# NTSB ATL03LA040: Beech A24R, N9769L, Titusville, FL, February 2, 2003 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: February 2, 2003, 12:06 local (17:06 UTC) - Place: Titusville, FL - Coordinates: 28.513889, -80.797225 - Nearby events: https://openairdocs.org/map.md?lat=28.5139&lon=-80.7972&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 3 minor - Status: Completed, report September 30, 2003 - Report: Approved by Office Director - Parties: Orlando FSDO, Textron Lycoming - NTSB case key (mKey): 56424 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL03LA040 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56424/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56424 - Page: https://openairdocs.org/ntsb/ATL03LA040 ## Probable cause The loss of engine power for undetermined reasons. The pilot's failure to attain full power for takeoff in accordance with the operation handbook was a factor. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - roll/run - flight manuals - not followed, pilot in command (contributing factor) - reason for occurrence undetermined (cause) - Forced landing, emergency landing after takeoff - In flight collision with object, emergency landing after takeoff - object - wire,static - object - tree(s) ## Analysis The pilot advanced the throttle for takeoff until the throttle was completely in and at the hub. He initially noted the rpm showed 2,300, rpm and during the takeoff roll the rpm showed 2,500 rpm. The Pilot's Operating Handbook states that full throttle 2,700 rpm is required for takeoff. The throttle slipped back about 1/2 inch on two different occasions, and the pilot pushed the throttle back in. No increase in engine power was noted and he continued the takeoff roll. Once airborne, the pilot retracted the landing gear and continued applying full throttle. The throttle felt like it was sticking and the engine was not producing full power. The airplane reached about 75 to 100 feet, and was not climbing. The pilot realized he would not clear wires and trees to his immediate front and applied aft pressure on the control yoke to decrease his airspeed and the impending impact. Examination of the airplane wreckage revealed the throttle cable was hard to move and fractured. The throttle cable was removed, and forwarded to the NTSB Materials Laboratory. The examination revealed the fractures were typical of bending overstress while the cable was under a tension load. No determination was made for the loss of engine power. ## Factual narrative On February 2, 2003, at 1206 eastern standard time, a Beech A24R, N9769L, registered to a private owner, collided with wires and trees on initial takeoff climb from runway 09 at Space Coast Regional Airport, Titusville, Florida. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The airplane sustained substantial damage. The private pilot reported serious injuries and the three passengers reported minor injuries. The flight originated from Titusville, Florida, on February 2, 2003, at 1205. The pilot advanced the throttle for takeoff until the throttle was completely in and at the hub. He initially noted the rpm showed 2,300, rpm and during the takeoff roll the rpm showed 2,500 rpm. The throttle slipped back about 1/2 inch on two different occasions, and he pushed the throttle back in. No increase in engine power was noted and he continued the takeoff roll. The pilot stated he probably had enough runway left to stop the airplane if he had aborted the takeoff soon enough. Once airborne, the pilot retracted the landing gear and continued applying full throttle. The throttle felt like it was sticking and the engine was not producing full power. The airplane reached about 75 to 100 feet, and was not climbing. The wind was out of the south and the pilot started a turn. The pilot stated he knew the airplane was not going to clear the wires and trees. The pilot applied aft pressure on the control yoke to decrease his airspeed and lessen the impending collision. The controller in charge at Space Coast Regional Tower stated the pilot departed from runway 9. The ground run appeared to be slow. The airplane rotated and climbed to about 15 to 20 feet above the runway and flew straight ahead. Just before colliding with wires and trees he observed the nose of the airplane to pitch up. Review of the Pilot's Operating Handbook, Section II Limitations, Power Plant Limitations states, "Take-off and Maximum Continuous Power......... Full throttle or 2700 rpm, whichever occurs first." Section IV Normal Procedures states, "Takeoff.....................Full throttle- 2700 RPM." Examination of the crash site revealed the throttle cable was hard to move and would not move through the full range of travel. The cable was removed and visually inspected. The inner cable separated near the swaged assembly connected to the throttle handle. The throttle cable assembly was forwarded to the NTSB Materials Laboratory for further analysis. Examination revealed the inner cable was fractured near the cockpit end of the assembly. Magnified optical examination of the fracture area revealed the seven individual wires of the inner cable were all deformed in a common direction adjacent to the fracture. The fractures were all typical overstress breaks, and there was no evidence of wear or corrosion deterioration at the fracture location. Fracture features and associated deformation were consistent with a bending overstress fracture while the cable was under a tension load. Review of the airplane logbooks revealed the throttle cable had not been replaced since the airplane was manufactured. The engine control cables were lubed on October 7, 2001, and the last annual inspection was on November 11, 2002. The total time on the throttle cable at the time of the accident was 4,533 hours. The aircraft wreckage was released to the registered owner on February 4, 2003. The throttle cable assembly was released to Atlanta Air Recovery, Griffin, Georgia, on April 30, 2003. ## Aircraft - Registration: [N9769L](https://openairdocs.org/deregistered/N9769L-2003-07-15), registration cancelled 2003-07-15, S/N MC-109, built 1972 (OpenAirDocs) - Reported make and model: Beech A24R - Registry model: [Beech A24R](https://openairdocs.org/model/beech-a24r) (registry code 1151252) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: MC109 - Airframe hours: 4533 - Engines: Lycoming IO-360-A1B 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Steven J. Halm - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 6, 2002, 25 hours before - Departed: TIX, Titusville, FL - Destination: 78N, Reidsville, NC - Flight plan: IFR - Airport: TIX, Space Coast Regional, runway 09, 5,001 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; last flight review May 11, 2001; seat: left; flight hours: 850 total, 500 in this make and model, 800 as pilot in command, 25 in the last 90 days, 7 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 4 knots - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 64 °F - Altimeter: 30.14 inHg - Observed at: TIX ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20030202014119A](https://openairdocs.org/incident/20030202014119A), Feb 2, 2003: Beech A24R, Titusville, FL, Substantial damage. (-23) Pilot initiated takeoff roll on runway 9 at tix. Engine failed to develop full power, pilot failed to abort takeoff. Aircraft did not gain sufficient… ## Docket (6 files) The files NTSB released with the investigation on July 21, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56424. 10.6 MB in all. - Materials Laboratory 15 - Factual Report 03-023 throttle cable (item 1, .PDF, 429 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177918&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2003-023%20throttle%20cable-Master.PDF - Extract Airplane Logbook (item 2, .PDF, 7.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40187461&FileExtension=.PDF&FileName=Extract%20Airplane%20Logbook-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 3, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40187462&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 4, .PDF, 663 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382953&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Extract Pilot's Operating Handbook (item 5, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40187568&FileExtension=.PDF&FileName=Extract%20Pilot%27s%20Operating%20Handbook-Master.PDF - Statements (item 6, .PDF, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382954&FileExtension=.PDF&FileName=Statements-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.