# NTSB MIA90FA090: Butler Aerostar 601, N7443S, Lake Butler, FL, March 16, 1990 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Field investigation · Final report - Date: March 15, 1990, 22:45 local (Mar 16, 1990, 03:45 UTC) - Place: Lake Butler, FL - Coordinates: 30.01943, -82.329315 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.0194&lon=-82.3293&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report September 10, 1992 - Report: Approved by Office Director - NTSB case key (mKey): 32552 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA90FA090 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/32552/pdf - Page: https://openairdocs.org/ntsb/MIA90FA090 ## Probable cause INFLIGHT FAILURE OF THE LEFT ENGINE WHICH WAS CAUSED BY INADEQUATE MAINTENANCE AND INSPECTION BY COMPANY MAINTENANCE PERSONNEL RESULTING IN HEAT DAMAGED MAGNETO LEADS AS A RESULT OF A MISSING EXHAUST FLANGE-TO-TURBOCHARGER SEAL. IN ADDITION, THE INFLIGHT POWER LOSS OF THE RIGHT ENGINE WAS CAUSED BY THE PILOT'S FAILURE TO FOLLOW THE PROCEDURES IN THE AIRPLANE OPERATING HANDBOOK AND LAND AS SOON AS POSSIBLE RESULTING IN FUEL STARVATION OF THE RIGHT ENGINE. DARKNESS WAS A RELATED FACTOR. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - normal - 1 engine - exhaust system,gasket - not installed (cause) - maintenance,installation - improper, company maintenance personnel (cause) - exhaust system,turbocharger - leak (cause) - ignition system,magneto grounding lead (p-lead) - shorted (cause) - Loss of engine power(total) - nonmechanical, cruise - normal - 1 engine - fluid,fuel - starvation (cause) - flight manuals - not followed, pilot in command (cause) - Forced landing, landing - flare/touchdown - In flight collision with object, landing - flare/touchdown - light condition - dark night (contributing factor) - object - other - object - tree(s) ## Analysis SHORTLY AFTER LEVELING OFF AT 14,000 FT THE LEFT ENGINE QUIT. THE PILOT DIVERTED TO TAMPA, AND 34 MINUTES LATER THE RIGHT ENGINE QUIT. DURING THE SUBSEQUENT FORCED LANDING THE AIRPLANE COLLIDED WITH THE ROOF OF A COVERED SIDEWALK AND THEN TREES. TEARDOWN OF THE LEFT ENG REVEALED THAT THE SEAL BETWEEN THE EXHAUST FLANGE & TURBOCHARGER WAS NOT INSTALLED; BOLT CLAMP WAS FINGER TIGHT. HEAT HAD MELTED WIRING HARNESS & MAG GROUNDING LEADS INSULATION; BOTH 'P' LEADS WERE GROUNDED. PILOT STATED THAT AFTER LOSING THE LEFT ENG HE INITIATED A LEFT TANK TO RIGHT ENGINE CROSSFEED, AND AFTER 20 MINUTES OF SINGLE ENG FLIGHT IN THIS CONFIGURATION THE RIGHT ENG QUIT. FLIGHT MANUAL STATES TO LAND AS SOON AS POSSIBLE IN CASE OF ONE ENG FAILURE. IN ADDITION, IT WARNS THAT WHEN FLYING ON ONE ENG & CROSSFEEDING FUEL, ABSOLUTE COORDINATED FLIGHT MUST BE MAINTAINED TO PREVENT UNPORTING OF THE TANK'S FUEL PICKUP TUBE WHEN THE TANK IS NOT FULL. ## Aircraft - Registration: [N7443S](https://openairdocs.org/deregistered/N7443S-2013-05-08), registration cancelled 2013-05-08, S/N 61-0063-117, built 1970 (OpenAirDocs) - Reported make and model: BUTLER AEROSTAR 601 (AEROSTAR 6) - Registry model: [Butler AEROSTAR 601](https://openairdocs.org/model/butler-aerostar-601) (registry code 1710606) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 61-0063 - Airframe hours: 3234 - Engines: LYCOMING IO-540-AA1A5 290 horsepower reciprocating - Damage: Destroyed - Flight: Part 135 - Registered owner: Top Flight Air Service - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, February 7, 1990, 42 hours before - Departed: CRG, JACKSONVILLE, FL - Destination: ATLANTA, GA - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 26; commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 4,548 total, 2,024 in this make and model, 3,835 as pilot in command, 350 in the last 90 days, 109 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 120° at 4 knots - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 57 °F - Altimeter: 30.00 inHg - Observed at: GNV, 29 nm away ## 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 19900315004499A](https://openairdocs.org/incident/19900315004499A), Mar 15, 1990: Piper PA60601, Lake Butler, FL, Destroyed. Left engine quit, exhaust leak melted magneto p leads. Right engine quit approximately 20 minutes later in descent. 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.