Piper PA-61 Aerostar (Ted Smith 601)

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.

The airplane crashed into rising terrain after departure from an uncontrolled public airport. The runway used by the pilot is 4,600 feet long and has a 1.8 percent upward gradient. The density altitude was 4,937 feet msl, and a slight quartering tailwind existed at the time. The pilot held in position, powered up the engines, and started his departure. The airplane was observed using most of the runway length before rotation and then it assumed a higher than normal pitch attitude in the initial climb. Witnesses watched the airplane turn left following the route of a canyon and into rising terrain. The reciprocal runway departs towards decreasing elevations. In the area of the crash, two witnesses reported the airplane was at a low altitude, nose high, and wallowing just before it descended into a drainage area 0.69 miles from the runway. Post accident examination of the engines revealed worn camshaft lobes and tappets, which would negatively affect the ability of the engines to produce full rated power. One engine exhibited severe rust on the entire crankshaft. The accident site was located in a canyon, and the wreckage and ground scars was confined to an area about the diameter of the wing span. Major portions of the airframe and most of the engine accessories were consumed by a post accident fire. Examination of the wreckage established that all major components of the airframe and powerplants were at the site.

The airplane was destroyed during an attempted forced landing following an in-flight fire in cruise flight. The pilot was reported to be flying the airplane to an airport in order to have maintenance work performed on the right engine due to a boost problem. It was reported that the pilot had another mechanic at another airport look at the airplane. A work order for a transient airplane was found that indicated work performed on the right engine turbocharger system about 1 month before the accident. The work order shows that the wastegate oil filter was found clogged and collapsed and that it was cleaned, straightened and reinstalled. The pilot operated the airplane with a right engine boost problem. The boost problem with the right engine is evidenced by the previous work order, the excessive amount of runway used during takeoff, the reported smoke from the right engine after takeoff, and the airplane not climbing as expected after takeoff. Due to the reduced power from the right engine, the pilot was required to apply left brake in order to maintain directional control during takeoff, as evidenced by the blued left brake disk with metal transfer into the relief holes and slots. As a result of the pilot using left brake during takeoff, a fire erupted in the left wheel well, which spread to the aft fuselage. This is evidenced by the sooting, fire, and heat damage to the wheel well, the carpet above the wheel well, and aft fuselage. The fuselage immediately behind the baggage compartment had extensive fire damage. The damage in this area included blistered paint on the upper surface, and a two foot square section of the left fuselage skin that was burned away. The area that was burned away was in the vicinity of the hydraulic fluid reservoir. The aluminum hydraulic fluid reservoir was not found, only the steel filler neck, mounting screws, and cap were found. No evidence of fire was found within the right main landing gear wheel well or in the engine compartments. A witness reported seeing the airplane flying south and trailing smoke then banking to the left making a complete circle before descending and ultimately impacting the ground.

The pilot was aware of thunderstorms along his route of flight. He paralleled a line of storms for about 20 minutes looking for a hole in the storms to penetrate, without any success. He turned, and climbed to an altitude of 13,500 feet. He noticed what seemed to be an opening to the south, and turned southbound, through the hole, for about 2 or 3 miles, and then the hole closed. He turned the airplane to the right to reverse course, when he inadvertently penetrated a cell. At this point he said he "lost control of the airplane, and was turned upside down…...heading straight down towards the ground...…traveling at a high rate of speed..….the airspeed indicator was pegged." At an altitude of about 2,000 feet, he was able to level the wings, reduce power and raise the nose. He said he was then able to slow the airplane for a "controlled crash landing," straight a head in a sugar cane field. According to the Sheriff's Report, he struck the field in which the aircraft was lying in immediately after slowing the airplane. The distance from the initial impact area to where the airplane came to rest was about 75 yards.

The airplane collided with mountainous terrain during approach to the destination airport. While approaching the airport, the pilot requested vectors for a localizer approach to runway 19. Due to traffic, air traffic control (ATC) issued the pilot a holding clearance. The airplane was approaching the holding fix about 8,000 feet, when the pilot advised ATC that the airplane was picking up a little ice. ATC initially offered an amended clearance of 9,000 feet, but the pilot declined. Subsequently, he accepted the clearance and climbed back to 9,000 feet. ATC then told the pilot that after one more airplane had landed, he would be issued an approach clearance. The airplane was about 9,200 feet when the pilot replied "thank you." Review of radar data revealed that the accident airplane made one complete 360-degree turn, and one 270-degree turn on the non-holding side of the published holding pattern. During the two turns, the airplane descended to approximately 8,400 feet, climbed to 8,900 feet, then descended again to 8,300 feet. The two turns were tighter than the expected standard 2-minute turns in a holding pattern, with radii ranging from 0.3 to 0.4 nautical miles and 0.1 to 0.2 nautical miles respectively. Following the two holding turns, no more radio transmissions or radar returns were received by ATC. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. Another pilot flying in the area reported moderate rime ice at 8,000 feet, but added that he climbed out of the ice and was between cloud layers at 9,000 to 10,000 feet.

Witnesses watching N900CE's approach for landing to runway 17 at Marco Island Executive Airport stated the pilot appeared to have difficulty aligning the Machen modified Aerostar with the runway centerline. They stated the aircraft appeared unstable about the yaw and roll axes, and appeared too fast. Winds were from the southwest at about 15 knots, gusting to about 20 knots. One pilot/witness close to the touchdown area saw the right wheel touch down instantly, and climb back up to about 50 feet, agl without the full addition of engine power. Most witnesses thought he was either performing a go-around or an extended touch down further down the runway. The airplane continued, "..more and more wobbly" until it entered a climbing attitude and sharp left bank and turn. About half way down the runway the left wing dropped until it contacted the terrain left of the runway, and the aircraft slid into mangrove trees and burned. During postcrash examination, flight control continuity from surface to cockpit floorboards was confirmed. No condition was found with either engine or propeller that would have precluded proper operation, precrash. A witness listening to the pilot's initial radio call up for approach and landing stated that no abnormality was reported by the pilot. Postmortem toxicology testing on specimens obtained from the pilot by the FAA Toxicology and Accident Research Laboratory and the Dade County Medical Examiner revealed quinine found in the blood and urine. The side effects of quinine can include disturbances of vision, hearing, and balance.
Crew:
Glenn Cross.

The pilot reported that after rotation, he obtained a positive rate of climb. At 110 knots, with the landing gear retracted and the wing flaps at 10 degrees, he noticed a right roll, a drop in climb performance, and a drop of manifold pressure on the right engine to at least 34 inches. The left engine maintained 42 inches. The pilot decided that, due to a "very minimum climb rate, rising terrain ahead, [and] airspeed not increasing," he would land the airplane in a small field about 1/4 mile and 50 degrees to the left. The pilot abruptly lowered the nose of the airplane and raised the flaps to gain airspeed, then landed with a nose-high attitude and the landing gear partially extended. Post-accident examination of the airplane revealed there was vertical compression to the belly area, the fuselage was spilt across the top at the aft end of the cabin, and both wings were damaged, with the left wing buckled downward just inboard of the engine. Examination also revealed that a clamp on the right engine intake manifold was loose. An estimated takeoff weight placed the airplane 74 pounds over the maximum allowed of 6,200 pounds. The type certificate holder estimated that with the airplane at 6,400 pounds, climbing at 110 kts, and with a partial power loss down to 26 inches on one engine, the rate of climb should have been 1,150 fpm with flaps and landing gear up, and 830 fpm with flaps 10 degrees and landing gear down. Higher terrain was to the east, and lower terrain was to the west. Terrain elevation for a straight-out departure was 25 feet above the runway at 0.5 nm, and 70 feet above the runway at 2.8 nm. The pilot reported his total flight experience as 15,000 hours, which included 13,000 hours in multi-engine airplanes, and 30 hours in make and model, all with the preceding 90 days.