Aircraft Accident/Incident Report

Caribbean Sea
Thursday, November 24, 2011 12:23 UTC

NTSB Narrative Summary Released at Completion of Accident

While delivering the single-engine, turbine-powered airplane to Brazil during a multiple leg trip, the pilot decided to fly direct from his departure airport in Puerto Rico to his destination airport in Grenada instead of following the island chain and staying within power-off gliding distance of the shore. During the cruise portion of the flight, a total loss of engine power occurred over open water in visual meteorological conditions at 27,000 feet, about 119 miles west of a suitable landing area. During the loss of power, the engine torque indication dropped from the cruise power setting to 0 foot-pounds (ft-lbs) of torque, the engine then began to vibrate, and smoke began emanating from the engine. The pilot ditched the airplane, it sank, and it was not recovered. The pilot and the pilot-rated passenger were rescued by a French Navy helicopter. The pilot said that he had decided to take a direct route instead of staying closer to the island chain between the two airports because he had ferried 3 airplanes down to Brazil in the last year and that it was a judgment call and a calculated risk because the engine was reliable. At the airplane’s planned operating altitude of 27,000 feet, the airplane could have glided about 54 miles; if the route had been planned to take advantage of this glide distance, the pilot could have remained off shore island chain and taken a shorter, although not direct, route. Review of fueling documentation, the Pilot's Operating Handbook (POH), and statements made by the pilot and pilot-rated passenger also revealed that on the accident flight, good operating practices were disregarded. For instance, during fueling, the airplane which was not equipped with fuel heaters, had been topped off with fuel, but no fuel icing additive had been added, even though the pilot was planning to operate the airplane at 27,000 feet. The airplane was also operated in excess of the manufacturer's published weight limitations, and no power setting or performance information was available for climb and cruise operations in excess of these limitations. Furthermore, according to the pilot, before the loss of engine power, the torque was about 937 ft-lbs. According to the pilot-rated passenger, before the failure, the torque gauge was indicating about 980 ft-lbs. Review of the maximum cruise performance chart in the POH and Airplane Flight Manual (AFM) revealed that both of the stated torque settings exceeded the maximum torque setting listed on the chart. Operating the engine beyond the recommended power settings specified in the POH/AFM for a prolonged period will result in accelerated deterioration due to hot section component distress and will affect engine reliability and durability.

NTSB Probable Cause Narrative

The total loss of engine power during cruise flight for reasons that could not be determined because the airplane was not recovered. Contributing to the accident was the pilot’s failure to comply with the airplane and engine limitations, and his decision to fly over water beyond power-off gliding distance from shore.

Event Information

Type of Event Accident
Event Date 11/24/2011
Event Day of the Week Thursday
Time of Event 1223
Event Time Zone Coordinated Universal Time? Same as GMT
Event City Caribbean Sea
Event State CARIBBEAN SEA
Event Country --
Zipcode of the event site --
Event Date Year 2011
Event Date Month 11
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 142042N
Event Location Longitude 0623519W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1200 Coordinated Universal Time? Same as GMT
Direction of event from weather observation facility (degrees) 100
Weather Observation Facility ID TFFF
Elevation of weather observation facility 15
Distance of event from weather observation facility (units?) 119
Time Zone of the weather observation UTC
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 24
Dew Point at event time (in degress fahrenheit) 24
Wind Direction (degrees magnetic) 60
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 4
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.94
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None --
Injury Total Serious 2
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 31251
NTSB Notification Source FAA SROCC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jun 4 2013 2:35PM
User who most recently changed record johb
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N534P
NTSB Number ERA12LA085
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name PIPER AIRCRAFT INC
Aircraft Model PA 46-350P
Aircraft Series Identifier --
Aircraft Serial Number 4636423
Certified Max Gross Weight 4340
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 6
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Aug 1 2011 12:00AM
Airframe hours since last inspection --
Airframe Hours 215
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Yes
ELT Type Unknown
Aircraft Owner Name Inacio Carlos Urban
Aircraft Owner Street Address --
Aircraft Owner City Patos de Minas
Aircraft Owner State --
Aircraft Owner Country BR
Aircraft Owner Zipcode --
Operator is an individual? No
Operator Name Boeck & Boeck Inc.
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City Santa Rosa
Operator State CA
Operator Country USA
Operator Zip code 95404-1041
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Ferry
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code TJBQ
Departure City Aguadilla
Departure State PR
Departure Country USA
Departure Time 1033
Departure Time Zone UTC
Destination Same as Local Flt --
Destination Airport Code TGPY
Destination City St. George's
Destination State --
Destination Country GJ
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Apr 23 2013 3:06PM
User who most recently changed record kenj
Since inspection or accident Time of Accident
Event Location Runway Number and Location --
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --