# NTSB ERA11LA179: Beech C23, N6015F, Carrollton, GA, March 4, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 4, 2011, 11:30 local (16:30 UTC) - Place: Carrollton, GA - Coordinates: 33.625556, -85.15139 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.6256&lon=-85.1514&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 1, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 78495 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11LA179 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78495/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78495 - Page: https://openairdocs.org/ntsb/ERA11LA179 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel distribution](https://openairdocs.org/ntsb-findings/01022820): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/01022820/cases.md?model=1151242), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/01022820/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=1151242), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech C23, 8 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151242), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=1151242), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-climb to cruise: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=1151242), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Taxi-from runway: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=1151242), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## 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](https://openairdocs.org/deregistered/N6015F-2011-07-23), registration cancelled 2011-07-23, S/N M-2134, built 1979 (OpenAirDocs) - Reported make and model: BEECH C23 - Registry model: [Beech C23](https://openairdocs.org/model/beech-c23) (registry code 1151242) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-2134 - Airframe hours: 6132 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 49; injuries: none; 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 - Pilot; age 57; injuries: none; 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 ## 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 20110304004689A](https://openairdocs.org/incident/20110304004689A), Mar 4, 2011: Beech C23, Carrollton, GA, Destroyed. On 03/04/2011 at aproximately 10:00, [privacy data omitted] iii took off from kctj for the purpose of providing instrument flight instruction. After leveling… ## Other investigations on N6015F (1) 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. - [NTSB MIA81DLD16](https://openairdocs.org/ntsb/MIA81DLD16), Dec 3, 1980: Beech C23 (N6015F), St.Petersburg, FL, substantial damage ## Docket (12 files) The files NTSB released with the investigation on October 25, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78495. 8.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354493&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Interview Summary (item 2, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354494&FileExtension=.PDF&FileName=Pilot%20Interview%20Summary-Master.PDF - Co-pilot Statement (item 3, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354495&FileExtension=.PDF&FileName=Co-pilot%20Statement-Redacted.PDF - Witness Statement (item 4, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354496&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - FAA Inspector Statement (item 5, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354497&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Redacted.PDF - FAA Inspector Statement Concurrence (NTSB) (item 6, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354529&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement%20Concurrence%20(NTSB)-Redacted.PDF - Annual Inspection (item 7, .PDF, 464 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354530&FileExtension=.PDF&FileName=Annual%20Inspection-Redacted.PDF - Photo 1: Front View of Damaged Airplane (item 8, .PDF, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354498&FileExtension=.PDF&FileName=Photo%201%3A%20Front%20View%20of%20Damaged%20Airplane-Master.PDF - Photo 2: View of Fuel Line Fitting (item 9, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354499&FileExtension=.PDF&FileName=Photo%202%3A%20View%20of%20Fuel%20Line%20Fitting-Master.PDF - Photo 3: Front View of Fuel Line Fitting (item 10, .PDF, 855 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354501&FileExtension=.PDF&FileName=Photo%203%3A%20Front%20View%20of%20Fuel%20Line%20Fitting-Master.PDF - Photo 4: Side view of Fuel Line Fitting (item 11, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354502&FileExtension=.PDF&FileName=Photo%204%3A%20Side%20view%20of%20Fuel%20Line%20Fitting-Master.PDF - Photo 5: Another Side View of Fuel Line Fitting (item 12, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354503&FileExtension=.PDF&FileName=Photo%205%3A%20Another%20Side%20View%20of%20Fuel%20Line%20Fitting-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.