Primary finding
Probable cause
The pilot's inability to establish a normal climb rate after takeoff for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal operation.
Investigator assessment
Analysis narrative
The purpose of the flight was to demonstrate the amphibious airplane for a potential buyer. Four months earlier, the accident pilot performed a forced landing on water due to a loss of engine power. Maintenance personnel subsequently found a broken fuel injector line and repaired same. The propeller was also removed, overhauled, and replaced. A witness stated that the pilot had difficulty starting the engine prior to the accident flight. Maintenance personnel reported that the pilot performed high speed taxi tests prior to the flight and the pilot stated to them that the engine and propeller were performing satisfactorily. During the takeoff and initial climb, witnesses reported that the airplane appeared to be climbing slowly and then stopped climbing and was on the verge of a stall. The airplane "pancaked" into trees and exploded. One witness heard a backfire or popping noise prior to the crash. The airplane collided with trees and then the ground, resulting in a post-crash fire that consumed a majority of the wreckage. An examination of the airframe, engine, and propeller did not reveal evidence of a pre-existing malfunction or failure. Smooth cuts in tree limbs indicated that the engine was operating at the time of impact. The reason for the pilot's inability to establish a normal climb gradient could not be determined.
Source record
Factual narrative
Propeller Assembly On March 13, 2013, the propeller assembly was examined at the facilities of Quality Aircraft Salvage, Groveland, Florida. The propeller was a Hartzell propeller Model HC-E3YR-1RF, Serial No. FM1082A with a propeller hub number A34830A. The propellers were labeled "A", "B", and "C" to correlate with previously handwritten labels located on the blades. The piston remained attached and secured in position with a cotter pin. The piston was disassembled and the change rod remained intact and was unremarkable in appearance. The spring indicated thermal damage to the tension but otherwise remained intact. The aft portion of the rear hub exhibited impact damage co-located with the preload plates. The blade pitch change knobs exhibited impact damage and were sheared in overload. The preload plate for the blade labeled "C" was measured and indicated approximately 13 degrees of pitch at impact, which correlated to a low pitch setting. The other two (2) blades' preload plates exhibited similar indications and all were considered unremarkable. Blade "A" visually indicated in a "feather" position while mounted on the hub, and the tip exhibited extensive thermal damage. The blade indicated a slight twist in the leading edge towards the low pitch position. The bearing and race were removed and were unremarkable. Blade "B" visually indicated an "extreme reverse" position while mounted on the hub. Extensive thermal damage was noted approximately five inches from the hub which resulted in extensive deformation of the blade. The bearing and race were removed and were unremarkable. Blade "C" visually indicated a "flat pitch" position while mounted on the hub. The preload plate exhibited an impact crack along the radius on one side of the circumference. Extensive thermal damage was noted and the outboard section of the blade, beginning approximately six inches from the hub, was burned away. Fuel Injection Nozzles Six fuel injection nozzles from the accident engine were submitted to the NTSB Materials Laboratory to determine if the nozzles were blocked and to identify the material inside the nozzles. The nozzles were arbitrarily numbered 1 through 6 by the laboratory examiner. The nozzles were x-rayed to determine if any blockage was present before the nozzles were removed from the bags they were received in. No blockages were observed in the radiographs of any of the nozzles. Visual examination of the nozzles found no significant blockages of any of the submitted nozzles. All of the nozzles were moderately sooted on both the exterior and the interior surfaces. Each nozzle interior was swabbed with a clean cotton swab. Each cotton swab was examined using a Fourier Transform Infrared (FTIR) micro-spectrometer with a germanium attenuated total reflectance (ATR) accessory. The spectrometer was used to collect and process infrared wavelength absorbance spectra of each sample. Nozzles #1 through #4 and Nozzle #6 showed no significant spectral patterns with the exception of a negative peak at ~2400 cm-1 which is often indicative of the presence of elemental carbon which absorbs infrared energy. Nozzle #5 did have one peak pattern, a carbon-hydrogen bonding peak located between ~3000-2800 cm-1 indicating the presence of an aliphatic hydrocarbon. Aliphatic hydrocarbons are found in aircraft materials such as fuel, lubricating and hydraulic oils. The swab samples were then analyzed by scanning electron microscopy (SEM) and quantitative standardless energy dispersive x-ray spectroscopy (EDS). The EDS analysis showed the presence of carbon, aluminum, silicon, oxygen, magnesium, and iron. These constituents are consistent with soot and materials found within the aircraft engine compartment and A postmortem examination of the commercial pilot was performed at the offices of District Twelve Medical Examiner, Sarasota, Florida, on January 13, 2013. The autopsy report noted the cause of death as "Thermal Cutaneous Burns" and the manner of death was "accident." The autopsy report noted a positive carboxyhemoglobin level of 7 percent saturation. Forensic toxicology testing was performed on specimens of the pilot by the Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The CAMI toxicology report indicated no carbon monoxide in the blood (10 percent cutoff), no ethanol in the urine, and salicylate (a metabolite of aspirin) in the urine. Testing for cyanide was not performed. The 1553 surface weather observation for SRQ included scattered clouds at 6,500 feet, wind from 230 degrees at 8 knots, visibility 10 statute miles or greater, temperature 77 degrees F, dew point 67 degrees F, and altimeter 30.08 inches of mercury. According to local maintenance personnel, the airplane had been at SRQ since September, 2012. The accident pilot was involved in an emergency landing in the accident airplane; he landed in the Indian River Lagoon, near Sebastian Inlet, Florida, following a loss of engine power. According to the aircraft records, a fuel injector line was subsequently replaced because of a broken fitting. Also, the propeller and propeller governor were overhauled during maintenance unrelated to the engine problem. On the morning of January 12, the pilot reportedly performed some high speed taxi tests on the runways at SRQ to determine that the engine and propeller were working satisfactorily. The pilot reportedly stated that 120 knots was achieved on the ground and the engine and propeller were working correctly. The passenger, who was a potential buyer of the airplane, arrived about 1400 that afternoon. Reportedly, this was the first flight for the airplane since the maintenance work was completed. According to the aircraft maintenance logbooks, the last condition inspection was performed on September 11, 2012. The aircraft and engine accrued times were not recorded in the logbook entries. The pilot, age 70, held a commercial pilot certificate with airplane single engine land, airplane single engine sea, airplane multi-engine land, and instrument airplane ratings. He was also a flight instructor (airplane single engine) and held an experimental aircraft builder certificate. He reported a total flight experience of 15,000 hours, including 250 hours during the last six months, on his third class medical certificate application, dated October 3, 2012. His pilot logbooks were not located following the accident. The pilot-rated passenger held a private pilot certificate with airplane single engine land, glider aero tow, and instrument airplane ratings. He reported a total flight experience of 1,200 hours, including 20 hours during the last six months, on his second class medical certificate application, dated September 1, 2011. His pilot logbooks were not located following the accident. The airplane struck three tall pine trees on the campus of New College of Florida before impacting terrain and coming rest on a lawn. The wreckage was largely consumed in a post-crash fire. The main wreckage was located about 0.3 nautical miles beyond the departure end of runway 22. The length of the wreckage debris field was about 300 feet and was oriented on a heading of 240 degrees. The fuselage was found inverted. The left wing was fragmented and its components were found along the debris field leading to the main wreckage. The wing parts were burned except for some composite pieces that were outside the ground fire zone. The left wing fuel tank was compromised. The left aileron remained partially attached to the outboard section of the left wing and was burned. The left wing flap was broken from the wing. The pre-impact position of the left flap could not be determined. One left aileron control cable was disconnected at the turnbuckle and the other end showed indications of tension overload. This section of cable was found loose in the left wing debris field. The other half of the ai