Piper PA-61 Aerostar (Ted Smith 601)

During the initial climb, a "throbbing or surging" sound was heard as the airplane departed in gusting wind conditions with a 600-foot ceiling and 1/2 mile visibility in snow. Moments later the airplane came "straight down" and impacted the ground. During examination of the wreckage, it was discovered that that the fuel selector switch for the right engine had been in the "X-FEED" position during the accident. Examination of documents discovered in the wreckage revealed, three documents pertaining to operation of an Aerostar. These documents consisted of two airplane flight manuals (AFMs) from two different manufacturers, and a checklist. Examination of the first of the AFMs revealed, that it had the name of both the pilot and the operator on the cover of the document. Further examination revealed that it had been published 4 years prior to the manufacture of the accident airplane, and contained information for a Ted Smith Aerostar Model 601P, which the operator had previously owned. This document contained no warnings regarding the use of the crossfeed system during takeoff. Examination of the second of the two AFMs found in the wreckage revealed that it was the Federal Aviation Administration (FAA) approved AFM for the accident airplane. Unlike the first AFM, the second AFM advised that the fuel selector "X-FEED" position should be used in "level coordinated flight only." It also advised that each engine fuel selector "must be in the ON position for takeoff, climb, descent, approach, and landing." It also warned that, if the airplane was not in a level coordinated flight attitude, "engine power interruptions may occur on one or both engines" when "X-FEED" is selected "due to unporting of the respective engine's fuel supply intake port." Review of the checklist contained in the FAA approved AFM for the Piper Aircraft Model 601P under "STARTING ENGINES," required a check of the crossfeed system prior to engine start by selecting each fuel selector to "ON," then selecting "X-FEED," and after verifying valve actuation and annunciator light illumination, returning the fuel selector to "ON." Additionally, under "BEFORE TAKEOFF" It also required that the fuel selectors be checked in the "ON" position, and that the "X-FEED" annunciator light was out, prior to takeoff. Examination of the pilot's checklist revealed that, it consisted of multiple pages inserted into plastic protective sleeves and included both typed, and hand written information. A review of the section titled "BEFORE TAKEOFF" revealed that the checklist item "Fuel Selectors - ON Position," which was listed in the AFM, had been omitted.

On the day of the accident, the pilot was returning to his home airport, after dropping off friends at a different airport. No weather briefing or flight plan was filed with Flight Service for either flight. A witness and radar data depicted the accident airplane on a straight-in approach for runway 1, in a landing configuration, at a ground speed of approximately 120 knots. The last radar target was recorded about 1/4 mile from the runway threshold, at an altitude of approximately 150 feet agl. The wreckage was later found about 1/2 mile east of the runway threshold. Review of weather information revealed general VFR conditions along the route of flight, and at reporting stations near the accident site. Gusty winds, low-level wind shear, and moderate to severe turbulence also prevailed at the time of the accident. In addition, weather radar depicted scattered light snow showers in the vicinity of the accident site, and possibly a snow squall. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. The pilot had a total flight experience of 14,000 hours, with 8,500 hours in multiengine airplanes, including 2,600 hours in the same make and model as the accident airplane. He also had 4,100 hours of instrument flight experience.

The 700-hour private pilot flying the twin-engine airplane with four passengers aboard used approximately three-quarters of runway 18 before becoming airborne. After establishing a positive rate of climb, the pilot retracted the landing gear and pitched the airplane for a 92 knot climb. Shortly thereafter the rate of climb decreased and the airplane's control authority began to decay. The pilot responded by applying full throttle to both engines and reduced the angle of attack in an attempt to regain airspeed. The pilot was able to arrest the airplane's decaying airspeed and descent; however, the airplane collided with a barn and then a grassy field before coming to rest in an upright position. The pilot and passengers were able to egress the airplane unassisted and the airplane was engulfed in flames a few minutes later. About 23 minutes after the mishap the weather reporting station 24 miles north of the accident site reported, the wind from 230 degrees at 6 knots, the temperature 84 degrees Fahrenheit, and dew point of 60 degrees Fahrenheit. Runway 18 was reported as a 4,002-foot long by 60-foot wide asphalt runway with trees near the departure end. The field elevation at the airport was reported at 544 feet and the density altitude was calculated at 1,860 feet. The estimated weight of the airplane at the time of departure was near its maximum gross weight of 6,000 pounds. The pilot reported that he had not performed a weight and balance check, calculated density altitude, and was not sure of how much fuel was onboard the airplane prior to departure. The pilot further reported that there were no apparent anomalies with the airplane.

After takeoff for a maintenance check flight, both engines on the twin-engine airplane experienced a loss of engine power. The 7,200-hour pilot had recently purchased the airplane, which had not been flown for nearly four years. The pilot, who is also a certificated airframe and powerplant mechanic, completed the inspection of the airplane prior to takeoff. During the engine run-up, the pilot noticed that the RPM and manifold pressure on the left engine did not correspond with those of the right engine. During the takeoff roll, the pilot believed the RPM on both engines began to rise to near acceptable levels, but not entirely. However, he did not abort the takeoff. The airplane became airborne for a short time, and then began to descend into trees before impacting the ground. The reason for the reported loss of engine power could not be determined.

Immediately after taking off and raising the landing gear, the pilot noticed the left engine began to lose power. The airplane subsequently veered to the left before impacting up slopping terrain in a left wing low attitude, resulting in a fire breaking out which consumed the left side of the airplane. A postaccident examination revealed that the left engine had sustained thermal but no impact damage, and that the engine's right hand turbocharger had no thermal or impact damage. A further examination indicated that no restrictions were found in the center section of the turbocharger and there was no damage to the housing or the impeller; however, the impeller was frozen in the center section and would not turn. Indications of grooving and scraping from a lack of lubrication to the bearings and drive shaft was observed. No mechanical anomalies with the aircraft were noted by the pilot prior to takeoff which would have prevented normal operations.

The pilot attempted a night landing on a taxiway in front of the control tower, which was closed at the time. The airplane overran the end of the taxiway, rolled down an embankment and struck trees. The pilot, whose identity was not confirmed, was believed to have incurred minor injuries. He subsequently paid a passerby to take him to a local hotel, and after a night's rest, he left the area. Ownership of the airplane could not be determined due to a recent sale. Approximately 250 kilos of cocaine were found onboard the airplane. Further investigation was being conducted by federal authorities and local law enforcement.

The commercial pilot, who managed the airplane and jointly owned it with one of the passengers, departed from a 3,930-foot-long, asphalt runway on a warm day. Weight and balance calculations, which investigators derived from estimated weights for total fuel, passengers, and cargo loads, determined that the airplane was likely within center of gravity limitations and about 208 pounds below its maximum gross weight. One witness stated that the airplane became airborne near the end of the runway before it began a shallow climb and clipped small branches on the tops of trees that were about 30 feet tall. That witness and others observed that the airplane continued past the trees, made a steep bank to the left, rolled inverted, and nose-dived to the ground. The witnesses' descriptions of the airplane's flightpath and the examination of the debris path and wreckage at the accident site are consistent with an impact following an aerodynamic stall. According to calculations performed using the airplane's published performance data chart, for the airplane's configuration and estimated weight and the density altitude conditions at the time of the accident, the airplane would have required about 3,800 feet on a paved, level runway to clear a 50-foot obstacle with the pilot using the short-field takeoff technique. Although the chart does not make any allowances for an upsloping runway or provide data for a 30-foot obstacle, the runway slope is slight (a 27-foot rise over the entire length) and likely did not significantly increase the airplane's takeoff roll, and interpolation of the data revealed no significant distance differences for the shorter obstacle. However, according to the chart, the 3,800-foot distance is contingent upon the pilot holding the airplane's brakes, applying full engine power with the brakes set, and then releasing the brakes to initiate the takeoff roll. In addition, the airplane's ability to achieve its published performance parameters (which are derived from test flights in new airplanes) can be degraded by a number of factors, such as pilot deviations from the published procedures, reduced engine performance, or increased aerodynamic drag associated with minor damage and wear of the airframe. It could not be determined where on the runway the pilot initiated the takeoff roll or at what point full engine power was applied. However, because the runway was only 130 feet longer than the airplane required (according to its published performance data), there was little margin for any deviations from the published takeoff procedure. Although examination of the engines, propellers, and related systems revealed no evidence of precrash anomalies, postaccident damage precluded engine performance testing to determine whether the engines were capable of producing their full-rated power. Therefore, the significance of maintenance issues with the airplane (in particular, a mechanic's assessment that the turbochargers needed to be replaced and that the airplane's required annual inspection was not completed) could not be determined with respect to any possible effect on the airplane's ability to perform as published. A review of Federal Aviation Administration (FAA) and insurance records revealed evidence that the pilot may have been deficient with regard to his ability to safely operate a PA 60-601P. For example, according to FAA records, as a result of an April 2004 incident in which the pilot landed the accident airplane on a wet grassy runway with a tailwind, resulting in the airplane going off the runway and striking a fence, the FAA issued the pilot a letter of reexamination to reexamine his airman competency. However, the pilot initially refused delivery of the letter; he subsequently accepted delivery of a second letter (which gave the pilot 10 days to respond before the FAA would suspend his certificate pending compliance) and contacted the FAA regarding the matter on Monday, August 2, 2004 (the day before the accident), telling an FAA inspector to "talk to his lawyer." In addition, as a result of the same April 2004 incident, the pilot's insurance company placed a limitation on his policy that required him to either attend a certified PA-60-601P flight-training program before he could act as pilot-in-command of the accident airplane or have a current and properly certificated pilot in the airplane with him during all flights until he completed such training. There was no evidence that the pilot adhered to either of the insurance policy requirements. In addition, the FAA had a previous open enforcement action (a proposed 240-day suspension of the pilot's commercial certificate) pending against the pilot for allegedly operating an airplane in an unsafe manner in September 2003; that case was pending a hearing with an NTSB aviation law judge at the time of the accident. Although the FAA's final rule for Part 91, Subpart K, "Fractional Ownership Operations," became effective on November 17, 2003, the regulations apply to fractional ownership programs that include two or more airworthy aircraft. There was no evidence that the pilot had a management agreement involving any other airplane; therefore, the rules of Part 91, Subpart K, which provide a level of safety for fractional ownership programs that are equivalent to certain regulations that apply to on-demand operators, did not apply to the accident flight. In the year before the accident, the FAA had conducted a ramp check of the pilot and the accident airplane and also conducted an investigation that determined there was not sufficient evidence that the pilot was conducting any illegal for-hire operations.

A witness at a nearby maintenance facility stated the pilot telephoned him and told him that, during engine start, one engine sputtered and abruptly stopped. The witness stated the pilot told him he wanted to fly the airplane over to have the problem looked at. A witness, who was an airline transport-rated corporate pilot, observed the airplane on takeoff roll and stated the airplane rotated "really late," using approximately 4,000 feet of runway. He stated the airplane climbed to about 400 or 500 feet, then descended in a left spin into the trees. The airplane collided with the ground and caught fire. Examination of the right engine revealed external fire damage and no evidence of mechanical malfunction. Examination of the left engine revealed external fire damage. Disassembly examination of the left engine revealed the rear side of the No. 5 piston from top to bottom was eroded away with characteristics consistent with detonation. The spark plugs displayed "normal" deposits and wear, except the No. 5 bottom plug was contaminated with a fragment of piston ring material, the No. 5 top plug had a dark sooty appearance, and the nose core of the No. 2 bottom plug was fragmented. Flow bench examination of the left fuel servo revealed no abnormalities. The fuel flow manifold diaphragm was heat-damaged. Flow bench examination of the fuel injector lines and nozzles on a serviceable fuel flow manifold revealed the lines and nozzles were free of obstruction. A review of Emergency Operating Procedures for the Aerostar 601P revealed the following: "Normal procedures do not require operation below the single engine minimum control speed, however, should this condition inadvertently arise and engine failure occur, power on the operating engine should immediately be reduced and the nose lowered to attain a speed above ... the single engine minimum control speed."

The Ted Smith Aerostar 601 aircraft, registered VH-WRF, departed Coolangatta at 1301 ESuT with a flight instructor and a commercial pilot on board. The aircraft was being operated on a dual training flight in the Byron Bay area, approximately 55 km south-south-east of Coolangatta. The aircraft was operating outside controlled airspace and was not being monitored by air traffic control. The weather in the area was fine with a south-easterly wind at 10 - 12 kts, with scattered cloud in the area with a base of between 2,000 and 2,500 ft. The purpose of the flight was to introduce the commercial pilot, who was undertaking initial multi-engine training, to asymmetric flight. At approximately 1445, the operator advised Australian Search and Rescue that the aircraft had not returned to Coolangatta, and that it was overdue. Recorded radar information by Airservices Australia revealed that the aircraft had disappeared from radar coverage at 1335. Its position at that time was approximately 18 km east-south-east of Cape Byron. Search vessels later recovered items that were identified as being from the aircraft in the vicinity of the last recorded position of the aircraft. Those items included aircraft checklist pages, a blanket, a seat cushion from the cabin, as well as a number of small pieces of cabin insulation material. No item showed any evidence of heat or fire damage. No further trace of the aircraft was found.

The airplane collided with mountainous terrain 5 miles from the departure airport during a dark night takeoff. Review of recorded radar data found a secondary beacon code 7267 (the code assigned to the airplane's earlier inbound arrival ) on the runway at 2021:08, with a mode C report consistent with the airport elevation. Two more secondary beacon returns were noted on/over the runway at 2021:12 and 2021:19, reporting mode C altitudes of 1,600 and 1,700 feet, respectively. Between 2021:08 and 2021:38, the secondary beacon target (still on code 7267) proceeded on a northeasterly heading of 035 degrees (runway heading) as the mode C reported altitude climbed to 2,000 feet and the computed ground speed increased to 120 knots. Between 2021:38 and 2021:52, the heading changed from an average 035 to 055 degrees as the mode C reports continued to climb at a mathematically derived 1,300 feet per minute and the ground speed increased to average of 170 knots. At 2022:23, the code 7267 target disappeared and was replaced by a 1200 code target. The mode C reports continued to climb at a mathematically derived rate of 1,200 feet per minute as the ground speed increased to the 180- knot average range. The computed average heading of 055 degrees was maintained until the last target return at 2022:53, which showed a mode C reported altitude of 3,500 feet. The accident site elevation was 3,710 feet and was 0.1 miles from the last target return. The direct point to point magnetic course between Scottsdale and Santa Fe was found to be 055 degrees. Numerous ground witnesses living at the base of the mountain where the accident occurred reported hearing the airplane and observing the aircraft's lights. The witnesses reported observations consistent with the airplane beginning a right turn when a large fireball erupted coincident with the airplane's collision with the mountain. No preimpact mechanical malfunctions or failures were found during an examination of the wreckage. The radar data establishes that the pilot changed the transponder code from his arrival IFR assignment to the VFR code 30 seconds before impact and this may have been a distraction.