Nov. 28, 2011, was scheduled to be a long day for the pilots and medical attendant flying Lifeguard N59773, a Piper PA-31-350 Navajo Chieftain operated by Trans North Aviation Ltd., doing business as Travel Care International. The crew would leave Crawfordsville, Ind., Municipal Airport (CFJ) early in the morning, then dead-head two legs to West Palm Beach, Fla., International (PBI) where they would board a patient and his wife for a two-leg flight to Chicago Executive Airport (PWK).

The crew started the day at 0700 hr.; stopped for fuel in Perry, Ga.; landed at PBI; boarded passengers; departed PBI at 1642; stopped for fuel at Jesup-Wayne County, Ga., Airport at 1830; departed Jesup at 1900. At 2250, the Chieftain crashed just 2.5 mi. north of PWK as the pilot attempted to dead-stick the fuel-starved Navajo to an off-airport landing. The pilot and two passengers were killed. A pilot-rated passenger and the medical attendant survived, but with serious injuries.

The NTSB has yet to publish a probable cause for this accident, but there is no question that the engines had stopped and the fuel tanks were empty when the airplane made its controlled descent into wooded terrain at Riverwoods, Ill. The logistics of the flight were a bit complicated.

The 58-year-old airline transport rated pilot held an airplane multiengine land rating and commercial pilot privileges for single-engine land airplanes. He held a flight instructor certificate with single-engine, multiengine and instrument airplane ratings, and a type rating in the Swearingen SA-227 Metroliner. He had passed a 1-hr. check ride in the PA-31-350 with the operator's chief pilot on June 7, 2011. The pilot had accumulated 6,607 hr. of total flight time, 120 hr. of that time in the PA-31-350. He had flown 171 hr. of total flight time in the previous 90 days, 12 hr. of that time in the Chieftain.

The pilot-rated passenger, an employee of the operating company, was 24-years-old. He held a commercial pilot certificate with single-engine land, multiengine land and instrument airplane ratings. He was a flight instructor with single-engine, multiengine and instrument airplane ratings. He had accumulated 314.3 hr. of total flight time, 259.5 hr. of PIC time, 66.6 hr. of multiengine time and 7 hr. of SIC time in airplanes associated with the operator. The operator's chief pilot told investigators that the pilot-rated passenger was compensated by the operator for the positioning flights to PBI, but was considered a passenger on the flights from PBI.

Paperwork for this flight seems a bit fragmented. The manifest for the southbound legs listed the pilot-passenger as the pilot-in-command and the senior pilot and medical crewmember as “other crew.” This form stated that the crew started their duty period at 0700 when they departed CFJ and they ended their duty period at 1430 in PBI.

Investigators said another load manifest form, also dated Nov. 28, 2011, for the PBI to JES to PWK legs lists the older pilot as the PIC and the pilot-rated passenger and medical crewmember as “other crew.” This form indicated that this crew started their duty period at 1430 at PBI. The form stated the flight departed from PBI at 1642 and landed at JES at 1830. Fueling records showed the airplane was topped-off with 165 gal. of avgas and then departed JES at 1900 destined for PWK. The duty period ending time was not completed.

Chicago area cloud tops at about 2200 hr. were at 3,000 ft. PWK was overcast at 1,400 ft. with winds out of the north at 9 kt.; visibility of 10 mi.; temperature 2 C and dew point was -2 deg. The published inbound course for PWK's ILS runway 16 approach was 161 deg. magnetic with a published straight-in DH of 893 ft. MSL (HAT 250 ft.). The crossing altitude for the locator outer marker PAMME was 2,279 ft. The distance between PAMME and the touchdown zone was 4.9 nm. The touchdown zone elevation was 643 ft. The published weather minimums for the ILS Runway 16 approach were a 300-ft. ceiling and three-quarter mile visibility. MDA altitude for the circling approach was 1,140 ft. MSL and the height above the airport was 493 ft. AGL.

Just before 2200 hr., the flight was receiving vectors from Chicago approach when the crew declared a fuel emergency reporting that the airplane was gliding without power toward Chicago Executive. Investigators were able to interview the surviving pilot-passenger and review ATC recordings to learn more about the sequence of events that led to the crash.

The pilot-passenger told investigators that the flight from PBI to PWK was routine and that the engines were operating “OK.” The right engine was new, he said, and had been installed on the airplane about 15 days prior to the flight. He believed the engine's gauges (CHT, oil temp, oil pressure) were not accurate.

The pilot “bumped up [enriched beyond POM settings] the mixture” about one gph during the en route segment, he continued, because the engine was “breaking in.” Generally, the pilot set power settings from a card that was kept in his window visor.

As the airplane approached the Chicago area near the south end of Lake Michigan, the senior pilot became concerned with the fuel situation. He switched from the main tanks to the auxiliary tanks to use all the fuel there, then switched back to the main tanks. The pilot-passenger said he observed that “the last quarter of the main tanks was consumed pretty fast as it appeared on the gauges.” The right fuel-flow warning light illuminated as the airplane maneuvered north of PWK. The pilot selected the crossfeed valve to its ON position. The fuel warning light extinguished.

The pilot radioed ATC requesting direct routing to the PWK outer marker, but the controller denied the request because of traffic, stating that she would have to vector the flight up the shoreline first. The fuel warning light illuminated again and the pilot declared an emergency. In response the controller cleared the flight directly to PWK. The pilot-passenger said he had no idea of the amount of fuel that remained in the fuel tanks. (He had studied the fuel system workings for the first time the day before the accident flight.)

Moments later, the right engine “started to shudder as the airplane descended through the overcast. The pilot initiated a left turn, leveled out on a westerly heading and then the engines quit. At that point, the pilot-passenger recalled, the airplane began to “coast.” The pilot moved the mixture to idle/cutoff, feathered the propellers and asked the pilot-passenger to look up the airplane's best glide speed. The landing gear and flaps were retracted. The pilot stayed on instruments until the airplane broke out of the overcast at about 1,400 ft. AGL.

During the descent the pilot-passenger was communicating with ATC. [See transcript for the exact communications.] The airplane turned to a southbound heading. The approach controller asked if the flight had the airport in sight and the pilot-passenger initially replied, “No.” He later told investigators he advised the pilot of suitable landing sites, but the flight was unable to get to them. With about 700 ft. to go, the pilot-passenger pointed out a dark (unlighted) spot and the pilot turned to it. The pilot-passenger said the airplane scraped the tops of trees with the first tree striking the pilot's side and then crashing through the window. Both the pilot and the pilot-passenger were on the flight controls, which then “went limp.” The pilot-passenger said he tried to keep the airplane away from nearby houses, but both of his yoke handles broke off.

The Wreckage

The airplane crashed into trees and terrain in a wooded residential neighborhood about 3 nm northeast of PWK. There was no post-impact fire. Neighbors and first responders rushed to the scene and assisted the two survivors, who were extricated and transported to a local hospital.

The wreckage path was 250 ft. in length from the first impacted tree to the main wreckage and on a magnetic heading of about 130 deg. The airplane was found fragmented along the path. The left propeller separated from its engine and was found 32 ft. west of the main wreckage.

The on-site inspection located the fuselage, empennage, wings and all flight control surfaces within the wreckage debris path. The landing gears were found in the up position in their wheel wells. The left and right throttle levers were found in the full forward position. Both left and right mixture levers were found in the forward rich position. The left and right propeller levers were found in the forward high rpm position. Left- and right-engine control and flight control continuity were established.

All four magneto switches were in the ON position. The left fuel boost pump switch was in the ON position and the right fuel boost pump switch was in the OFF position. Both the left and right fuel tank selectors were positioned on their respective inboard fuel tanks. The crossfeed valve was found in the ON position. All fuel caps were in place in their filler necks. Approximately 1.5 oz. of a liquid consistent with avgas was found within the airplane fuel system. All four electric fuel pumps were operational when electrical power was applied to them. The flap jackscrew extension was consistent with the flaps being in the up position.

Both engines' crankshafts were rotated and each engine exhibited gear and valve train continuity. All cylinders produced thumb compression and suction. Both dual magnetos produced sparks at all leads. All removed spark plugs exhibited the appearance of normal combustion when compared to the Champion AV-27 spark plug chart. Both engines' turbocharger impellers spun when rotated by hand. The left and right propellers were found in the feathered position. No airframe or engine pre-impact anomalies were found.

The Investigation

Investigators looked into the pilot's performance and certification along with flight planning. An autopsy was performed on the pilot by the Lake County Coroner's Office. The study listed multiple traumatic injuries as the cause of death. The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report on toxicological samples taken during the autopsy. The report, in part, stated that traces of marijuana were detected in his tissues. A pre-employment drug test on April 14, 2011, reported negative indications of drug use.

The pilot-passenger told Safety Board investigators “the pilot acted abnormally sporadic and weird in Florida,” but the investigator's report does not elaborate.

The pilot held a first-class medical certificate, dated Feb. 15, 2011, with limitations for hearing amplification and corrective lenses. The pilot previously reported to the FAA that he had a history of convictions for driving under the influence on both May 31, 2002, and Feb. 1, 1997.

The operator initiated a background check in accordance with the Pilot Records Improvement Act of 1996 (PRIA) on the pilot. This check showed his training records and check rides at previous employers and also revealed no legal enforcement actions resulting in a finding of a violation pertaining to the pilot. It listed a possible match and gave contact information for a Department of Transportation Compliance and Restoration Section in reference to checking the pilot's driver's record. The operator did not get that background check but was aware of the pilot's history of convictions.

The passenger-pilot said that the senior pilot had done all the flight planning for the trip. Investigators could not locate the original flight planning records but were able to re-create the navigation logs in consultation with FltPlan.com — the resource used by the pilot for his planning.

The accident flight plan showed a proposed departure time from JES of 1708, a proposed cruising altitude of 10,000 ft. MSL en route to PWK, 5 hr. of fuel on board, and it listed DuPage Airport as an alternate airport.

The flight plan logs showed that the 182 gal. of usable fuel available for the Piper Chieftain should have been sufficient for all flight legs that day. The final accident leg from JES to PWK would have required the most fuel. FltPlan.com calculations assumed a fuel burn rate between 34-37 gph for cruise and the operating manual indicated a fuel burn between 26-35 gph (depending on the power setting) with the engines leaned to best economy. The average actual fuel burn computed for the flight legs flown on Nov. 28, 2011, was 47 gph.

Fuel records recovered from the wreckage indicated that the airplane was filled to its capacity with fuel at CFJ, PXE and at JES. The fuel records also indicated that only 75 gal. of fuel were added at PBI. A nominal fuel burn rate of 30 gph would indicate that landing with a minimum of 22.5 gal. of fuel would meet the 45-min. IFR fuel reserve requirement: With the Chieftain's 182 gal. of usable fuel, the maximum amount of fuel that should be added after a flight conducted under instrument flight rules is 159.5 gal. N59773 was serviced with 167.3 gal. and 165.0 gal. at PXE and JES, respectively.

The fuel system consisted of fuel cell, engine-driven and emergency fuel pumps, fuel boost pumps, control valves, fuel filters, fuel-pressure and fuel-flow gauges, fuel drains and non-icing fuel tank vents. Fuel could be stored in four flexible fuel cells, two in each wing. The outboard cells hold 40 gal. each and the inboard cells hold 56 gal. each, giving a total of 192 gal., of which 182 gal. were usable.

The fuel management controls were located in the fuel control panel at the base of the pedestal. Located here were the fuel tank selectors, fuel shutoffs and crossfeed controls. During normal operation, each engine was supplied with fuel from its own respective fuel system. The fuel controls on the right controlled the fuel from the right cells to the right engine and the controls on the left controlled the fuel from the left fuel cells to the left engine. For emergencies, fuel from one system can supply the opposite engine through a crossfeed system. The crossfeed valve was intended only for emergencies. The crossfeed control was located in the center of the fuel control panel. A warning light, located on the fuel control panel, was incorporated in the firewall fuel shutoff system to indicate that one or both of the shutoff valves were not fully open.

Right and left fuel-flow warnings lights, mounted at the base of the windshield divider post, illuminated to warn the pilot of an impending fuel-flow interruption. A sensing probe mounted near each inboard fuel tank outlet activated the lights. In the event the fuel level near the tank outlet dropped to a point where a fuel-flow interruption and power loss could occur, the sensing probe would illuminate its corresponding warning light. The warning light would be on for a minimum of 10 sec. and would remain on if the condition were not corrected.