Pilot Debrief

BEECH 23 near Laurel, MD — 2013-07-18

Final reportERA13FA325
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Date
2013-07-18
Location
Laurel, MD, USA
Airport
W18
Aircraft
BEECH 23
Registration
N2333Z
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

The pilot's inadequate preflight preparation of the airplane, which resulted in a total loss of engine power during takeoff and his decision to operate the unairworthy airplane.

NTSB narrative

The pilot stated that he had sold the airplane the previous year and that the new owner had left the airplane at the pilot's home airport, where mechanics were working on it. The new owner told the pilot that someone had taken one of the cowl plugs. The new owner then removed the remaining one. The airplane sat unattended for 7 months without any cowl plugs before the new owner moved and wanted the airplane relocated to an airport near his home. The pilot volunteered to fly it there. Two days before the flight, the pilot began to prepare the airplane. He stated that he conducted a thorough check of the cowling, engine, and engine mount area due to the amount of time that it sat without cowl plugs. He removed two bird nests, straw, and other debris. He checked the engine mount area through an access panel. After cleaning, there appeared to be no debris in the engine compartment. On the day before the flight, he fueled the airplane with 50 gallons of fresh fuel and ran the engine for 30 minutes. He taxied around to verify flight control continuity and checked the brakes. He stated that everything was normal. On the day of the accident, the pilot preflighted the airplane and visually confirmed that the wing tanks were full of fuel. He selected the left tank before taxi, and prior to departure conducted an engine run-up, checking the engine for about 15 minutes. He checked the magnetos and carburetor heat during the run-up, and both were normal. He then extended the wing flaps to 15 degrees and proceeded to take off. He reported that everything was normal until the airplane was over the end of the runway, about 250 feet above the ground, when the engine suddenly lost power. The pilot switched tanks and turned on the boost pump in an unsuccessful attempt to get the engine to run. He maneuvered to find a place to land, but was over a residential area and crashed into a tree and houses before coming to rest. Examination of the wreckage revealed preexisting damage to the left wing and fuselage, as well as other anomalies that would have rendered the airplane unairworthy before the accident. The engine compartment contained the remains of bird nests and bird excrement, which would have affected the air-cooled engine's ability to maintain a normal operating temperature. The cloth jacketing from a foam-filled cowl plug along with the foam insert were protruding from and blocking the engine combustion air inlet opening. This would have cut off the engine's ability to intake air. Examination of the carburetor also revealed the presence of a golf ball-size mud dauber wasp nest in the carburetor throat below the main fuel nozzle, which would have also restricted air flow and atomization of fuel in the carburetor. Therefore, the condition of the airplane casts doubt on the thoroughness of the pilot's preparations and preflight inspection. Review of Federal Aviation Administration (FAA) and maintenance records revealed that the pilot's most recent application for a medical certificate was in 2006, and that the airplane's last annual inspection was in 1998. The investigation also discovered that the airplane had been operated for about 278 hours in the 15 years since that inspection was performed. Further, the pilot had not applied for a special flight permit from the FAA for the flight, even though the airplane was overdue for its annual inspection. The pilot's decision to fly the airplane without a valid medical certificate, current annual inspection, or ferry permit indicates that he made a conscious decision to disregard basic safety practices.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have ensured cowl plugs were in place before flight.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 22 docket documents
View NTSB final reportView NTSB docket

Docket documents22

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