CEN11FA125

NTSB accident investigation · Beech C24R · Wheeling, IL · December 22, 2010

Accident · FatalField investigationFinal report
Date
December 22, 2010, 14:46 local (20:46 UTC)
Place
Wheeling, IL
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N5293MBeech C24R
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report January 17, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA-DPA-FSDO, Lycoming Engines, Beechcraft
FAA report
20101222054739A
Case key
78048

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

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.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech C24R: 5 casesAll aircraft: 9,295 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Not specifiedBeech C24R: 2 casesAll aircraft: 497 cases
Fuel system: fuel pumpsAircraft › Aircraft systems · Incorrect service/maintenanceBeech C24R: 1 caseAll aircraft: 71 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Not specifiedBeech C24R: 1 caseAll aircraft: 371 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

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.

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 heretracted 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. Thepilot’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 installed because of an oil leak. Another entry dated May 7, 2010, indicated that another propeller governor was installed on the engine. The tachometer reading at this time was listed as 2,948 hours. An entry in the engine logbook dated June 18, 2010, indicated that the engine had been removed for overhaul. The tachometer time was listed as 2,961 hours and the time since overhaul was listed as being 1,545 hours. An entry regarding what was accomplished during the engine overhaul was dated September 9, 2010. This entry contained the information, “Installed overhauled LW15472 fuel pump s/n AA26207.” According to the mechanic at the flight school, the airplane was involved in a propeller strike approximately two years prior to the accident and a new propeller was installed on the airplane. The airplane was then flown 25 to 50 hours and metal shavings were found in the engine oil, so the engine was sent out for overhaul. The engine was received back from the overhaul, but there were still problems with the induction system, the starter, and other “discrepancies.” Hecontinued to work on the airplane and believed that he had all the issues resolved. The airplane had been flown about 1 hour after the overhauled engine was installed. He stated that at some point the airplane was sold and there were several delays of the new owner picking up the airplane. He stated he charged the battery and ran the airplane several times during the delay period and that the engine operated normally during these engine runs. He stated that to his knowledge there was not a pre-buy inspection performed on the airplane. The owner of the flight school stated they received the overhauled engine back around October 2010. He stated they were not able to start the engine and they discovered that the wrong starter had been returned with the engine from the overhaul shop. The correct starter was installed, but the engine was running rough. They then discovered that there was a plug missing from the bottom of the engine. They installed the plug and several engine runs were performed and he flew the airplane for about one hour. He stated that by the end of October, early November, the issues were resolved and the engine was in good running condition. The airplane sat out on the ramp for at least one month prior to the accident flight. The airplane was topped off with 19.8 gallons of fuel prior to takeoff. The line person who fueled the airplane stated he did not notice any ice, frost, or snow on the airplane. Nor did he notice any standing water around the fuel caps. The mechanic that performed the engine overhaul stated that after the engine was overhauled, he was contacted by the flight school that owned the airplane and was told the engine was running rough, especially at low idle. He stated he offered suggestions regarding troubleshooting the problem. He suggested they check the fuel injectors for clogging, check for a missing intake plug, and/or send the fuel injector out for overhaul. METEOROLOGICAL INFORMATION A review of the recorded surface observation weather data from PWK, revealed the conditions at 1452 were winds from 020 degrees at 11 knots; visibility 10 miles; ceiling 3,500 broken; temperature 2 degrees Celsius; dew point minus 2 degrees Celsius; and altimeter 30.33 inches. WRECKAGE AND IMPACT INFORMATION The airplane initially contacted the roof of an office/warehouse building located on the corner or Wolf and Hintz Roads. The building was approximately 40 feet high. The roof of the building consisted of snow covered gravel. Three elongated impact marks, the longest of which was about 25 feet, were visible on the roof. One of the track marks continued to the edge of the roof where the nose gear impacted a raised portion of the building’s façade. The nose gear was located on the roof next to the façade and the left wing tip was also located on the roof. The airplane then descended into a parking lot adjacent to the building where it damaged five parked cars. The airplane ultimately contacted the trunk area of one of thecars. This car was pushed about 20 feet and rotated 90 degrees from where it was originally parked. The nose of the airplane came to rest alongside the trunk of the car and the right wing was up against the right side of the car. The airplane and engine sustained fire damage with the structure between the firewall and the aft fuselage partially consumed by fire. Examination of the recovered airframe and flight control system components revealed no evidence of preimpact mechanical malfunction. All three landing gear were separated from the airplane with portions of the gear still attached to their trunnions. The left main landing gear actuator was in the extended position. The number of exposed threads on the flap actuator corresponded to 1 degree of flap extension. The stabilator trim actuator was measured suggesting the airplane was trimmed slightly nose up. The engine remained attached to the engine mounts, three of which had been pulled out of the firewall. The engine sustained impact and fire damage with most of the fire damage occurring to the accessory section of the engine. The magnetos sustained fire damage and could not be tested.. Engine continuity and cylinder thumb compression were established. The fuel servo was removed from the engine. The servo could not be tested due to the amount of fire damage and a teardown was accomplished. The inside and outside of the fuel inlet filter screen were coated which what appeared to be a melted substance that had solidified. It was noted that the plastic spacer and aligner for the mixture control valve was missing and presumed to have melted resulting in the substance found on the inlet screen. The inlet screen was cut in half and a foreign piece of material was found inside the screen. The material was opaque and cylindrical in shape. It matched the inside diameter of the metal fitting at the end of the screen. This material was sent to the National Transportation Safety Board (NTSB) Materials Laboratory for examination. The propeller remained attached to the engine. Approximately 18-inches of one propeller blade were separated from the remainder of the blade and the separated portion was not located. The tips of the two remaining blades exhibited gouges and scrapes. Both blades exhibited slight twisting. Examination of the fractured propeller blade revealed mechanical bending and mechanical surface damage consistent with impact damage. A propeller teardown was performed and it revealed that the propeller had sustained heavy impact damage. By aligning internal impact marks it was determined that the propeller was most likely on the low pitch stop at the time of impact. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the passenger on December 23, 2010, by the Cook County Medical Examiner’s Office, Chicago, Illinois. The cause of death was reported as smoke inhalation and thermal injuries. The Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory,Oklahoma City, Oklahoma performed a Forensic toxicology on specimens from the passenger by. The toxicology report listed 16 percent Carbon Monoxide detected in blood and 0.46 (ug/ml) Cyanide was detected in blood. ADDITIONAL INFORMATION The NTSB’s Materials Laboratory examination of the material found inside the fuel servo fuel inlet screed revealed material appeared to by polymeteric. The material was off-white and opaque with darkened/browned areas. The material also contained some areas where bubbles had been trapped, giving it the appearance of a material that had been exposed to high heat. Further examination revealed the material was most likely polyacetal. Polyacetal, also known as polyoxymethylene, is a thermoplastic that can be found in some fuel system components. The majority of the engine-driven fuel pump was destroyed by the postimpact fire; however, the base of the pump remained attached to the accessory case. The numbers 15472 were stamped into the base of the pump. There was no serial number visible on the base. Part number 15472 is a low pressure fuel pump that delivers a fuel pressure between 4 and 6 psi. According to Textron Lycoming Engines, the IO-360-A1B6 engine installed on the accident airplane required a high pressure fuel pump, part number 15473 which could deliver a fuel pressure of approximately 14 psi. The Beechcraft Sierra C24R Pilot Operating Handbook indicates a maximum fuel pressure of 12 psi.

Aircraft

Registration
N5293M
Reported as
Beech C24R
Category
Airplane
Serial number
MC-572
Airframe hours
2,951
Engine
Lycoming IO-360, 200 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 29, 2010 · 0 hours before
Departed
PWK · Wheeling, IL
Destination
06C · Schaumburg, IL
Airport
PWK · Chicago Executive, runway 34, 5,000 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
36
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
January 9, 2009
Seat
Left
Flight hours
1,132 total · 4 in this make and model · 1,089 as pilot in command · 11 in the last 90 days · 4 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 11 knots
Visibility
10 statute miles
Lowest ceiling
3,500 ft broken
Temperature
36 °F, dew point 25 °F
Altimeter
30.32 inHg
Observed at
PWK, 1 nm away

Docket · 46

The files NTSB released with the investigation on December 1, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.9 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 417 KBAirframe and Engine ExaminationItem 2 · .PDF · 66 KBMaterials Laboratory 15 - Factual Report 11-066Item 3 · .PDF · 129 KBRecord of Interviews and Witness StatementsItem 4 · .PDF · 1.1 MBRecord of ConversationItem 5 · .PDF · 23 KBAir Traffic Control Information and TranscriptItem 6 · .PDF · 352 KBIllinois State Police ReportItem 7 · .PDF · 227 KBPropeller Inspection ReportItem 8 · .PDF · 75 KBFuel Servo Exempler Cut-AwayItem 9 · .PDF · 1.0 MBFueling RecordsItem 10 · .PDF · 62 KBAirframe Maintenance RecordsItem 11 · .PDF · 1.5 MBEngine Maintenance RecordsItem 12 · .PDF · 1.6 MBEngine Overhaul RecordsItem 13 · .PDF · 434 KBIO, AIO-360-A,-B Series Parts Catalog, ExcerptItem 14 · .PDF · 86 KBBeechcraft Sierra POH ExcerptsItem 15 · .PDF · 895 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 16 · .PDF · 186 KBToxicological ReportItem 17 · .PDF · 52 KBStatement of Party Representatives to NTSB InvestigationItem 18 · .PDF · 124 KBPhoto 01. Impact Marks on Roof of Building. Police PhotoItem 19 · .PDF · 88 KBPhoto 02. Impact Mark on Roof of Building and Nose Gear. Police PhotoItem 20 · .PDF · 123 KBPhoto 03. Accident Site. Police PhotoItem 21 · .PDF · 117 KBPhoto 04. Left Wing. Police PhotoItem 22 · .PDF · 97 KBPhoto 05. Left Rear View of N5293M. Police PhotoItem 23 · .PDF · 128 KBPhoto 06. Right Rear View of N5293M. Police PhotoItem 24 · .PDF · 112 KBPhoto 07. Right Wing and Vehicle Impacted. Police PhotoItem 25 · .PDF · 133 KBPhoto 08. Front Right View of N5293M. Police PhotoItem 26 · .PDF · 121 KBPhoto 09. Engine and Vehicle Impacted.Item 27 · .PDF · 126 KBPhoto 10. Engine and Propeller.Item 28 · .PDF · 358 KBPhoto 11. Propeller Blade.Item 29 · .PDF · 416 KBPhoto 12. Fractured Propeller Blade.Item 30 · .PDF · 480 KBPhoto 13. Top of Engine.Item 31 · .PDF · 578 KBPhoto 14. Right Side of Engine.Item 32 · .PDF · 488 KBPhoto 15. Left Side of Engine.Item 33 · .PDF · 492 KBPhoto 16. Rear Accessory Case of Engine.Item 34 · .PDF · 539 KBPhoto 17. Underside of Engine.Item 35 · .PDF · 600 KBPhoto 18. Accessory Gears.Item 36 · .PDF · 490 KBPhoto 19. Fuel Servo.Item 37 · .PDF · 501 KBPhoto 20. Melted Diaphragm in Fuel Servo.Item 38 · .PDF · 926 KBPhoto 21. Debris in Fuel Servo.Item 39 · .PDF · 1.5 MBPhoto 22. Mixture Valve Components with Exemplar SpacerItem 40 · .PDF · 1.1 MBPhoto 23. Fuel Inlet Filter and Foreign MaterialItem 41 · .PDF · 970 KBPhoto 24. Foreign Material from Inside Fuel Inlet FilterItem 42 · .PDF · 161 KBPhoto 25. Accessory HousingItem 43 · .PDF · 873 KBPhoto 26. Fuel Pump Part NumberItem 44 · .PDF · 909 KBOriginal and Updated Factual NarrativesItem 45 · .PDF · 123 KBOriginal and Update Brief and Probable CauseItem 46 · .PDF · 52 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.