# NTSB ERA19LA282: Cessna 337, N108LS, St. Augustine, FL, September 24, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: September 24, 2019, 10:02 local (14:02 UTC) - Place: St. Augustine, FL - Coordinates: 29.959167, -81.339721 - Nearby events: https://openairdocs.org/map.md?lat=29.9592&lon=-81.3397&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Continental Motors, Inc. - NTSB case key (mKey): 100332 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA282 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100332/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100332 - Page: https://openairdocs.org/ntsb/ERA19LA282 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 337G, 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=2075730), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Designated examiner (probable cause); cases with it: [Cessna 337G, 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=2075730), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Incorrect use/operation (probable cause); cases with it: [Cessna 337G, 1 case](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=2075730), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Cessna 337G, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=2075730), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Maneuvering: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 337G, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2075730), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Cessna 337G, 2 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=2075730), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## 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](https://openairdocs.org/deregistered/N108LS-2021-05-04), registration cancelled 2021-05-04, S/N 33701488, built 1973 (OpenAirDocs) - Reported make and model: Cessna 337 (G) - Registry model: [Cessna 337G](https://openairdocs.org/model/cessna-337g) (registry code 2075730) (OpenAirDocs) - Registry engine: [Continental IO-360 series](https://openairdocs.org/engine/continental-io-360-series) (registry code 17025, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 33701488 - Year built: 1973 - Airframe hours: 3842.8 - Engines: Continental IO-360-G 210 horsepower reciprocating; Continental 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: serious; 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 - Check pilot; age 76; injuries: serious; 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 ## 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 20190924019399A](https://openairdocs.org/incident/20190924019399A), Sep 24, 2019: Cessna 337G, St. Augustine, FL, Substantial damage. After a wait of approximately 15 minutes before take-off due to air traffic, the rear engine was noted to have a high oil temperature. The PIC was concerned… ## Docket (12 files) The files NTSB released with the investigation on April 26, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100332. 17.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11976373&FileExtension=pdf&FileName=NTSB%20Report%20Recd%2012%2016%202019%20v2_Redacted-Rel.pdf - Memorandum for record - witness statements (item 2, PDF, 3 pages, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11978157&FileExtension=pdf&FileName=Memorandum%20For%20Record%20-%20Witness%20Statements-Rel.pdf - Record of NTSB conversation (item 3, PDF, 4 pages, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12024727&FileExtension=pdf&FileName=Record%20of%20NTSB%20Conversation_Redacted-Rel.pdf - Statement from designated pilot examiner (item 4, PDF, 1 page, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12016142&FileExtension=pdf&FileName=Statement%20from%20DPE-Rel.pdf - Excerpts from owner's manual (item 5, PDF, 3 pages, 421 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11986302&FileExtension=pdf&FileName=Excerpts%20from%20Owners%20Manual-Rel.pdf - Chronological summary of flight communications (item 6, PDF, 1 page, 427 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11977383&FileExtension=pdf&FileName=Chronological%20Summary%20of%20Flight%20Communications-Rel.pdf - Investigative photographs (item 7, PDF, 4 pages, 4 photos, 989 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12024968&FileExtension=pdf&FileName=Investigative%20Photographs_ERA19LA282-Rel.pdf - Report from party to investigation - Continental aerospace technologies (item 8, PDF, 32 pages, 85 photos, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11981912&FileExtension=pdf&FileName=Reports%20from%20Party%20to%20the%20Investigation%20-%20Continental%20Aerospace%20Technologies_Redacted_Reduce%20File%20Size-Rel.pdf - Electronic devices - specialist's factual report (item 9, PDF, 10 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11875668&FileExtension=pdf&FileName=ERA19LA282%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to electronic devices - specialist's factual report (item 10, CSV, 264 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11875562&FileExtension=csv&FileName=ERA19LA282%20Attachment%201%20to%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Statement of party representatives to NTSB investigation (item 11, PDF, 9 pages, 271 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11981922&FileExtension=pdf&FileName=Party%20Form%20w%20Attachments_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15, and NTSB evidence control forms (item 12, PDF, 3 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12015872&FileExtension=pdf&FileName=Wreckage%20Release%20and%20Evidence%20Control%20Forms_Redacted-Rel.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.