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NTSB investigation record

CEN11FA125

Completed

Beech C24R· N5293M

Date
December 22, 2010
Location
Wheeling, IL
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The installation of the wrong engine-driven fuel pump, which resulted in a loss of engine power during takeoff, and the pilot's subsequent decision to turn back toward the airport at an insufficient altitude to complete the maneuver. Contributing to the accident was the pilot’s failure to maintain airspeed, which resulted in a loss of aircraft control.

Investigator assessment

Analysis narrative

The pilot stated that the engine operated normally during the three pretakeoff run-ups that he performed. He stated that, after takeoff, the airplane began to sink, and he retracted the flaps at an altitude of about 200 feet above ground level. He turned the airplane back toward the airport, at which time the engine began to vibrate and lose power. The pilot leveled the wings, and the airplane contacted the roof of a building before descending into a parking lot where it struck five cars, and a postimpact fire ensued. Witnesses reported seeing the airplane having difficulty gaining altitude after takeoff. They reported that the airplane was in a nose-high attitude and that the wings were rocking back and forth. They stated that the airplane banked abruptly to the left and descended, that the landing gear remained extended, and that the flaps were retracted. The witnesses who heard the engine stated that it sounded normal during the takeoff. The engine had been overhauled and the airplane had been flown for 1 hour prior to the accident. The person who flew the airplane at that time stated it operated normally. Although a postaccident examination found foreign debris inside the fuel servo inlet strainer, the debris was most likely a result of the fuel servo being exposed to intense heat during the postimpact fire. All three propeller blades exhibited rotational signatures. Aircraft maintenance records and an inspection of the engine revealed that a low-pressure fuel pump had been installed on the engine during the engine overhaul instead of a high pressure pump. The low-pressure pump likely could not produce enough fuel pressure to sustain engine operation.

Source record

Factual narrative

HISTORY OF FLIGHT On December 22, 2010, at 1446 central standard time, a Beech C24R, N5293M, impacted a building and several unoccupied parked vehicles prior to coming to rest in a parking lot one-half mile northwest of the Chicago Executive Airport (PWK), Wheeling, Illinois. The private pilot was seriously injured and the passenger was fatally injured. The privately owned airplane was substantially damaged by impact forces and post impact fire. The flight was being conducted under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed. The reported destination for the flight was the Schaumburg Regional Airport (06C), Schaumburg, Illinois. The airplane had been operated by Chicago Executive Flight School and had been sold to a private individual in October 2010. The pilot, who was also an airframe and powerplant mechanic, flew into PWK with three other people on the day of the accident to pick up the airplane for a new owner. The pilot and one of the other three people were to fly the accident airplane back to Jacksonville, Illinois, with an en route stop at 06C. The accident airplane was going to be one of a flight of two airplanes, with the other airplane being the one that the pilot flew in up to PWK. The pilot reported the airplane was parked outside on the ramp and he cleared the snow off of it while a mechanic installed the battery. He then started the airplane and taxied to the fixed base operator to have the airplane de-iced and fueled. The pilot then performed an aircraft pre-flight during which he sumped the fuel tanks. The pilot stated the fuel sample he drained did not contain any water and that instead of dumping the fuel on the ramp he put it back in the fuel tank as advised by line personnel. He stated that he performed an engine run-up on the ramp and the airplane operated normally. The pilot used a typical small fuel sample cup when he sumped the fuel tanks. A mechanic who worked for the flight school that sold the airplane stated he installed the battery when the pilot arrived to pick up the airplane. He stated the pilot started the engine and allowed it to run for 5 to 10 minutes prior to taxiing the airplane to another area of the airport to be fueled and de-iced. The mechanic stated he then heard the pilot having trouble starting the engine, so he went outside and instructed the pilot on how to start a fuel injected engine that was already hot. He did not notice any anomalies with the way the engine sounded. At 1436, the pilot of requested a taxi clearance for both airplanes and air traffic control cleared the airplanes to taxi to runway 34. The pilot stated he ran the engine up two more times while waiting for takeoff. He stated the engine performed normally. At 1444, the accident airplane was cleared for takeoff on runway 34 at the intersection of runway 06. The intersection takeoff resulted in the pilot having 4,200 feet of useable runway. The pilot stated he retracted the landing gear at an altitude of 50 to 75 feet above ground level (agl), and the flaps at an altitude of about 200 feet agl. During an interview the pilot recalled that the airplane began to sink when he retracted the flaps, so he decided to return to the airport. During the turn back toward the airport, the engine began to vibrate and lose power. He stated he could feel the vibrations in the control yoke. He then lowered the landing gear in preparation for an emergency landing. In his written statement the pilot stated the takeoff was normal until the engine began to lose power when he reached an altitude of 200 to 300 feet agl. He reported he leveled the wings and noticed the engine vibration changed so he radioed the control tower that he needed to return to the airport. At 1446, the pilot declared an emergency with the control tower and stated he was turning around because there were “all kinds” of vibrations and the airplane was “losing power quick.” This was the last radio transmission from the airplane. Air traffic cleared the pilot to land on any surface. The pilot stated he began a left turn, was unable to maintain altitude, and the airplane descended into the parking lot. The airplane contacted the roof of a two-story office building prior to descending into an adjacent parking lot. Several witnesses observed the airplane during the takeoff. These witnesses described the airplane’s maximum altitude as being between 50 and 200 feet agl. They described the airplane as being in a nose high attitude with the wings rocking. The airplane entered a left turn, the left wing suddenly dropped, and the airplane began a descent. The witnesses then lost sight of the airplane as it descended toward the building. One witness stated the airplane’s wings and pitch attitude leveled as it descended toward the building. The witnesses stated the landing gear remained extended and the flaps were retracted. Witnesses who heard the airplane stated the engine sounded normal during the takeoff. The mechanic who watched the takeoff stated the engine sounded “strong.” A line person who worked for the local fixed based operator stated that a mechanic had to start the airplane when the pilot was unable to get the engine started. He stated that the engine did not sound right when the mechanic got it started. He stated he heard what sounded like “burbles.” This witness did not witness the takeoff or accident. PERSONNEL INFORMATION The pilot, age 36, held a private pilot certificate for airplane single-engine land, and a third-class airman medical certificate issued March 17, 2008. The medical certificate contained a limitation for corrective lenses. The pilot’s last flight review was completed on January 9, 2009. The pilot also held an airframe and powerplant mechanic certificate. A review of the pilot’s logbooks revealed the last entry was made on July 12, 2010. As of that date the pilot had recorded a total flight time of approximately 1,170 hours. The pilot’s logbooks indicated that of the total time, 12 hours were in multi-engine airplanes and about 1 hour was in a helicopter. On the accident report form completed by the pilot he reported having 1,132 hours of total flight time of which 1,112 were in single-engine airplanes. Although not identified in the pilot’s logbooks that were provided, he reported having 3.5 hours of flight time in a Beech C24R. AIRCRAFT INFORMATION The four-seat, low-wing, retractable-gear airplane, serial number MC-572, was manufactured in 1978. It was powered by a Lycoming IO-360-A1B6 200-hp engine equipped with a McCauley model B3036C429 constant speed propeller. The aircraft maintenance records were on board the airplane at the time of the accident. The records sustained fire damage which resulted in portions of the records being illegible. A review of the legible maintenance logbook records showed the last airframe and engine annual inspection was completed on October 29, 2010, at a recorded tachometer time of 2,951.31 hours. This record also recorded the installation of the overhauled engine. The airframe and engine logbooks contained entries dated February 14, 2008, that the airframe and engine received a Ferry Flight inspection following a gear up landing. The airframe and engine total times were listed as being 2,908.9 hours at this inspection. An entry in the logbooks dated September 24, 2009, indicated an annual inspection had been completed at a tachometer time of 2,909.77 hours. The engine logbook indicated that new main bearings, new gaskets, new spark plugs and ignition harness, and new engine isolator mounts were installed at this time. The entry also indicated the cylinders, crankshaft, and magnetos were inspected. An entry in the engine logbook dated November 24, 2009, at a total time of 2,923.7 hours indicated that an overhauled propeller governor and a new propeller governor gasket was

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