History of Flight
On March 25, 2017, about 1530 central daylight time, a Piper PA-28-140, registration N4329T, impacted a fence and pond during a landing overrun on runway 18 at Burg Lake Aero Airport (30TX), Stonewall, Texas. The commercial pilot received fatal injuries, and the airplane sustained substantial damage. The airplane was owned by the pilot and his brother and operated by the pilot under 14 CFR Part 91 as a personal flight. Day visual meteorological conditions prevailed, and no flight plan was filed. The flight originated from 30TX about 1525 and was destined for New Braunfels Regional Airport (BAZ), New Braunfels, Texas, but returned to 30TX.
The accident flight was the airplane's first flight after its annual inspection and replacement of one of the fuel pumps. The pilot's brother-in-law stated that the pilot performed a full-power run-up, which was "okay." The engine cowl was then reinstalled, and the pilot fueled the airplane from the airport fuel tank to a level at the fuel tank "tabs." The pilot then performed another engine run-up at full power near the approach end of runway 18. During takeoff, the airplane was not more than 10 ft above the runway when it was about halfway down the runway. The brother-in-law thought the airplane was going to hit trees near the departure end. The airplane was gone for about 5–10 minutes before returning. The brother-in-law reported that the airplane touched down about halfway down the runway, and it was "going way too fast." He thought the pilot never increased engine power after touchdown and that the engine was at idle during the landing but was "not sure" because he was in his hangar and the airplane produces little engine noise at idle.
A witness driving westbound toward Stonewall saw an airplane descend toward the 30TX runway. He said the airplane was "way too high" and its approach was "pretty steep." He thought to himself that the airplane was "not going to make it." He stated that he was in his truck with windows closed and could not hear the airplane engine.
The airplane overran the departure end of the runway during the landing, went through a barbed wire fence, and entered a pond.
Personnel Information
According to the pilot's logbook, his last flight entry was a flight review in a Piper PA-28R-200 on December 21, 2016, lasting 1.1 hours. The entry did not have a flight review endorsement by the flight instructor who provided the review. The FAA had no record of previous accidents, incidents, or enforcement actions for the pilot. The pilot's brother-in-law stated that the pilot had previously landed at the airport "several times" because the airplane received two or three annual inspections at 30TX.
The mechanic held an airframe and powerplant mechanic certificate with inspection authorization, renewed on March 17, 2017, by an FAA inspector from the San Antonio Flight Standards District Office (SAT FSDO). The FAA had no record of previous enforcement actions against the mechanic.
Aircraft Information
The 1971-model Piper PA-28-140 (Cherokee) was purchased by the pilot and his brother on November 3, 2010, and the registration was accepted on February 9, 2011. It was powered by a Lycoming O-320-E3D engine (serial number L-46554-27A) that underwent its last overhaul by the engine manufacturer on June 29, 1988, at a total engine time of 1,945.45 hours. The engine underwent its last overhaul, performed by an airframe and powerplant mechanic, on May 29, 1998, at an engine total time of 2,991.8 hours and a tachometer time of 4,236.2 hours. The Hobbs meter and tachometer indications at the accident site were 889.5 hours and 5,063.7 hours, respectively.
According to an airframe and powerplant mechanic, the pilot called him in late February 2017 to schedule an annual inspection. The pilot did not report any issues and said the airplane had been flying "beautifully." On March 4, 2017, the mechanic arrived; the airplane was at 30TX and already "opened up." The pilot reported occasional fuel pressure problems. After inspection, the airplane was towed outside, started easily, and the engine ran for about 10 minutes. The mechanic stated the engine was running "satisfactorily" and signed off the logbooks.
An FAA inspector from the SAT FSDO stated that the mechanic, who signed off the annual inspection, said he watched but did not work on the airplane. The mechanic and pilot used an inspection checklist that was not the one in the Piper Cherokee Service Manual. It is unknown whether the Piper Cherokee Service Manual was used during the inspection. Since 2011, all annual inspections were signed by that mechanic.
Lycoming Service Instruction No. 1009AZ stated that engine deterioration and corrosion can occur if an engine is out of service for an extended period, and engines that do not accumulate the TBO hourly period are recommended to be overhauled in the twelfth year. A review of the logbooks revealed that the magnetos, exhaust, fuel and oil lines, and carburetor had not been replaced or overhauled since the 1998 engine overhaul. The Piper Cherokee Service Manual states that a 100-hour inspection is a complete inspection identical to an annual inspection, and that engine flexible hoses should be replaced as required but not to exceed 1,000 hours time-in-service, 8 years, or engine overhaul, whichever comes first, with no fluid hose exceeding 20 years.
The Airplane Flight Manual provided landing distance versus density altitude information for flaps 40°, power off, paved level runway, no wind, maximum braking, short field effort, and gross weight of 2,150 lbs. Based on a density altitude of 1,535 ft, the landing distance at gross weight was about 550 ft, and the landing distance over a 50-ft obstacle was about 1,100 ft.
Meteorological Information
Based on the 1535 recorded weather, the density altitude was about 1,314 ft.
Airport Information
Burg Lake Aero Airport (30TX) has runway 18. The airplane overran the departure end during landing.
Wreckage and Impact Information
The airplane was completely submerged and inverted in an 18- to 20-ft-deep pond about 80 to 100 ft from the departure end of runway 18. While inverted, the nose pointed toward the runway. The bottom of the fuselage had a longitudinal tear along its left side from the firewall to the left wing trailing edge, consistent in width with a round barbed wire metal fence post between the runway and the pond, which was bent about 30° toward the pond. The upper 8 inches of the post exhibited paint transfer from the airplane.
The cockpit/cabin door had been opened by a diver using the top and side latches. Postaccident examination showed the door could be opened using those latches without binding. Ground scars consistent with skidding from the main landing gear wheels were present along the last 300 ft of runway 18. A ground scar was in front of the post, consistent with the airplane tail tie-down being broken off. The barbed wire fence was not attached to the airplane or wrapped around the propeller. Wing flaps were in the 40° extended position.
One blade of the two-bladed metal propeller exhibited spanwise scratches angled about 20° to 45° relative to the blade chord, consistent with rotation. The second blade was straight. Neither blade had S-shaped bending consistent with torque.
Cockpit examination: magneto key switch in "both" position, master switch in "on," auxiliary fuel pump switch in "on," engine primer in and locked. Throttle control near idle, mixture control about ¾ forward of idle cutoff. Flap selector in 40° position. The left pilot seat shoulder harness was stowed to its ceiling retainer.
Flight control continuity was confirmed from all control surfaces to cockpit controls. The tailcone cover did not exhibit impact damage. All eight tailcone cover retaining screw holes along the longitudinal axis had vertical cracks from the hole edges through the cover. The four screws perpendicular to the axis were dark brown, consistent with long-term corrosion and non-recent removal; screw heads were stripped. The tailcone was removed to expose underlying components: rudder cable ends, stabilator trim screw, stabilator screw/tab links, stabilator hinge points, and rudder trim assembly, which exhibited a dry appearance consistent with lack of lubrication. The Piper Cherokee Service Manual requires lubrication every 100 hours.
The electrically driven fuel pump operated with no mechanical anomalies when tested on the airplane by turning the master and auxiliary fuel pump switches on, and by removal and connection to an automotive battery. Testing before removal revealed the cockpit fuel pressure gauge was inoperative.
The three-position cockpit fuel selector control handle was positioned to the left fuel tank. It did not turn freely using hand pressure through repetitive selections; a vice and wrench were required to remove the plastic fuel selector plug valve, with difficulty. The valve stem exhibited a dull white color consistent with oxidation. No obstruction to the attached ports or when the valve was selected to all three positions was found.
Engine examination: fuel and oil lines were intact. The engine sump contained liquid consistent with engine oil and water. Top and bottom plugs were removed, and the engine rotated by hand; air was drawn into and expelled through spark plug holes. Continuity to accessory section, valve train, and drive train was confirmed. Spark plugs had intact electrodes displaying normal operation features per Champion Aerospace Service Manual.
The engine-driven fuel pump was removed and actuated by hand; it produced suction and expulsion of air through inlet and outlet ports. Disassembly revealed no debris in the pump diaphragm.
The air inlet hose leading to the carburetor was SCAT hose, an incorrect part for the application; it did not exhibit impact damage and was collapsed.
The right exhaust pipe bolt leading to the heat exchanger/muffler could not be unscrewed, and the pipe was cut for examination. The heat exchanger housing had two repairs: a weld and a riveted square metal patch. The heat exchanger exhaust was blocked about 50 percent with fractured internal pieces, with fracture surfaces brown in color, consistent with a long-term preexisting fracture. The Piper Cherokee Service Manual states the heat exchanger/muffler is to be replaced at or near 1,000 hours time-in-service.
Engine timing was 27° top dead center (TDC); the engine data plate specified 25° TDC. The left magneto (Slick 4371, serial number 01120168, manufactured 2001) did not spark. The right magneto (Slick 4250, serial number 7090045, manufactured 1970) did not turn freely and exhibited corrosion of its bearing. Magneto examination at Navajo Accessories, Inc. under FAA supervision revealed the left magneto had corrosion on the impulse coupling and was nonfunctional; the rotor was worn with flat spots; points were seized and nonfunctional. The right magneto rotor and bearings exhibited corrosion; the capacitor wire was pinched and broken; points were seized; and the coil was obsolete. Both magnetos were issued red tags as not serviceable.
The flexible fuel line leading to the carburetor was hardened and difficult to bend by hand. Its fire sleeve was removed, exposing a date code showing manufacture in 1971. The airplane service manual calls for replacement or overhaul as required or at engine overhaul; the Piper Cherokee Service Manual states inspection at 100-hour intervals and replacement as necessary.
Carburetor examination at RLB Accessories under NTSB supervision revealed the throttle arm shaft was loose due to wear. Fuel screens had no debris. The metallic brass float exhibited travel of about half the required 7/32-inch. The RLB representative stated the brass float should have been replaced per a service bulletin issued about 1990. The carburetor needle valve had an incorrect cotter pin. The gap between the throttle body valve and the carburetor throat when closed was 4/1000 inch, but should have been about 20/1000 inch. The carburetor drain plug had safety wire in place. The representative stated the engine should have been washed as part of the annual inspection but was not, based on external condition, and the carburetor condition would have caused a rich fuel mixture.
The airplane's emergency locator transmitter (ELT) was not present; its retaining hardware was undamaged and in an open/unretained position.
Medical and Pathological Information
An autopsy performed by Central Texas Autopsy, PLLC, Lockhart, Texas, reported the cause of death as "fresh water drowning." Toxicological testing by the FAA Bioaeronautical Sciences Research Laboratory detected no carbon monoxide in blood (femoral), no ethanol in vitreous, and amlodipine (a blood pressure medication not generally considered impairing) in liver and blood (femoral). Cyanide testing was not performed.