ERA14LA363

NTSB accident investigation · Temco GC 1B · Yulee, FL · July 28, 2014

Accident · FatalLimited investigationFinal report
Date
July 28, 2014, 10:00 local (14:00 UTC)
Place
Yulee, FL
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N1CYTemco GC 1B
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report March 2, 2016
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Continental Motors Inc.
FAA report
20140728018569A
Case key
89750

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

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Probable cause

The pilot’s failure to maintain airplane control, which resulted in subsequent impact with terrain.

Findings · 4

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 · PilotTemco GC-1B: 3 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: lateral/bank controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedTemco GC-1B: 2 casesAll aircraft: 390 casesProbable cause
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Not specifiedTemco GC-1B: 2 casesAll aircraft: 435 cases

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 airline transport pilot was taking off in the airplane for a personal flight. A witness reported seeing the airplane depart and then noting that the engine rpm was "low but steady." About 200 ft above ground level, the airplane banked left, "stalled," and then descended out of the witness's view. The airplane impacted terrain in a marshy area about 0.2 nautical mile from the departure end of the runway. A postaccident examination of the airframe and engine revealed no evidence of preimpact mechanical malfunctions or failures. Although atmospheric conditions at the time of the accident were favorable for the accumulation of carburetor icing at glide and cruise engine power settings, it could not be determined if carburetor ice had formed while the airplane was on the ground before the accident. Although the pilot was susceptible to an increased risk of impairment/incapacitation from an enlarged heart and septal scarring, the investigation was unable to determine if pilot impairment due to heart disease or other identified medical conditions contributed to the accident.

Factual narrative

HISTORY OF FLIGHT On July 28, 2014, about 1000 eastern daylight time, a Temco GC-1B, N1CY, impacted a swamp shortly after departure from Flying-A-Ranch Airport (FL84), Yulee, Florida. The airline transport pilot was fatally injured. The airplane sustained substantial damage to the firewall and fuselage. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The airplane was registered to and operated by a private individual under the provisions of Title 14 Code of Federal Regulations Part 91. The flight was originating at the time of the accident. According to an eyewitness, he observed the airplane depart on runway 5 and noted that the "engine rpm's were low but steady." About 200 feet above ground level, the airplane banked left, "stalled," and descended out of his view. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot held an airline transport pilot certificate with ratings for airplane single-engine land, multiengine land, and single-engine sea. In addition, he held a flight instructor certificate with ratings for airplane single and multiengine, and instrument airplane. He held a Federal Aviation Administration first-class medical certificate that was issued on May 8, 2014, with a limitation of "must wear lenses for distant – possess glasses for near vision." At that time, the pilot reported 30,000 total hours of flight time, of which, 75 hours were in the previous six months of the medical exam. No pilot logs could be located. AIRCRAFT INFORMATION According to FAA records, the airplane, manufactured in 1948, was registered to the pilot/owner in 1980. It was equipped with a Continental Motors O-300-A, 145-hp engine. According to airplane maintenance logbooks, the most recent annual inspection was completed on June 8, 2014, and at that time, the airplane had accumulated 2,934.8 hours in-service. AIRPORT INFORMATION The airport was privately-owned and did not have an air traffic control tower. The airport was equipped with one runway designated as runway 5/23. The runway condition was not reported. The turf runway was 2,000 feet-long by 100-feet-wide, and a 25-foot tall tree was located 650 feet from the departure end of runway 5. The airport elevation was approximately 25 feet above mean sea level. METEOROLOGICAL INFORMATION The 0955 recorded weather observation at Fernandina Beach Municipal Airport (FHB) , Fernandina Beach, Florida, located approximately 6 miles to the northeast of the accident location, included wind from 260 at 7 knots gusting to 14 knots, visibility 10 miles, sky clear, temperature 30 degrees C, dew point 24 degrees C; barometric altimeter 29.97 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane impacted terrain in a marshy area approximately 0.2 nautical miles from the departure end of runway 5. The airplane came to rest in the marsh and was partially submerged. A postaccident examination of the wreckage confirmed flightcontrol to all flight control surfaces. The main fuel tank was approximately three-quarters full of fuel and the auxiliary tank was nearly empty. Samples of fuel drained from the airframe were absent of debris or water. The fuel selector was position to the main fuel tank. The throttle and mixture controls were in the full forward position. The carburetor heat control was in the "OFF" position. A postaccident examination of the engine revealed that continuity of the crankshaft and valvetrain was confirmed to all cylinders and to the rear of the engine. The top spark plugs were removed and exhibited normal wear when compared to the Champion Check-A-Plug chart, and were light gray in color. Thumb compression was obtained on all cylinders when the propeller was rotated by hand. All valves were in place and no anomalies were noted. The magnetos sparked on all terminals when the crankshaft was rotated, and the impulse couplings operated without anomaly. The fuel pump contained fluid similar to 100LL aviation fuel and the fuel screen was free of debris. The engine controls remained attached to the carburetor and moved without anomaly. The carburetor was removed and disassembled. The carburetor bowl contained about 4oz of brown water, and the bottom of the bowl was corroded and rusted. The water was similar in color and smell to the water in the swamp surrounding the wreckage. No other anomalies were noted with the carburetor. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot's remains on July 29, 2014, by the Office of the Medical Examiner, Jacksonville, Florida. The autopsy findings included "multiple blunt force injuries," which was also listed as the cause of death. In addition, the heart was enlarged, and demonstrated hypertensive heart disease. It weighed 475 grams and was described as having a floppy and soft consistency. The left ventricle and the interventricular septum measured 15 and 17 mm, respectively. For comparison, the average weight of a heart of a man his weight is 395 grams with a range from 299-521 grams and the average left ventricle and the interventricular septum are 12.3 mm (SD 1.6 mm) and 13.6 mm (SD 2 mm) respectively. In addition, mild coronary artery disease with about 30% stenosis was seen in multiple arteries. There was no evidence of acute myocardial infarct or coronary thrombosis. Microscopic examination of the left ventricular septum identified patchy mild myocardial fibrosis with no sign of myocarditis. Finally, cirrhosis of the liver was also identified. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol was detected in the vitreous fluid and no drugs were detected in the blood. ADDITIONAL INFORMATION The carburetor icing probability chart from Federal Aviation Administration (FAA) Special Airworthiness Information Bulletin (SAIB): CE-09-35 Carburetor IcingPrevention, June 30, 2009, showed a potential for icing at cruise/glide engine power settings at the temperature and dew point reported around the time of the accident.

Aircraft

Registration
N1CY
Reported as
Temco GC 1B
Category
Airplane
Serial number
3572
Built
1948
Airframe hours
2,934.8
Engine
Continental Motors O-300-A, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 8, 2014
Departed
FL84 · Yulee, FL
Airport
FL84 · Flying-A-Ranch, runway 05, 2,000 × 100 ft, grass/turf

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
65
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
30,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 7 knots, gusting 14
Visibility
10 statute miles
Lowest ceiling
None
Temperature
86 °F, dew point 75 °F
Altimeter
29.96 inHg
Observed at
FHB, 6 nm away

Docket · 12

The files NTSB released with the investigation on January 27, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.5 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.