# NTSB ERA14LA363: Temco GC 1B, N1CY, Yulee, FL, July 28, 2014 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: July 28, 2014, 10:00 local (14:00 UTC) - Place: Yulee, FL - Coordinates: 30.605556, -81.566108 - Nearby events: https://openairdocs.org/map.md?lat=30.6056&lon=-81.5661&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 2, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Continental Motors Inc. - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 89750 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA363 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89750/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89750 - Page: https://openairdocs.org/ntsb/ERA14LA363 ## Probable cause The pilot’s failure to maintain airplane control, which resulted in subsequent impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Temco GC-1B, 3 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=9230108), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Temco GC-1B, 2 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=9230108), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Not specified; cases with it: [Temco GC-1B, 2 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=9230108), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Health/Fitness: predisposing condition](https://openairdocs.org/ntsb-findings/02013035): Personnel issues › Physical · Pilot; cases with it: [Temco GC-1B, 1 case](https://openairdocs.org/ntsb-findings/02013035/cases.md?model=9230108), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02013035/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 control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Temco GC-1B, 2 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=9230108), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## 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](https://openairdocs.org/aircraft/N1CY), registered now, S/N 3572, built 1948 (OpenAirDocs) - Reported make and model: TEMCO GC 1B - Registry model: [Temco GC-1B](https://openairdocs.org/model/temco-gc-1b) (registry code 9230108) (OpenAirDocs) - Registry engine: [Continental C125 series](https://openairdocs.org/engine/continental-c125-series) (registry code 17011, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 3572 - Year built: 1948 - Airframe hours: 2934.8 - Engines: Continental Motors, Inc. 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: fatal; 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 ## 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 20140728018569A](https://openairdocs.org/incident/20140728018569A), Jul 28, 2014: Temco GC-1B, Yulee, FL, Substantial damage, 1 fatal. N1CY accident FSDO narrative On July 28, 2014 at 11:20 eastern daylight time (EDT) I ([privacy data omitted] aviation safety inspector) was given initial… ## Docket (12 files) The files NTSB released with the investigation on January 27, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89750. 11.5 MB in all. - Witness Statements (item 1, .PDF, 561 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435954&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Diagram of Accident Location (item 2, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435955&FileExtension=.PDF&FileName=Diagram%20of%20Accident%20Location-Master.PDF - FAA Inspector's Statement (item 3, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435956&FileExtension=.PDF&FileName=%20FAA%20Inspector%27s%20Statement%20-Master.PDF - FAA Wreckage Examination Summary (item 4, .PDF, 272 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435957&FileExtension=.PDF&FileName=FAA%20Wreckage%20Examination%20Summary-Master.PDF - Most Recent Maintenance Records (item 5, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435958&FileExtension=.PDF&FileName=Most%20Recent%20Maintenance%20Records-Master.PDF - Engine Examination Report (item 6, .PDF, 7.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435959&FileExtension=.PDF&FileName=Engine%20Examination%20Report-Master.PDF - Weather Reports and Records (item 7, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435960&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%20-Master.PDF - Carburetor Icing Chart (item 8, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435961&FileExtension=.PDF&FileName=Carburetor%20Icing%20Chart-Master.PDF - Toxicological Report (item 9, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435962&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Memorandum of Record - NTSB Medical Review (item 10, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435963&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20NTSB%20Medical%20Review-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 342 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435964&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Photograph of Accident Site (item 12, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435965&FileExtension=.PDF&FileName=Photograph%20of%20Accident%20Site-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.