CEN12FA586

The pilot's improper decision to attempt to execute a forced landing to an open field with obstacles. Contributing to the accident was the left engine’s total loss of power due to fuel starvation as a result of the introduction of air into the fuel system through a gascolator seal breach and the pilot’s use of an improper substance on the left wing gascolator bowl during maintenance operations, which led to the gascolator seal breach.

A witness, who was a private pilot, stated that he observed a twin-engine airplane flying overhead on a northerly heading. He reported that the airplane was about 2,000 feet above ground level in level flight and that the left propeller blades were not rotating. The accident site, located in an open field with obstacles, including rolling hills, woods, and roads, was about 6.5 miles from the private pilot's location. Evidence indicated that the airplane struck a tree in a near wings-level attitude. Larger fields and flatter terrain with fewer obstacles were located northwest of the apparent route of flight (the airplane's actual flight route was unknown), and, if the pilot had landed in one of these areas, he would have had a greater opportunity for a successful forced landing. However, the airplane was near or exceeded its maximum takeoff weight upon departure. According to the accident airplane's climb chart, the airplane was unable to maintain altitude when the left engine lost power due to its excessive weight and single-engine performance, the existing high-density altitude (2,963 feet), and, possibly, the pilot's execution of single-engine flight procedures, which left the pilot fewer options to reach a more suitable landing location. Evidence indicates that the left engine experienced a total loss of power. The spark plugs in the Nos. 1, 2, and 4 cylinders, which had fuel primer lines attached, exhibited carbon-fouling, indicating that a rich-fuel mixture existed at the time of the accident and that the pilot most likely unsuccessfully attempted to regain the left engine's power by using the fuel primer to prime the cylinders. The left wing gascolator bowl was removed and a blue silicon jell-type sealant was found covering about two-thirds of the area of the bowl's circumference and the area where a gasket is typically placed; however, no gasket was found in the gascolator. The blue silicon jell was consistent with Permatex Blue Silicon Gasket Maker, which has the following note in its directions: "NOTE: Not recommended for use on head gaskets or parts in contact with gasoline." If the gascolator seal is breached, air can enter the fuel system and possibly unport the carburetor, which would cause an uncommanded engine shutdown due to fuel starvation. The pilot was also an airframe and powerplant mechanic with inspection authorization. He performed the last annual maintenance inspection of the airplane and subsequent aircraft maintenance. He likely improperly used the blue silicon sealant during maintenance operations. Although the autopsy and toxicological examinations revealed that the pilot possibly had significant health issues, no evidence was found indicating that the pilot was incapacitated during the flight.

The iFly GPS unit was sent to the NTSB Vehicle Records Laboratory for examination. The unit still operated; however, the Scan disk flash card that stored the non-volatile memory was not in the GPS unit's flash card slot, and it was not found at the accident site. The fuel primers for both engines were examined for leaks by testing them on a fuel bench and applying vacuum pressure to the primers. No leaks or other anomalies were observed. The eight spark plugs from the left engine were examined. Both spark plugs from the Nos. 1, 2, and 4 cylinders exhibited carbon fouling. All eight spark plugs from the left engine were installed in a Piper Cherokee with a 160-horsepower Lycoming O-320 engine. The engine started immediately and operated normally at all power settings. On June 18, 2013, an exemplary Piper gascolator was filled with Permatex Blue RTV Silicone Gasket Maker in the area where a normal gasket sits. The gascolater bowl was secured to the base of the gascolator and was filled with 100 low lead aviation fuel for a 24-hour period. The gascolator was opened and the blue RTV silicone was observed to have expanded inside the gascolator bowl, which was similar to the blue silicone jell observed in the accident airplane's left wing's gascolator. The directions for using Permatex Blue RTV Silicon Gasket Maker states: "NOTE: Not recommended for use on head gaskets or parts in contact with gasoline." Aircraft Performance Total Empty Weight 2,348 2,348 Oil 30 30 Fuel (Main – 72 gal) 432 432 Aux Fuel (36 gal) 216 Pilot and Pax 410 410 Equipment 120 120 Baggage 200 200 Total T/O Weight 3,540 3,756 Fuel Burn (17 gph @ 1.58 hour) 161 161 Approx. Weight at Accident Site 3,379 3,595 The elevation at the accident site was about 657 feet, and the density altitude at the time of the accident was about 2,963 feet. The Piper PA-23 Rate of Climb chart for single-engine operation indicated that an airplane weighing 3,379 pounds with a density altitude of 2,963 feet, the rate of climb would be about 170 feet per minute. An airplane weighing 3,595 pounds with a density altitude of 2,963 feet, the rate of climb would be about 110 feet per minute. The rate of climb chart was based on the performance of a new engine, and proper pilot inputs for single-engine operation. The Piper PA-23 Pilot Operating Handbook states that the procedures for single-engine failure during cruise flight is to correct the yaw with rudder or the rudder trim tab; pull the throttle to idle; feather the propeller by pulling back on the propeller lever; pull mixture lever to idle cut-off; turn the ignition off; and raise the dead engine wing up about 3 degrees higher than level to counteract the tendency to turn in that direction. The debris path was on a 100 degree magnetic heading, and there was an open field located on the east side of the road from where the airplane wreckage was found. The terrain between the accident site and where the airplane was observed by the witness consisted of rolling hills, woods, open fields, and roads near the Mississippi River. However, larger fields and flatter terrain with fewer obstacles were located to the northwest of the apparent route of flight, and on the east side of the river. An autopsy of the pilot was conducted on August 31, 2012, at the Boone/Callaway County Missouri Medical Examiner's office. The "Cause of Death" was noted as "blunt trauma to the head, trunk, and extremities secondary to an airplane crash." A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aerospace Medical Institute. The results were negative for carbon monoxide and cyanide. 15 (mg/dL, mg/hg) ethanol was detected in the urine, but none in the blood. N-propanol was detected in the urine. 0.018 (ug/mL, ug/g) of cetirizine was detected in the blood and it was detected in the urine. Glucose was not detected in vitreous. 171 (mg/dl) glucose was detected in urine. 8.6(%) hemoglobin A1C was detected in blood. Cetirizine is an over-the-counter sedating antihistamine used to control allergies. The therapeutic low level is 0.1900 ug/mL, and the high therapeutic level is 1.4500 ug/mL. Postmortem urine levels of glucose above 100 mg/dL are considered abnormal. Hemoglobin A1C blood levels above 6% are considered abnormal. At 1754, the surface weather observation at the Quincy Regional Airport-Baldwin Field (UIN), Quincy, Illinois, located about 20 miles southeast of the accident, was: wind calm; visibility 10 miles; sky clear; temperature 33 degrees Celsius; dew point 15 degrees Celsius; altimeter 30.02 inches of mercury. The airplane was a twin-engine Piper PA-23-150, serial number 23-255, manufactured in 1956, powered by 150-horsepower Lycoming O-320 engines. It was manufactured with a "Super Custom" configuration which included two 18-gallon auxiliary fuel tanks and a fifth passenger seat, and it had a maximum gross weight of 3,500 pounds. The airplane's original logbooks were lost or destroyed in 1995, and the first entry in the current logbooks was dated October 1, 1995. The available airplane records indicated that the airplane total time was 5,724 hours; and the left engine total time was 3,609 hours, with 1,773 hours since major overhaul (SMOH); and the right engine total time was 3,624 hours, with 1,567 hours SMOH. The last annual inspection was completed on October 15, 2011, but no total airplane time or engine time was shown on the logbook entry. The logbook entry was made by the accident pilot/IA. The airplane had flown about 21 hours since March 10, 2010. The last available weight and balance found for the airplane dated back to 1962, and the empty weight listed was 2,348 pounds. A witness reported that the airplane was topped off before the flight. A fuel receipt showed that 62.23 gallons of fuel were purchased by the pilot about 1508 on the day of the accident at the Sparta Community Airport (SAR), Sparta, Illinois, located about 19 nautical miles northwest of PJY. The airplane's main fuel tanks held 72 gallons of fuel which weighed 432 pounds. It is not known if the auxiliary fuel tanks contained any fuel. The total weight of the pilot and passenger was about 410 pounds. The baggage found at the accident site was weighed and it totaled about 320 pounds. The 4 gallons of oil weighed 30 pounds. The estimated takeoff weight of the airplane was about 3,540 pounds, not including any fuel that might have been in the outboard auxiliary fuel tanks. If the auxiliary fuel tanks were topped off, the takeoff weight of the airplane was about 3,756 pounds. The 74-year-old commercial pilot held single-engine land, single-engine sea, and multi-engine land ratings. He held a third-class medical certificate that was issued September 10, 2010. The pilot's logbook was destroyed in a hangar fire in August 2011. Remaining pilot records indicated that the pilot had about 6,459 total flight hours and 809 multi-engine hours. It is unknown how many hours he had flown in the make and model of the accident airplane. The pilot also held an airframe and powerplant (A&P) mechanic's rating and had inspection authorization (IA). The airplane was purchased by the pilot on October 15, 2011. He performed the last annual maintenance inspection of the airplane and subsequent aircraft maintenance. The airplane i