Pilot Debrief

BEECH C23 near Carrollton, GA — 2011-03-04

Final reportERA11LA179
Sign in to save
Date
2011-03-04
Location
Carrollton, GA, USA
Airport
CTJ
Aircraft
BEECH C23
Registration
N6015F
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Initial climb

Probable cause

The mechanic's failure to re-connect a fuel line following an annual inspection. Contributing to the accident was the pilot's improper decision to depart with a known mechanical deficiency.

NTSB narrative

According to the pilot, the purpose of the flight was to pick up the airplane after the completion of an annual inspection. He said that the inspection was completed, and during the engine start, the fuel pressure gauge showed no pressure; however, the engine started and ran normally with no anomalies noted during the takeoff or initial climb. About 2,000 feet mean sea level and 4 miles from the airport, smoke was observed coming from the engine cowling and the engine ran roughly. Witnesses stated that smoke and flames trailed from the airplane as it landed back at the departure airport, steered into the grass infield, and the occupants egressed. The instrument panel, cockpit, cabin area, and right wing were consumed by fire. A postaccident examination revealed that the fuel line from the fuel boost pump to the carburetor was disconnected. Closer examination revealed melted metals and soot accumulated on the threads of the male fitting of the pump, and on the threads of the female b-nut fitting of the fuel line, consistent with the line being disconnected prior to the fire. The fuel line was in close proximity to the carburetor fuel strainer that would routinely be removed during an annual inspection. A t-fitting on the line routed fuel to the fuel pressure indicator. With the affected line disconnected, fuel pressure would not register on the gauge, but the engine would continue to operate.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Addressing fuel line disconnection during annual inspection could have prevented fire.

NTSB coding

Evidence available

  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

Related mishaps