Calhoun, KY, USA
N9448Q
BEECH 58
The pilot was departing his home airport to fly to another airport to refuel the airplane. Witnesses reported that the airplane lifted off from the 1,800-foot-long grass runway; however, none of the witnesses observed the airplane crash shortly after takeoff. The airplane rolled left and impacted the ground inverted in a wooded area near the departure end of the runway; there was no postcrash fire. Examination of the flight controls revealed no evidence of preimpact failure or malfunction. Damage to one of the right engine propeller blades was consistent with engine power at impact, whereas the left engine propeller blades showed no evidence of power at impact. Thus it is likely that the left engine experienced a total loss of power just after takeoff, which the pilot was unable to control. Both engines were removed, transported to the manufacturer’s facility, and test run with no mechanical discrepancies noted. Rust-colored water was detected in various fuel system components from both engines. Further, the strainer drain lines and outer tank drains in both engines’ fuel systems were partially blocked by rust-colored debris. Postaccident examination revealed evidence of long-term water contamination of both engines’ fuel systems due to leakage past the fuel caps, which are normally replaced on an “on-condition” basis during maintenance. The engine failure was likely due to the water contamination in the fuel system, which was not detected by the pilot during the preflight inspection. Further, the leaking fuel caps most likely existed, but went undetected, when the airplane’s most recent annual inspection was performed about 4 months earlier. A review of airplane maintenance records revealed that the only entry related to the fuel filler caps since the airplane was manufactured in 1972 was dated July 2010, at which time the left fuel filler cap was replaced and an outer o-ring of the incorrect dimension was installed. In April 2011, as a result of a 2008 investigation of a Canadian registered Beech 58 airplane that had water enter the fuel tank due to deteriorated fuel filler cap o-rings, the manufacturer revised the maintenance manual of Beech 55 and 58-series airplanes to require fuel cap overhaul. Maintenance manual guidance in effect when the accident airplane’s most recent annual inspection was performed excluded the accident airplane (by serial number) from this overhaul. Since this accident, the manufacturer has revised its Beech 55 and 58 maintenance manuals to include the fuel cap overhaul requirement for all potentially affected airplanes, including the accident airplane.
HISTORY OF FLIGHT On April 1, 2012, about 1600 central daylight time, a Beech 58, N9448Q, registered to and operated by a private individual, crashed shortly after takeoff from Woosley Field Airport (96KY), Calhoun, Kentucky. 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 96KY to Madisonville Municipal Airport (2I0), Madisonville, Kentucky. The airplane sustained substantial damage and the private pilot, the sole occupant was fatally injured. The flight was originating at the time of the occurrence. The purpose of the flight was for the pilot to fly to 2I0 for fuel. Two witnesses reported to the Federal Aviation Administration (FAA) inspector-in-charge (IIC) that they observed the airplane takeoff and noted the airplane became airborne before being abeam a building on the north side of the runway. One witness also reported that after becoming airborne and before reaching tree height, the wings rocked then returned to wings level. The witness reported the airplane turned left and flew over trees on the south side of the runway. The witnesses who were familiar with the pilot reported he “always” flew past the departure end of the runway then turned to fly over the neighborhood, and they considered it strange for him to turn before reaching the end of the runway. Another witness reported observing the accident airplane being taxied to the approach end of runway 27, followed by staying there for a longer than normal period of time. While there, the witness heard run-up of the engines followed by seeing the airplane being positioned into alignment for takeoff. The witness further stated the airplane was on the takeoff roll and appeared to get airborne faster than normal. The witness estimated that the airplane became airborne abeam the pilot’s house, then she lost sight of the airplane but heard what she thought was the sound of an impact. She went inside her house and listened to her local scanner and heard nothing about the crash. Because she did not see any smoke, and not believing the airplane had crashed, she did not immediately report the crash. About 2246 that evening, she called the McClean County 911 Center, and reported observing the airplane takeoff. Later that same day, because the pilot did not return as expected, a search was initiated. The wreckage was located about 2330. PERSONNEL INFORMATION The pilot, age 46, held a commercial pilot certificate with ratings airplane single land and instrument airplane. He also held a private pilot certificate with airplane multi-engine land rating which was limited to visual flight rules only. He was issued a third class medical certificate with no limitations or restrictions on April 30, 2010. Review of the pilot’s third logbook that begins with an entry dated May 29, 2010, and ends with an entry dated December 10, 2011, revealed the carry forward time on the first page was recorded to be approximately 1,609 hours. Between those dates, he logged a total of approximately 138 hours, of which, approximately 117 hours were in multi-engine airplanes. Of the 117 hours in multi-engine airplanes, approximately 2 hours were logged in the accident airplane on the date of his airplane purchase (December 10, 2011). The approximately 2 hours of flight were from Middlesboro-Bell County Airport (1A6), Middlesboro, Kentucky, to the Madisonville Municipal Airport (2I0), Madisonville, Kentucky. The airplane hour meter reflected that the airplane had been operated approximately 5 hours since the pilot’s purchase on December 10, 2011. A certified flight instructor reported that during the flight on December 10, 2011, the accident pilot had performed all of the maneuvers required for a flight review, so he endorsed the pilot logbook. The pilot’s wife reported that her husband did not have any significant health issues. Review of his medical file from FAA located in Oklahoma City, Oklahoma, revealed he had not previously reported any heart issues. AIRCRAFT INFORMATION The airplane was manufactured in 1972 by Beech Aircraft Corporation as model 58, and was designated serial number TH-204. It was powered by two 285 horsepower Continental Motors, Inc., IO-520-C engines and equipped with Hartzell constant speed propellers. The airplane was equipped with 172 gallon total capacity bladder type fuel tanks of which 166 gallons are usable. Each wing contained three interconnected fuel cells for a total capacity of 86 gallons per wing. The fuel cells consist of an inboard leading edge baffled cell, an outboard leading edge cell in which the fuel filler cap is installed, and a box section cell. Each wing fuel system has 3 drains consisting of one in the inboard aft section of the inboard leading edge baffled cell, the fuel strainer drain, and a drain in the aft inboard section of the box section cell. The fuel system is an off/on/crossfeed selectable arrangement controlled from the cockpit via cable to a valve located in each respective wheel well. With the fuel selector in the on position, each engine receives its fuel supply from the inboard baffled cell, to the selector valve, strainer, airframe electric boost pump, then to the engine-driven fuel pump on the accessory section of the engine. Review of the maintenance records that begin with the standard airworthiness certificate issuance entry in the 1st airframe logbook dated February 23, 1972, to the last entry in the 4th airframe logbook dated December 9, 2011, revealed only 1 entry specifically referencing replacement or repair of the fuel filler caps. The entry, dated July 2, 2010, indicates the left fuel cap was replaced with a serviceable unit and a new packing part number (P/N) MS29513-338 was installed; the hour meter reading at that time was recorded to be approximately 778. There was no entry in the maintenance records indicating the right fuel cap was repaired, replaced, or overhauled since the airplane was manufactured. The airplane was last inspected in accordance with an annual inspection on December 9, 2011, which was 1 day before the pilot purchased the airplane. The airplane total time at the time of the annual inspection was recorded to be approximately 5,542 hours, and the hour meter reading was 784. The mechanic who performed the last annual inspection of the airplane reported he used 14 CFR Part 43 Appendix D and the Beech 100-Hour or Annual Long Form Inspection Guide as references; however, he did not keep the copy of the Beech 100-Hour or Annual Long Form Inspection Guide which he marked on during the inspection signifying compliance with each inspection item. The mechanic further stated that discrepancies noted during the inspection were annotated on the invoice he provided to the airplane owner and subsequently to NTSB. A statement from the mechanic is an attachment to the public docket for this case. The hour meter reading at the time of the accident was approximately 789. METEOROLOGICAL INFORMATION A surface observation weather report taken at Owensboro-Daviess County Airport (OWB), Owensboro, Kentucky, on the day of the accident at 1556 hours local, or approximately 4 minutes before the accident indicates the wind was from 230 degrees at 11 knots with gusts to 16 knots, the visibility was 10 miles, and scattered clouds existed at 8,500 feet. The temperature and dew point were 31 and 17 degrees Celsius, respectively, and the altimeter setting was 29.68 inches of Mercury. The accident site was located about 205 degrees and 13 nautical miles from OWB. AIRPORT INFORMATION The Woosley Field Airport (96KY) is a private airstrip owned by the pilot and is equipped with a single grass runway oriented 09/27, which is listed as being 1,800 feet in length and 100 feet wide. The airport elevation was reported to be an estimated 465 feet. A steep drop-off in terrain elevation from the runway elevation was noted beyond the departure end of runway 27. Trees border the south side of the runway beginning at 37 degrees 33.146 North latitude and 087 degrees 16.360 minutes West longitude. Inspection of the trees revealed no evidence of tree contact. Inspection of the airstrip and hangar on April 3, 2012, revealed no airplane parts on the runway and no evidence of fuel storage. Further inspection of the airstrip revealed tie down stakes associated an outside parking space; the pilot’s stepson reported his stepfather would park the airplane outside if intended to be flown soon. WRECKAGE AND IMPACT The airplane impacted in a wooded area and came to rest inverted with the empennage elevated; the airplane was resting on a magnetic heading of approximately 250 degrees. The accident site was located at 37 degrees 33 minutes 03.9 seconds North latitude and 087 degrees 16 minutes 37.2 seconds West longitude, or approximately 1000 feet and 225 degrees from the departure end of runway 27. Examination of the airplane revealed all components necessary to sustain flight remained attached or were in close proximity to the main wreckage. There was no in-flight or postcrash fire noted. Flight control cable continuity was confirmed for roll, pitch, and yaw; the elevator and rudder flight control cables were cut to facilitate recovery of the airplane. All primary and secondary flight control surfaces remained attached at their respective attach points. Both engines remained attached and the right propeller remained attached to the engine while the left propeller was separated from the engine but found in the area of the left engine. The landing gear was extended and the flaps were symmetrically extended approximately 15 degrees (approach setting). Both engines were removed and retained for further examination. Examination of the fuel system of left wing revealed a section of the outer fuel cell with attached fuel cap was separated; no fuel was detected in the remaining cells of the wing. An aluminum fuel line from the auxiliary fuel pump to the fuel strainer was partially fractured; no fuel stains were noted in the area. Additionally, the spar web in that area was fractured. The fuel sump/strainer was not safety wired. Following removal of the fuel sump/strainer bowl, rust colored water was noted and the interior surface of the strainer bowl was heavy corroded. The strainer filter was also corroded. Disassembly of the fuel strainer drain line revealed it was nearly completely blocked internally by rust debris. Examination of the drain of the inboard baffled fuel cell revealed no obstructions, while inspection of the box section cell sump drain revealed the drain holes were plugged by unknown debris. The fuel selector was in the on position and there were no obstructions from the inboard cell to the engine. No obstructions were noted to the fuel vent system. The fuel cap and adapter were retained for further examination. Further examination of the left wing revealed the aileron trim measured 1.75 inches extended, which equates to approximately 6 units tab trailing edge down (up and down limits are 12.5 units). Examination of the right wing revealed fuel leakage was noted from the installed right wing fuel cap during recovery of the airplane. Approximately 11 gallons of blue colored fuel consistent with 100 low lead were drained from the right wing fuel tank. No fuel was noted at the fuel sump/strainer. Rust colored water was noted coming from the fuel sump/strainer during removal of the strainer bowl. Following removal of the fuel sump/strainer bowl, rust colored water was noted and the interior surface of the strainer bowl was heavy corroded. The strainer filter was also corroded. The fuel strainer drain line was nearly completely blocked internally by white powdery substance (consistent from corrosion) at the 90-degree fitting. A sample of liquid from the auxiliary fuel pump to the strainer then to the firewall contained fuel admixed with water. Examination of the drain of the inboard baffled fuel cell revealed no obstructions, while inspection of the impact damaged drain of the box section cell sump also revealed no obstructions. The fuel selector was in the on position and there were no obstructions from the inboard cell to the engine. No obstructions were noted to the fuel vent system. The fuel cap and adapter were retained for further examination. Examination of the cockpit revealed the elevator trim indicator indicated 6 units airplane nose up, the aileron trim indicated neutral, and the rudder trim indicated 6 units airplane nose left. The left and right fuel selectors were in the on position, and both fuel boost pump switches were in the high position. Inspection of the single control throw-over control yoke revealed it was positioned to the left seat and found consistent with right roll input. The cockpit floor was crushed and clockwise displacement of the co-pilot’s rudder torque tube was noted. Examination of the rudder flight control system revealed the rudder interconnect rod was connected to the pilot’s rudder bellcrank; however, the rod was fractured near the attach point of the co-pilot’s rudder bellcrank. Further, the interconnect rod exhibited chafing associated with contact by a lighting hole of a structural member adjacent to the pilot’s rudder bellcrank. Examination of the empennage revealed the left elevator trim actuator near the control surface revealed an extension between 1 1/8 to 1 3/16 inches, which corresponds to 7 to 8 degrees tab trailing edge down (limits are 10 units up and 25 units down). The right elevator trim actuator near the control surface measured 1.0 inch extension which corresponds to 2 to 3 degrees tab trailing edge down. Inspection of the rudder trim actuator near the control surface revealed an extension of 3 ¾ inches, which corresponds to 5 degrees trailing edge tab right (limits are 25 left and right). The fuel system components of both engines were examined to determine whether fuel or contaminants were noted. Testing of samples of fluid recovered from the fuel system components and lines in both engine compartments was performed with a new tube of “SAR-GEL”, which is an alcohol and water indicating paste. By design, a change to red indicates the presence of water and/or alcohol. Water/alcohol was detected in the samples taken at the left engine-driven fuel pump, left engine fuel strainer sump filter, and left engine-driven fuel pump drain line, while water/alcohol was detected in samples taken at the right engine fuel pressure line, right engine fuel metering unit, right engine fuel strainer sump filter, and right engine fuel boost pump to firewall. No water/alcohol was detected in a sample of blue colored fuel consistent with 100 low lead fuel drained from the right fuel tank. The water and fuel samples drained from the airplane’s fuel system were not further analyzed. Both engines were removed from the airframe, and sent to the engine manufacturer’s facility for proposed engine runs. Impact damaged components of the left engine consisting of the starter adapter, starter, induction elbows, and engine mounts were removed and replaced. Also, the oil pump housing which was cracked was temporary repaired for the engine run. The crankshaft flange was fractured and missing a section consisting of approximately 1 ½ propeller mounting holes; circumferential cracks were noted on the exterior surface of the crankshaft aft of the crankshaft flange. Safety concerns pertaining to the cracked crankshaft precluded a full operational test of the engine, which was operated a total of approximately 9 minutes. The engine was placed in the test cell with a test club propeller installed, started, and allowed to warm up. Magneto testing was performed at 2,100 rpm, each magneto drop was approximately 40 rpm, and full throttle rpm was recorded to be approximately 2,550 (specification is 2,700 rpm). Throttle chop and throttle burst checks were performed twice, no discrepancies were noted. During the engine run, there was no oil pressure at the oil transfer collar; this was later attributed to impact damage to the nose section of the engine. Removal of the alternator to inspect the collar revealed no visible discrepancies. Post engine run, a differen
The failure of the pilot to maintain airplane control after experiencing a loss of power from the left engine due to water contamination of the fuel system. Contributing to the accident was the pilot’s inadequate preflight inspection of the airplane and maintenance personnel’s inadequate annual inspection, because both failed to detect the long-term water contamination of the fuel system and the deteriorated outer o-rings on both fuel caps. Also contributing to the water contamination of the fuel system was the inaccurate information and instructions in the airplane maintenance manual pertaining to overhaul requirements of the fuel filler caps.
Source: NTSB Aviation Accident Database
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