# NTSB MIA99FA114: Grumman G-21A, N5548A, Lauderdale Lake, FL, March 25, 1999 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 25, 1999, 11:39 local (16:39 UTC) - Place: Lauderdale Lake, FL - Coordinates: 26.189264, -80.169265 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.1893&lon=-80.1693&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report July 12, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 45968 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA99FA114 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/45968/pdf - Page: https://openairdocs.org/ntsb/MIA99FA114 ## Probable cause The pilots failure to correctly identify an in-flight emergency (fluctuating manifold pressure and rpm due to a disconnected spark plug lead / unscrewed ignition lead shroud) and failure to complete the engine shutdown procedure once it was initiated (propeller not feathered). This resulted in a forced landing and subsequent in-flight collision with a tree, dirt bank and canal. Contributing to the accident was the FAA inspectors improper supervision of the pilot, and the improper supervision of the inspector by her supervisor, in his failure to follow written procedures / directives in assigning a non-current inspector to conduct a competency flight. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, descent - ignition system,spark plug - disconnected - emergency procedure - improper, pilot in command (cause) - ignition system,spark plug - not secured - emergency procedure - initiated, pilot in command - engine instruments,manifold pressure gage - fluctuating - emergency procedure - not complied with, pilot in command (cause) - engine instruments,propeller rpm gage - fluctuating - supervision - improper, faa inspector (contributing factor) - supervision - improper, faa(other/organization) (contributing factor) - procedures/directives - not complied with, faa(other/organization) - Forced landing, descent - emergency - In flight collision with object, emergency descent/landing - object - tree(s) - In flight collision with terrain/water, emergency descent/landing - terrain condition - dirt bank/rising embankment - terrain condition - water ## Analysis The pilot was receiving a competency flight in the seaplane from an FAA inspector. The pilot was returning to their initial departure airport, descended to 1,000 feet, contacted the control tower for landing instructions, and was instructed to enter on a right base. Before he could acknowledge the landing instructions the engines started to make loud, rough, and unusual noises. The pilot informed the control tower that he was 2 miles south , declared an emergency, and stated he had a bad engine on the left side. The FAA inspector stated the pilot started the emergency procedure, the manifold pressure and rpm was fluctuating. The inspector could not determine the dead engine by the dead foot, dead engine method, because her rudder pedals were stowed. She pointed out a pasture and the pilot stated they were going to the water. She did not recall the pilot shutting down the engine or feathering the propeller. She could not recall the final seconds of the flight. The airplane collided with a tree, canal bank, and came to rest inverted in the canal. Examination of the airframe and flight control systems revealed no evidence of a precrash mechanical failure or malfunction. Examination of the left propeller revealed it was not feathered. The No. 6 front forward spark plug ignition lead was disconnected from the spark plug. The ignition lead shroud threaded coupling on the No. 4 front forward spark plug was unscrewed and the carbon wire was exposed. The left and right engines were removed from the airplane and transported to an authorized FAA approved repair station. The left engine was placed in an engine test cell. The engine was started, developed rated power, and achieved takeoff power. The spark plug lead was removed from the No.6 forward cylinder. The left magneto had a 125 rpm drop during the magneto check. The right magneto had a 75 rpm drop. The magneto drop exceeded the allowable drop indicated by the engine overhaul manual. The right engine was placed in a engine test cell. The engine was started, developed rated power, and achieved takeoff power. Review of the FAA inspectors FAA Form 4040.6 revealed she was not Event Based Current (EBC) for the 4th quarter of the Flight Standards EBC program, and she did not meet the EBC quarterly events required by the end of the 14-day grace period. FAA Order 4040.9 states for an FAA inspector to be eligible / assigned to perform flight certification job function they must be EBC current., and inspectors should not accept assignments without being in compliance with the FAA Order. Managers and supervisors should not assign inspectors who are not current. The FAA inspector's supervisor was aware that the inspector was not current. He contacted the FAA Safety Regulation Branch, FAA Southern Region Headquarters, and stated that FAA Southern Region indicated that the inspector could administer the checkride. FAA Southern Region stated at no time did they approve or agree to an operation outside the parameters of the FAR's, Inspector Handbook or FAA Order. ## Factual narrative HISTORY OF FLIGHT On March 25, 1999, about 1139 eastern daylight time, a Grumman G-21A, N5548A, registered to Tropic Bird Holdings Inc., operating as a 14 CFR Part 135 competency flight, experienced a reported loss of left engine power, and crashed into a canal about 2 miles south of Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. Visual meteorological conditions prevailed and no flight plan was filed. The airplane was destroyed. The airline transport pilot was fatally injured. The airline transport pilot FAA inspector sustained serious injuries. The flight originated from Watson Island International, Miami, Florida, about 10 minutes before the accident. The competency flight initially originated originated from FXE, at 0949. Review of radio transcriptions between Fort Lauderdale Executive Air Traffic Control Tower (FXE) and N5548A, revealed that N5548A initially contacted the tower at 1136:33, with the ATIS information. At 1138:06, N5548A informed the tower that he was 3 miles south for landing. The controller asked N5548A to state type of airplane. N5548A replied, "standby sir standby." At 1138:36, N5548A replied, "five five four eight alpha we'd like to declare an emergency sir ah we're two miles south." The controller informed N5548A to enter right base runway eight, cleared him to land and asked the nature of the emergency at 1138:44. N5548A replied, "ok we have a bad engine on the left side sir." The controller cleared N5548A to land again and provided the winds. There was no other recorded communication with N5548A. The FAA inspector stated in an initial interview with another FAA employee present, that shortly before the accident she heard a bad engine sound, and looked at the manifold pressure and rpm, which was fluctuating. She informed the pilot that there was a pasture. He stated he was going for the water. They went down like a rock turning towards the canal and crashed. When asked if she heard the pilot declare an emergency or shut down an engine she said no. The FAA inspector stated in a subsequent written statement to the NTSB that the load manifest showed the ballast and fuel, and that they had about 4.5 hours of fuel at cruise flight, which meant they could stay airborne just under 4 hours, because they would be using full power frequently. The pilot showed her the fuel system. She stated, "I do not recall the setting or that he ever mentioned his intentions for handling fuel or if and when he changed the fuel selector." The pilot had a paper copy of the checklist. It was their intentions to record any required changes that may be required. A certified letter was sent to the FAA inspector on June 3, 1999, requesting clarification of her statement. She was asked in the letter if she reviewed the Pilot Operating Handbook (POH), (Model JRF-5 airplane) before conducting the competency flight , and were there any deficiencies noted with the POH? She was asked if the airplane was equipped with dual controls, and were all of the flight controls available to her during the flight? In addition, she was asked if there were any deficiencies noted during the preflight inspection, during propeller governor and magneto check? In her response dated July 14, 1999, she stated, "Mr. O'Leary presented me with a copy of a manual, not a POH, which had been described by Mr. Santiago, when we met on March 24, 1999, to use for the oral. I used it that evening to additionally familiarize myself with the aircraft. I had four questions for him when I met him the next day, and he answered all of them." She further stated, "The airplane was equipped with dual controls. It is rated for one pilot. The rudder pedals on the right side can be stowed. After the runup and check of the controls, I stowed them in the aft position. The pilot was aware of this because we had had a satisfactory discussion of what I would need to do should he become incapacitated or for any other reason I would need to take control of the aircraft. They were within reach to pull up into position for use." She also stated she did not recall any deficiencies during the preflight except for a minor correction to the load manifest, which was made, and there were no deficiencies with the propeller governor or magneto check. They departed FXE, flew southbound, north of Turkey Point and set up for maneuvers conducting steep turns, stalls, and compass turns with the directional gyro and gyro horizon covered. They proceeded to Dolphin VOR and tracked inbound. Once established, they terminated the high work and positioned themselves for Government Cut, circling to wait access to the water. They landed and ramped the airplane at Chalk's seaplane base. They departed again, returned for a normal landing, steptaxied with turns, took off again, and power was reduced on one engine just past 500 feet. The pilot reacted quickly and power was restored. Abeam the probable touchdown point, power was reduced again on one engine. The pilot's procedures were good; however, the airplane was descending too fast and a go-around was commanded. The pilot returned for another landing without flaps, which resulted in another go-around. The appropriate checklist was completed and they headed to the Fort Lauderdale VOR. They contacted Fort Lauderdale tower and were instructed to climb to 1,500 feet. They over flew the Fort Lauderdale-Hollywood International Airport. Once clear of their airspace, they descended to 1,000 feet, and called Fort Lauderdale Executive tower. The controller asked all aircraft to be silent and to listen to him for clearance. They made two shallow 360-degree turns while waiting for the controller to get back with them. The controller came back and stated that they were to make a right base to runway 08. Before the pilot could acknowledge, the engines started to make loud, rough, and unusual noises which could not be related to any particular problem. The pilot asked the tower for an emergency landing, which was approved by the controller. The pilot went through the first three or four steps of the emergency procedures. I looked at the rpm and manifold pressure, and the pilot stated the right engine was out. She informed the pilot, "I don't know, Paddy," and observed the needles on both engines and gauges fluctuating. She further stated, "my rudder pedals were stowed, so I could not determine the dead engine by the dead foot, dead engine method." She pointed out a pasture and the pilot stated they had to go to the water, and continued to work with both engines, but the noise never decreased. She did not recall the pilot shutting down either engine or feathering a prop, and said, "we seemed to be, not in a glide, but sinking like a rock after the effect of going over the top of a roller coaster." She did not recall the last few hundred feet or the collision with the trees. Witnesses stated they saw the airplane flying towards the north at a very low altitude, descending. The engines were making a loud popping sound. The airplane started a shallow turn estimated less than 45 degrees. The airplane collided with a tree and crashed into the canal. PERSONNEL INFORMATION The 40-year-old deceased pilot held an airline transport pilot certificate, with ratings for airplane multiengine land, and multiengine sea. In addition, he held a private pilot certificate with a rating for airplane single-engine land. He indicated on an application for a first class medical certificate dated December 14, 1998, that he had accumulated 10,000 hours, with 400 hours flown in the last 6 months. Attempts to locate the pilot's logbook were unsuccessful. A certified letter was mailed to the wife of the deceased pilot on April 28, 1999, requesting a copy of the pilot's logbook. The letter was returned to the NTSB by the U.S. Postal Service, on May 6, 1999. Review of a pilot history form submitted to Aviation Insurance Management Inc., on March 17, 1999, re ## Aircraft - Registration: [N5548A](https://openairdocs.org/aircraft/N5548A), registered now, S/N 75-7661, built 1959 (OpenAirDocs) - Reported make and model: Grumman G-21A - Registry model: [Grumman G-21A](https://openairdocs.org/model/grumman-g-21a) (registry code 3951204) (OpenAirDocs) - Registry engine: [Pratt & Whitney R-985 series](https://openairdocs.org/engine/pratt-whitney-r-985-series) (registry code 52008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 75-7661 - Airframe hours: 13136 - Engines: P&W R-985-14B 450 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Registered owner: Tropic Bird Landing Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 8, 1998, 31 hours before - Departed: X-44, MIAMI, FL - Destination: FXE ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; airline transport; airplane ratings: multi-engine land, multi-engine sea, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 10,000 total, 520 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 140° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 187 °F, dew point 172 °F - Altimeter: 30.00 inHg - Observed at: FXE, 2 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 19990325017249A](https://openairdocs.org/incident/19990325017249A), Mar 25, 1999: Grumav G21A, Ft Lauderdale, FL, Destroyed, 1 fatal. (.19) On March 25, 1999, about 1139 eastern daylight time, a Grumman G-21A, N5548A, registered to tropic bird holdings inc., operating as a 14 CFR part 135… ## Other investigations on N5548A (1) 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. - [NTSB MIA66A0109](https://openairdocs.org/ntsb/MIA66A0109), Mar 19, 1966: Grumman G-21A (N5548A), C.Amalie St.Th., VI, substantial damage 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.