- Date
- September 24, 2019, 10:02 local (14:02 UTC)
- Place
- St. Augustine, FL
- Injuries
- 2 serious
- Damage
- Substantial damage
- Phase of flight
- Takeoff
- Aircraft
- N108LSCessna 337
- Defining event
- Takeoff: Miscellaneous/other
- Weather
- Visual (VMC) · Day
- Status
- Completed
- Report
- Approved by Office Director
- Investigation class
- Class 3
- NTSB office
- Eastern Region Aviation
- Parties
- FAA/FSDO, Continental Motors, Inc.
- FAA report
- 20190924019399A
- Case key
- 100332
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 the pilot and examiner to recognize that the rear engine was not developing power, which resulted in an attempted partial-power takeoff and the airplane’s subsequent descent and impact with terrain.
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.
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 pilot was conducting a practical test with a designated pilot examiner to add a multi-engine rating to her pilot certificate. After performing airwork in the local area, they returned to the departure airport to conduct takeoffs and landings. The pilot initiated the takeoff and reported that the airplane accelerated to 85 mph, then rotated as normal. She then reported that the airplane “discontinued climbing”; shortly thereafter, the examiner took control of the airplane. The examiner stated that there was inadequate runway remaining on which to land; however, the airplane would not fly out of ground effect. He maneuvered to avoid obstructions and the airplane impacted terrain with a descent rate between 400 to 600 feet per minute. Postaccident examination of the front engine and its systems revealed no evidence of preimpact failure or malfunction. The rear propeller was found in the feathered position. Onboard engine monitor data for the accident flight revealed that, during the accident takeoff, the front engine was operating normally, while the rear engine was operating at a level below idle power. A successful postaccident test run of the rear engine revealed no evidence of malfunctions or anomalies that would have precluded normal operation. The airplane owner’s manual advised that, during takeoff, the pilot should apply rear engine power first, followed by front engine power, and monitor the engine instruments throughout the takeoff roll for signs of power loss. A placard on the instrument panel advised, “Do not initiate single engine take-off.” Although the reason that the rear engine was operating at such a low level during the accident takeoff could not be determined, both pilots should have recognized that the rear engine was not operating as expected during the takeoff roll and aborted the takeoff. The continuation of the takeoff in this condition resulted in the airplane’s inability to climb and its subsequent descent and impact with terrain.
Factual narrative
On September 24, 2019, about 1002 eastern daylight time, a Cessna 337G, N108LS, was substantially damaged when it was involved in an accident near St. Augustine, Florida. The private pilot and designated pilot examiner sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight test. The pilot and examiner departed on the flight portion of the practical test for the pilot’s multi-engine rating. They conducted air work and then returned to the departure airport to perform takeoffs and landings. After landing, the pilot cleared the runway and requested with the tower controller to perform traffic pattern work. The controller indicated that there would be a delay of five to ten minutes, which the pilot acknowledged, and held the airplane short of the runway. While waiting for a takeoff clearance, the examiner questioned the pilot about the rear engine temperature, which the pilot determined was within limits. The controller subsequently cleared the airplane for an expedited takeoff. The pilot stated that all instrument indications were normal and the airplane accelerated to 85 mph then rotated. She then reported that the airplane “discontinued climbing” and shortly thereafter, the examiner assumed control of the airplane. The examiner reported that he could not land on the remaining runway; however, the airplane would not fly out of ground effect. The examiner began a left turn to land in an open area on the airport, and the airplane began to descend. He leveled the wings and slowed the airplane as it approached the touchdown area, and the airplane impacted terrain with a descent rate around 400 to 600 feet per minute. Examination of the airplane before recovery by a Federal Aviation Administration (FAA) inspector revealed that the rear propeller blades were in the feathered position, and the rear engine cowl flaps were open. The front propeller blades exhibited considerable distortion and were rotated in the propeller hub. Examination of the throttle quadrant revealed that the throttle and propeller controls for both engines were full forward, while both mixture controls were in the idle cut-off position. The airplane was recovered for further examination of both engines. Examination of the rear engine in advance of an engine run revealed no evidence of any preimpact failure or malfunction of the engine or its systems. An external fuel tank was plumbed into the airframe boost pump fuel inlet. The engine started normally without hesitation or stumbling. The engine was warmed up, then powered to 1,600 rpm, where the propeller control was cycled several times. The engine was then advanced to full power and left for about 5 minutes to stabilize. During that time, the No. 3 cylinder head temperature approached the maximum limit, and engine power was reduced allowing the engine to cool. The throttle was then advanced to full for about 1 minute and the rpm increased without hesitation or stumbling. Theengine was brought back to idle for several minutes to duplicate some of the delay on the ground, then again advanced to full throttle; no anomalies were noted. The rear engine was secured using the mixture and the propeller remained in a normal low pitch position. Damage to the front engine oil filter adapter precluded operational testing of the engine. The front engine and its systems were examined, and no discrepancies were noted that would have precluded normal operation. Review of recorded engine monitor data revealed that, when power was applied for the accident takeoff, the front engine was within 100 rpm of its rated takeoff power, while at the same time the rear engine was at 137 rpm, and remained at that value for the remainder of the recorded data. Further review of the recorded data revealed that the rear engine oil temperature while on the ground awaiting takeoff clearance reached a maximum of 227°F, which was 13°F below the maximum red line value. A placard on the instrument panel stated, “Do not initiate single engine take-off.” The owner’s manual indicated that, during takeoff, it was recommended to advance the rear engine throttle ahead of the front engine throttle and to periodically monitor fuel flow and rpm throughout the takeoff. If either of these indicators was below normal, the takeoff should be discontinued immediately while sufficient runway remained. The owner’s manual also indicated that full throttle checks on the ground are not recommended.
Aircraft
- Registration
- N108LS
- Reported as
- Cessna 337 (G)
- Category
- Airplane
- Serial number
- 33701488
- Built
- 1973
- Airframe hours
- 3,842.8
- Engines
- Continental IO-360-G, 210 horsepower, reciprocatingContinental IO-360-G, 210 horsepower, reciprocating
- Damage
- Substantial damage
- Flight
- Flight test · Part 91
- Airworthiness certificate
- Standard, Normal
- Last inspection
- Annual · July 12, 2019
- Departed
- SGJ · St. Augustine, FL
- Destination
- SGJ · St. Augustine, FL
- Flight plan
- Unknown
- Airport
- SGJ · Northeast Florida Regional, runway 31, 7,997 × 150 ft, asphalt
- Equipment
- Electronic multifunction display, Stall warning system, ADS-B, Auto-pilot, Data recorder
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
- 73
- Injuries
- Serious
- Certificate
- Private
- Airplane ratings
- Single-engine land
- Instrument ratings
- Airplane
- Medical
- Class 3, With waivers/limitations
- Last flight review
- September 23, 2019
- Seat
- Left
- Restraint
- 3-point
- Flight hours
- 668.7 total · 140.7 in this make and model · 668.7 as pilot in command · 41 in the last 90 days
- Role
- Check pilot
- Age
- 76
- Injuries
- Serious
- Certificates
- Flight instructor, Airline transport
- Airplane ratings
- Multi-engine land, Single-engine land
- Instrument ratings
- Airplane, Helicopter
- Medical
- Class 3, With waivers/limitations
- Last flight review
- January 16, 2018
- Seat
- Right
- Restraint
- 3-point
- Flight hours
- 5,254 total · 10 in this make and model · 4,474 as pilot in command · 7.9 in the last 90 days · 5.7 in the last 30 days · 1.3 in the last 24 hours
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 280° at 8 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Altimeter
- 29.96 inHg
- Observed at
- SGJ
Docket · 12
The files NTSB released with the investigation on April 26, 2022, 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.