History of Flight
On March 12, 2019, at 1516 eastern daylight time, a Piper PA-31-350, N400JM, was substantially damaged when it impacted terrain in Madeira, Ohio. The commercial pilot was fatally injured. The airplane was operated by Marc, Inc. under Title 14 CFR Part 91 as a commercial aerial observation flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight that originated from Cincinnati Municipal Airport-Lunken Field (LUK), Cincinnati, Ohio, at 1051.
Federal Aviation Administration (FAA) radar data revealed that, after departure from LUK, the airplane flew several survey tracks near Cincinnati before proceeding north to fly survey tracks near Dayton, Ohio. According to air traffic control (ATC) voice communications, the pilot contacted ATC at 1503 to request direct routing to LUK due to a fuel problem. The air traffic controller advised the pilot to proceed as requested and offered Dayton-Wright Brothers Airport (MGY), which was 8 miles ahead, as a landing alternative. The pilot responded that he had MGY in sight but wanted to continue to LUK, which was 30 miles away. The controller then asked the pilot if he wanted to declare an emergency, and the pilot responded “negative.”
About 1505, when the airplane was at 5,000 ft mean sea level (msl), the controller asked the pilot if he required any assistance with the fuel issue, and the pilot responded that he should be “okay.” The controller then advised the pilot that “multiple airports” were available between his location and LUK, and the pilot informed the controller that he would advise if the fuel issue developed again.
About 1513, the pilot established radio contact with the LUK ATC tower and advised the controller that the airplane had a fuel problem and that he was hoping to reach the airport. At that time, the airplane was at an altitude of 1,850 ft msl and was about 8 miles north of LUK. Shortly thereafter, the pilot advised the controller that he was unsure if the airplane would reach the airport. No further communications were received from the pilot. Radar data showed that, between 1513 and 1516, the ground track of the airplane was about 200°, the airplane descended to an altitude of 1,275 ft msl, and its estimated groundspeed decreased from about 140 to 98 knots. At 1516, the radar data depicted a right turn to a heading of about 250° and a ground track that aligned with a golf course fairway (which had an elevation of 865 ft msl). At 1516:27, radar data indicated that the airplane was about 180 ft from the fairway at an altitude of 1,050 ft msl and an estimated groundspeed of about 82 knots. The airplane’s last radar-recorded position was located about 550 feet from the accident site.
According to witnesses, the airplane engine sputtered before making two loud “pop” or “back-fire” sounds. One witness reported that, after sputtering, the airplane “was on its left side flying crooked.” Another witness reported that the “unusual banking” made the airplane appear to be flying “like a ‘stunt’ in an air show.” Two additional witnesses reported that the airplane was flying low when it turned to the left and “nose-dived” into their neighborhood. The airplane then impacted a tree and the backyard of a residence. A witness from an adjacent residence heard the impact, approached the wreckage, and noted a “whitish gray smoke coming from the left engine.” He reported that “a small flame began rising from that same area.” Video recorded on the witness’ mobile phone about 1522 showed the area around the left engine engulfed in flames. The witness stated that the airplane was fully engulfed in flames about 3 minutes later.
Personnel Information
According to FAA records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. He also held a flight instructor certificate with ratings for airplane single-engine and instrument airplane, and a ground instructor certificate. His most recent FAA first-class medical certificate was issued November 8, 2018. According to the operator, the pilot was contracted to work for them about 1 month before the accident. Examination of the pilot’s logbook revealed that as of February 19, 2019, he had accrued 6,392 total hours of flight experience. The logbook included seven entries for Marc, Inc., all of which were in the Cessna 310. The pilot had logged 1,364 hours of flight time in the accident airplane make and model, all accumulated prior to 2010. The logbook also showed no piston multiengine airplane flight time between that time and his employment with the operator; all of the pilot’s logged flights during that time were in turbine and/or single-engine airplanes. The available evidence did not indicate if the pilot received any training or a flight check in the PA-31-350. Review of daily flight logs showed that the pilot flew the accident airplane for 2.5 hours the day prior to the accident.
Aircraft Information
A review of the airplane’s maintenance logs revealed that the most recent annual inspection was completed on July 1, 2018, at 19,094 total hours of operation. The left engine had accumulated 453.5 hours of operation since its most recent inspection and 2,991.5 hours since overhaul. The right engine had accumulated 448.5 hours since its last inspection; the time since overhaul could not be determined. Several entries logging maintenance had been added as loose, unbound sheets; several entries documented maintenance performed on other airplanes; and the right propeller logbook documented maintenance to a propeller whose serial number did not match the installed propeller. A company pilot reported that the accident airplane had a fuel leak in the left wing and provided a photograph of fuel on the hangar floor taken about a week before the accident. The company pilot also reported that the airplane was due to be exchanged with another company PA-31-350 the week before so that the fuel leak could be repaired, but it remained parked and was not exchanged. The accident pilot was then assigned to fly the airplane. One of the pilot’s relatives reported that the pilot told him about the fuel leak about 1 week before the accident. Review of the maintenance records revealed no entries in the 2 weeks preceding the accident. The accident airplane was flown by another company pilot about 1 month before the accident, and he had to perform an unscheduled single-engine landing at Smyrna Airport (MQY), Smyrna, Tennessee, after he secured the right engine due to an indication of low oil pressure. Maintenance work to address “external oil leaks” was performed at a fixed-base operator at MQY. Review of the maintenance records revealed no entries associated with any repairs following this event. The company owner/manager stated that he knew “of no single engine landings” involving the accident airplane.
Each wing contained an inboard (main) and an outboard (auxiliary) fuel tank. Fuel for each engine was routed from either tank to the selector valve, fuel filter, fuel boost pump, emergency fuel pump, firewall shutoff, engine-driven fuel pump, and fuel injectors. Two electric fuel quantity gauges indicated the fuel quantity in the selected fuel system tank. During normal operation, each engine was supplied with fuel from its respective fuel system; an emergency crossfeed allowed fuel from one system to supply the other engine. Each wing also had a nacelle fuel tank installed according to a supplemental type certificate in June 2017. The airplane flight manual supplement included the operating limitation: “Do not transfer fuel until main tanks are at least one-half full or less.” It also stated: “Approximately 55 minutes are required to transfer all the fuel out of the nacelle tanks.” Postaccident interviews revealed no way to directly monitor the quantity of fuel in the nacelle tanks during flight, nor any direct indication that the fuel pumps were operating. Company pilots reported using various methods of managing fuel; there was no standardized procedure or published guidance issued by the operator. Postaccident interviews and review of company maintenance records revealed that at least three of the company’s PA-31-350 airplanes had nacelle fuel pumps replaced in the months before and after the accident. A company pilot reported checking the fuel quantity gauge after 30 minutes of flying with the auxiliary tanks and seeing the same amount as when he started the fuel transfer from the nacelle tanks. Two company pilots indicated that they discussed fuel transfer pump failures with the company owner/manager and the director of maintenance.
Meteorological Information
The 1453 recorded weather observation at LUK included wind from 350° at 3 knots, 10 miles visibility, clear skies, temperature 9°C, dew point -7°C, and an altimeter setting of 30.37 inches of mercury.
Wreckage and Impact Information
Examination of the accident site revealed that the airplane came to rest upright with its nose oriented on a magnetic heading of about 335°. The airplane initially impacted a tree, spun 180°, and came to rest in the backyard of a residence. Multiple tree limbs with propeller cuts were observed. All major portions of the airplane were at the site. The wreckage displayed evidence of a postcrash fire. The fuselage was substantially damaged. The instrument panel was fragmented and destroyed. The engine control levers were fire damaged and all were in the full forward position. Fire damage precluded determination of the fuel selector panel configuration. Control continuity was established from flight controls to control surfaces; one elevator cable attachment exhibited a tensile overload fracture. The left wing remained attached to the fuselage. The outboard leading edge of the left wing was crushed upward and aft, and the inboard section showed thermal and impact damage. The fuel selector valve was positioned to the auxiliary tank and revealed no blockages. The firewall fuel shutoff valve was open, the crossfeed valve was closed. Fuel caps for all three left wing fuel tanks remained in place. No fuel or fuel odor was noted. The inboard fuel bladder was consumed by fire; the outboard bladder was intact with no holes and no residual fuel. The nacelle fuel tank was heat- and impact-damaged with no residual fuel; its transfer pump was fire damaged and the interior melted. The right wing separated outboard of the nacelle; a section came to rest on the roof of the residence. The right wing fuel selector valve was positioned to the auxiliary tank and revealed no blockages. The gascolator contained some cloudy water and no fuel or fuel smell. The left horizontal stabilizer and elevator were dented; the right horizontal stabilizer and elevator were bent upward at the tip. The rudder trim barrel revealed a nose-right trim setting.
Left engine examination revealed the crankshaft did not rotate initially; ignition harness leads were damaged. Both magnetos produced sparks. Less than 2 ounces of fuel remained in the fuel servo inlet; a sample tested negative for water. The fuel servo was disassembled with both diaphragms present and undamaged; the fuel inlet screen was unobstructed. Crankshaft rotation was achieved after removal of impact-damaged pushrods. Spark plugs showed normal coloration. Borescope inspection of cylinders revealed no anomalies. The oil filter contained no debris. Fuel injectors were free of obstructions. Residual or no fuel was found in fuel system components. The left propeller was not feathered; it had separated from the engine mounting flange. Two blades exhibited aft bending with no remarkable twist or leading edge damage; the third blade had no remarkable bending or twisting. All blades showed mild chordwise/rotational abrasion.
Right engine examination revealed the crankshaft did not rotate initially; ignition harness leads sustained minor impact damage. Cylinders 2, 4, and 6 had varying impact damage. Spark plugs showed normal coloration. Both magnetos produced sparks. The fuel servo diaphragms were present and undamaged. Crankshaft rotation was achieved after removal of damaged pushrods. Borescope inspection of cylinders revealed no anomalies. The oil filter contained no debris. Fuel injectors were free of obstructions. The oil suction screen was unobstructed but contained nonferrous pieces. Fuel was found in the right engine fuel lines, injector lines, and fuel pump. The right propeller had separated; all blades exhibited aft bending, bending opposite rotation, leading-edge-down twisting, and chordwise rotational scoring.
Medical and Pathological Information
The Hamilton County Coroner’s Office performed an autopsy; the pilot’s cause of death was blunt force injuries. Toxicology testing detected dextromethorphan in cavity blood, dextrorphan in cavity blood and liver, and doxylamine in cavity blood (61 ng/mL) and liver (489 ng/g). No ethanol or carbon monoxide were detected. Dextromethorphan is a nonsedating cough suppressant; dextrorphan is its metabolite. Doxylamine is a sedating antihistamine with a therapeutic range of 50 to 150 ng/mL and a half-life of 6 to 12 hours; it can decrease alertness and impair performance of hazardous tasks.
Organizational Information
Marc, Inc. was based in Brandon, Mississippi. At the time of the accident, they owned 15 PA-31-350 airplanes, 4 of which were non-operational.
Additional Information
According to the PA-31-350 pilot operating handbook, the airplane’s air minimum control speed (VMCA) was 76 KIAS. The handbook procedure for an engine failure during flight above 76 KIAS included identifying the inoperative engine, adjusting the operative engine, attaining 106 KIAS, and attempting a restart if altitude permitted. Prior to securing, the pilot was to check fuel flow, turn on the emergency fuel pump if deficient, check fuel quantity and switch tanks, and check oil pressure and magnetos. The securing procedure included closing the throttle and moving the propeller control to feather before propeller speed dropped below 1000 rpm.
The FAA issued Special Airworthiness Information Bulletin CE-05-51 on April 29, 2005, alerting operators of piston multiengine airplanes about the possibility of inability to continue level flight with one engine inoperative and a windmilling propeller. The bulletin stated that a windmilling propeller increases drag and induces asymmetric drag, potentially causing total drag to exceed power available, making the aircraft unable to sustain level flight.