MIAMI, FL, USA
N7131D
BEECH 60
ABOUT 21 MINUTES AFTER TAKEOFF, THE PLANE CRASHED ON UNEVEN/WOODED TERRAIN ABOUT 10 MI NORTH OF THE DEPARTURE AIRPORT. THE SERIOUSLY INJURED PILOT REPORTED NO RECOLLECTION OF EVENTS LEADING TO THE ACCIDENT. AN A&P MECHANIC, WHO SAW THE PLANE TAKE OFF, STATED IT WAS CLIMBING SLOWLY & THE ENGINES WERE RUNNING SMOOTHLY, BUT THE ENGINES SOUNDED AS IF THEY WERE NOT AT FULL POWER. JUST BEFORE IMPACT, 2 WITNESSES SAW THE PLANE AT LOW ALTITUDE; ONE SAID THAT NEITHER ENGINE WAS OPERATING. EXAM OF THE LEFT ENGINE REVEALED THE FUEL SERVO WAS CONTAMINATED INTERNALLY; 2 OF 12 IGNITION LEADS FAILED CONTINUITY TESTS; & CONTAMINATION WAS FOUND IN THE MIXTURE HOUSING AREA. WATER WAS FOUND IN THE RIGHT INBOARD LEADING EDGE FUEL CELL. EXAM OF THE RIGHT ENGINE REVEALED LEFT MAGNETO WAS NOT PROPERLY SECURED; TIMING OF RIGHT MAGNETO(S) 42 DEG BTC (SHOULD HAVE BEEN 20 DEG BTC). INVESTIGATION REVEALED BOTH PROPS AT LOW PITCH, LEFT MAGNETO SWITCHES OFF, RIGHT BOOST PUMP OFF, SHOULDER HARNESS NOT USED, LAST ANNUAL INSPECTION DATED 2/25/92. THIS WAS 1ST FLIGHT IN 5 MONTHS.
HISTORY OF FLIGHT On October 17, 1993, about 1530 eastern daylight time, a Beech BE-60, N7131D, registered to the pilot, Robert E. Lee, crashed about 10 nautical miles northwest of the Miami International Airport, Miami, Florida, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The airplane was substantially damaged and the private pilot, the sole occupant, was seriously injured. The flight originated about 1509 from the Miami International Airport, Miami, Florida. The pilot stated that he has no recollection of events leading up to or occurring during the crash. He stated that he normally follows a checklist before flying. The morning of the accident a fuel truck serviced the airplane with 100 gallons of fuel, 50 gallons into each of the left and right fuel tanks of the airplane. The pilot was observed to preflight the airplane, however, no witness watched the entire preflight to determine if the pilot checked the fuel tanks for contaminants. A certificated FAA mechanic stated that he checked the "outboard" tanks for contaminants after the fueling and no contaminants were found. The airplane was taxied to takeoff but taxied to Signature Flight Support for minor electrical system assistance. After assistance was obtained, the airplane was then taxied to runway 27R and according to a witness who is an FAA certificated A & P mechanic, the airplane was observed to climb to about 400 feet above ground level in a shallow climb. The witness reported that the engines sounded like they were running smooth but the engines were not at full power. He also stated that he thought the landing gear was not completely retracted. According to two witnesses near the accident site, the airplane was seen flying low then pitched nose down and crashed. One of the witnesses reported that he did not hear any sounds from either engine. PERSONNEL INFORMATION Information pertaining to the pilot is contained in the NTSB Factual Report-Aviation. According to the manager of the FAA Aeromedical Certification division, the pilot did not hold a valid FAA medical certificate on October 17, 1993. AIRCRAFT INFORMATION Information pertaining to the airplane is contained in the NTSB Factual Report-Aviation and Supplements A & B. Review of the aircraft and engine logbooks revealed that the last annual inspection occurred on February 25, 1992. On May 18, 1993, a ferry permit was issued by the FAA for a flight from Sumter, South Carolina, to Miami, Florida. The airplane was flown on May 20, 1993, to Miami, Florida, to have an annual inspection performed and according to the pilot, he did not experience any problem with the engines, propellers, fuel system, or flight controls during the flight. No work was done to the airplane in Miami, however, an FAA certificated mechanic stated that he checked the fuel tanks for contaminants and operated each engine checking the magnetos, and propeller governor weekly. His last check of the airframe and engines occurred about 5-6 days before the accident. No discrepancies were noted. METEOROLOGICAL INFORMATION Information pertaining to weather is contained in the NTSB Factual Report-Aviation. COMMUNICATIONS At the time of the accident the pilot was not in contact with any FAA air traffic control facility. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that the airplane first impacted a small dirt bank in a field, nose and left wing low on a heading of about 260 degrees. The left engine separated during impact. The airplane then rotated to the left and the right wing impacted a tree causing the airplane to rotate to the right. The airplane came to rest upright in about 6 inches of water about 60 feet from the first impact point on a heading of about 040 degrees with the landing gear extended. The right engine assembly was nearly separated. The left wing was bent up about 45 degrees with a compression wrinkle located just outboard of the engine mount. The wing tip leading edge was crushed chordwise. The right wing had slight wing tip damage and damage near the engine mount area. Examination of the flight controls revealed no evidence of preimpact failure or malfunction. The flaps were retracted. The right inboard leading edge fuel cell drain was opened the evening of the accident at the accident site and about 8 ounces of water were found. The fuel cell drain located in the right wing box section cell and the right strain/drain/thermal relief valve were opened to check for contaminants; none were found. The left wing inboard leading edge and the left strain/drain/thermal relief valve drains were nearly completely plugged internally with unknown object(s). No water contamination was found in either of these drains when they were removed nor in the left wing box section cell fuel drain. The left and right fuel selectors were in the "on" position. Examination of the fuel delivery and vent systems for both wings revealed no evidence of preimpact failure or malfunction. The left and right magneto switches were in the "off" and "both" positions respectively. Testing of each magneto switch revealed no evidence of failure or malfunction. Impact damage to the sidewall adjacent to the magneto switches was noted. The left and right fuel boost pump switches were in the "on" and "off" positions respectively. Testing of each fuel boost pump revealed they operated normally. Examination of the left engine which separated revealed that the throttle, mixture, and propeller control cables were attached to their respective control arms at the fuel servo and propeller governor. Noncontaminated fuel was found in all of the fuel lines, the engine driven fuel pump, fuel servo, and the fuel distribution valve. The fuel inlet screen at the fuel servo was clean. Crankshaft, camshaft, and valve train continuity was confirmed throughout the engine; thumb compression and suction was verified at all cylinders. The left magneto to engine timing was determined to be 22 degrees before top center (BTC). The right magneto to engine timing was determined to be 42 degrees BTC. According to the engine manufacturer the magneto timing should be 20 degrees BTC. Two of the 12 ignition leads failed the continuity test. The magnetos were removed from the engine and turned by hand which revealed spark at all towers of each magneto. The fuel servo was removed and flow tested which revealed that it operated normally with no evidence of preimpact failure or malfunction. Disassembly revealed an unknown contaminant in the mixture housing area. Additionally, a small piece of rubber like material was found on the idle control valve. The engine driven fuel pump drive shaft was intact. The propeller was removed for examination. Examination of the left engine propeller revealed no evidence of preimpact failure or malfunction. Propeller blade angle at impact was determined to be low pitch. Examination of the right engine which nearly separated revealed that the throttle, mixture, and propeller control cables were attached to their respective control arms at the fuel servo and propeller governor. Noncontaminated fuel was found in all of the fuel lines, the fuel servo, and the fuel distribution valve. The fuel inlet screen at the fuel servo was clean. Crankshaft, camshaft, and valve train continuity was confirmed throughout the engine; thumb compression and suction was verified at all cylinders. The left magneto was loosely secured to the accessory case of the engine and magneto to engine timing was not determined. The right magneto to engine timing was determined to be about 42 degrees BTC. According to the engine manufacturer the magneto timing should be 20 degrees BTC. The magnetos were removed from the engine and turned by hand which revealed spark at all towers of each magneto. Continuity of all ignition leads was confirmed. The fuel servo was removed and flow tested which revealed that it operated normally with no evidence of preimpact failure or malfunction. Disassembly revealed no evidence of contamination. The engine driven fuel pump was found separated from the engine and the mounting pad and drive shaft were failed from signatures consistent with overload. The propeller was removed for examination. Examination of the right engine propeller revealed that two of the three propeller pitch change knobs were failed due to overload. Signatures inside the propeller hub revealed that the propeller blades were at the low pitch positions at impact. The high pitch stop unit was not engaged. MEDICAL AND PATHOLOGICAL Toxicological testing was not performed on blood samples of the pilot taken upon admittance to the hospital due to lack of chain of custody. SURVIVAL ASPECTS A shoulder harness was installed at the pilot's seat but was not worn. ADDITIONAL INFORMATION The fueling facility was notified of the accident the evening of the accident and a fuel sample was immediately taken from the truck which fueled the airplane for testing. Testing of the fuel sample revealed no evidence of contaminants. The wreckage was released to Mr. Timothy Gaither of Aviation Propeller, Inc., on June 29, 1994.
INADEQUATE PREFLIGHT BY THE PILOT, AND HIS FAILURE TO ASSURE THAT PROPER MAINTENANCE/ANNUAL INSPECTION WAS ATTAINED. FACTORS RELATED TO THE ACCIDENT WERE: WATER AND OTHER CONTAMINATION IN THE FUEL SUPPLY, LACK OF CONTINUITY IN TWO IGNITION LEADS, LOOSE LEFT MAGNETO ON THE RIGHT ENGINE, AND IMPROPER TIMING OF THE RIGHT MAGNETO ON THE RIGHT ENGINE; TERRAIN CONDITIONS IN THE EMERGENCY LANDING AREA AND THE PILOT'S FAILURE TO USE A SHOULDER HARNESS PROBABLY ATTRIBUTED TO THE DEGREE OF INJURY AND DAMAGE.
Source: NTSB Aviation Accident Database
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