# NTSB ERA19LA217: Beech 77, N1802Y, Leesburg, FL, June 28, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: June 28, 2019, 10:30 local (14:30 UTC) - Place: Leesburg, FL - Coordinates: 28, -81 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.0000&lon=-81.0000&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 99800 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA217 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99800/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99800 - Page: https://openairdocs.org/ntsb/ERA19LA217 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Beech 77, 2 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=1153007), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Beech 77, 5 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1153007), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Beech 77, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1153007), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Beech 77, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=1153007), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 77, 9 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1153007), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N1802Y-2020-01-06), registration cancelled 2020-01-06, S/N WA-268, built 1983 (OpenAirDocs) - Reported make and model: Beech 77 - Registry model: [Beech 77](https://openairdocs.org/model/beech-77) (registry code 1153007) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: WA-268 - Year built: 1983 - Airframe hours: 2090 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: minor; 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 - Pilot-rated passenger; age 66; injuries: minor; 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 ## 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 20190628011219A](https://openairdocs.org/incident/20190628011219A), Jun 28, 2019: Beech 77, Leesburg, FL, Destroyed. On June 28th, 2019 at 10:15 am, aircraft N1802Y, a Beech BE-77 aircraft, crashed into a heavily forested unimproved area in the vicinity of Leesburg FL.… ## Docket (10 files) The files NTSB released with the investigation on January 3, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99800. 7.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479582&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - NTSB Summary of Record- CFI (item 2, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479583&FileExtension=.PDF&FileName=NTSB%20Summary%20of%20Record-%20CFI-Master.PDF - Written Statement - Pilot Rated Passenger (item 3, .PDF, 865 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479584&FileExtension=.PDF&FileName=Written%20Statement%20-%20Pilot%20Rated%20Passenger-Master.PDF - NTSB Record of Conversation - Representative of the Operator (item 4, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479585&FileExtension=.PDF&FileName=NTSB%20Record%20of%20Conversation%20-%20Representative%20of%20the%20Operator-Master.PDF - Exceprt of Beecraft Skipper 77 POH (item 5, .PDF, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479586&FileExtension=.PDF&FileName=Exceprt%20of%20Beecraft%20Skipper%2077%20POH-Master.PDF - Maintenance Records (item 6, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479587&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Carburetor Icing Probability Chart (item 7, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479588&FileExtension=.PDF&FileName=Carburetor%20Icing%20Probability%20Chart-Master.PDF - Photos (item 8, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479589&FileExtension=.PDF&FileName=Photos-Master.PDF - NTSB Engine Examination Factual Report (item 9, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479590&FileExtension=.PDF&FileName=NTSB%20Engine%20Examination%20Factual%20Report-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479591&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.