Primary finding
Probable cause
The pilot's inadequate preflight preparation of the airplane, which resulted in a total loss of engine power during takeoff and his decision to operate the unairworthy airplane.
Investigator assessment
Analysis narrative
The pilot stated that he had sold the airplane the previous year and that the new owner had left the airplane at the pilot's home airport, where mechanics were working on it. The new owner told the pilot that someone had taken one of the cowl plugs. The new owner then removed the remaining one. The airplane sat unattended for 7 months without any cowl plugs before the new owner moved and wanted the airplane relocated to an airport near his home. The pilot volunteered to fly it there. Two days before the flight, the pilot began to prepare the airplane. He stated that he conducted a thorough check of the cowling, engine, and engine mount area due to the amount of time that it sat without cowl plugs. He removed two bird nests, straw, and other debris. He checked the engine mount area through an access panel. After cleaning, there appeared to be no debris in the engine compartment. On the day before the flight, he fueled the airplane with 50 gallons of fresh fuel and ran the engine for 30 minutes. He taxied around to verify flight control continuity and checked the brakes. He stated that everything was normal. On the day of the accident, the pilot preflighted the airplane and visually confirmed that the wing tanks were full of fuel. He selected the left tank before taxi, and prior to departure conducted an engine run-up, checking the engine for about 15 minutes. He checked the magnetos and carburetor heat during the run-up, and both were normal. He then extended the wing flaps to 15 degrees and proceeded to take off. He reported that everything was normal until the airplane was over the end of the runway, about 250 feet above the ground, when the engine suddenly lost power. The pilot switched tanks and turned on the boost pump in an unsuccessful attempt to get the engine to run. He maneuvered to find a place to land, but was over a residential area and crashed into a tree and houses before coming to rest. Examination of the wreckage revealed preexisting damage to the left wing and fuselage, as well as other anomalies that would have rendered the airplane unairworthy before the accident. The engine compartment contained the remains of bird nests and bird excrement, which would have affected the air-cooled engine's ability to maintain a normal operating temperature. The cloth jacketing from a foam-filled cowl plug along with the foam insert were protruding from and blocking the engine combustion air inlet opening. This would have cut off the engine's ability to intake air. Examination of the carburetor also revealed the presence of a golf ball-size mud dauber wasp nest in the carburetor throat below the main fuel nozzle, which would have also restricted air flow and atomization of fuel in the carburetor. Therefore, the condition of the airplane casts doubt on the thoroughness of the pilot's preparations and preflight inspection. Review of Federal Aviation Administration (FAA) and maintenance records revealed that the pilot's most recent application for a medical certificate was in 2006, and that the airplane's last annual inspection was in 1998. The investigation also discovered that the airplane had been operated for about 278 hours in the 15 years since that inspection was performed. Further, the pilot had not applied for a special flight permit from the FAA for the flight, even though the airplane was overdue for its annual inspection. The pilot's decision to fly the airplane without a valid medical certificate, current annual inspection, or ferry permit indicates that he made a conscious decision to disregard basic safety practices.
Source record
Factual narrative
HISTORY OF FLIGHTOn July 18, 2013, about 1011 eastern daylight time, a Beech 23, N2333Z, was substantially damaged after a loss of power when it struck a tree and then houses shortly after takeoff from Suburban Airport (W18), Laurel, Maryland. The private pilot was seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight operated under the provisions of Title 14 Code of Federal Regulations Part 91, destined for Gettysburg Regional Airport (W05), Gettysburg, Pennsylvania. According to the pilot, on the morning of the accident, he awoke about 0830, and left for the airport. He arrived at W18 at approximately 0910. He then preflighted the airplane and visually checked the fuel. It was full of fuel as he had topped it off two days before, and "everything was normal". He selected the left tank before taxi, and prior to departure did an engine runup, checking the engine for about 15 minutes. He did a "mag and mag drop" check and a "carb heat drop" check during the run-up and "both were normal". Prior to departure he selected "one notch of flaps", and proceeded to takeoff from runway 03. Everything was normal until the airplane was over the end of the runway at approximately 250 feet when the engine suddenly lost power. The pilot switched tanks, and turned on the boost pump in an attempt to get the engine to run without result. He then maneuvered to the left, and then to the right. The last thing he remembered was seeing a gray house. Review of air traffic control data revealed that the pilot had filed a VFR special flight rules area (SFRA) flight plan. Prior to departure, the pilot had obtained a beacon code to operate within the Washington SFRA however; he was not able to contact air traffic control prior to the loss of engine power. Radar data indicated that after takeoff, the airplane reached a peak altitude of 300 feet, but approximately 9 seconds later at 10:10:20, descended below the floor of radar coverage. According to a witness, at approximately this time, she observed the airplane flying west to east and noticed the left wing "dropped" and the plane started heading towards the ground. She then heard a "boom" and observed smoke. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with ratings for airplane single-engine land, and instrument airplane. He also held a repairman experimental aircraft builder certificate. His most recent application for a FAA third-class medical certificate was dated July 19, 2006. The pilot reported that he had accrued 3,571 total hours of flight experience. AIRCRAFT INFORMATION The accident aircraft was a four place, low wing monoplane of conventional construction. The all metal semi-monocoque airframe structure was composed of aluminum, magnesium, and alloy steel. The wings were constructed of bonded aluminum honeycomb. It was equipped with tricycle landing gear, and was powered by a 160 horsepower, four cylinder, normally aspirated, air cooled engine, driving a two bladed, fixed-pitch, forged aluminum propeller. According to the pilot, the airplane had been previously damaged prior to the accident, when it had been involved in an off airport landing in Wyoming in 1984 where the right main landing gear, wing box assembly, and right wing lower wing skins were damaged. Then in 1985 the rudder was replaced after it was damaged, and then most recently, the right wingtip had been hit by a lawnmower. According to FAA and maintenance records the airplane was manufactured in 1962. The engine had been overhauled on January 1, 1992 at 4,476.44 total hours of operation. The airplane's most recent annual inspection was completed on January 5, 1998 at 4719.0 total hours of operation, and at the time of the accident, the airplane had accrued 4997.56 total hours of operation. METEOROLOGICAL INFORMATION The recorded weather at Tipton Airport (FME), Fort Meade, Maryland, located 3 nautical miles east of the accident site, at 1012, included: winds 360 at 3 knots, 10 miles visibility, sky clear, temperature 31 degrees C, dew point 22 degrees C, and an altimeter setting of 30.12 inches of mercury. WRECKAGE AND IMPACT INFORMATION Accident Site Examination Post accident examination of the accident site revealed that the airplane had come to rest approximately a ½ mile from the departure end of runway 03. It initially made contact with a 40 foot tall pine tree, striking the tree approximately 24 feet above the base of the tree and fracturing the upper portion of the tree into two sections. The airplane then struck the northwest corner of a house separating the right wing from its mounting location. The airplane then continued forward approximately 70 feet, struck the west side of another house located across the street from the initial impact point with the tree, fracturing the fuselage just aft of the baggage door. It then came to rest against the southwest side of the residence with the left wing penetrating the front of the house. Airplane Examination Examination of the wreckage did not reveal any preimpact malfunctions of the airplane. There was no indication of structural failure and control continuity was established from the flight controls to the rudder pedals and control wheel. Further examination revealed that the right wingtip and right wing outboard leading edge displayed damage that had been taped over with duct tape and appeared to have occurred prior to the accident. The rudder was also a different color than the rest of the airplane. Both wing tank fuel caps were closed and locked. Both the left and right wing fuel tanks were compromised however; approximately 12 ounces of fuel was recovered from left wing fuel tank. Examination of the fuel revealed that it was consistent with 100LL aviation gasoline, and a check with water finding paste revealed no indication of water being present. Examination of the fuel strainer also revealed the presence of fuel consistent with 100LL aviation gasoline and a check with water finding paste also did not reveal the presence of water. Examination of the cockpit revealed that the wing flap lever was in the 15 degree (first notch) position and the stabilator pitch trim was in the takeoff range (green arc). The fuel selector was in the right wing tank position. The primer was in and locked. The throttle was full open, the mixture was full rich, and the carburetor heat was off. The fuel boost pump was also off. Propeller and Engine Examination Examination of the propeller revealed that the propeller had remained attached to the crankshaft flange. One blade was curved aft about 10 degrees and exhibited chord-wise abrasions on the forward surface. The other blade was bent aft about 45 degrees at about mid-span. It exhibited chord-wise abrasions and paint transfer on the forward surface of the blade. Examination of the engine revealed that it had remained attached to the aircraft firewall by the tubular engine mount. Examination of the engine revealed that the engine compartment contained the remains of bird nests, and bird excrement. A red colored piece of cloth was also visible inside the right cowling inlet. Further examination of the cloth revealed that it was the cloth jacketing from a foam filled cowl plug and that the cloth jacketing along with the foam insert were protruding from, and blocking, the engine combustion air inlet opening. The drive train was rotated by turning the crankshaft flange and continuity of the crankshaft to the rear gears and to the valve train was confirmed. Suction and combustion were observed from all four engine cylinders. The carburetor remained attached to the engine and no external damage was noted. The carburetor bowl screws were snug and no fuel stains were noted on the exterior surfaces of the carburetor. The carburetor was partially disassembled.