# NTSB ERA10LA297: Beech B19, N1958W, Rockohoma, NY, June 5, 2010 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 5, 2010, 15:05 local (19:05 UTC) - Place: Rockohoma, NY - Coordinates: 40.784999, -73.121665 - Nearby events: https://openairdocs.org/map.md?lat=40.7850&lon=-73.1217&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 3 serious; on the ground: 1 serious - Status: Completed, report August 11, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Hawker Beechcraft Corp, Lycoming Engines, FAA/FSDO - NTSB case key (mKey): 76221 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA297 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/76221/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=76221 - Page: https://openairdocs.org/ntsb/ERA10LA297 ## Probable cause The pilot's inadequate preflight inspection which resulted in a total loss of engine power during the initial climb due to fuel contamination. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [Beech B19, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151215), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech B19, 2 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1151215), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Beech B19, 1 case](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=1151215), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech B19, 5 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151215), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech B19, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151215), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech B19, 11 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151215), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Post-impact: Fire/smoke (post-impact)](https://openairdocs.org/ntsb-events/170); cases with it: [Beech B19, 2 cases](https://openairdocs.org/ntsb-events/170/sequence.md?model=1151215), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## Analysis According to the certified flight instructor (CFI), he and the student were planning to practice takeoffs and landings. During the first takeoff approximately 400 feet above ground level, the engine power began to degrade and lose power. The CFI took control of the airplane, checked the throttle and mixture position and looked for a suitable place to perform a forced landing. During the landing, the airplane impacted a nearby parking lot, came to rest against a building, and was engulfed in fire. A postaccident examination revealed several tablespoons of water in the carburetor. The CFI reported that he had completed a normal preflight inspection. Examination of the fuel system did not disclose any evidence of a mechanical malfunction. ## Factual narrative HISTORY OF FLIGHT On June 5, 2010 about 1505 eastern daylight time, a Beech B19 (Musketeer Sport), N1958W, was substantial damaged when it impacted the ground in an industrial area in Rohokomo, New York shortly after takeoff from the Long Island Mac Arthur Airport (ISP), Islip, New York. Day visual meteorological conditions prevailed, and no flight plan had been filed for the local instructional flight. The certificated flight instructor (CFI) and student pilot/owner sustained serious injuries. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the CFI they were planning to practice takeoffs and landings and on the first takeoff, approximately 400 feet above ground level, the engine power began to degrade and the engine began to "sputter." He took control of the airplane and saw an opening in which he aimed the airplane towards. Approximately 10 seconds after the degradation of power, the airplane "hit hard, skidded, hit hard again, came to a stop, and the cockpit was immediately engulfed in flames." According to records obtained from the flight school that facilitated the instructional flight, the airplane was last refueled on May 22, 2010, and at that time 30 gallons of Avgas 100LL fuel was acquired. The student completed the flight school's ground course in March 2010 and the student's most recent flight in the accident airplane was conducted on June 4, 2010 and was about two-hours in duration. Flight school records also indicated that on April 21, 2010 their maintenance facility completed an annual inspection on the airplane and at that time the airplane had a 2,225.5 hours total time in service. According to the Federal Aviation Administration (FAA) inspector that responded to the accident location the airplane impacted several trees, left several gouge and scrape marks in the adjacent parking lot, and came to rest against an office building. The airplane had departed runway 24 and came to rest against a building approximately 2,650 feet to the west-southwest of runway 24 and approximately 400 feet to the west of the extended centerline for that runway. Photographs provided to the NTSB revealed that the cabin area of the airplane and approximately the inboard one-half of each wing were consumed by fire; and the vertical and horizontal stabilizers were impact damaged. PERSONNEL INFORMATION The CFI, age 48, held an airline transport pilot certificate, with a rating for airplane single-engine land and a flight instructor certificate with ratings of airplane single-engine land and instrument airplane. His most recent FAA second-class medical was issued on November 2, 2009. The student pilot/owner held an FAA third-class medical and student pilot certificate that was issued January 27, 2010. According to flight school records he had about 57 total hours of flight experience and 50.9 of those hours were in the accident airplane make and model. AIRCRAFT INFORMATION The airplane was issued an FAAairworthiness certificate on November 29, 1973, and was registered to the accident pilot on December 11, 2009. It was equipped with a 150 hp Lycoming O-320-E3D engine. METEOROLOGICAL INFORMATION The 1456 recorded weather observation at ISP, included winds from 220 degrees at 10 knots with gusts of 18 knots; visibility 10 miles, few clouds at 6,000 feet, scattered clouds at 13,000 feet, and broken cloud layer at 25,000 feet, temperature 30 degrees C, dew point 18 degrees C; altimeter 29.64 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane was examined by the NTSB investigator on August 2, 2010 at a salvage facility near Clayton, Delaware. The cabin area aft of the firewall to the area immediately forward of the vertical empennage and the inboard one-half of both wings were thermal and soot damaged. The right wing exhibited chordwise scrape marks along the underneath side of the wing. The main landing gear was impact separated. The right wing fuel cap assembly was separated along with the surrounding approximate 4 inches of wing skin. The right wing fuel cap was inserted in the fuel cap receiver; however, the cap was not completely seated. The latch was flush with the surrounding skin area. The left wing fuel cap was closed and the fuel cap latch was flush with the surrounding wing area. The flap position was unable to be confirmed; however, appeared to be in the retracted position. The stabilator and vertical empennage remained attached. The elevator actuator was measured extended to 2 1/2 inches which, according to the Beechcraft service manual, was not within the rigging value for the serial number of the airplane, but equates to a full trim tab trailing edge up position for the previous serial number block of B19 airplanes. The actuator was removed and limits of travel confirmed; the actuator rod full extended position of 3 1/2 inches and the minimum extension was 1 5/8 inches. The elevator trim chain was intact and both ends were wrapped correctly around the elevator trim actuator capstan. Flight control cable continuity was confirmed to all surfaces from the area immediately below the control column in the cabin. The engine was detached from the firewall. The spark plugs were removed and appeared to be light brown in color and indicated normal wear when compared to the Champion Spark Plug guide. The magnetos, vacuum pump and fuel lifter remained attached to the rear accessory case and were covered in soot. The magnetos were removed and produced spark on all towers. The vacuum pump was removed, disassembled, and the vanes were intact. Drive train continuity was confirmed from the propeller to the rear accessory case with minimal friction and thumb compression was verified on all cylinders. The fuel lifter was verified to exercise up and down. The carburetor was removed from the engine and was intact and all fuel lines remained attached. The carburetor exhibited soot damage and fuel staining was unable to be verified. Thecarburetor was disassembled and approximately 2 tablespoons of water was in carburetor bowl and was void of fuel. The brass floats remained intact and the venturi remained in place. The throttle cable was exercised and water was observed coming out of the accelerator pump. The gascolator was disassembled and the sump drain was impact separated. The oil filter was removed and exhibited thermal and soot damage. The filter was disassembled and no metal was observed in the paper element. The oil screen was free of debris. The fuel selector valve which consisted of four detents, according to the Beechcraft service bulletin No. 2053, were labeled "OFF, LEFT TANK, RIGHT TANK, OFF." The selector was located in the 8 o'clock position which was one of the "OFF" positions. The selector valve was disassembled and was verified in the "OFF" position. The fuel selector valve shroud and the "OFF" position lock-out mechanism was not located. ## Aircraft - Registration: [N1958W](https://openairdocs.org/deregistered/N1958W-2018-01-12), registration cancelled 2018-01-12, S/N MB-623, built 1973 (OpenAirDocs) - Reported make and model: BEECH B19 - Registry model: [Beech B19](https://openairdocs.org/model/beech-b19) (registry code 1151215) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: MB-623 - Airframe hours: 2226 - Engines: LYCOMING O-320 E3D 180 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, April 21, 2010 - Departed: ISP, Islip, NY - Destination: ISP, Islip, NY - Flight plan: Unknown - Airport: ISP, Long Island Mac Arthur Airport, runway 24, 7,006 × 150 ft ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 51; injuries: serious; student; medical: class 3, without waivers/limitations; seat: left; flight hours: 57 total, 51 in this make and model - Flight instructor; age 48; injuries: serious; airline transport, flight instructor; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; flight hours: 2,100 total ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 10 knots, gusting 18 - Visibility: 10 statute miles - Lowest ceiling: 25,000 ft broken - Temperature: 86 °F, dew point 64 °F - Altimeter: 29.63 inHg - Observed at: ISP, 1 nm away ## 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 20100605052449A](https://openairdocs.org/incident/20100605052449A), Jun 5, 2010: Beech B19, Ronkonkoma, NY, Destroyed. On Saturday June 5, 2010 , at approximately 1500 , CFI [privacy data omitted] cert # [privacy data omitted] was instructing [privacy data omitted] (student) in… ## Docket (9 files) The files NTSB released with the investigation on June 20, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=76221. 6.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - CFI (item 1, .PDF, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346854&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20CFI-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Student Pilot/Owner (item 2, .PDF, 547 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346855&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Student%20Pilot%2FOwner-Redacted.PDF - Eyewitness Statement (item 3, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346856&FileExtension=.PDF&FileName=Eyewitness%20Statement-Master.PDF - Memorandum For Record: Interview with Flight School with Vice President and a Flight Instructor from Flight School (item 4, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346857&FileExtension=.PDF&FileName=Memorandum%20For%20Record%3A%20Interview%20with%20Flight%20School%20with%20Vice%20President%20and%20a%20Flight%20Instructor%20from%20Flight%20School-Master.PDF - Islip Weather Observations (item 5, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346858&FileExtension=.PDF&FileName=Islip%20Weather%20Observations-Master.PDF - Fuel Receipt (item 6, .PDF, 578 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346865&FileExtension=.PDF&FileName=Fuel%20Receipt-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346866&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346859&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photos: 4 Embedded (item 9, .PDF, 4 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346864&FileExtension=.PDF&FileName=Photos%3A%204%20Embedded-Master.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.