N123MD

HISTORY OF FLIGHT

On September 21, 2007, at 1328 eastern daylight time, a Beech H-18, N123MD, operated by Monarch Air Group, LLC, was destroyed when it impacted terrain during a forced landing after takeoff from Fort Lauderdale Executive Airport (KFXE), Fort Lauderdale, Florida. The certificated airline transport pilot was seriously injured. Visual meteorological conditions prevailed for the cargo flight, destined for Pindling International Airport (MYNN), Nassau, Bahamas. A visual flight rules flight plan was filed for the flight conducted under 14 Code of Federal Regulations Part 135.

According to witness statements, the airplane departed runway 8, and the pilot reported that he could not maintain altitude. The plane was then observed to drift to the south (right) of the extended runway centerline, at an approximate altitude of 150 feet above ground level (agl), and the tail appeared to be "wagging" side to side.

As the airplane approached Interstate 95 (I-95), it then appeared to enter an uncoordinated turn, and the tail of the airplane appeared to skid to the left. The right wing then dropped and the airplane rolled "rapidly" to its right at 50 to 75 feet agl. The nose pitched up and the plane appeared to "hang for a second" with the right side of the fuselage facing the direction of travel, "slightly nose up." A "puff" of smoke was observed as the right wingtip disappeared out of view, the nose then pitched down and the plane disappeared behind trees located along the edge of I-95. About 20 seconds later, smoke was observed rising from the area.

PERSONNEL INFORMATION

According to pilot and Federal Aviation Administration (FAA) records, the pilot held an airline transport pilot certificate with multiple ratings, including airplane multi-engine land. He reported 3,700 total hours of flight experience, with 450 hours in the accident airplane make and model. His most recent FAA first-class medical certificate was issued on May 7, 2007.

AIRCRAFT INFORMATION

According to FAA and maintenance records, the airplane was manufactured in 1964. The airplane's most recent 100 hour inspection was completed on March 26, 2007, and at the time of the inspection, it had accumulated 13,066 total hours of operation.

METEOROLOGICAL INFORMATION

The reported weather at FXE, 11 minutes after the accident, included: wind 120 degrees at 8 knots, visibility 10 miles, thunderstorms and light rain showers, few clouds at 3,700 feet, temperature 30 degrees Celsius, dew point 23 degrees Celsius, and an altimeter setting of 29.94 inches of mercury.

AIRPORT INFORMATION

FXE had two runways, oriented in a 13/31 and 08/26 configuration. Runway 8 was asphalt, grooved, and in good condition. The total length of the runway was 6,001 feet, and its width was 100 feet.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site revealed that the airplane had impacted the northeast corner of a building with the right wing tip and a portion of the wing was torn away. The airplane then struck a railroad right of way, skipped off of the rails, impacted a chain link fence, and then an inclined swale adjacent to the southbound lane of I-95.

Examination of the main wreckage revealed a wreckage path heading of 157 degrees magnetic. The majority of the fuselage came to rest on a heading of 069 degrees magnetic. The nose section and nose gear wheel well had separated from the fuselage. The left wing had separated from its attach fittings, and was found adjacent to the fuselage. The right wing had also separated from its attach fittings, and was discovered forward of the main wreckage. The majority of the fuselage was found lying on its right side. The cockpit roof and sidewalls were separated from the cockpit floor, and the instrument panel was separated from its mounting location.

Examination of the cockpit revealed that both the left and right electric fuel boost pumps were off, and the throttle control levers were in the full-throttle position. The mixture control levers were in the full-rich position, the propeller control levers were midrange, the landing gear handle was in the retracted position, and the wing flap handle was in the off position.

Examination of the engines revealed that both had separated from their mounts. The left engine's propeller blades exhibited leading edge gouging and chordwise scratching, however, the right engine's propeller blades did not. Further examination of the right engine also revealed that the propeller blades were in the "feathered" position, and only one side of the spinner was crushed. No evidence of any preimpact malfunctions of either engine was discovered. Examination of the right engine's fuel strainer, engine driven fuel pump, and carburetor float bowl revealed that they were devoid of fuel.

Examination of the fuel system revealed that fuel was present in the wing tanks. The left auxiliary wing tank was full and the left main wing tank was half full. The right auxiliary wing tank had been breached, and the right main wing tank was full. Approximately 245 gallons of 100LL aviation gasoline was recovered from the airplane. A fuel sample of the recovered fuel revealed no evidence of contamination.

No evidence of any preimpact malfunctions of the fuel system was discovered; however, the right engine fuel selector was found positioned between the "60 GAL RIGHT AUX" detent and the "RIGHT ENG OFF" detent. When the right engine fuel selector valve was examined, it was discovered that the fuel selector valve position agreed with the position of the right engine fuel selector and that fuel was present in the fuel lines which led from the right main wing tank, and from the right auxiliary wing tank, to the fuel selector valve. No fuel was discovered in the outlet port or the fuel line, which led from the fuel selector valve to the right engine.

TESTS AND RESEARCH

Pilot Statements

According to the pilot, he did not have the electric boost pumps on for takeoff. He had climbed to 250 to 300 feet in altitude and then the airplane started to yaw to the right. He added full power and then declared an emergency. He looked for a place to land and aimed for an area on the other side of Interstate 95. The airplane was descending at 250 feet per minute and "he could not have been in a worse spot to lose his engine" and "he had a 1/2 second to react."

He advised that the company pilots would plan round trip fuel. He would normally monitor the fueling but did not on the day of the accident. He would always visually check the inboard (Main) fuel tank caps but not the outboard (Auxiliary) fuel tank caps. The flight to MYNN would normally take 1 hour and 15 minutes and they would flight plan for 42 gallons per hour fuel burn.

The pilot would always assist in loading the airplane. On the day of the accident he and the hangar supervisor loaded the airplane, the pilot did the weight and balance calculations himself, and "knew what was in each bin position." He could not remember who secured the cargo straps.

Hangar Supervisor Statements

According to the hangar supervisor, he would normally assist in the loading of the entire airplane but in this particular instance, the pilot had arrived at the airplane before he did and had "80 to 90 percent" of the airplane already loaded. He offered to load the last few items in the rear two bins while the pilot "wrote down" the exact weights for the items that he had placed in the bins.

After loading the last few items, the pilot then asked him to calculate the total weight in each bin and derive a number for the entire airplane load using the numbers the pilot gave him.

He also advised that he attached the right cargo strap but did not secure the left cargo strap as the pilot was the one who closed up the airplane while he was busy entering the cargo weight numbers the pilot provided into the computer.

Airplane Loading

Examination of the interior of the fuselage revealed that the airplane was full of cargo from aft of the pilot compartment to the rear bulkhead of the cabin. Both the left side and right side cargo hold down straps were installed, but only the right side strap had been secured.

Further examination revealed that the interior was subdivided with vertical paint stripes into 7 sections (A through G) to assist in loading. Section "A" was the pilot's compartment, and Sections B through G were designated for the carriage of cargo and were referred to as "Bins." Additionally, each bin was placarded for the maximum weight that could be carried in that bin.

During offloading and weighing of the cargo it was discovered, that Bin G (the furthest aft bin) contained 265 pounds of cargo. The bin was placarded however, for 75 pounds maximum weight.

Moving forward from Bin G, All of the other bins were loaded below their maximum placarded limitations.

Bin F contained 260 pounds of cargo (placarded for 350 pounds), Bin E contained 150.5 pounds of cargo (placarded for 350 pounds), Bin D contained 294.5 pounds of cargo (placarded for 950 pounds), Bin C contained 178 pounds (placarded for 950 pounds), and Bin B contained 647.5 pounds (placarded for 950 pounds).

Weight and Balance Form

A review of the accident flight's Weight and Balance Form, revealed that the maximum allowable operating weight for the airplane was 10,100 pounds and that the maximum allowable aft center of gravity (CG) limit was 120.5 inches aft of the datum. The form also listed the maximum weight limitations for each bin.

Examination of the pilot's weight entries revealed that the entries were below the specified bin limitations but did not agree with the weight of the cargo, which had been recovered from each bin.

According to the pilot's entries, the airplane's actual weight was 9,581 pounds and it was at the aft CG limit of 120.5 inches.

Post accident weight and balance calculations utilizing three different scenarios were performed by the FAA. The first scenario utilized the actua...