ERA19LA217

NTSB accident investigation · Beech 77 · Leesburg, FL · June 28, 2019

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
June 28, 2019, 10:30 local (14:30 UTC)
Place
Leesburg, FL
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N1802YBeech 77
Defining event
Initial climb: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20190628011219A
Case key
99800

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

A partial loss of engine power due to carburetor icing, which resulted from the flight instructor's decision not to use carburetor heat.

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.

Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentBeech 77: 2 casesAll aircraft: 435 casesProbable cause
Info processing/decision: decision making/judgmentPersonnel issues › Action/decision · Instructor/check pilotBeech 77: 5 casesAll aircraft: 3,098 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Instructor/check pilotBeech 77: 1 caseAll aircraft: 1,391 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

The flight instructor was performing a checkout flight with the commercial pilot. They completed about 30 minutes of air work before returning to the airport to practice takeoffs and landings. The first landing was normal, and the commercial pilot added power to take off. When the airplane reached an altitude of 400 ft above the ground, the engine lost partial power and the airplane began to descend. The flight instructor took control of the airplane and landed in trees and a swamp adjacent to the airport. Examination of the engine revealed that it was full of water and debris from immersion in the swamp; however, no mechanical discrepancies were identified that would have precluded normal operation at the time of the accident. A carburetor icing probability chart indicated that the airplane was operating in an environment associated with a serious risk of carburetor ice accumulation at glide power settings. The flight instructor stated that they did not use carburetor heat before landing because the carburetor heat caused the engine to run very rough when applied. Given that a postaccident examination of the engine revealed no mechanical issues with the engine, and the flight instructor stated that the carburetor heat was not being used during the flight while operating in an environment that was conducive to carburetor icing, the loss of engine power was most likely due to carburetor ice that accumulated during the approach.

Factual narrative

On June 28, 2019, about 1030 eastern daylight time, a Beechcraft 77, N1802Y, was substantially damage when it impacted terrain after a partial loss of engine power during takeoff at the Leesburg International Airport (LEE), Leesburg, Florida. The flight instructor and the commercial pilot sustained minor injuries. The airplane was registered to Silver Flyers LLC and operated by Village Flyers Inc under the provisions of Title 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight that originated at LEE at 1000. The flight instructor stated he was giving the commercial pilot a check-out in the airplane. He said that they both performed a preflight inspection of the airplane and the fuel level was just below the tabs on both wing fuel tanks (about 20 gallons). The flight instructor said they completed about 30 minutes of air work before returning to the airport to practice takeoffs and landings. The first landing was normal, and the commercial pilot added power to takeoff. When the airplane reached an altitude of 400 ft above the ground, the engine started to lose power and the airplane began to descend. The flight instructor took control of the airplane and attempted to turn back and land on a taxiway, but they airplane was unable to reach the taxiway and he landed in trees and a swamp adjacent to the airport. The commercial pilot said that during the touch and go, he added power to takeoff and initiated a climb at 68 knots but felt "that we were not climbing acceptably." He verified the throttle was full forward, the mixture was rich, and the fuel boost pump was on. The tachometer, which should have indicated at 2,400 rpm, was at 2,000 rpm. The flight instructor took control of the airplane and landed in trees. The airplane then descended into a shallow swamp, which resulted in substantial damage to the empennage and both wings. Examination of the engine revealed that when the bottom spark plugs were removed, water and mud poured out of each cylinder. The interior of each cylinder was examined with a lighted borescope and no mechanical anomalies were noted. However, there were signs of corrosion and mud. The engine was rotated via the propeller flange and valve train continuity was established on each cylinder. Compression was established on the No. 2 and No. 4 cylinders, but not on the remaining cylinders. The No. 1 and No. 3 cylinders were removed and were covered in mud and exhibited corrosion. Both magnetos were removed and rotated with a drill. Spark was produced to each ignition lead. The oil screen was removed and was absent of debris. The carburetor icing probability chart included in Federal Aviation Administration (FAA) Special Airworthiness Information Bulletin (SAIB) No. CE-09-35, Carburetor Icing Prevention, indicated that the airplane was operating in an area that was associated with a serious risk of carburetor ice accumulation atglide and cruise power settings. The flight instructor stated that they did not use carburetor heat on landing because "the carburetor heat on that plane caused the engine to run very rough when applied." According to a representative of the operator, the engine would sporadically "run rougher than normal" when carburetor heat was applied. He said that he flew the airplane the day before the accident and he had no issues with the carburetor heat and was unsure as to why the engine would run rough on some days but not others. A mechanic had looked at the carburetor prior to the accident and found nothing wrong, but they had already planned to have the carburetor examined more closely at the next scheduled oil change. According to the airplane's Pilot Operating Handbook (POH), the before landing checklist stated, "Carburetor Heat - FULL HOT or FULL COLD, AS REQUIRED." The flight instructor held a commercial pilot certificate with ratings for airplane single-engine sea, single-engine land, multiengine land, and instrument airplane. He was also a certified flight instructor with a rating for airplane single engine. The flight instructor's last FAA Basic Med medical certificate was issued on July 17, 2017. He reported a total of 1,985 hours, of which, 11 hours were in the same make/model as the accident airplane. The commercial pilot held a commercial pilot certificate with ratings for airplane single-engine land, and instrument airplane. His last FAA Basic Med medical certificate was issued on May 4, 2017. The commercial pilot reported a total of 627 hours, of which, 2 hours were in the make/model as the accident airplane. Weather reported LEE at 1023 was wind from 100° at 7 knots, visibility 10 miles, sky clear, temperature 84° F, dew point 73° F, and an altimeter setting of 30.14 inches of mercury.

Aircraft

Registration
N1802Y
Reported as
Beech 77
Category
Airplane
Serial number
WA-268
Built
1983
Airframe hours
2,090
Engine
Lycoming O-235-L2C, 115 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 17, 2018 · 46 hours before
Departed
LEE · Leesburg, FL
Destination
LEE · Leesburg, FL
Airport
LEE · Leesburg International
Equipment
ADS-B, 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
Pilot
Age
68
Injuries
Minor
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
BasicMed, With waivers/limitations
Last flight review
February 17, 2018
Seat
Right
Restraint
3-point
Flight hours
1,985 total · 11 in this make and model · 1,932 as pilot in command · 18 in the last 90 days · 7.5 in the last 30 days · 0.8 in the last 24 hours
Role
Pilot-rated passenger
Age
66
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
BasicMed, With waivers/limitations
Last flight review
July 21, 2017
Seat
Left
Restraint
3-point
Flight hours
627 total · 2 in this make and model · 623 as pilot in command · 3.4 in the last 90 days · 2 in the last 30 days · 0.8 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 73 °F
Altimeter
30.13 inHg
Observed at
LEE, 5 nm away

Docket · 10

The files NTSB released with the investigation on January 3, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.3 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.