History of Flight
On June 3, 2017, at about 1417 Atlantic standard time, a Piper PA-23-250, registration N21WW, impacted water and a reef shortly after takeoff from Luis Munoz Marin International Airport (TJSJ) in San Juan, Puerto Rico. The commercial pilot sustained minor injuries, two passengers were seriously injured, and one passenger was fatally injured. The airplane was destroyed. The flight was operated by Air America, Inc., as a Title 14 Code of Federal Regulations Part 135 on-demand air taxi flight. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the planned flight to Benjamin Rivera Noriega Airport (TJCP), Isla de Culebra, Puerto Rico.
According to air traffic control (ATC) information from the Federal Aviation Administration (FAA), the flight was cleared for an intersection takeoff on runway 8 from taxiway S5. Runway 8 was 10,400 ft long, and the intersection takeoff allowed about half the runway length. At 1414:09, the pilot contacted ATC, ready for takeoff. The tower controller noted a wake turbulence delay of about 30 seconds due to an Embraer 190 that had departed about 2 minutes 30 seconds earlier. The pilot waived the delay, and the tower cleared the flight for takeoff at 1414:26. At 1416:33, the tower instructed the pilot to contact departure control, but the pilot said he was "unable" and returning to the airport. At 1416:46, the pilot stated, "we are trying hard we lost power on an engine we're trying to go back." No further communications were received.
Review of radar data showed the airplane near the departure end of the runway at 1415:52 at an altitude of 100 ft. The last radar target at 1416:16 was about 1,000 ft beyond the departure end, indicating 0 ft altitude (about 100 ft agl). Airport surveillance video showed the airplane lifted off by about 1415:40 and climbed to between 100 and 150 ft agl as it passed over the departure end at 1416:01. The airplane remained nose-up and began to descend, then entered a shallow left turn at 1416:17. It continued turning left at low altitude to a position consistent with the left downwind leg of the traffic pattern and disappeared from view at 1416:43. It reappeared as it impacted water about 0.75 mile abeam the departure end of runway 8 at 1417:07.
According to the pilot's written statement and recorded interview, after completing a preflight inspection and final walkaround, passengers boarded. He performed a safety/emergency briefing, started engines, and taxied to runway 8 via N taxiway, holding short at S5. He performed a run-up using the checklist, and everything was within parameters. After takeoff clearance, he rotated at 85 knots. At about 100 ft agl, he retracted the landing gear and noted the airplane did not seem to climb or accelerate beyond 85-90 knots. He verified magnetos, fuel pumps, and that throttle, mixture, and propeller levers were full forward. All engine instruments were in the green arc. The airplane then yawed left; he noticed left engine rpm less than right but still in the green arc. He turned left with the yaw to return to the airport, but the airplane could not maintain altitude. He attempted to avoid a populated beach and ditched in shallow water. He did not remember exiting but recalled his face burned when he swam to the surface due to a fire. He tried twice more to reach the surface away from the fire, then saw two of three passengers and attempted to swim back for the third but was in shock and had ingested water. A person on a paddle board pulled him from the water.
During a postaccident interview with two FAA inspectors, the front seat passenger stated he was not a pilot but was familiar with airplanes as an aerospace engineer with time in a Boeing 757 simulator. He said the pilot did not provide a safety briefing; instead, he instructed the other passengers (minors) to fasten seatbelts, and he fastened his own. As the airplane approached the runway, the pilot secured the door and started takeoff without reading any checklist. The airplane initially gained altitude but then yawed left. The front seat passenger noticed the pilot did not correct the yaw, letting the airplane turn perpendicular to the wind; he mentally questioned the pilot's competency but did not touch anything. The airplane lost altitude and flew under a tree line while in a left banking turn. The pilot then moved the yoke abruptly right, and the airplane collided with water.
The front seat passenger reported the pilot egressed first, but he did not recall how because the door was on the passenger side. The front seat passenger egressed, followed by another passenger. The third passenger did not egress; the front seat passenger tried to go back but fire was too intense, and he was badly burned. He noted no change in engine sound and no smoke or fuel odor.
Personnel Information
The pilot held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane, plus a flight instructor certificate with single- and multiengine ratings. His most recent FAA first-class medical was issued December 14, 2016. He reported about 1,200 total flight hours, about 200 in multiengine airplanes, and about 20 in the accident make and model. Company records showed he was hired in December 2016 and completed ground and flight training, reporting 900 total hours (110 multiengine) at hire. From December 2016 through May 2017, he flew about 220 hours in a Britten-Norman BN-2A-21 Islander. He completed training in the accident airplane on May 25, 2017, and accumulated about 20 hours in it over 6 months before the accident. The last logbook entry was dated February 28, 2017, showing about 933 total hours (234 multiengine).
FAA records showed the pilot received a Notice of Disapproval for a private pilot certificate on November 8, 2014, but obtained it on November 12, 2014. He obtained a multiengine rating on first attempt December 4, 2014. He received another Notice of Disapproval for an instrument rating on January 30, 2015, with comments on reexamination of preflight preparation and procedures; he obtained the rating February 6, 2015. He obtained commercial pilot (single-engine) on first attempt March 18, 2015, and commercial (multiengine and instrument) on first attempt April 11, 2015. He received a Notice of Disapproval for a flight instructor certificate (multiengine) on June 16, 2015, with comments to review airplane systems; he obtained it July 7, 2015, reporting 221 total hours (96.9 multiengine). He received another Notice of Disapproval for a flight instructor certificate (single-engine) on July 14, 2015, with comments for more training on teaching takeoffs and landings; he obtained it July 22, 2015.
Aircraft Information
The six-seat, low-wing, tricycle-retractable-gear airplane was manufactured in 1975, powered by two Lycoming IO-540, 250-horsepower engines with Hartzell controllable pitch full-feathering propellers. The most recent annual inspection was completed November 16, 2016, at which time the airframe had 9,087.3 total hours, and engines had 695.3 hours since major overhaul. The airplane flew about 95 hours from that inspection to the accident. The airspeed indicator showed mph on an outer ring and knots on an inner ring. The airplane was not equipped with counter-rotating engines.
Meteorological Conditions
At 1421, recorded weather at TJSJ was wind from 070° at 17 knots, visibility 10 miles, few clouds at 2,400 ft, scattered clouds at 4,000 ft and 7,000 ft, temperature 31°C, dew point 24°C, altimeter 29.98 inches of mercury.
Wreckage and Impact Information
Examination after recovery revealed both wings had separated during impact. The right wing had leading edge impact damage and buckling at the outboard section; the right flap and aileron had separated. The right engine remained attached; the propeller (two blades) was undamaged and in normal operating range, not feathered. Internal continuity was confirmed; thumb compression was attained on all cylinders. Fuel injector servo screen was clean; fuel odor consistent with 100LL. The left magneto produced no spark (consistent with saltwater immersion); right magneto produced spark at five of six leads. Right flow divider attachment bolts were loose; two divider lines had separated consistent with impact; one line was loose and its B-nut could be removed by hand with two turns. Fuel injector nozzles were unobstructed.
The left wing also had leading edge impact damage and buckling. The left flap remained attached; the left aileron had separated. The left engine remained attached; one propeller blade was undamaged, the other bent aft; both blades in normal range, not feathered. Internal continuity confirmed; thumb compression attained on all cylinders. Fuel injector servo screen clean; fuel odor consistent with 100LL. Fuel inlet hose B-nut at the fuel servo was loose. Magnetos produced no spark (saltwater). Five of six fuel injector nozzles unobstructed; one obstructed. Oil filter and suction screen free of metallic contamination.
Cockpit examination: landing gear and flaps retracted; seatbelts and shoulder harnesses intact; master switch off; left and right fuel pumps on; left magneto switches on; right magneto switches off. Underwater photos showed right throttle lever forward, right mixture and propeller levers midrange; left throttle midrange, left propeller and mixture levers forward. Preimpact positions could not be verified due to wing separation. Left engine fuel selector positioned to left inboard main tank; right engine fuel selector to right outboard main tank; crossfeed switch midrange and fragmented. Rudder trim jackscrew measurement indicated neutral rudder trim. Stabilator trim jackscrew measurement indicated full nose-up stabilator trim, but damage and separated trim indicator cable were present. Control continuity confirmed for rudder, stabilator, and ailerons to cockpit area.
Additional Information
Fuel: The airplane had six fuel tanks: each wing had a 36-gallon inboard, 36-gallon outboard, and 24-gallon auxiliary wingtip tank. The pilot reported "all tanks" full; however, the fueler stated he always filled the four main tanks, not the auxiliary tanks. The former director of operations said auxiliary tanks were usually left empty. Estimated fuel onboard at takeoff was 144 gallons (864 lbs) in the four main tanks.
Weight and Balance: The pilot's operating manual listed maximum gross takeoff weight at 5,200 lbs. The pilot calculated 4,335 lbs for the accident takeoff. Postaccident recalculation, assuming four main tanks full, front seat occupants (220 lbs and 190 lbs), middle seat occupants (115 lbs and 120 lbs), and 125 lbs baggage in rear, yielded a recalculated weight of about 4,850 lbs (350 lbs below maximum). Center of gravity was near the forward limit.
Performance: A takeoff performance chart from the pilot's operating manual, given conditions (88°F, sea level, takeoff weight 4,850 lbs, 15-knot headwind), indicated required distance of about 1,250 ft to take off and climb over a 50-ft obstacle. The chart noted liftoff speed at 80 mph (70 knots) and speed at obstacle at 97 mph (84 knots). Best angle-of-climb speed was 107 mph (93 knots); best rate-of-climb speed was 120 mph (102 knots). Single-engine rate of climb was 240 ft per minute with best single-engine rate-of-climb speed of 102 mph (89 knots).
Medical and Pathological Information
The FAA's Bioaeronautical Science Research Laboratory conducted toxicological testing on a serum sample from the pilot; results were negative for alcohol.
Tests and Research
The lap belt securing the deceased passenger was examined by an NTSB Survival Factors Specialist; no preimpact mechanical malfunctions were found, and the insert tab released from the buckle when the latch was lifted about 90°.