MIA94FA008

NTSB accident investigation · Beech 60 · Miami, FL · October 17, 1993

Accident · Serious injuriesField investigationFinal report
Date
October 17, 1993, 15:30 local (19:30 UTC)
Place
Miami, FL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Unknown
Aircraft
N7131DBeech 60
Weather
Visual (VMC) · Day
Status
Completed · report November 10, 1994
Report
Approved by Office Director
FAA report
19931017039529A
Case key
37404

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Inadequate preflight by the pilot, and his failure to assure that proper maintenance/annual inspection was attained. Factors related to the accident were: water and other contamination in the fuel supply, lack of continuity in two ignition leads, loose left magneto on the right engine, and improper timing of the right magneto on the right engine; terrain conditions in the emergency landing area and the pilot's failure to use a shoulder harness probably attributed to the degree of injury and damage.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine powerUnknown
2 engines
Aircraft preflight - inadequatePilot in commandCause
Maintenance,annual inspection - not attainedPilot in commandCause
Fluid,fuel - contaminationFactor
Fluid,fuel - waterFactor
Ignition system,ignition lead - failure,partialFactor
Ignition system,magneto - looseFactor
Ignition system,magneto - improperFactor
Forced landingDescent - emergency
Propeller feathering - not attained
In flight collision with terrain/waterLanding
Shoulder harness - not usedPilot in commandFactor
Object - tree(s)
Terrain condition - rough/unevenFactor

Analysis

About 21 minutes after takeoff, the plane crashed on uneven/wooded terrain about 10 mi north of the departure airport. The seriously injured pilot reported no recollection of events leading to the accident. An A&P mechanic, who saw the plane take off, stated it was climbing slowly & the engines were running smoothly, but the engines sounded as if they were not at full power. Just before impact, 2 witnesses saw the plane at low altitude; one said that neither engine was operating. Exam of the left engine revealed the fuel servo was contaminated internally; 2 of 12 ignition leads failed continuity tests; & contamination was found in the mixture housing area. Water was found in the right inboard leading edge fuel cell. Exam of the right engine revealed left magneto was not properly secured; timing of right magneto(s) 42 deg btc (should have been 20 deg btc). Investigation revealed both props at low pitch, left magneto switches off, right boost pump off, shoulder harness not used, last annual inspection dated 2/25/92. This was 1st flight in 5 months.

Factual narrative

History of flight

On October 17, 1993, about 1530 eastern daylight time, a Beech BE-60, N7131D, registered to the pilot, Robert E. Lee, crashed about 10 nautical miles northwest of the Miami International Airport, Miami, Florida, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The airplane was substantially damaged and the private pilot, the sole occupant, was seriously injured. The flight originated about 1509 from the Miami International Airport, Miami, Florida.

The pilot stated that he has no recollection of events leading up to or occurring during the crash. He stated that he normally follows a checklist before flying. The morning of the accident a fuel truck serviced the airplane with 100 gallons of fuel, 50 gallons into each of the left and right fuel tanks of the airplane. The pilot was observed to preflight the airplane, however, no witness watched the entire preflight to determine if the pilot checked the fuel tanks for contaminants. A certificated FAA mechanic stated that he checked the "outboard" tanks for contaminants after the fueling and no contaminants were found. The airplane was taxied to takeoff but taxied to Signature Flight Support for minor electrical system assistance. After assistance was obtained, the airplane was then taxied to runway 27R and according to a witness who is an FAA certificated A & P mechanic, the airplane was observed to climb to about 400 feet above ground level in a shallow climb. The witness reported that the engines sounded like they were running smooth but the engines were not at full power. He also stated that he thought the landing gear was not completely retracted. According to two witnesses near the accident site, the airplane was seen flying low then pitched nose down and crashed. One of the witnesses reported that he did not hear any sounds from either engine.

Personnel information

Information pertaining to the pilot is contained in the NTSB Factual Report-Aviation. According to the manager of the FAA Aeromedical Certification division, the pilot did not hold a valid FAA medical certificate on October 17, 1993.

Aircraft information

Information pertaining to the airplane is contained in the NTSB Factual Report-Aviation and Supplements A & B. Review of the aircraft and engine logbooks revealed that the last annual inspection occurred on February 25, 1992. On May 18, 1993, a ferry permit was issued by the FAA for a flight from Sumter, South Carolina, to Miami, Florida. The airplane was flown on May 20, 1993, to Miami, Florida, to have an annual inspection performed and according to the pilot, he did not experience any problem with the engines, propellers, fuel system, or flight controls during the flight. No work was done to the airplane in Miami, however, an FAA certificated mechanic stated that he checked the fuel tanks for contaminants and operated each engine checking the magnetos, and propeller governor weekly. His last check of the airframe and engines occurred about 5-6 days before the accident. No discrepancies were noted.

Meteorological information

Information pertaining to weather is contained in the NTSB Factual Report-Aviation.

Communications

At the time of the accident the pilot was not in contact with any FAA air traffic control facility.

Wreckage and impact information

Examination of the accident site revealed that the airplane first impacted a small dirt bank in a field, nose and left wing low on a heading of about 260 degrees. The left engine separated during impact. The airplane then rotated to the left and the right wing impacted a tree causing the airplane to rotate to the right. The airplane came to rest upright in about 6 inches of water about 60 feet from the first impact point on a heading of about 040 degrees with the landing gear extended. The right engine assembly was nearly separated. The left wing was bent up about 45 degrees with a compression wrinkle located just outboard of the engine mount. The wing tip leading edge was crushed chordwise. The right wing had slight wing tip damage and damage near the engine mount area. Examination of the flight controls revealed no evidence of preimpact failure or malfunction. The flaps were retracted. The right inboard leading edge fuel cell drain was opened the evening of the accident at the accident site and about 8 ounces of water were found. The fuel cell drain located in the right wing box section cell and the right strain/drain/thermal relief valve were opened to check for contaminants; none were found. The left wing inboard leading edge and the left strain/drain/thermal relief valve drains were nearly completely plugged internally with unknown object(s). No water contamination was found in either of these drains when they were removed nor in the left wing box section cell fuel drain. The left and right fuel selectors were in the "on" position. Examination of the fuel delivery and vent systems for both wings revealed no evidence of preimpact failure or malfunction. The left and right magneto switches were in the "off" and "both" positions respectively. Testing of each magneto switch revealed no evidence of failure or malfunction. Impact damage to the sidewall adjacent to the magneto switches was noted. The left and right fuel boost pump switches were in the "on" and "off" positions respectively. Testing of each fuel boost pump revealed they operated normally.

Examination of the left engine which separated revealed that the throttle, mixture, and propeller control cables were attached to their respective control arms at the fuel servo and propeller governor. Noncontaminated fuel was found in all of the fuel lines, the engine driven fuel pump, fuel servo, and the fuel distribution valve. The fuel inlet screen at the fuel servo was clean. Crankshaft, camshaft, and valve train continuity was confirmed throughout the engine; thumb compression and suction was verified at all cylinders. The left magneto to engine timing was determined to be 22 degrees before top center (BTC). The right magneto to engine timing was determined to be 42 degrees BTC. According to the engine manufacturer the magneto timing should be 20 degrees BTC. Two of the 12 ignition leads failed the continuity test. The magnetos were removed from the engine and turned by hand which revealed spark at all towers of each magneto. The fuel servo was removed and flow tested which revealed that it operated normally with no evidence of preimpact failure or malfunction. Disassembly revealed an unknown contaminant in the mixture housing area. Additionally, a small piece of rubber like material was found on the idle control valve. The engine driven fuel pump drive shaft was intact. The propeller was removed for examination.

Examination of the left engine propeller revealed no evidence of preimpact failure or malfunction. Propeller blade angle at impact was determined to be low pitch.

Examination of the right engine which nearly separated revealed that the throttle, mixture, and propeller control cables were attached to their respective control arms at the fuel servo and propeller governor. Noncontaminated fuel was found in all of the fuel lines, the fuel servo, and the fuel distribution valve. The fuel inlet screen at the fuel servo was clean. Crankshaft, camshaft, and valve train continuity was confirmed throughout the engine; thumb compression and suction was verified at all cylinders. The left magneto was loosely secured to the accessory case of the engine and magneto to engine timing was not determined. The right magneto to engine timing was determined to be about 42 degrees BTC. According to the engine manufacturer the magneto timing should be 20 degrees BTC. The magnetos were removed from the engine and turned by hand which revealed spark at

Aircraft

Registration
N7131D
Reported as
Beech 60
Category
Airplane
Serial number
P-55
Airframe hours
2,606
Engine
Lycoming TIO-541-E1A4, 380 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Lee, Robert
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 25, 1992 · 23 hours before
Departed
MIA
Destination
23J · Jacksonville, FL
Airport
MIA · Miami International

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
59
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Seat
Left
Flight hours
8,000 total · 50 in this make and model · 7,860 as pilot in command · 30 in the last 90 days · 20 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 7 knots
Visibility
15 statute miles
Lowest ceiling
20,000 ft broken
Altimeter
29.00 inHg
Observed at
OPF, 8 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.