ERA19LA282

NTSB accident investigation · Cessna 337 · St. Augustine, FL · September 24, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
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.

Info processing/decision: identification/recognitionPersonnel issues › Action/decision · Designated examinerCessna 337G: 1 caseAll aircraft: 559 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Incorrect use/operationCessna 337G: 1 caseAll aircraft: 497 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 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.