ERA11LA179

NTSB accident investigation · Beech C23 · Carrollton, GA · March 4, 2011

Accident · No injuriesLimited investigationFinal report
Date
March 4, 2011, 11:30 local (16:30 UTC)
Place
Carrollton, GA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6015FBeech C23
Defining event
Enroute-climb to cruise: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed · report December 1, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20110304004689A
Case key
78495

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 mechanic's failure to re-connect a fuel line following an annual inspection. Contributing to the accident was the pilot's improper decision to depart with a known mechanical deficiency.

Findings · 3

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.

Fuel system: fuel distributionAircraft › Aircraft systems · Incorrect service/maintenanceBeech C23: 1 caseAll aircraft: 141 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelBeech C23: 1 caseAll aircraft: 320 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

According to the pilot, the purpose of the flight was to pick up the airplane after the completion of an annual inspection. He said that the inspection was completed, and during the engine start, the fuel pressure gauge showed no pressure; however, the engine started and ran normally with no anomalies noted during the takeoff or initial climb. About 2,000 feet mean sea level and 4 miles from the airport, smoke was observed coming from the engine cowling and the engine ran roughly. Witnesses stated that smoke and flames trailed from the airplane as it landed back at the departure airport, steered into the grass infield, and the occupants egressed. The instrument panel, cockpit, cabin area, and right wing were consumed by fire. A postaccident examination revealed that the fuel line from the fuel boost pump to the carburetor was disconnected. Closer examination revealed melted metals and soot accumulated on the threads of the male fitting of the pump, and on the threads of the female b-nut fitting of the fuel line, consistent with the line being disconnected prior to the fire. The fuel line was in close proximity to the carburetor fuel strainer that would routinely be removed during an annual inspection. A t-fitting on the line routed fuel to the fuel pressure indicator. With the affected line disconnected, fuel pressure would not register on the gauge, but the engine would continue to operate.

Factual narrative

On March 4, 2011, about 1130 eastern standard time, a Beech C23 Sundowner, N6015F, was destroyed following an in-flight fire and emergency landing after takeoff from West Georgia Regional Airport (CTJ), Carrollton, Georgia. The certificated flight instructor (CFI) and private-rated pilot receiving instruction were not injured. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight, which departed CTJ about 1125. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The CFI stated that the purpose of the flight was to pick up the airplane after the completion of an annual inspection. He brought the student along to conduct training on the return flight. No anomalies were noted during a preflight inspection of the airplane. The CFI stated that, during the engine start, they observed that the fuel pressure gauge indicated zero, but that the engine started and ran normally, and no anomalies were observed during the takeoff or initial climb. According to the CFI, they departed CTJ under visual flight rules (VFR) and intended to obtain an IFR clearance after takeoff. While communicating with air traffic control (ATC), about 2,000 feet mean sea level, and about 3 miles east of CTJ, the engine began to run roughly, and smoke was observed coming from under the cowling. The pilots turned back towards the airport, and announced to ATC that they would be returning to CTJ. The CFI performed a visual approach to runway 17, and stated that there was a significant amount of smoke in the cockpit. After landing, both pilots egressed the airplane, and called emergency services, the airplane's owner, and ATC by telephone to notify them of the accident. The pilot receiving instruction provided a written statement, and his account of events was consistent with that of the CFI. A witness stated that he saw the airplane about 20 feet above the runway, with the engine running, as it trailed smoke and flames. The CFI held a commercial pilot certificate with ratings for airplane single- and multiengine land. He held a flight instructor certificate for airplane single-engine, multiengine, and instrument airplane. His most recent Federal Aviation Administration (FAA) first class medical certificate was issued November 8, 2010. The pilot reported 3,500 total hours of flight experience, of which 1,200 hours were in the accident airplane make and model. The pilot receiving instruction held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third class medical certificate was issued August 4, 2010. He reported 63 total hours flight experience, all of which were in the accident airplane make and model. According to FAA records, the airplane was manufactured in 1979. The airplane’s maintenance records revealed that the airplane had accrued 6,132.8 total aircraft hours as of its most recent annual inspection, which wascompleted March 1, 2011. The entries annotated that run-up checks were completed and that no leaks were noted. The 1137 weather observation at CTJ included an overcast ceiling at 2,300 feet, visibility 10 miles, winds from 140 at 10 knots, gusting to 21 knots, temperature 12 degrees C, dewpoint 7 degrees C, and an altimeter setting of 30.38 inches of mercury. Photographs of the airplane provided by an FAA inspector revealed that the airplane's engine compartment received significant fire damage. The instrument panel, cockpit, cabin area, and right wing were consumed by fire. The inboard section of the left wing out to the landing gear was also destroyed by fire. A detailed examination of the wreckage performed by an FAA inspector revealed that the fuel line from the electric fuel boost pump to the carburetor was disconnected. Closer examination revealed melted metal and soot accumulated on the threads of the male fitting of the pump, and on the threads of the female b-nut fitting of the fuel line, consistent with the line being disconnected prior to the fire. The fuel line was in close proximity to the carburetor fuel strainer that would routinely be removed during an annual inspection. According to the inspector, a t-fitting on the line routed fuel to the fuel pressure indicator. With the affected line disconnected, fuel pressure would not register on the gauge, but the engine would continue to operate.

Aircraft

Registration
N6015F
Reported as
Beech C23
Category
Airplane
Serial number
M-2134
Airframe hours
6,132
Engine
Lycoming O&VO-360 SER, 180 horsepower, reciprocating
Damage
Substantial damage
Fire
In-Flight
Flight
Instructional · Part 91
Operator
Quality Aviation Inc
Registered owner
Quality Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 1, 2011 · 1 hours before
Departed
CTJ · Carrollton, GA
Destination
PDK · Atlanta, GA
Flight plan
IFR
Airport
CTJ · West Georgia Regional Airport, runway 17, 5,503 × 100 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
49
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
July 6, 2009
Seat
Right
Flight hours
3,500 total · 1,200 in this make and model · 3,400 as pilot in command · 120 in the last 90 days · 50 in the last 30 days · 2 in the last 24 hours
Role
Pilot
Age
57
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
January 28, 2011
Seat
Left
Flight hours
63 total · 63 in this make and model · 15 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 10 knots, gusting 21
Visibility
10 statute miles
Lowest ceiling
2,300 ft overcast
Temperature
54 °F, dew point 45 °F
Altimeter
30.37 inHg
Observed at
CTJ

Docket · 12

The files NTSB released with the investigation on October 25, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.0 MB in all.

FAA reports on this event · 1

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

Other investigations on N6015F · 1

Matched to the same aircraft by N-number and date.