CEN17FA139

The pilot's failure to attain a proper touchdown point following a loss of engine power and his inability to stop the airplane on the short, soft runway. Contributing to the accident was the inadequate maintenance of the airplane by the owner and the mechanic and the improper annual inspection by the mechanic.

The airplane owner and a mechanic completed the airplane's annual inspection the morning of the accident. The mechanic did no work but returned the airplane to service with an endorsement that the annual inspection/airworthiness requirements had been met based on his determination that the engine runup was satisfactory. The airplane departed but returned to the airport shortly after the departure. During the return, a witness said that the airplane was "way too high," and its approach was "pretty steep." The airplane touched down about halfway down the short-grass runway and was "going way too fast." The airplane overran the end of the runway and into a pond where it became submerged. Postaccident examination of the runway revealed the presence of skid marks from the airplane main landing gear wheels along the last 300 ft of the runway.   The propeller exhibited rotational signatures but with some loss of torque. Postaccident examination of the airplane revealed numerous unairworthy maintenance items and/or lack of maintenance to the engine and accessories; further the engine and various accessories surpassed their manufacturers' recommended time for overhaul/replacement. The exhaust manifold was blocked with internal fractured pieces that would have resulted in power loss. The condition of these pieces was consistent with a failure that had been preexisting. The induction hose to the carburetor was the wrong part for the installation. The hose was collapsed and would have restricted airflow into the carburetor resulting in power loss. Both magnetos were no longer serviceable and would have produced minimal ignition. The engine timing was not set to the engine manufacturer's specification. Had the mechanic conducted a proper annual inspection, he would have identified many of the issues found during the airplane's postaccident examination. Based on the evidence, the pilot likely returned to the airport due to a loss of engine power. It could not be determined which of the many discrepancies led to the loss of engine power. Further, the pilot did not attain a power-off approach glideslope that would have led to a proper touchdown point near the approach end of the runway.

Central Texas Autopsy, PLLC, Lockhart, Texas, performed an autopsy of the pilot. The autopsy report stated that the cause of death was "fresh water drowning." The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. No carbon monoxide was detected in blood (femoral), cyanide testing was not performed, no ethanol was detected in vitreous, amlodipine was detected in liver and in blood (femoral). Amlodipine is a blood pressure control medication that is not generally considered impairing. Based upon the 1535 recorded weather, the density altitude was about 1,314 ft. According to the pilot's logbook, his last flight entry was a flight review in a Piper PA-28R-200 on December 21, 2016; the duration was 1.1 hours. The entry did not have a flight review endorsement by the flight instructor who provided the review. The Federal Aviation Administration (FAA) had no record of any previous accidents, incidents, or enforcement actions for the pilot. The pilot's brother-in-law stated that the pilot had previously landed at the airport "several times" because the airplane received 2 or 3 annual inspections at 30TX. The mechanic held an airframe and powerplant mechanic certificate with inspection authorization, which was renewed on March 17, 2017, by an FAA inspector from the San Antonio flight standards district office (SAT FSDO). The FAA had no record of any previous enforcement actions against the mechanic. The 1971-model-year Piper PA-28-140 (Cherokee) airplane was purchased by the pilot and his brother on November 3, 2010, and the aircraft registration was accepted on February 9, 2011 The airplane was powered by a Lycoming O-320-E3D, serial number L-46554-27A, case number 4865, engine that underwent its last overhaul by the engine manufacturer dated June 29, 1988, at an engine total time of 1,945.45 hours. The engine underwent its last overhaul, which was performed by an airframe and power plant mechanic, dated May 29, 1998, at an engine total time of 2,991.8 hours and a tachometer time of 4,236.2 hours. The Hobbs meter and tachometer indications at the accident site were 889.5 hours and 5,063.7 hours, respectively. According to an airframe and powerplant mechanic, the pilot called him at the end of February 2017 to schedule an annual inspection of the airplane. The pilot did not report any issues and said that the airplane had been flying "beautifully." On the day of the inspection, March 4, 2017, the mechanic arrived and the airplane was at 30TX and the airplane was already "opened up." The pilot reported that the airplane was having occasional fuel pressure problems. Upon completion of the inspection, the airplane was towed outside, started easily, and the engine was run for about 10 minutes. The mechanic stated that the engine was running "satisfactorily," and he signed off the logbooks. According to an FAA inspector from the SAT FSDO, the mechanic, who signed off the annual inspection, stated that he watched but did not work on the airplane. The mechanic and the pilot used an inspection checklist that was not the inspection checklist in the Piper Cherokee Service Manual. It is unknown if the mechanic or the pilot used the Piper Cherokee Service Manual during the inspection of the airplane. Since 2011, all of the annual inspections, which were performed every year, were signed by the mechanic that had signed off the annual inspection. Lycoming Service Instruction No. 1009AZ stated, in part: Engine deterioration in the form of corrosion (rust) and the drying out and hardening of composition materials such as gaskets, seals, flexible hoses and fuel pump diaphragms can occur if an engine is out of service for an extended period of time. Due to the loss of a protective oil film after an extended period of inactivity, abnormal wear on soft metal bearing surfaces can occur during engine start. Therefore, all engines that do not accumulate the hourly period of TBO specified in this publication are recommended to be overhauled in the twelfth year. A review of the engine and airframe logbooks revealed that the magnetos, exhaust, fuel and oil lines, and carburetor had not been replaced/overhauled since the engine's last overhaul in 1998. The Piper Cherokee Service Manual states that a 100-hour inspection is a complete inspection of the airplane, identical to an annual inspection. The manual stated to replace the engine flexible hoses (fuel, oil, etc.) as required but not to exceed 1,000 hours time-in-service, 8 years, or engine overhaul, whichever comes first; no fluid hose may exceed 20 years time-in-service. The Airplane Flight Manual (AFM) provided landing distance versus density altitude information for the only the following conditions: flaps 40°; power off; paved, level runway; no wind; maximum braking; short field effort; and airplane gross weight of 2,150 lbs. Based upon a density altitude of 1,535 ft, the landing distance at gross weight was about 550 ft, and the landing distance over a 50-ft obstacle was about 1,100 ft. The airplane was completely submerged and inverted in an 18- to 20-ft-deep pond that was about 80 to 100 ft from with the departure end of the runway 18. While inverted, the airplane nose was pointing toward the runway. The bottom of the fuselage had a longitudinal tear along its left side that extended from the firewall to the left wing trailing edge, consistent in width with a round barbed wire metal fence post that was between the runway and the pond and was bent over about 30° toward the pond. About the upper 8 inches of the post exhibited paint transfer from the airplane. The airplane cockpit/cabin door had been opened by a diver using the top and side latches. Postaccident examination of the door latches revealed that the door was able to be opened using the top and side latches. There was no binding of the door during its opening or closing. Ground scars consistent with skidding from the main landing gear wheels were present along the last 300 ft of runway 18. A ground scar was in front of the post, which was consistent with the airplane tail tie-down that was broken off the airplane. The barbed wire fence was not attached to the airplane nor was it wrapped around the propeller. The wing flaps were in the 40° extended position. One blade of the two-bladed metal propeller exhibited spanwise scratches that were angled about 20° to 45° relative to the blade chord, consistent with rotation. The second blade was straight. Neither blade exhibited S-shaped bending consistent with torque. Examination of the cockpit revealed that the magneto key switch was in the "both" position, the master switch was in the "on" position, the auxiliary fuel pump switch was in the "on" position, and the engine primer was in and locked. The cockpit throttle control was near the idle position, and the cockpit mixture control was about ¾ forward of the idle cut off position. The cockpit flap selector was in the 40° position. The shoulder harness for the left pilot seat was stowed to its ceiling retainer. Examination of the flight control system confirmed flight control continuity from all the control surfaces to left and right seat cockpit flight controls. The tailcone cover did not exhibit accident-related impact damage. All eight tailcone cover retaining screw holes along the longitudinal axis of the airplane had vertical cracks from the hole edges and through the cover. The four tailcone cover screws that were perpendicular to the longitudinal axis of the airplane were dark brown, consistent with long-term corrosion and non-recent removal. The screw heads were stripped. The tailcone was removed to expose the underlying flight control system components: the rudder cable ends, the stabilator trim screw, the stabilator screw/tab links, the stabilator hinge points, and the rudder trim assembly. These components exhibited a dry appearan