History of Flight
On July 20, 2023, about 0934 central daylight time, a Piper PA-31P airplane, N200RA, was destroyed when it was involved in an accident near Kearney, Missouri. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 maintenance ferry flight from the Midwest National Air Center Airport (GPH), Mosby, Missouri, to Clyde Cessna Field (9K8), Kingman, Kansas.
Before the accident flight, a lineman fueled the airplane with 18.53 gallons of avgas, during which an unknown amount of fuel leaked from the right-wing inboard fuel tank. The lineman was unable to fuel the left-wing auxiliary fuel tank due to a known leak of the nipple at the bottom of the tank.
Witnesses reported that the pilot did not perform an engine run-up before takeoff. During the takeoff roll, the pilot had to bring the airplane back to the centerline with a power reduction as it yawed to the right. Cellphone video recordings showed the airplane veer to the right, attempt to rotate, then settle back to the runway before becoming airborne near the end of the runway. It initially yawed to the right, entered a shallow climb, barely cleared a line of trees, and made a left turn before disappearing behind trees.
A witness about 1.6 nautical miles north of the airport reported hearing a loud airplane that appeared from behind trees. The airplane struck two static wires on a power transmission line, then impacted the canopy of a large tree in the witness's front yard. It continued in a left bank toward a nearby soybean field and impacted the terrain in a nose-low, left-bank attitude. The airplane slid several hundred feet and a postcrash fire ensued.
Aircraft Information
Witnesses reported that the airplane was chained to a tree in an agricultural field adjacent to GPH from August 2021 until December 2022 due to its previous owner being evicted. The last recorded annual inspection was on August 15, 2015, with a tachometer time of 1182.2 hours. A propeller inspection record from May 19, 2019, still reported a tach time of 1182 hours.
According to witnesses, the owner and a mechanic worked on the airplane for about six months. Two witnesses reported that during an engine ground run about two weeks before the accident, the right engine was difficult to start and would not produce full power. They also stated that the inboard fuel tanks leaked "horribly" when fueled.
About two weeks before the accident, the owner received a Special Airworthiness Certificate: Special Flight Permit to ferry the airplane to Kingman, Kansas, to complete an annual inspection. Witnesses and the mechanic reported that two or three pilots declined to perform the ferry flight before the accident pilot agreed.
The mechanic stated that the only work performed before the accident flight was replacing the nose and one main landing gear tire, servicing the brakes, a landing gear swing, replacement of burnt wiring in the right engine, and several maintenance engine runs. He knew about the fuel leaks and stated it was an item to be fixed once the ferry flight was complete. He and the owner also spent several days vacuuming out bird nests and debris from the airplane. During engine start, the pilot contacted the mechanic several times to ask about the location of the radio master switch, how to transfer fuel, and the inoperative left vacuum pressure gauge.
The Special Airworthiness Certificate was issued on June 29, 2023, and reissued on July 11, 2023, with an expiration date of July 23, 2023. A logbook entry recorded a tach time of 1192.2 hours on June 28, 2023, for the ferry flight. The entry stated that the mechanic removed the emergency locator beacon (ELT) for repair, but postaccident examination showed the ELT was in its cradle with an undisturbed animal nest in the antenna wiring. Additionally, the mechanic stated he reviewed applicable airworthiness directives (AD), but paperwork showed the ADs were signed off by an apprentice, not the mechanic. The FAA inspector who issued the permit did not physically inspect the airplane or logbooks.
Wreckage and Impact Information
Postaccident examination revealed that the first impact point was struck electrical wires about 65 ft above ground level and 735 ft before the main wreckage. The second contact was a tree canopy about 60 ft agl and 150 ft after the wire strike. The airplane then impacted the ground, and a debris path extended 313 ft on a heading of 254° to the main wreckage.
The main wreckage consisted of the fuselage, empennage, left wing, and inboard portion of the right wing. The outboard 4 ft of the right wing was found separated about 210 ft from the first ground impact point. The left propeller and gear reduction drive were found separated and located about 30 ft from the airplane.
Examination revealed the main landing gear assemblies were retracted. Cockpit instruments were destroyed by thermal damage. The throttle quadrant control levers were found full forward. Thermal damage occurred along the fuselage to the aft pressure bulkhead. The empennage was intact with no thermal damage rearward. The left horizontal stabilizer had upward deformation. The vertical stabilizer was intact; the rudder above the upper hinge was displaced left about 45° with no impact damage. Preaccident vegetation debris, bird and insect nests, tree sap, and bird droppings were located on and in the empennage.
Elevator, rudder, and trim flight control continuity was established. Both fuel selectors were found in the Main positions. The rudder trim jackscrew was in neutral with a preaccident insect nest surrounding it. The elevator trim was full nose-up. Both engines and propellers were examined. The left engine showed no preaccident mechanical malfunctions. The right engine had two blocked fuel injectors, corrosion and rust in the induction housing and all fuel injectors, and an oil filter installed in 2012 that was not changed during recent maintenance. The right engine turbocharger had no rotational signatures, rust internally and externally, and no oil in bearing galleries. Both propellers had extensive rust. The right propeller low pitch stop had an impact mark consistent with rotation in low pitch and not feathered.
An airplane performance study using cellphone video estimated the left propeller at rated speed and the right propeller about 100 rpm below rated. Rotation occurred at a ground speed of about 70.8 knots, corresponding to an estimated airspeed of about 74.8 knots, below the recommended 85 knots.
Medical and Pathological Information
An autopsy determined the pilot's cause of death as inhalation of products of combustion and thermal injuries. The autopsy identified evidence of hypertensive cardiovascular disease, including an enlarged heart and dilated cardiac ventricles, and a cardiac pacemaker was recovered. Pacemaker interrogation showed no clear evidence of a potentially impairing arrhythmia leading up to the crash. Toxicological testing detected carboxyhemoglobin at 20% in femoral blood, and warfarin, carvedilol, and valsartan were detected. Carbon monoxide exposure likely occurred from smoke inhalation during the postcrash fire.
Organizational and Management Information
A review of FAA policy found no procedures for issuing Part 91 Special Flight Permits via the Airworthiness Certification Tool (AWC). The issuing inspector stated that the permit issuance was a local task with no national standardization. The inspector relied on FAA Order 8130.2J and conversations with management. The front-line manager confirmed no job task analysis code exists for special flight permits.