ERA21LA361

NTSB accident investigation · Beech C24R · Augustine, FL · September 13, 2021

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
September 13, 2021, 10:45 local (14:45 UTC)
Place
Augustine, FL · airport grounds marsh
Injuries
3 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N5246MBeech C24R
Defining event
Initial climb: Loss of engine power (partial)
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
20210913014619A
Case key
103880

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

Improperly installed fuel injection system components, which resulted in a partial loss of engine power shortly after takeoff.

Findings · 2

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.

Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelBeech C24R: 1 caseAll aircraft: 167 casesProbable cause
Engine fuel and control: fuel distributionAircraft › Aircraft power plant · Not serviced/maintainedBeech C24R: 1 caseAll aircraft: 55 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 chief flight instructor of the flight school was performing a checkout flight for two other flight instructors, one of whom was in the front right seat and conducted the short-field takeoff. During the takeoff roll, the airplane lifted off in about 2,000 ft, leaving about 6,000 ft of runway remaining. Shortly after liftoff, the airplane failed to maintain airspeed or altitude upon reaching an altitude of about 150 ft above ground level. The chief flight instructor took control of the airplane and attempted to land on the remaining runway; however, the airplane struck the approach lighting system, flipped over, and came to rest inverted in a marsh. Examination of the engine revealed that two fuel injector lines were not installed properly: one contained a damaged nut and was pulled off the injector with ease, and the other was secured by only one thread. In addition, the oil filter screen was contaminated with large pieces of carbon and metal. These discrepancies should have been detected and addressed during the previous annual/100-hour inspections that occurred 5 flight hours before the accident flight. Based on this information, it is likely that condition of one or both of the fuel injector components allowed air to be introduced into the fuel stream for their respective cylinders, thus reducing the engine performance and resulting in a partial loss of power during the initial climb.

Factual narrative

On September 13, 2021, about 1045 eastern daylight time , a Beechcraft C24R, N5246M, was substantially damaged when it was involved in an accident at Northeast Florida Regional Airport (SGJ), St Augustine, Florida. The two flight instructors and pilot rated passenger, who was also a flight instructor, sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the three flight instructors, who were all employed by the flight school, the chief flight instructor, who was in the left front seat, was checking out the other two flight instructors in the airplane when the accident occurred. After conducting a preflight inspection and engine run up, the flight instructor in the front right seat performed a short-field takeoff maneuver from runway 13 at SGJ. The runway was 8,001 ft in length. The airplane became airborne in about 2,000 ft; however, about 150 ft above ground level, the airplane failed to climb and “wouldn’t hold altitude or airspeed.” The chief flight instructor in the left seat took control of the airplane and attempted a forced landing on the remaining runway. During the forced landing, the airplane impacted the approach lighting system, flipped over, and came to rest in a marsh about 150 ft off the runway 31 displaced threshold. Postaccident examination of the wreckage by a Federal Aviation Administration inspector revealed that the left wing partially detached from the fuselage, the empennage was twisted, and there was crushing and buckling damage to much of the airframe. The airplane’s last annual inspection on March 12, 2021, 6 months before the accident over which time it accumulated about 5 hours. The engine had 5,386 hours total time and 1,883 hours total time since overhaul. According to the maintenance logbooks the airplane was under a 100 hour/annual maintenance inspection program. As of the last inspection, both the engine, airframe and propeller were signed off as being airworthy and no defects or irregularities were noted in the logbooks. The wreckage was recovered from the marsh and examined. The valve covers were removed for examination of the rocker arms. The propeller was rotated by hand and thumb compression was established on all cylinders. Crankshaft continuity was established through the engine. The magneto couplings could be heard rotating and the vacuum pump shaft was observed rotating. Upon removal, the magnetos were rotated by electric drill with no spark produced on either magneto. Upon disassembly, examination of the magnetos revealed water damage, and corrosion. The No. 4 fuel injector line was observed cracked on the threaded nut. The injector fuel line pulled off the injector and was not secured tightly to the injector. The No. 2 fuel injector line was only secured to the injector by one thread and removed by fingers turning the nut. Examination of the air filter box revealed that the filter element was in the intake hose andpartially obstructing the air intake line but the damage to the filer box was consistent with water impact damage. Examination of the oil filter screen revealed large pieces of carbon and metal deposits. The weight and balance and performance data were computed using the airplane’s pilot operating handbook. The weight of the airplane was within the weight and moment envelope and the take-off distance was calculated to be about 1,600 ft.

Aircraft

Registration
N5246M
Reported as
Beech C24R
Category
Airplane
Serial number
MC-564
Built
1978
Airframe hours
8,510.6
Engine
Lycoming IO-360-A1B6, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Florida Aviation Career Training Inc
Registered owner
Florida Aviation Career Training Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 12, 2021 · 5.1 hours before
Airport
SGJ · Northeast Florida Rgnl, runway 13, 7,997 × 150 ft, asphalt
Equipment
Stall warning system, ADS-B

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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
67
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
September 24, 2020
Seat
Left
Restraint
3-point
Flight hours
4,100 total · 15 in this make and model · 3,500 as pilot in command · 40 in the last 90 days · 10 in the last 30 days · 0 in the last 24 hours
Role
Flight instructor
Age
24
Injuries
Minor
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Restraint
3-point
Role
Pilot-rated passenger
Seat
Rear
Restraint
3-point

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 8 knots
Visibility
10 statute miles
Lowest ceiling
1,500 ft broken
Temperature
82 °F, dew point 73 °F
Altimeter
30.21 inHg
Observed at
SGJ
METAR
METAR KSGJ 131456Z 05008KT 10SM BKN015 28/23 A3021 RMK AO2 SLP230 T02830228 53001 $=

Docket · 10

The files NTSB released with the investigation on July 26, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.8 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.