ERA18LA010

NTSB accident investigation · Beech A24 · Manteo, NC · October 18, 2017

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
October 18, 2017, 10:00 local (14:00 UTC)
Place
Manteo, NC
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N400LEBeech A24
Defining event
Initial climb: Electrical system malf/failure
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Textron Aviation
FAA report
20171018014889A
Case key
96206

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 failure of maintenance personnel to properly secure wiring during an electrical component installation, which resulted in arcing and smoke in the cockpit. Contributing to the outcome was the flight instructor's failure to attain a proper descent rate during the forced landing.

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.

Electrical power system: electrical pwr sys wiringAircraft › Aircraft systems · Incorrect service/maintenanceBeech A24R: 1 caseAll aircraft: 44 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelBeech A24R: 2 casesAll aircraft: 371 casesProbable cause
Performance/control parameters: descent rateAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech A24R: 1 caseAll aircraft: 242 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotBeech A24R: 2 casesAll aircraft: 9,295 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

Shortly after takeoff on the instructional flight, the pilot receiving instruction heard a "pop" sound; the flight instructor saw smoke coming from the right lower portion of the instrument panel and felt a melted wire contact her leg. The pilot receiving instruction continued to fly the airplane briefly, then the flight instructor took the controls. With inadequate runway remaining ahead on which to land, the instructor initiated a turn to return to the runway. The airplane impacted the ground and slid about 500 ft, coming to rest upright and resulting in substantial damage to the airframe. Postaccident examination of the cockpit revealed that electrical wires of a recently-installed avionics switch had arced against the top aft edge of the adjacent autopilot control unit and also at the edge of a vertical support member. The wires did not have circuit protection, nor was there any mechanical protection or supports present along the length of the wires to prevent chafing, contrary to FAA guidance. The pilots' failure to secure the electrical system from memory in response to the cockpit smoke would not have mitigated the hard landing, but may have decreased the smoke in the cockpit and lessened the urgency to land.

Factual narrative

On October 18, 2017, about 1000 eastern daylight time, a Beech A24R, N400LE, was substantially damaged when it was involved in an accident near Manteo, North Carolina. The private pilot undergoing instruction (PUI) sustained serious injuries while the flight instructor sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor, who was seated in the right seat, stated that there were no discrepancies with the airplane during the preflight inspection or engine run-up before takeoff. The PUI stated that that about 3 seconds after rotation when the flight was about 1/2 way down the runway at no more than 10 to 15 ft above the runway with the landing gear extended, he heard a "pop" sound from inside the airplane that was not over the intercom. He attributed the sound to be consistent with the tripping of a circuit breaker, though he did not look at the circuit breakers. He did not change the landing gear position and continued flying the airplane. There was no discussion at that time about landing straight ahead, though that would not have been possible based on the airplane's location, and speed. The flight instructor further stated that the flight was at 100 ft and at that time the cockpit filled with smoke and electrical wires on her side of the cockpit were on fire and contacting her leg. The PUI verbalized fire 3 times, which she agreed, and he reportedly asked if she wanted him to secure the battery and alternator switches, to which she verbalized aloud yes because they lost the capability to communicate on the intercom. She indicated that he initially turned off the battery, then later turned off the alternator switches, while the PUI indicated that the battery, alternator and avionics switches remained on until he secured them postaccident because she did not reply to his hand motions on the battery switch. She took the controls from the PUI and when near the VOR antenna executed a 180° turn to return to the runway. The PUI indicated that she was not rolled out of the turn and did not arrest the rate of descent impacting the ground while in a slight left wing and nose low attitude, which the flight instructor characterized as a hard landing. She had previously experienced smoke in a cockpit before and wanted to get the airplane on the ground. She also indicated that it happened quickly which did not allow enough time to complete any checklist, adding that the emergency procedures section of the Pilot's Operating Handbook did not contain a checklist for an "electrical in-flight fire." Neither she or the PUI felt airframe buffet or recalled hearing the stall warning system. Examination of the accident site by several Federal Aviation Administration (FAA) inspectors revealed the airplane first impacted on airport property east of runway 17 near the approach end of the runway. The airplane came to rest upright about 500 ft and 212° from the initial impactlocation. Examination of the cockpit by a FAA airworthiness inspector revealed a wire with melted insulation hanging from under the right side of the instrument panel. The airplane was recovered and secured for further examination. Postaccident examination of the airplane following recovery was performed by a representative of the airframe manufacturer with oversight from the Federal Aviation Administration. Examination of the cockpit revealed an avionics switch and associated electrical wiring was located at the top center portion of the instrument panel above the autopilot control unit. The electrical wires from the switch were 14 gauge and the markings were different from the airplane's original wires consistent with installation of the switch on April 12, 2017. Following removal of the instrument glare shield, no evidence of fire was noted behind the instrument panel. Further examination of the avionics switch revealed one attached electrical wire connected to the electrical bus bar which was co-located with the landing gear circuit breaker. The other attached electrical wire connected to the "COM 2" circuit breaker. Both electrical wires exhibited evidence of electrical arcing where both crossed over the top aft edge of the autopilot control unit and also at the edge of a vertical support member. The majority of insulation of the electrical wire from the bus bar to the avionics switch was melted or completely missing, while portions of insulation of the electrical wire from the "COM 2" circuit breaker to the avionics switch exhibited melting where it was located in proximity to the other electrical wire. Further examination of the electrical wires associated with the avionics master switch revealed they were tie wrapped together at various places and were also tie wrapped to a larger wire bundle near the bus bar, but there was no mechanical protection or supports present along the length of the wires. Additionally, no circuit protection was observed between the bus bar and the avionics switch. Following removal of the switch and wires from the airplane, the wires had a distinct bend where they passed around the vertical support member. Since installation of the switch, the airplane had accrued about 96 hours. Paragraph 11-47 of Advisory Circular (AC) 43.13-1B specifies that all electrical wires must be provided with some means of circuit protection (circuit breakers or fuses) located as close as possible to the electrical power source bus. Paragraph 11-96(b) of the same AC indicated that metal stand-offs must be used to maintain clearance between wires and structure, while (q) of the same paragraph indicated "Ensure that wires and cables are routed in such a manner that chafing will not occur against the airframe or other components."

Aircraft

Registration
N400LE
Reported as
Beech A24 (R)
Category
Airplane
Serial number
MC-72
Built
1971
Airframe hours
3,970.6
Engine
Lycoming IO-360-A1B, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · October 6, 2017 · 3 hours before
Departed
MQI · Manteo, NC
Destination
MQI · Manteo, NC
Airport
MQI · Dare County Regional, runway 05, 4,305 × 100 ft, asphalt
Equipment
Auto-pilot, Stall warning system

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
32
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
April 30, 2017
Seat
Right
Restraint
Lap only
Flight hours
7,000 total · 100 in this make and model · 6,800 as pilot in command · 250 in the last 90 days · 70 in the last 30 days
Role
Student pilot
Age
23
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
260 total · 11 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Altimeter
30.36 inHg
Observed at
MQI

Docket · 9

The files NTSB released with the investigation on October 17, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 17.6 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.