# NTSB ERA21LA361: Beech C24R, N5246M, Augustine, FL, September 13, 2021 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: September 13, 2021, 10:45 local (14:45 UTC) - Place: Augustine, FL · airport grounds marsh - Coordinates: 29.959252, -81.339732 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.9593&lon=-81.3397&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 3 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 103880 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA361 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103880/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103880 - Page: https://openairdocs.org/ntsb/ERA21LA361 ## Probable cause Improperly installed fuel injection system components, which resulted in a partial loss of engine power shortly after takeoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Beech C24R, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=1151254), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Engine fuel and control: fuel distribution](https://openairdocs.org/ntsb-findings/01057310): Aircraft › Aircraft power plant · Not serviced/maintained (probable cause); cases with it: [Beech C24R, 1 case](https://openairdocs.org/ntsb-findings/01057310/cases.md?model=1151254), [All aircraft, 55 cases](https://openairdocs.org/ntsb-findings/01057310/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Beech C24R, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=1151254), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Beech C24R, 2 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=1151254), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Beech C24R, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=1151254), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## 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](https://openairdocs.org/aircraft/N5246M), registered now, S/N MC-564, built 1978 (OpenAirDocs) - Reported make and model: BEECH C24R - Registry model: [Beech C24R](https://openairdocs.org/model/beech-c24r) (registry code 1151254) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: MC-564 - Year built: 1978 - Airframe hours: 8510.6 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: minor; 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 - Flight instructor; age 24; injuries: minor; 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 - 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 $= ## 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 20210913014619A](https://openairdocs.org/incident/20210913014619A), Sep 13, 2021: Beech C24R, St. Augustine, FL, Substantial damage. The Beech sierra C24R aircraft departed north Florida regional (sgj) airport with three instructors on board with the intent of performing an aircraft… ## Docket (10 files) The files NTSB released with the investigation on July 26, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103880. 11.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12854176&FileExtension=pdf&FileName=N5246M%20NTSB%20Form%206120-1_Redacted-Rel.pdf - Operator's statement (item 2, PDF, 1 page, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14926248&FileExtension=pdf&FileName=Operators%20Accident%20Statement-Rel.pdf - Pilot and passenger statements (item 3, PDF, 3 pages, 862 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14121417&FileExtension=pdf&FileName=N5246M%20Pilots%27%20%26%20passenger%27s%20statement_Redacted-Rel.pdf - Engine exam (item 4, PDF, 3 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14931064&FileExtension=pdf&FileName=Engine%20Exam-Rel.pdf - FAA inspector's statement (item 5, PDF, 1 page, 570 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14932334&FileExtension=pdf&FileName=INSPECTOR%20STATEMENT%20N5264M-Rel.pdf - Engine maintenance records excerpt (item 6, PDF, 5 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14121122&FileExtension=pdf&FileName=Engine%20Maintenance%20Records%20Excerpt_Redacted-Rel.pdf - Airframe and prop maintenance records excerpt (item 7, PDF, 4 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14926207&FileExtension=pdf&FileName=N5246M%20Airframe%20%26%20Prop%20logbook%204%20last%20pg_Redacted-Rel.pdf - Performance calculations (item 8, PDF, 2 pages, 569 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14931789&FileExtension=pdf&FileName=ERA21LA361-WgtBal-TOcalcs-Rel.pdf - Photo array_accident site and damage (item 9, PDF, 3 pages, 558 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14932324&FileExtension=pdf&FileName=Accident%20Site%20and%20Damage%20Photographs-Rel.pdf - Wreckage release (item 10, PDF, 1 page, 600 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14926328&FileExtension=pdf&FileName=Wreckage%20Release%20Form%20N5246M_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.