On Jan. 7, 2023, a Piper PA-28-140, was destroyed when it was involved in an accident near Suffolk, Virginia.
The pilot owned the airplane and based it at the departure airport, Northeast Regional Airport (KEDE), in Edenton, North Carolina.
According to a mechanic at KEDE, the pilot and he were friends. The pilot contacted him on Jan. 1, 2023, to inform him that the engine RPM drop was excessive during a magneto check and that he had parked the airplane on the ramp in front of the mechanic’s hangar for further evaluation.
The mechanic looked at the airplane on Jan. 4, 2023. He removed the spark plugs, cleaned them, and checked them for resistance. He found that two spark plugs had very high resistance and one spark plug fired a little weak, so he replaced the three affected spark plugs and reinstalled the five other spark plugs in the engine.
The pilot arrived later that day, before the mechanic had a chance to perform an engine run as he was busy working on another airplane. The pilot asked if he could perform an engine run on the ramp and the mechanic said yes, because he could listen to the engine from his hangar.
As soon as the pilot ran the engine, the mechanic knew “right away” that the new spark plugs did not correct the problem as the engine was “skipping.”
The pilot shut down the engine and the mechanic informed him that the airplane was not to be flown until he could investigate further, and he would most likely be able to do so on Monday, Jan. 9, 2023.
The mechanic moved the pilot’s airplane from the ramp area in front of his hangar into the pilot’s hangar, as bad weather was forecast for Sunday. The mechanic added that the pilot returned to the airport on Saturday, Jan. 7, saw the airplane in his hangar, and took it flying without contacting him. At the time of the accident, the airplane had not been released from maintenance as the mechanic had not had an opportunity to further investigate the engine anomaly.
According to family members, the accident flight was a short — 40 nautical miles — cross-country flight to get lunch at a restaurant at Suffolk Executive Airport (KSFQ), Suffolk, Virginia.
According to Automatic Dependent Surveillance-Broadcast (ADS-B) flight track information from the FAA, the airplane approached KSFQ in cruise flight at an altitude of about 1,800 feet mean sea level (msl).
About two miles from the wreckage location, the airplane’s descent rate rapidly increased to 500 feet per minute with the airspeed staying just above 90 knots. The descent rate slowed to 200 feet per minute before it rapidly increased to more than 1,500 feet per minute during the final minute of flight.
An aircraft performance study showed that a steep banked turn close to the airplane’s stall speed would have been required to orient the flight path with the wreckage direction.
A witness reported that she was a front seat passenger in a car and observed the airplane in a nosedive. At that time, there were two spiral trails of black smoke, about five to 10 feet behind the airplane. However, she did not observe any fire from the airplane.
The airplane crashed nose-down in a marshy field, about five miles from the destination airport and no debris path was observed. The wreckage came to rest upright and was oriented south. A section of engine cowling was located about 50 feet south of the main wreckage.
A post-impact fire consumed the majority of the wreckage, with the exception of the wings and engine. The pilot and his passenger died in the crash.
The engine was buried in about three feet of mud and was examined following its transport to a recovery facility. The propeller remained attached to the engine. Both propeller blades exhibited some S-bending and chordwise scratching.
The examination revealed that the right magneto had separated from the accessory housing (consistent with impact). Its hold-down nuts remained with the accessory housing on the engine were found finger tight against the remainder of the magneto mounting flange. The left magneto remained attached to the rear accessory housing and its hold-down nuts were also finger tight.
The pilot’s logbook was not recovered. On his application for a private pilot certificate, dated Nov. 15, 2022, he reported a total flight experience of 102.2 hours, of which 36 hours were solo/pilot-in-command. The pilot received his private pilot certificate on Dec. 1, 2022.
Probable Cause: The pilot’s decision to fly the airplane without confirming it had been released from maintenance, which resulted in a partial loss of engine power due to loose magnetos. Contributing to the outcome was the pilot’s failure to maintain adequate airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall.
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This January 2023 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
During pre-flight I always bump the magnetos to make sure they are tight. just so the habit is in place for an after maintenance flight. Learned from my Guatemalan bush pilot brother in law.
Leaving a note may have helped, but in dealing with a friend, he probably thought verbal was enough. The plane was not scheduled for service until after the ill-advised flight, and there was no note to say that work was completed early, nor a call to that effect was made.
If the mechanic had lied and *said* he left a note, the proof would have burned up in the fire.
Sometimes people do things they are not supposed to do, and casting blame to make it shared doesn’t bring the deceased back.
Myself as experienced Heavy Equipment Mechanic we always Red Tag all equipment & if equipped we even put our personal locks on the master disconnect electrical switch to stop such accidents. Just a little extra safety precautions that plane never should have rolled 1 inch without the Aircraft mechanic OK.
In my experience my mechanic would generally NOT put my aircraft back in my hangar until all work is complete and the aircraft has been returned to service. In the one case where they did need to return the aircraft to my hangar before work was completed it was “red tagged” with very obvious “do not fly” placarding taped to the entry door and at the pilot station, AND they called me to let me know. At this point we have only the mechanic’s account of what the conversation was between the mechanic and the pilot after the engine run, but hopefully it will be something the investigators look in to, especially as it relates to regular past practices with returning aircraft to the owner’s hangars when work was not complete.
I’m not sure that locking a chain around the propeller would have helped. Also from the limited view of the provided photo I see no reason for this to end in a smoking hole as opposed to an attempted off field landing.
Sad situation when people are killed for lack of attention to detail.
Obviously the owner had a poor decision to not consult the mechanic. The owner apparently had poor piloting skills also.
The mag hold downs were likely loose because the mechanic was checking the timing prior to suspending work.
Have to agree with EdC….The mechanic did absolutely nothing wrong and the pilot was 100 percent at fault. Sometimes judgement is needed….not for blaming the pilot for making a mistake, but to learn from. Stunning that a pilot could disregard the mechanics advice so blatantly.
Sure sounds like judgement to me. As a mechanic and pilot for close to 50 years, when I have a direct conversation with a pilot/owner of when I can work on their plane the expectation is the pilot will not fly until maintenance is completed. Additionally the pilot was full aware of the situation. This wasn’t a rental on the flight line or a club plane subject multiple pilots that might be out of the information loop. Plain and simple, owner made the decision to fly after direct communication with the mechanic. What would a note have accomplished? Had a note been left and the pilot done the same thing (and I’ve seen it before) , you’d probably be saying the note should’ve been written in 4 different language’s as well as braille for the odd blind pilot. No!! I’m sure the mechanic feels terrible at the outcome of all this. He has lost a friend and customer. But he more than adequately communicated the expectation for the start of additional maintenance and he doesn’t need you heaping your “without judgment” comments on his shoulders.
I offer this without judgement on the actions of the mechanic or the pilot, but a note on the seat of the airplane sure would have helped the situation.
That was kind of what I was thinking. Some way of red-tagging the airplane.