Primary finding
Probable cause
Fatigue failure of the No. 5 engine cylinder fuel supply line, which resulted in an engine compartment fire. Also causal was the pilot's failure to immediately secure the engine/perform a forced landing after discovery of the fire, which resulted in the pilot's loss of control of the airplane.
Investigator assessment
Analysis narrative
While en route to the destination airport, about 3,800 feet over swampy terrain, the pilot declared a mayday and advised air traffic control that there was fire in the engine. The controller asked the pilot's intentions, noting that there were two airports about 25 nautical miles from the airplane's position. The pilot stated that he would like to continue to one of the airports. The controller instructed the pilot to descend to 3,000 feet, and during the next 4 minutes, the pilot made multiple transmissions, including; that he thought he had lost a cylinder, that there was still fire coming off the nose of the airplane, they were getting smoke in the cockpit, and he may have to land on the highway. Approximately five minutes, 45 seconds after his first transmission, the pilot stated "we're on fire." There were no further transmissions from the pilot. A witness subsequently observed the airplane on fire, in a 20-degree nose-down, 40-degree left bank before it impacted terrain. Postflight examination of the wreckage revealed that the fire had emanated from a fuel leak caused by a fatigue fracture in the No. 5 pressurized fuel supply line. The pilot's operating handbook and Federal Aviation Administration publications noted that in case of fire, the pilot should immediately terminate the fuel flow to the engine and perform a forced landing. Although the failure of the fuel line would have, by itself, likely resulted in an accident, the pilot's loss of control of the airplane was a direct consequence of his failure to immediately perform the required emergency procedures.
Source record
Factual narrative
HISTORY OF FLIGHT On September 20, 2009, at about 1750 eastern daylight time, a Piper PA-32R-301T, N2467Y, registered to Bull Gator Air, Incorporated, operating as a 14 Code of Federal Regulations Part 91 personal flight, crashed in the Florida Everglades, 22 miles east of the Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The certificated private pilot and three passengers were killed, and the airplane was destroyed. The flight originated at Gainesville Regional Airport, Gainesville (GNV) Florida, at 1613. Review of transcripts of communications provided by the Federal Aviation Administration (FAA) revealed that the pilot contacted the FAA Miami (MIA) approach control at 1740. At 1745:47, the pilot issued a "mayday" call and reported a "fire in the engine." The controller then asked, "are you going to try and make it to executive airport -that's the closest to you sir." Radar data revealed that at the time, the airplane was on an assigned heading of 110 degrees, at an altitude of 3,800 feet above mean sea level (msl). The airplane subsequently continued on its assigned heading, but a 300-foot descent was noted. The airplanes flight track showed that the airplane was flying over the everglades marshland area during the flight. At the time there were no roads in the vicinity. At 1746:01, the pilot responded that he had "smoke in the cockpit and we're trying to get to the nearest airport." The controller informed the pilot that "Pahokee Airport" [Palm Beach County Glades Airport (PHK), Pahokee, Florida] was the closest airport, 24miles from his location. The controller then asked the pilot if he wanted to go to Pahokee or "get to exec?" The pilot responded, "we'd like to get to exec," and added that he thought he had still had power, that "we've lost one cylinder," "that we can see some fire coming off the nose," and that the smoke had dissipated in the cockpit. The airplane maintained an altitude of 3,500 feet for a short period of time before descending to 3,400 feet. At 1747:02, the controller advised the pilot that FXE was 24 miles away and asked if he still wanted to try to continue to FXE. The pilot advised the controller that he was going to try to continue FXE, and about 40 seconds later, added that he wanted a "visual straight to the runway." Radar data indicated that the airplane was at an altitude of 3,400 feet. At 1748:12, the controller directed a heading of "one one zero...vectors straight in for runway eight" at FXE for a visual approach. Radar data indicated the airplane was at 3,300 feet during the transmission. The controller then advised the pilot that he was going to keep him at 3,000 feet just in case he had another problem he would be able to glide to the airport, which the pilot acknowledged. At 1749:08, the controller advised the pilot that if he felt comfortable, the controller would switch the pilot to a discreet frequency so that he could be worked by "just one" controller, "can you do that?" When the pilot acknowledged with the airplane's call sign, the controller provided him the new frequency, and stated that the new controller "knows the situation." At 1749:40, the new controller acknowledged the pilot's heading, and informed the pilot that "boca is about the same distance, so whichever one you like; twelve o'clock and twenty five miles for executive." At 1749:52, the pilot advised the controller that "we're getting more smoke in the cockpit, we're thinking we might have to land on runway (unintelligible) highway two seven here." Radar data indicated the airplane was at an altitude of 2,900 feet. The controller acknowledged the pilot's transmission and requested confirmation of the pilot's decision to land on highway 27, to which the pilot responded, "yes yes." The controller then requested the number of souls onboard the airplane. Radar data indicated the airplane was at an altitude of 2,700 feet. At 1750:31, the pilot reported, "we're on fire, we're on fire." There were no further transmissions from the pilot, and the radar data went into coast mode. A Florida Wildlife Conservation officer, located about 1/8 mile from the entrance to the Francis F. Taylor North Treatment Area, stated that he observed the airplane to the north about 75 feet above power transmissions lines about 1/2 mile in front of him. The nose of the airplane was approximately 20 degrees below the horizon and the airplane was in a 40-degree left bank. The airplane was trailing black smoke, extending back about 100 yards. Visible flames could be seen on top of the engine cowling, extending back toward the cockpit about 3 feet. The flames closest to the cowling were blue and the flames towards the cockpit were orange. The trailing black smoke was "like the exhaust of an 18-wheel diesel truck." The bank angle continued to increase and the nose continued to lower until the airplane collided with the ground in a near-vertical attitude. PERSONNEL INFORMATION The pilot, age 46, held a private certificate, with ratings for airplane single engine land, and instrument airplane. In addition, he held an FAA third class medical certificate issued on December 3, 2008, with no limitations. The pilot reported 2,000 flight hours on his last medical application. The pilot's logbook was destroyed in the accident, and his total flight hours and last flight review could not be determined. According to an insurance application dated May 28, 2009, the pilot indicated a total flight experience of 1,883 hours; of which 1,183 hours were in the PA-32R. AIRCRAFT INFORMATION The six seat, low-wing, retractable gear airplane, serial number 32R-8529019, was manufactured in 1985. A Lycoming TIO-540-S1AD, 300- horsepower horizontally opposed six cylinder engine powered the airplane, equipped with a Hartzell three-bladed propeller. Review of the engine logbooks revealed the engine was overhauled on April 11, 1994, and had accumulated 2,030 hours since overhaul. The engine manufacturer recommended that the engine be overhauled after 1,800 hours time in service or 12 years. The last annual inspection was conducted on February 9, 2009, with a total tachometer time and aircraft total time of 3,590.1 hours. The tachometer was not located in the wreckage and the total airframe time could not be determined. Review of the last refueling record from GNV dated September 20, 2009, revealed that the airplane was topped off with 25 gallons of 100 low lead (LL) fuel before the airplane departed on the accident flight. Review of corporation records revealed that the registered agent was the pilot of the airplane. Further review of the insurance records showed that Bull Gator Air, Incorporated was listed as the applicant and the pilot was listed as the operator. METEOROLOGICAL INFORMATION The 1753 FXE surface weather observation, located about 22 miles west of the accident site, was: wind from 110 degrees at 7 knots; visibility 10 miles; a few clouds at 2,600 feet above ground level (agl); scattered clouds at 3,400 feet; scattered clouds at 4,500 feet; temperature 29 degrees Celsius; dew point 23 degrees Celsius; altimeter 29.97 inches of mercury. WRECKAGE AND IMPACT INFORMATION The crash site was located in the Frances Taylor Conservation Area 3A-North in the Florida Everglades. The airplane came to rest inverted in approximately 6 feet of water about 22 nautical miles west of FXE, and on a heading of 258 degrees magnetic. The wreckage was located at 26°32' 61.0" north latitude, 080° 59'15.0" west longitude. The propeller remained attached to the engine crankshaft flange. Two of the three propeller blades exhibited aft bending and twisting toward the lower pitch stop. The remaining propeller blade exhibited fore and aft bending. No leading edge damage or rotational scoring was present on the cambered o