Accident Details
Probable Cause and Findings
The pilot’s improper response to a loss of power in the No. 2 engine and his failure to ensure that the airplane was airworthy. Contributing to the accident was the inadequate engine maintenance by the operator's maintenance personnel.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On May 2, 2011, about 0809 eastern daylight time, a Beech E18S, N18R, was substantially damaged when it impacted terrain in Miami Gardens, Florida. The airline transport pilot was fatally injured. The airplane was registered to Aircap Management Company Inc., and was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Visual meteorological conditions prevailed, and a flight plan had been filed for the non-scheduled international cargo flight which departed from Opa-Locka Executive Airport (OPF), Opa-Locka, Florida, destined for Marsh Harbour International Airport (MYAM), Marsh Harbour, Bahamas.
According to recorded communications from the OPF air traffic control tower, after takeoff for an "East departure" from runway 9L at OPF, the pilot advised that he was "turning downwind" According to witness statements, just after takeoff, the airplane did not sound like it was developing full power. The airplane then climbed to approximately 100 feet, banked to the left, and "slowly" began losing altitude. It then impacted a tree, a fence, and two vehicles before coming to rest in a residential area. A post crash fire then ensued.
PERSONNEL INFORMATION
According to Federal Aviation Administration (FAA) records, the pilot held an airline transport pilot certificate with a rating for airplane multi-engine land. His most recent FAA second-class medical certificate was issued on April 25, 2011. He reported 6,400 total hours of flight experience on that date.
AIRCRAFT INFORMATION
The accident aircraft was a twin-engine, low-wing, conventional-gear airplane of all metal semi-monocoque construction. It was powered by two 450 horsepower Pratt & Whitney R-985-AN-14B, 9-cylinder, radial engines.
The airplane had previously been involved in an accident on November 6, 2007 when it collided with another airplane during taxi at OPF and had been repaired and returned to service.
According to FAA and airplane maintenance records, the accident airplane was manufactured in 1957. The airplane’s most recent annual inspection was completed on June 30, 2010. At the time of the inspection, the airplane had accumulated 13,198.5 total hours of operation.
METEOROLOGICAL INFORMATION
The reported weather at OPF at 0753, included: winds 110 degrees at 12 knots, 10 miles visibility, a few clouds at 2,800 feet, temperature 26 degrees C, dew point 20 degrees C, and an altimeter setting of 30.08 inches of mercury.
AIRPORT INFORMATION
According to the Airport Facility Directory, OPF was a public use airport. It had three runways, oriented in a 12/30 and 09/27 (left and right), configuration. Runway 9L was grooved asphalt, in good condition. It was 8,002 feet long by 150 feet wide.
WRECKAGE AND IMPACT INFORMATION
The accident site was located approximately 1,753 feet northeast of the departure end of runway 9L. Examination of the accident site revealed that the airplane had initially struck the tree with its left inboard wing at an approximate height of 20 feet above ground level and multiple tree branches which exhibited propeller cuts were found near the base of the tree. Ground scarring on the street which corresponded to the airplane's flight path also existed on a 055 degree magnetic heading leading from the tree to the impact point with the fence and the two vehicles. Further examination of the ground scarring revealed the presence of tire marks on both sides of the ground scarring and propeller strike marks on the left side of the ground scarring which corresponded to the location of the No. 1 propeller. Minimal propeller marks were evident on the right side of the ground scarring.
Examination of the main wreckage revealed no evidence of preimpact failure or malfunction of the airplane or flight controls. The airplane after impacting the fence and two vehicles had come to rest with the left wing root and forward side of the nose section against one of the vehicles that it had impacted.
The No.1 engine and its cowling were separated from their mounting location and were found lying near the left side of the fuselage against the other vehicle. The No.2 engine and its cowling were found to have separated from their mounting location and were discovered against the south wall of a residence. The cowl flaps were open on both of the engine's cowlings.
The majority of the cabin area, and the left wing were consumed by a post crash fire. The right wing was separated from its mounting location and exhibited areas of crush and compression damage and a large area of deformation similar in size to one of the concrete block fence support columns. The empennage also exhibited impact damage.
Examination of the landing gear system revealed that the landing gear was in the down position. The main landing gear drag legs were in the over center position, and the slide for the tailwheel was at its travel limit.
Flight control continuity was confirmed from the aileron on the right wing, the aileron on the surviving outboard portion of the left wing, and the elevators, and rudders on the empennage to the breaks in the system and then to the cockpit.
Examination of the cockpit revealed that both the left and right throttle control levers were in the full-throttle position. The mixture control levers were in the full-rich position, the propeller pitch control levers were full forward, and both fuel selector valves were in the main wing tank positions.
Examination of the fuel system revealed that despite the post impact fire, approximately 9 gallons of fluid consistent with 100LL aviation gasoline was still present in the right main tank. When the fluid was applied to a coupon containing water finding paste, the paste did not change color indicating that no water was present.
There was no evidence of any preimpact failure or malfunction of the propellers. Examination of the propellers revealed that the No.1 propeller's blades exhibited evidence of chordwise scratching and S-bending but, the No.2 propeller's blades did not. Neither propeller was feathered.
The spinners and spinner bulkheads exhibited impact damage but did not exhibit any evidence of preimpact cracking. The propeller blades were still attached to their hubs and the pitch change mechanisms were intact and showed no evidence of any preimpact damage. Further examination revealed no evidence of a blade angle split, rotational, lateral, or longitudinal play of the blades, or worn links. The blade tapes which were also present on the blades and the blade clamps were aligned, and did not reveal evidence of the blades having moved in the blade clamps. Examination of the hub assembly also did not reveal any evidence of any preimpact grease leaks, oil leaks, or cracking.
Examination of the No.1 engine revealed no evidence of any preimpact malfunction or failure. Its compression was within specifications on the majority of its cylinders, and the others exhibited impact damage. The main fuel pump rotated freely, and the left magneto produced spark. The right magneto was impact damaged but, internal examination revealed no evidence of preimpact malfunctions.
Examination of the No.2 engine revealed however, that the compression on four of the nine cylinders was below specification and there were metallic particles suspended in the oil. The main fuel pump could not be rotated by hand, it exhibited play in the gear bearings, and corrosion was present internally. Both magnetos contained moisture and corrosion internally. The left magneto when tested would spark internally in a random pattern and its point gap was in excess of the required tolerance. The right magneto's camshaft follower exhibited excessive wear, and its points would not open.
MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed on the pilot by the Miami-Dade County Medical Examiner Department.
Toxicological testing of the pilot was conducted by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens were negative for basic, acidic, and neutral drugs. Carbon Monoxide and Cyanide were detected in blood consistent with the pilot's exposure to a post impact fire.
TESTS AND RESEARCH
According to the president of the shipping company whose cargo was onboard the airplane at the time of the accident, the airplane had been "down" most of the previous month. At first there was a problem with the tail of the airplane, and then approximately a week before the accident a cylinder went "bad". The pilot had called her and advised that even though he had a flight scheduled for another customer, as soon as the plane was fixed, her cargo would be first as she had been waiting for awhile.
According to witnesses, the airplane was kept outdoors when not flying and the local area had been experiencing large amounts of rain during the week before the accident.
The pilot had been having problems with the right engine for months and the pilot would takeoff with the engine "shuddering" and would circle his departure airport to gain altitude before heading to his destination. Then on the night before the accident witnesses observed maintenance being performed on the right engine while it was being illuminated by an automobile with its headlights on.
According to the mechanic, the maintenance performed was to replace the No.1 cylinder on the No.2 engine which had developed a crack in the fin area and had oil seeping out of it. After the mechanic performed the replacement he did not do a compression check or check the magnetos and stated that he had entered the replacement in the discrepancy log that was kept in a clipboard in the airplane.
When asked about how maintenance was being tracked for the airplane the mechanic stated that he had gotten a bulletin board and all of the inspections were tracked on the board. When asked what the total time on the airplane was when the cylinder was replaced the mechanic could not recall.
During review...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA11FA274