing tanks and slightly below 1/4 full for the left-wing tanks. Both throttle levers were approximately in the full-throttle position, both propeller levers were full forward, and both mixture control levers were just lean of full rich. The landing gear handle was found in the neutral position and damage to all three landing gear was consistent with the landing gear being extended at the time of the accident. The left fuel selector was found selected to MAIN and was in the detent. The right fuel selector was found between the AUX and OFF position and was not in a detent. About 4.5 inches of fuel remained in the right auxiliary fuel tank as measured using a dipstick. No fuel was present in the right main tank. No fuel was visible in the left main or left aux tanks; however, when the wreckage was moved for access to the underside of the fuselage, a small amount of fuel was observed flowing out from the front of the wing. Both fuel selector valves were disassembled for examination. Fuel was present in the left fuel selector valve. Fuel was not present in the right fuel selector valve. The screens of both fuel selector valves appeared clean except for a small amount of debris on the right screen. The fuel present in the left fuel selector valve appeared clear and was consistent with aviation gasoline. Both main tank in-line finger screens were clear and free of any obstructions. Both auxiliary fuel tank in-line finger screens were clear and free of any obstructions. Examination of the left engine revealed several ounces of fuel in the engine-driven fuel pump. Fuel was also found in the fuel distribution manifold and in the fuel servo. The fuel servo screen was clean. Thumb compression was attained on all cylinders; the magnetos produced spark; oil was present in the engine; and drivetrain continuity was established. The examination of the left engine did not reveal any preimpact failures or mechanical anomalies. Examination of the right engine revealed that only a few drops of fuel were present in the engine-driven fuel pump. No fuel was found in the fuel distribution manifold. About 1 tablespoon of fuel was found in the fuel servo. The fuel servo was clean. Thumb compression was attained on all cylinders; the magnetos produced spark; oil was present in the engine; and drivetrain continuity was established. The examination of the right engine did not reveal any preimpact failures or mechanical anomalies. The left propeller blades displayed blade polishing and S-bending. The right propeller blades did not display any signatures consistent with rotation under power at impact. Both propeller blades displayed a relatively flat pitch that was not consistent with either being in a feathered position at impact. The accident airplane was equipped with four fuel tanks, with main and auxiliary tanks in each wing. The main fuel tanks had a total capacity of 30 gallons, of which 27 gallons were usable. The auxiliary fuel tanks had a capacity of 15 gallons, all of which were usable. The airplane’s Owner’s Handbook stated that the auxiliary tanks were only for use in level flight and that, “Fuel should be used from the main fuel [tanks] during take-off, landing, climb and descent.” It also stated that, “Takeoffs should not be made… with the main [tanks] less than one-quarter full.” With regard to a loss of engine power during climb out after takeoff, the manual stated: …maintain directional control with rudder and ailerons, and establish best single engine rate of climb airspeed (105 mph at sea level). Speeds below or above the best rate of climb speed will result in lower than optimum rate of climb. Check that mixture, propeller and throttle controls are full forward and landing gear and wing flaps are up. If enough altitude has been reached before the failure occurred, or if performance is satisfactory for reaching the airport with the landing gear extended, leave the landing gear in the down position. Make positive identification of inoperative engine by gently throttling back on the suspected engine. If no effective power is being delivered by that engine, feather the propeller and trim directionally with rudder trim. Climb straight ahead to traffic pattern altitude and return to airport for landing. The engines’ propellers could be feathered while rotating above a speed of 1,000 rpm. Below that speed, stop pins would prevent the blades from reaching the feathered position. The handbook warned that, “Single engine flight with the propeller of the inoperative engine unfeathered will decrease single engine performance.” The pilot and flight instructor each held a commercial pilot certificate with multiple ratings, including airplane multi-engine land, as well as a flight instructor certificate with ratings that included airplane multi-engine. On the pilot’s most recent application for an FAA-issued medical certificate, dated October 18, 2022, he reported that he had accumulated 33,000 total hours of flight experience. On the flight instructor’s most recent application for an FAA-issued medical certificate, dated December 2, 2022, he reported that he had accumulated 9,167 total hours of flight experience. The Division of Forensic Sciences, Georgia Bureau of Investigation, performed the pilot’s autopsy. According to the pilot’s autopsy report, his cause of death was multiple blunt impact injuries, and his manner of death was accident. FAA toxicology testing detected alprazolam at 24 ng/mL in cavity blood and at 143 ng/mL in urine. Alpha-hydroxyalprazolam was detected in urine at 561 ng/mL and was not detected in cavity blood. Methadone was detected in cavity blood at 1711 ng/mL and was detected in urine at 1520 ng/mL. Methadone metabolite (EDDP) was detected in cavity blood at 116 ng/mL and in urine at 3057 ng/mL. Alprazolam, sometimes marketed as Xanax, is a potent benzodiazepine drug available as a prescription medication and is commonly used to treat anxiety and panic disorder. Alpha-hydroxyalprazolam is an active metabolite of alprazolam. Alprazolam is a federal Schedule IV controlled substance with a potential for dependence and withdrawal. Alprazolam typically carries a warning that it may depress central nervous system (CNS) function, and that users should be cautioned against engaging in hazardous occupations requiring mental alertness such as operating machinery or driving a motor vehicle. In addition to medicinal use, alprazolam is commonly misused, often in combination with other substances. Methadone is a prescription long-acting opioid medication commonly used to treat opioid use disorders and severe chronic pain not relieved by other means. EDDP is an inactive metabolite of methadone. Methadone is a federal Schedule II controlled substance with a high potential for abuse as well as psychological and physical dependence. Methadone typically carries a warning that use may impair the mental and physical abilities to perform potentially hazardous activities such as driving or operating heavy machinery. The use of methadone with benzodiazepine medications increases the risk of CNS depression. The Division of Forensic Sciences, Georgia Bureau of Investigation, performed the flight instructor’s autopsy. According to the flight instructor’s autopsy report, his cause of death was multiple blunt impact injuries, and his manner of death was accident. The flight instructor had CACI high blood pressure but did not disclose any other medical conditions at his last aviation medical examination in December 2022. FAA toxicology testing detected warfarin in cavity blood and urine. Warfarin is a prescription blood thinning medication commonly used to treat deep venous thrombosis, pulmonary embolism, cardiac arrhythmias and as an anti-coagulant for prosthetic heart valves. Historically, warfarin has been used to reduce thrombotic and embolic risk. Warfarin is not typically impairing; however, underlying conditions treated with warfarin use potentially could be impairing. The FAA states that warfarin is conditionally acceptable for pilots through the Authorization for Special Issuance process if the dosage of warfarin has been stable for at least 6 weeks, and the underlying condition is acceptable.

Flight

Event TypeAccident
Event Time12:32 EDT
Nearest AirportClaxton-Evans County (1nm E)
Runway10
Runway Length5151 ft
Runway Width75 ft
Flight Plan FiledNone
Flight Plan ActivatedNo
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-30
Tail NumberN7240Y
Aircraft CategoryAir
DamageSubstantial
OperatorMidcoast Aviation Services
Operating RulePart 91
Engines2
Engine TypeReciprocating
Engine DetailsLycoming · IO-320-B1A · Reciprocating · 160 | Lycoming · IO-320-B1A · Reciprocating · 160
Seats4

People & Injuries

Injury Summary3 injuries (3 fatalities)
Fatal3
Serious0
Minor0
Uninjured0
Total3
Crew 1Age 70 · Second Class · Fatal
Crew 2Age 67 · Second Class · Fatal
Crew 3Age 67 · Basc · Fatal

Conditions

ConditionsVMC
LightDaylight
Wind310° @ 4 kt
Visibility7 sm
CeilingNone
Temperature / Dew Point64 F
Altimeter29.98 inHg
Observation Time12:35
Weather SourceWFAC

Appendix: Source Data