Primary finding
Probable cause
The pilot’s failure to ensure that the fuel selector handle was correctly positioned, which resulted in an interruption of fuel to the engine and a loss of engine power during the takeoff, which necessitated a turn away from the trees at the end of the runway and the subsequent stall.
Investigator assessment
Analysis narrative
The pilot performed a preflight inspection and fueled the airplane with no anomalies noted. He performed two takeoffs and landings without incident. Before the third takeoff, the pilot verified that the flaps were retracted for takeoff and that the left fuel tank was selected. The pilot applied power to take off and released the brakes. As the airplane rolled down the runway, it lifted off the ground, and then settled back onto the runway. The pilot stated that he continued to apply full power but that the airplane was not performing as well as on the previous takeoffs. The airplane eventually became airborne. The pilot stated that he initiated a turn to the right in order to avoid striking trees off the end of the runway; the flight instructor subsequently took the flight controls as the right turn became steeper and the airplane began to descend. According to a witness, the airplane appeared like it would not clear the trees, banked right, and then entered a spin before impacting the ground. Postaccident examination of the fuel selector revealed it was in a mid-range position, with neither the left or right tank selected. When the fuel selector was placed to the center position, similar to where it was found after the accident, fuel would not flow through the fuel selector. Thus, it is likely that the pilot did not turn the fuel selector completely so that it was not locked in the detent, which restricted fuel flow and resulted in a loss of engine power. In addition, the main fuel line and the return fuel line were removed and there was no fuel present. A postaccident engine teardown was performed and the fuel manifold was disassembled; dry rot was noted on the manifold diaphragm and it was leaking. The leak might have reduced fuel consumption, but not a significant amount. It is likely that, because of the loss of engine power, the airplane would not have been able to adequately climb above the trees off the end of the runway. Therefore, the pilot attempted to avoid the trees and initiated a turn during the initial climb, which resulted in an aerodynamic stall and subsequent spin. Although postaccident testing indicated that the flight had adult-onset diabetes, it could not be determined if the flight instructor experienced symptoms from the condition or side effects from the medication that treated the diabetes, which could have hindered his ability to operate the airplane. Furthermore, the flight instructor did not report the diabetic condition or medications on his most recent application for an Aviation Medical Certificate.
Source record
Factual narrative
HISTORY OF FLIGHT On July 16, 2012, about 1905 eastern daylight time, a Beech A23, N8771M, was substantially damaged following a collision with terrain in Laytonsville, Maryland. The private pilot received minor injuries and the flight instructor was fatally injured. The airplane was registered to a corporation and was operated by an individual under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed and a Washington, DC, special visual flight rules flight plan was filed for the local flight. The flight originated from Davis Airport (W50), Laytonsville, Maryland, about 1845. According to the pilot, the purpose of the flight was to prepare for a flight review with the flight instructor. The pilot performed a preflight inspection and fueled the airplane prior to takeoff with no anomalies noted. They performed two takeoffs and landings prior to the accident. After each landing they would perform the after landing checklist, then prior to takeoff, they would perform the before takeoff checklist. During the check, the pilot verified that the flaps were retracted for takeoff and that the left fuel tank was selected with the fuel selector. During the final takeoff, the pilot applied power and released the brakes. The airplane rolled down the runway, lifted off the ground, and then settled back onto the runway. The pilot stated that he continued to apply full power but the airplane “did not have nearly as much lift” as the previous takeoffs. As the airplane continued to climb, the pilot initiated a turn to the right in order to avoid striking trees off the end of the runway. The flight instructor then took the flight controls as the right turn became steeper. The airplane then entered a spin and impacted the ground. According to witnesses, the pilot applied full engine power in order to take off on runway 26. One witness stated that it seemed the airplane was "having difficulty climbing out of ground effect." The airplane continued the takeoff, climbed to about 150-200 feet above ground level, banked right, and entered a stall and subsequent spin until it impacted the ground. One witness stated that the airplane would not be able to clear the trees at the end of the runway. Another witness noted that the engine "backfired" and that he heard it lose power prior to impacting the ground. According to an employee at the airport, he topped off the fuel tanks prior to the accident flight. He then observed the airplane perform several successful takeoffs and landings prior to the accident. The wreckage came to rest approximately 425 feet beyond and to the right of the departure end of runway 26. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot, age 83, held a private pilot certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. His most recent FAA third-class medical certificate was issued September 24, 2010, and at the time of the examination the pilot reported 2,300 total hours of flight experience. The medical certificate was issued with two restrictions: must wear corrective lenses and must wear hearing amplification. According to the pilot's logbook, he accumulated 2,319.2 total hours of flight time. His most recent flight review occurred in July 2010. He accumulated 1.9 hours of flight time in the past 90 days in the accident airplane. According to FAA records, the flight instructor, age 79, held a commercial pilot certificate with ratings for airplane single-engine land, single-engine sea, multiengine land, glider, and instrument airplane. In addition, he held a flight instructor certificate for airplane single-engine, multiengine, instrument airplane, gliders, as well as an advanced ground instructor certificate and an instrument ground instructor certificate. His most recent FAA third-class medical certificate was issued June 12, 2012, and at the time of the examination the pilot reported 18,000 total hours of flight experience. At the time of this writing no pilot logbooks had been located. AIRCRAFT INFORMATION According to FAA records, the airplane was manufactured in 1964, and was registered to a corporation in 2002. It was a low-wing, fixed, tricycle gear airplane that was equipped with a Continental Motors IO-346-A series engine rated at 165 horsepower. The most recent annual inspection was performed on September 13, 2011, and at that time, the airplane had accumulated 1,989.66 hours of total flight time. METEOROLOGICAL INFORMATION The 1855 recorded weather observation at Gaithersburg, Maryland (GAI), located approximately 5 nautical miles south of the accident location, included calm wind, clear skies, temperature 31 degrees C, dew point 23 degrees C, and an altimeter setting of 29.89 inches of mercury. AERODROME INFORMATION Davis Airport was located about three miles north of Laytonsville, Maryland, at 630 feet elevation. The asphalt runway was 2,005 feet long, 25 feet wide, and oriented 08/26. The Airport Facility Directory noted that there were trees at both ends of the runway and a glide angle of four degrees was needed to clear the trees. WRECKAGE AND IMPACT INFORMATION The main wreckage came to rest in an area of dense underbrush. The coordinates of the main wreckage were 39:14.545 N, 077:09.274 W, and the first indication of ground contact was about 45 feet east of the main wreckage. A note pad found in the fuselage indicated the date, July 16, and a start tach time of 1,993.08 for the flight. The tachometer discovered in the airplane indicated a tach time of 1,993.37 hours. There were no pre-impact anomalies noted with the airframe. All components of the airplane were located within the area of the main wreckage. The right wing tip was located next to the initial impact ground scar approximately 45 feet from the main wreckage. Flight control cable continuity was established from the cockpit controls to the control surfaces. Flight control cable continuity was observed to be intact from the cockpit control connection point to the empennage flight controls. The aileron flight controls were observed to be intact from the cockpit flight controls to the left and right aileron bell cranks. Rudder control continuity was confirmed from the cockpit area to the rudder. Flap control continuity was established from the flap control handle to the left and right flap turnbuckles. The left wing remained attached to the fuselage and was displaced slightly aft. The forward section of the left wing root was separated from the fuselage and the aft portion of the wing root was crushed into the fuselage. The outboard six feet of the wing was crushed in the aft and positive direction. The wing tip and pitot tube remained attached to the left wing. The left main landing gear remained attached to the wing. The outer leading edge, next to the wing tip attachment, was buckled and vegetation debris was found in the area of the buckle. The aileron remained attached to the wing at all attach points. The flap remained attached to the wing via the inboard flap attachment and the outboard attachment point. The flap control rod was separated from the flap torque tube. The left wing fuel tank was breached and empty. There was a small area of blight on the vegetation under the left wing root. The left wing fuel cap seals were examined with no anomalies noted. The left wing fuel vent was clear and free of debris. The stall warning indicator was located on the leading edge of the left wing. Stall warning continuity was confirmed with a multimeter through the switch housing. The right wing remained attached to the fuselage. The leading edge of the right wing exhibited brown scoring/markings in the left to right direction. The outboard three feet of the right wing was damaged in the aft and positive direction. The forward