MIA01FA077
MIA01FA077

HISTORY OF FLIGHT

On February 13, 2001, about 1816 eastern standard time, a Cessna 182J, N979ND, registered to Apex Aviation, Inc., experienced a loss of engine power shortly after takeoff from the Witham Field Airport, Stuart, Florida, and collided with trees following a forced landing on the Martin County Golf & Country Club golf course. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was destroyed by postcrash fire and the private-rated pilot, and pilot-rated passenger were fatally injured. The flight originated about 1621, from the Witham Field Airport, Stuart, Florida.

The accident pilot flew the airplane from Witham Field Airport, Stuart, Florida, to the North Palm Beach County General Aviation Airport, West Palm Beach, Florida, where one of the two passengers was dropped off. That flight departed Witham Field Airport at 1621:10, as determined by a transcription of communications, and was uneventful lasting approximately 20-30 minutes according to the passenger who was dropped off. The passenger further stated that a walker (walking aid device) was positioned next to him, and after landing, the pilot secured the engine but he was not sure if the pilot or other passenger exited the airplane. The passenger who was dropped off reported he did not hear the engine of the accident airplane restart nor did he witness the flight depart. It was later determined no fuel was purchased while at the North Palm Beach County General Aviation Airport.

According to a transcription of communications with the Witham Field Airport ATCT, the pilot made contact with the facility at 1803:31, and advised that the flight was approximately 7 miles southwest inbound for touch-and-go landings. The controller advised the flight to report right base for runway 12, and gave the wind and altimeter setting. The pilot acknowledged and the flight continued. At 1806:10, the controller advised the flight that the airplane was in sight and advised the flight to turn base, which was acknowledged. The flight continued and at 1807:00, the controller cleared the flight for a touch-and-go landing with left hand traffic pattern; this transmission was acknowledged. The flight continued and at 1811:59, the controller cleared the flight for another touch-and-go landing which was acknowledged by the pilot. The transcription of communication further indicates that at 1815:20, the pilot-in-command advised the controller, "ah niner november delta got a niner november delta niner november deltas landing on the golf course." The controller questioned if the engine had quit to which the pilot responded, "...we've lost our engine." There were no further recorded communication with the ATCT from the pilot. An acquaintance of the pilot verified by listening to a copy of the voice tape that the communications from the airplane contained in this paragraph were from the pilot-in-command.

Several witnesses reported hearing the engine either "sputter", "backfire", or misfire when the flight was climbing out along the length of runway 12. One of the witnesses who is a mechanic reported hearing the engine misfiring when the airplane was climbing out at the intersection of runway 12 and taxiway "C." The airplane leveled off at 100 feet and the engine quit misfiring. He then heard the engine "running rough again", and observed the airplane turning for what he thought was to return to the airport. Several of the witnesses stated that the airplane banked left then lost sight of the airplane due to obstructions. They then heard an impact and observed a fireball.

According to a flight medic who spoke with the pilot-in-command (PIC) after the accident, the PIC reported that the engine quit. The flight medic also stated that the PIC reported that he attempted numerous times to rescue the passenger but was unable. Copies of the witness statements are an attachment to this report.

PERSONNEL INFORMATION

The pilot-in-command who was seated in the left seat was the holder of a private-rated pilot certificate with ratings airplane single engine land, multi-engine land, instrument airplane. The multi-engine was limited to VFR only. He was issued a third class medical certificate on December 10, 1999, with the limitation that he must have available glasses for near vision. His medical application indicated he had accumulated a total time of 425 hours. Review of his pilot logbook that begins with an entry dated January 7, 1980, and ends with an entry dated January 22, 1999, revealed that he logged a total flight time of approximately 363 hours, of which, approximately 92 hours were in the accident airplane. His logbook reflects a gap in flying with one entry dated October 1984, and the next entry line dated April 1994. Records provided by Apex Aviation, Inc., indicate that he was billed for 75.8 hours of flight time between January 1999, and January 2001.

The passenger who was seated in the right seat was the holder of a commercial pilot certificate with the ratings airplane single and multi-engine land, instrument airplane. He was also the holder of a certified flight instructor (CFI) certificate with the ratings airplane single and multi-engine, instrument airplane. His flight instructor certificate was scheduled to expire February 28, 2002. His second class medical certificate was issued on August 28, 1998. His wife reported that he had accumulated a total flight time of approximately 5,000 hours and stopped logging flight time on February 17, 2000.

AIRCRAFT INFORMATION

The airplane was last inspected in accordance with a 100-hour inspection that was signed off on October 3, 2000. The airplane time since the inspection was not determined.

METEOROLOGICAL INFORMATION

A METAR weather observation taken at the Witham Field Airport at 1817, indicates that the wind was from 110 degrees at 7 knots. The visibility was 15 statute miles, scattered clouds existed at 4,000 and 15,000 feet. The temperature and dew point were approximately 72 degrees and 66 degrees, respectively. The altimeter setting was 30.25 inHg.

COMMUNICATIONS

The pilot was in contact with the Stuart Air Traffic Control Tower. A transcription of communications is an attachment to this report.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed onto the Martin County Golf and Country Club golf course, Stuart, Florida. The crash site was located at 27 degrees 10.98 minutes North latitude and 080 degrees 12.72 minutes West longitude. That location when plotted was located approximately 071 degrees and .56 nautical mile from the center of the Witham Field Airport.

Examination of the accident site revealed the top of a tree was damaged approximately 35 feet above ground level. A ground scar made by all landing gears was noted on the grass of a fairway and was located approximately 160 feet laterally from the damaged tree. The ground scar made by the nose landing gear was not centered on the ground scars made by both main landing gears; it was closer to the right main landing gear. A rut in the ground approximately 5 inches deep and 10 feet in length was associated with the nose landing gear which separated from the airplane and was found forward of the rut. Seven slash marks nearly perpendicular to the ground scar were noted beginning at the end of the rut made by the nose landing gear. The distance between the first and second ground scars measured 3 feet 5 inches (see TESTS AND RESEARCH SECTION of this report). A distance of approximately 34 feet was noted between the end of the first ground scar made by the nose landing gear and the beginning of the second ground scar from the remains of the nose landing gear. The airplane slid across a concrete sidewalk and impacted a palm tree with the left wing. Another tree impact was noted with the right wing. The airplane came to rest upright on a magnetic heading of approximately 012 degrees among a stand of palm trees.

Examination of the airplane at the accident site revealed that both wings were nearly separated from the airplane; both remained attached by the aileron flight control cables. The left wing was noted on the left side of the fuselage; a portion of the wing was resting beneath the empennage and was nearly consumed by post crash fire. The right wing was laying on the right side of the fuselage nearly parallel to the longitudinal axis of the airplane; the aft portion of the tank was damaged by postcrash fire. The cabin was consumed by fire from the firewall aft to the location of the main landing gear. No evidence of in-flight fire was noted on the structure of the airplane or in the engine compartment area. Flight control cable continuity was confirmed for roll, pitch, and yaw. The fuel selector was found in the detent positioned to the right fuel tank; no obstructions through the valve were noted when air was blown through all ports. The co-pilots seatbelt and shoulder harness was found buckled; the webbing was burned away and the buckle was noted to easily release post accident. A walker was found in the cabin of the airplane. The airspeed indicator was recovered and found to be indicating 68 miles per hour. An emergency locator transmitter was not located. The engine was removed from the airplane for examination.

Examination of the engine revealed crankshaft, camshaft, and valve train continuity. Examination of one of the propeller blades revealed evidence of coarse chordwise scratches on the leading edge of one of the blades. Both propeller blades were bent. The carburetor sustained heat and impact damage; the inlet screen was examined and found to contain a slight amount of black colored foreign substance. The heat damaged oil filter was removed and cut open; no metal particles were noted. A serviceable oil filer was installed. One of the heat damaged induction pipes and associated flexible coupling were replaced. The engine was placed on a test stand with the impact damaged propeller and impact and heat damaged carburetor installed. The engine was started and operated to approximately 2,600 rpm; normal oil pressure was noted during the engine run. The engine was operated several times for a total engine run of greater than 13 minutes, one engine run lasted approximately 8 minutes. The rpm decreased approximately 400 rpm when testing the right magneto, and approximately 100 when checking the left magneto. Heat damage was noted to the No. 2 and 4 bottom ignition leads; both of which are routed to the right magneto. Additionally, the exhaust gas temperature and cylinder heat temperatures on the Nos. 2 and 4 cylinders were noted to be lower than the other cylinders when tested using a digital probe. Differential compression readings of each cylinder after the engine run revealed that each was at or above 58 psi using 80 psi as a base. The carburetor was retained for further examination (see TESTS AND RESEARCH section of this report).

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot survived the accident but died in a hospital on February 15, 2001, about 2355 local hours. A postmortem examination of the pilot was performed by M. Scott McCormick, M.D., of District Thirteen Medical Examiner's Office, located in Tampa, Florida. The cause of death was listed as 92 percent Total Body Surface Area thermal burns and inhalation injuries. Toxicological analysis of specimens of the pilot obtained on his initial admittance into the hospital was performed by the District Thirteen Medical Examiner's Office. The FAA Toxicology and Accident Research Laboratory (CAMI) performed analysis of postmortem specimens. The results of analysis by the Medical Examiner's Office were negative for alcohol, and cyanide. Morphine (.14 mg/l), and carbon monoxide (4% saturation) were detected in the ante mortem blood specimen. The results of analysis by CAMI was negative for carbon monoxide, cyanide, and volatiles. Morphine was detected in blood (.604 ug/g), liver (1.078 ug/g), and bile (31.24 ug/g). Hydromorphine (unquantified) was detected in bile, and acetaminophen (1.893 ug/g) was detected in blood. Copies of the toxicological reports are an attachment to this report.

Postmortem examination of the passenger was performed by Charles A. Diggs, Associate Medical Examiner, of District Nineteen Medical Examiner's Office, located in Ft. Pierce, Florida. The cause of death was listed as blunt trauma to head; smoke inhalation was listed as a contributory cause of death. Toxicological analysis of specimens of the passenger were performed by CAMI and Wuesthoff Reference Laboratory (Wuesthoff). The results of analysis by CAMI were negative for carbon monoxide, cyanide, and volatiles. Acetaminophen (36.086 ug/g) and quinine (not quantified) were detected in urine. The results of analysis by Wuesthoff was positive in the blood for caffeine, and carbon monoxide (1.2 percent saturation). No other tested drugs or volatiles were detected. Copies of the toxicology reports are an attachment to this report.

According to the passenger's wife, her husband was first diagnosed with amyotrophic lateral sclerosis (ALS), commonly called Lou Gehrig's disease, on July 2, 1999. She reported that her husband was able to walk with the aid of a walker, and he was able to walk a few steps "not much" without the walker. He did not renew his medical certificate when it was scheduled to be renewed in March or April. She stated that as far as she knew, her husband was flying with the pilot who was going to practice commercial maneuvers.

TESTS AND RESEARCH

The carburetor was examined at the manufacturer's facility with FAA oversight. According to a report prepared by the manufacturer, examination of the data plate of the carburetor revealed "10-4893-1" was stamped over "10-5192." Flow testing of the carburetor was not possible due to impact damage. Disassembly of the carburetor revealed an economizer restrictor installed in the throttle body. According to personnel from Precision Airmotive Corporation, the economizer restrictor is not specified to be installed in carburetor model 10-4893-1, while it is installed in model 10-5192. A carburetor was assembled from parts duplicating the makeup of the accident carburetor and was flow tested with FAA oversight against the carburetor specified by the engine manufacturer. Flow testing revealed that the unit was within limits at the first test point and flowed an average of 6.2 pounds per hour greater than specified at the remaining four test points. Copies of the report of the carburetor examination and of the flow testing are an attachment to this report. A copy of the statement from the FAA inspector who witnessed the disassembly and flow testing is also an attachment to this report.

Review of the airplane maintenance records revealed that the carburetor was converted from part number (P/N) 10-5192 to P/N 10-4893-1. The work order dated March 17, 1999, indicates that the discharge nozzle was replaced, a valve assembly and metal float were also installed. A copy of the work order and serviceable tag are an attachment to this report. Excerpts from the maintenance records are an attachment to this report.

The carburetor specified for this airplane and engine is carburetor number 10-4893-1.

On the day and accident city location, the sunset was calculated to have occurred at 1812 hours and the end of civil twilight was calculated to have occurred at 1836 hours.

Using a computer program, the engine/propeller rpm was calculated to be 872 at the point of the first and second propeller ground scars. The calculations were based on: a) the distance between the first and second ground scars made by the propeller, b) the ground speed in feet per second based on the position of the airspeed indicator, c) the number of propeller blades, d) engine to propeller gear ratio, and e) diameter of the propeller. A copy of the printout from the program is an attachment to this report.

The airplane was fueled last on February 11, 2001, from the Stuart Jet Center, located on the Witham Field Airport, and was flown on 2 flights lasting a total of approximately 2.1 hours since fueling before the accident pilot flew the airplane. No water was found in the fuel tank that fueled the airplane last. Additionally, the facility that fueled the airplane last has a filter that absorbs water and stops the flow of fuel when loaded with water or dirt. The filter was replaced last November 20, 1999. Testing of a fuel sample taken by FAA the day after the accident from the facility that fueled the airplane last revealed no discrepancies. A copy of the statement from the FAA inspector who obtained the sample and tested the tank for water is an attachment to this report. A copy of the fuel analysis report is also an attachment to this report.

ADDITIONAL INFORMATION

The wreckage minus the retained carburetor was released to Kevin Twiss, "owners representative" of Phoenix Aviation Managers, Inc., on February 21, 2001. The retained carburetor was also released to Kevin Twiss, on January 18, 2002.

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