ERA10FA150
ERA10FA150

HISTORY OF FLIGHT

On February 25, 2010, about 0927 eastern standard time, a Hawker Beechcraft Corporation C23, N180ED, registered to Skyway Leasing, Inc., and operated by Tailwheels ETC, Inc., had a loss of engine power during the takeoff climb and impacted the ground approximately .6 statute mile west-northwest from the center of Winter Haven’s Gilbert Airport (GIF), Winter Haven, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from GIF to Lakeland Linder Regional Airport (LAL), Lakeland, Florida. The airplane sustained substantial damage and the certificated private pilot and one passenger were killed. The flight originated from GIF about 0925.

The operator reported that the pilot was allowed to fly the airplane and only had to reimburse them for the fuel cost.

Numerous witnesses at the operator’s facility saw both occupants before takeoff. One witness reported the passenger came into the building and asked to borrow a fuel sample device. Another witness saw the passenger check the right wing fuel tank, while a witness who is a student pilot heard an engine accelerate consistent with an engine run-up, but he walked inside the building and did not pay attention. The airplane was observed to taxi to the approach end of runway 29, and was noted to be airborne before the first intersection.

A pilot-rated witness who was outside near the departure end of runway 29 reported that he first saw the airplane when it was over the departure end of runway 29. At that time he thought the airplane was at 150 feet above ground level (agl) in a wings level normal Vy climb attitude. Approximately 5 seconds later while the airplane was at an estimated altitude of 200 to 300 feet agl, the engine “just stopped” as if an occupant had pulled the mixture back. The nose pitched down an estimated 5 degrees in his opinion in order to gain airspeed, and the airplane banked to the right an estimated 30 degrees. He didn’t think the nose was low enough to maintain airspeed. He knew the airplane was too low to return and perceived the airplane was flying slow. He lost sight of the airplane behind trees then heard the impact. He reported there was no sputtering, no smoke, and the engine suddenly went from running to quitting. Had it sputtered he would have been able to hear that. He also said that he did not see any parts separate from the airplane. After hearing the crash he drove to the scene and when he arrived there, sheriff’s office personnel were already on-scene tending to the occupants.

Another pilot rated witness located at the operator’s facility reported looking outside the window and saw the airplane in a nose-high pitch attitude and right bank estimated to be between 60 and 70 degrees. The witness then reported that the airplane began “dropping fast” to the right. He kept watching but the airplane disappeared behind trees.

PERSONNEL INFORMATION

The pilot, age 45, held a private pilot certificate with airplane single engine land rating issued January 1, 2000, and held a 2nd class medical certificate issued October 7, 2009.

Review of the pilot’s pilot logbook revealed the first flight logged was March 5, 1999, and the last flight logged was January 11, 2010; he logged a total time of 468.9 hours. There were no logged flights between November 22, 2003, and October 4, 2008. He only logged flying the accident airplane five times lasting a total of 5.7 hours. All flights in the accident airplane were logged as pilot-in-command. The five flights occurred between December 6, 2009, and December 16, 2009. There was no record of a sign off by a certified flight instructor for instruction in the accident airplane, although the operator reported it was their standard operating procedure to require a checkout.

The pilot’s last flight review in accordance with 14 CFR 61.56 occurred on October 16, 2009.

AIRCRAFT INFORMATION

The airplane was manufactured in 1974 by Beech Aircraft Corporation as model C23, and was designated serial number M-1622. It was powered by a 180 horsepower Lycoming O-360-A4J engine and equipped with a Sensenich fixed pitch propeller.

Review of the maintenance records revealed the airplane was last inspected in accordance with an annual inspection on April 10, 2009, and the last 100-Hour inspection was performed on August 12, 2009. The airplane total time at the annual and 100-hour inspections were recorded to be 5,841.8 and 5,939.79 respectively. The airplane total time at the time of the accident was approximately 6,003 hours.

Further review of the maintenance records from the first entry related to certification after manufacturing, to the last entry dated February 23, 2010, revealed no direct entry indicating the fuel selector valve was removed and replaced or repaired. The manufacturer of the valve reported there is no required overhaul interval; the part is an on condition part.

METEOROLOGICAL INFORMATION

A surface observation weather report taken at GIF at 0853, or approximately 34 minutes before the accident indicates the wind was from 330 degrees at 13 knots, clear skies existed. The temperature and dew point were 7 and minus 2 degrees Celsius respectively, and the altimeter setting was 30.09 inches of Mercury.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site revealed that the airplane first ground contact was located on a grass median between the east and westbound lanes of 92. The next ground contact was noted to be with concrete curbing on the south edge of the westbound lanes. A ground scar on the two westbound lanes was oriented on a magnetic heading of 045 degrees. Two parallel oriented ground scars consistent with propeller blade contact were noted in beginning area of the road ground contact location. The distance between the two was noted to be 57.5 inches. The airplane came to rest approximately 103 feet from the concrete curb contact location.

Examination of the wreckage revealed the airplane came to rest in a ditch located on the north side of the westbound lanes of 92. The right wing was separated at the wing root and also at the outboard edge of the fuel tank; the left wing remained connected by one aileron flight control cable, electrical wires and the brake line. The fuselage was resting on its left side, and the aft fuselage was separated approximately 4 feet 6 inches aft of the main spar. The firewall with attached engine mount, engine, and propeller were separated but found in close proximity to the main wreckage. All components necessary to sustain flight were found in close proximity to the main wreckage. Examination of the flight control system for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. No obstructions of the fuel supply system were noted from either fuel tank to the engine compartment, and no obstruction of the fuel vent system was noted. The flaps were retracted.

Examination of the cockpit revealed the ignition switch was in the both position, and the short end of the fuel selector handle which points to the tank selected was in the off range. No air could be blown thru the valve in the as-found position of the valve. The fuel selector valve, handle, plastic shroud and guard were retained for further examination. The throttle quadrant which separated from the structure was examined and the throttle cable was separated from the end fitting at the throttle quadrant. The other end of the cable remained secured to the carburetor. The throttle cable was retained for further examination. The carburetor heat was cold, and the mixture control was 2 inches back from full rich. The mixture and carburetor heat control cables remained secured to their respective attach points in the engine compartment.

Visual examination of the engine revealed the carburetor bowl contained approximately 1 ounce of blue colored fuel consistent with 100 low lead (100LL). All engine controls remained attached to their respective lever arms. The throttle valve, mixture control, and carburetor heat controls were found in the mid-range position. Examination of the spark plugs exhibited gray color combustion deposits. The top spark plugs exhibited advanced wear, while the bottom spark plugs exhibited slight wear. The gap settings for all spark plugs were normal. Borescope examination of each cylinder revealed no anomalies. Crankshaft, camshaft, and valve train continuity was confirmed. The engine with attached engine mount was placed on a test stand for an attempted engine run and a test club propeller shorter in diameter than the accident propeller was installed. The engine was started and operated. During the test run a magneto drop of 200 rpm was noted from one of the magnetos. The top spark plugs from the Nos. 2 and 4 cylinders were replaced and the engine was restarted. The magnetos were checked and the left and right decreased 150 and 200 rpm, respectively. The oil pressure was normal during the engine run and the idle was smooth at 650 rpm. Both magnetos were retained for further examination.

Examination of the propeller revealed one blade was bent aft approximately 180 degrees and exhibited course chordwise scratches on the blade tip. The other blade was bent aft approximately 30 degrees with leading edge twist towards low pitch, and chordwise scratches at the tip. The blade also exhibited spanwise scratches inboard of the tip.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examinations of the pilot and passenger were performed by the Office of the District Medical Examiner, Winter Haven, Florida. The cause of death for both was listed as “Blunt Impact to Head and Torso.”

Forensic toxicology was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma, and also by the University of Florida Diagnostic Reference Laboratories (University of Florida). The toxicology report by CAMI indicated the results were negative for carbon monoxide, cyanide, and volatiles. An unquantified amount of Atropine was detected in the liver and blood specimens. The toxicology report by University of Florida was negative for volatiles and the comprehensive drug screen.

Forensic toxicology was performed on specimens of the passenger also by CAMI and University of Florida. The toxicology report by CAMI indicated the results were negative for carbon monoxide, cyanide, and volatiles. Unquantified amounts of atropine, etomidate, and midazolam were detected in the liver specimen, and an unquantified amount of atropine was also detected in the blood specimen. Etomidate (0.03 ug/mL) was detected in the blood specimen, and varying amounts of Fentanyl were detected in the lung, kidney, muscle, and blood specimens. Midazolam (0.015 ug/mL) was detected in the blood specimen. The toxicology report by University of Florida was negative for volatiles. Laudanosine and lidocaine were detected in the comprehensive drug screen.

TESTS AND RESEARCH

Examination of the throttle cable was performed by the Safety Board’s Materials Laboratory located in Washington, D.C. The examination determined that the end fitting in the area of the throttle quadrant was bent approximately 10 degrees. Inspection of the ends of the wire strands of the separated cable revealed all were tightly wound together and the ends of each strand were cut in a manner consistent with an anvil cutter. Comparison of the crimp of the end fitting near the carburetor and at the throttle quadrant revealed no perceptible differences in the amount of crimping; the failure mode was consistent with the cable pulling from the end fitting at the throttle quadrant during separation of it from the airplane.

The airplane was last fueled at GIF by Winter Haven Air Services on January 28, 2010. A total of 17.8 gallons of 100 low lead (100LL) fuel were added. The president of Winter Haven Air Services reported that on the same day they also fueled 21 other airplanes dispensing a total of 533.5 gallons; there were no fuel related problems reported. Additionally, the operator of the airplane reported that they had not experienced any issues related to the quality of the fuel they received from Winter Haven Air Services.

A pilot and mechanic who flew the accident airplane the day before reported that during the preflight inspection the fuel tanks were noted to be within 1 inch of being full. They flew in the traffic pattern; the flight duration was between .3 and .5 hour. That flight was performed with the fuel selector positioned to the left tank and it was not moved during or after the flight. A CFI with the operator visually looked into both fuel tanks before the accident flight departed and noted the level of fuel in both was within 2 inches from the top of the tank.

Testing of an exemplar airplane by a representative of the airframe manufacturer was performed in an effort to determine the reported fuel level in each tank before engine start of the accident flight. The testing revealed that each tank contained approximately 22.1 gallons usable fuel.

Weight and balance calculations were performed using the latest airplane empty weight (1,602.5 pounds), the weights of the pilot and passenger per the autopsy reports (228 and 338 pounds respectively), and the amount of fuel in each tank determined by testing of an exemplar airplane (22.1 gallons usable fuel). The airplane weight and center of gravity were calculated to be approximately 2,434 pounds and 112.66 inches aft of datum. The airplane type certificate data sheet indicates that the gross weight is 2,450 pounds, and the center of gravity limits at approximately 2,434 pounds are approximately 114.2 to 118.3 inches aft of datum for a normal category operation.

Examination of both magnetos was performed with Safety Board oversight at a Federal Aviation Administration (FAA) certified repair station. The internal timing of the left magneto was correct. The magneto was placed on a test bench as received with a slave ignition harness and 5 mm gaps. The impulse coupling operated normally, and the magneto was noted to operate intermittently at 400 rpm. No other intermittent firing was noted during which time the magneto was operated between 643 and 4,204 rpm and noted to spark at all 5 mm gaps. The contact spring heights of all positions was measured and found to be .422 inch (specification is .422 inch). The e-gap measured 10 degrees (specification is 6 to 14 degrees). The contact points were pitted; because of this the point gap could not be checked. The distributor gear was missing 1 tooth, but this did not affect the timing. The carbon brush and the distributor gear electrode were unremarkable. The distributor block was checked for carbon tracks; none were found. The capacitor checked .3 microfarads (specification is .34 to .41 microfarads). The coil primary resistance tested .3 ohms (specification is .2 to .6 ohms), and the coil secondary resistance tested 14,000 ohms (specification is 12,000 to 16,000 ohms).

Examination of the right magneto revealed the internal timing was correct. No missing teeth were noted on the distributor block. The magneto was placed on a test bench as received with a slave ignition harness and 5 mm gaps; the impulse coupling operated satisfactory. The magneto was operated between 643 and 4,204 rpm and noted to spark at all 5 mm gaps; intermittent firing was noted at 643 magneto rpm. The points were visually inspected and appeared satisfactory. The e-gap measured 12 degrees (specification is 6 to 14 degrees). The point gap measured 0.013 inch (specification is 0.012 to 0.024 inch). The carbon brush and the distributor gear electrode were unremarkable. The distributor gear was missing a nylon washer P/N 10-391309; however, an extra washer, P/N 10-606505 was noted to be installed. The distributor block was checked for carbon tracks; none were found. The capacitor checked .3 microfarads (specification is .34 to .41 microfarads). The coil primary resistance tested .3 ohms (specification is .2 to .6 ohms), and the coil secondary resistance tested 14,000 ohms (specification is 12,000 to 16,000 ohms).

Visual inspection of the ignition switch revealed the P-leads were securely connected to the back of the switch but the shielded wire connected to the left terminal was separated 52 inches from the terminal splice and the shielded wire connected to the right terminal was separated 61 inches from the terminal splice. Testing of the P-leads and shielding revealed no continuity when either lead was moved back and forth all along its length. The ignition switch operationally tested satisfactory.

Airworthiness Directive (AD) 85-05-02, applicable to the accident airplane, required modification of the fuel selector guard by installation of a “Selector Stop” and also by installation of a decal P/N 169-920039-3. The AD referenced Beechcraft Mandatory Service Bulletin 2053, which in part depicts a decal required to be installed at the fuel selector and also depicts radial lines on the selector stop in-line with radial lines on the fuel selector guard associated with the left and right main tank detent positions. The permanent maintenance records indicate that AD 85-05-02 was originally complied with during an annual inspection on December 13, 1985. Additionally, the limitations section of the Pilot’s Operating Handbook and FAA Approved Airplane Flight Manual depicts a placard near the fuel selector that is consistent with the decal illustration listed in the service bulletin.

The fuel selector valve has four detents, one each for the left and right positions, and two off positions. A one-piece handle attached to the fuel selector valve has in part one end that resembles a blunt point; the upper surface of the point has a raised surface called an "arrow" that also resembles a blunt point. The side of the handle with the raised arrow points to the desired fuel tank to supply fuel to the engine, or to one of the two "off" positions. The arrow and handle by design are painted with white epoxy and red epoxy paint, respectively. A fuel selector guard made of plastic surrounds the fuel selector valve; a safety feature consisting of a stainless steel spring ("fuel selector stop") was installed in accordance with AD 85-05-02 to prevent inadvertent movement of the fuel selector to the "off" detent position. Further inspection of the fuel selector guard revealed it did have three individual placards labeled “L Tank 26 Gal”, “R Tank 26 Gal” and “off”. The portion of the shroud beneath the lower edge of the fuel selector stop exhibited two green line radial marks consistent with the positions of the left and right tank detents; however, the fuel selector stop did not exhibit continuation of either green line radial onto the full width of the stop, nor did the shroud exhibit continuation of the green line radials above the upper edge of the stop. The shroud also did not exhibit a red line arc above the upper edge of the fuel selector stop between the green line radials, nor did it have red arcs adjacent to the slots in the fuel selector guard.

Postaccident operational testing, disassembly, and re-assembly of the fuel selector valve was performed at the manufacturer’s facility with Safety Board oversight approximately 7 months after the accident. Although the valve did contain a portion of a metal-like data plate, no complete markings were visible. The airplane manufacturer reported the Beech part number (P/N) and manufacturer’s P/N for the valve are 169-3800086-1 and A-980-3, respectively. All detent positions could be felt. The unit was bench tested as received which revealed it failed due to excessive leakage from the “out” port when tested in both “off” positions at approximately 5.0 psi. The leakage amount was noted to be 500 mL a minute (maximum allowed leakage is 2 cc a minute). Each respective inlet port was then separately pressurized with the fuel selector positioned to the opposite tank; fuel leakage was noted from the outlet port. The fuel selector was then disassembled and the surface finish of the sealing side of the selector plate was 24 microfinish (specification is 4 microfinish). Inspection of the surface revealed multiple sets of full diameter scratch marks. All new o-rings were installed and the unit was re-assembled and returned to the test bench. No leakage was noted after replacement of the o-rings.

Section 3 of the Shop Manual specifies that the fuel selector valve should be checked at the 100 hour and annual inspection for proper engine shutdown and freedom of movement, and Section 5 of the Shop Manual specifies that during a 100 hour inspection, the fuel tank selector is to be checked “…for proper operation and freedom of movement.” The preface of the Shop Manual indicates that the inspection guide is not intended to be all-inclusive, for no such guide can replace the good judgement of a certified airframe and powerplant mechanic in the performance of his or her duties. The preface also indicates the guide may be used as an outline, but detailed information of the many systems and components in the airplane will be found in the various sections of this shop manual and the pertinent vendor publications.

As previously reported, the airplane was inspected in accordance with 100-Hour and annual inspections. The entry for the last 100-Hour inspection specifies the airplane was inspected in accordance with “AIRS Single Engine Generic Fixed Gear Periodic Checklist.” Review of this checklist revealed it contained an item indicating to check the fuel shutoff and check the fuel selector valve for proper operation. The mechanic who performed the inspection stated that during the inspection, he would have moved the fuel selector to the off position then accessed the fuel strainer. Additionally, he reported that as part of his normal procedure, he would have operated the engine at a setting slightly higher rpm than idle and moved the fuel selector to the off position and waited for the engine to “stumble.” He stated that in his opinion both tests would be adequate to detect an internal discrepancy with the fuel selector valve.

The mechanic who performed the last annual inspection reported the checklist she used was the same checklist as the one used for the 100-Hour inspection. She stated that she did check the fuel selector valve for proper operation, but did not perform a test of the fuel selector for engine shutdown with the engine operating. Rather, during the inspection, she moved the fuel selector to the off position and opened the fuel system at the fuel strainer. When asked what procedures she would perform to operationally test the fuel selector valve for engine shutoff she stated that she would run the engine and expected the engine to quit but would not be sure at what power setting and could not guess how long the engine would run.

Calculations were performed in an effort to determine engine rpm at the moment of ground contact by the propeller blades. Using the formula:

Propeller RPM= 1,212 multiplied by the estimated ground speed in knots (67) divided by the distance between the slash marks (57.5 inches) X number of propeller blades (2). The calculations revealed that based on the estimated stall speed at the point of ground contact, the engine rpm was approximately 706.

A previous NTSB investigation involving a Beech C23, N6645P, NTSB Case # MIA00FA177, which occurred on May 30, 2000, near Smyrna, Tennessee, revealed the fuel selector was leaking beyond acceptable limits in both “off” positions. During the investigation the accident fuel selector was placed in the same make and model airplane and with the engine operating at full static rpm (2,250) and the fuel selector in either of the “off” positions, the engine continued to operate more than 2 minutes and did not secure the engine.

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