Accident Details
Probable Cause and Findings
Maintenance personnel's failure to follow procedures and published directives in calibrating the continuous flow fuel system and failure to accurately diagnose debris in the throttle assembly, resulting in a loss of power in one engine. Contributing to the accident was the pilot's failure to comply with published engine out procedures, which resulted in an off-airport landing and subsequent impact with a tree and the ground.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn February 13, 2013, at 1314 eastern standard time, a Cessna T337C, N2576S, was destroyed when it impacted the ground in a farm pasture shortly after departure from New Smyrna Beach Municipal Airport (EVB), New Smyrna Beach, Florida. Day visual meteorological conditions prevailed and no flight plan was filed for the local maintenance test flight. The airline transport pilot was fatally injured. The local flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
According to transcripts of voice recording from the FAA contract Air Traffic Control tower at EVB, the airplane was issued a takeoff clearance with a left turn approved at 1312:40. At 1314:06, the pilot transmitted "mayday mayday" over the tower frequency. The flight was subsequently cleared to land on any runway but no further communication was received from the flight.
According to two eyewitnesses, the airplane was observed in a left wing down bank when it impacted a tree, powerlines, and then another tree prior to coming to rest. The witnesses further stated that they heard the engine producing power; however, they could not determine if both engines were operating or producing power. PERSONNEL INFORMATIONAccording to Federal Aviation Administration (FAA) records, the pilot held an airline transport pilot certificate with a rating for airplane multiengine land, a commercial pilot certificate with ratings for airplane single-engine land, airplane single-engine sea, and airplane multiengine sea. He also had a flight instructor certificate for airplane single-engine, multiengine, and instrument airplane. He held a second-class medical certificate which was issued on August 23, 2012, and had two restrictions of "not valid for any class after" and "must wear corrective lenses." At the pilot's most recent medical he had reported 4,186 total flight hours and 50 of those flight hours were in the 6 months preceding the medical application. AIRCRAFT INFORMATIONAccording to FAA and airplane maintenance records the airplane was issued an airworthiness certificate on June 1, 1968 and was registered to RoyalAir Aviation, Inc. on April 24, 2007. It was equipped with two engines. The front engine was a Continental Motors TSIO-360A3B, 210-hp engine and the rear engine was a Continental Motors TSIO-360 AcAB, 210-hp engine. It was also equipped with two McCauley propellers. The airplane's most recent annual inspection was completed on May 1, 2012. Paperwork located in the hangar, which included an FAA form 8130-1, indicated that on January 15, 2013 an engine driven fuel pump was tested and recorded as "tested good set to factory flows."
According to the aircraft Owner's Manual, the airplane had a total fuel capacity of 131 gallons. The fuel system comprised of two main fuel tanks with a capacity of 46 gallons each and two auxiliary tanks with a capacity for 19.5 gallons each. The last located recorded fueling was accomplished on October 28, 2012 at EVB. The airplane had been fueled with 58.09 gallons of fuel.
According to a mechanic who had performed maintenance on the airplane, the most recent work performed was due to the lack of full travel on the rear fuel selector valve. During operation of the selector valve it would only go from the "OFF" position to the "ON" position and would not allow the use of the auxiliary tank position. The airplane was defueled into clean containers and then the mechanic removed the "Right Hand Selector" valve, sent the valve to a repair facility, which was subsequently returned and reinstalled. The rigging was verified and "Full travel was confirmed and resistance was normal," on the fuel selector valve. In addition, the engine driven fuel pump was removed, repaired and reinstalled on February 11, 2013. According to the mechanic the pilot reported having difficulty starting in the "super rich" position as well as black smoke was reported coming from the rear engine by others that observed it. After the engine driven fuel pump was reinstalled, the mechanic adjusted the continuous flow fuel injection system per the guidance of Teledyne Continental Motors Service Information Directive 97-3E. He stated that he utilized the JPI engine monitor and an external low pressure gauge to set the takeoff fuel flow between 20 and 21 gallons per hour. He further reported that the pilot had the differential gauge as required in the guidance for the adjustment of the continuous fuel flow system; however, they utilized the JPI as well. The mechanic returned the fuel from the containers to the airplane and at that time, the tanks were "about eighty percent full." On the Monday prior to the accident, the pilot and the mechanic operated both engines and the pilot was going to test fly the airplane the following day. On the day prior to the accident, during the run-up, the pilot did not like the run-up on the rear engine and they readjusted the settings until 31 inches of manifold and a fuel burn of 20 gallons per hour was achieved. After the adjustment, the run-up appeared to be normal; however, due to the lateness of the day and the sun setting the pilot elected to "test fly" the airplane the following day. METEOROLOGICAL INFORMATIONThe 1347 recorded weather observation at EVB, included wind from 230 degrees at 15 knots with gusts to 20 knots, 7 miles visibility, broken clouds at 1500 feet above ground level (agl), temperature 28 degrees C, dew point 18 degrees C; barometric altimeter 29.86 inches of mercury. AIRPORT INFORMATIONAccording to FAA and airplane maintenance records the airplane was issued an airworthiness certificate on June 1, 1968 and was registered to RoyalAir Aviation, Inc. on April 24, 2007. It was equipped with two engines. The front engine was a Continental Motors TSIO-360A3B, 210-hp engine and the rear engine was a Continental Motors TSIO-360 AcAB, 210-hp engine. It was also equipped with two McCauley propellers. The airplane's most recent annual inspection was completed on May 1, 2012. Paperwork located in the hangar, which included an FAA form 8130-1, indicated that on January 15, 2013 an engine driven fuel pump was tested and recorded as "tested good set to factory flows."
According to the aircraft Owner's Manual, the airplane had a total fuel capacity of 131 gallons. The fuel system comprised of two main fuel tanks with a capacity of 46 gallons each and two auxiliary tanks with a capacity for 19.5 gallons each. The last located recorded fueling was accomplished on October 28, 2012 at EVB. The airplane had been fueled with 58.09 gallons of fuel.
According to a mechanic who had performed maintenance on the airplane, the most recent work performed was due to the lack of full travel on the rear fuel selector valve. During operation of the selector valve it would only go from the "OFF" position to the "ON" position and would not allow the use of the auxiliary tank position. The airplane was defueled into clean containers and then the mechanic removed the "Right Hand Selector" valve, sent the valve to a repair facility, which was subsequently returned and reinstalled. The rigging was verified and "Full travel was confirmed and resistance was normal," on the fuel selector valve. In addition, the engine driven fuel pump was removed, repaired and reinstalled on February 11, 2013. According to the mechanic the pilot reported having difficulty starting in the "super rich" position as well as black smoke was reported coming from the rear engine by others that observed it. After the engine driven fuel pump was reinstalled, the mechanic adjusted the continuous flow fuel injection system per the guidance of Teledyne Continental Motors Service Information Directive 97-3E. He stated that he utilized the JPI engine monitor and an external low pressure gauge to set the takeoff fuel flow between 20 and 21 gallons per hour. He further reported that the pilot had the differential gauge as required in the guidance for the adjustment of the continuous fuel flow system; however, they utilized the JPI as well. The mechanic returned the fuel from the containers to the airplane and at that time, the tanks were "about eighty percent full." On the Monday prior to the accident, the pilot and the mechanic operated both engines and the pilot was going to test fly the airplane the following day. On the day prior to the accident, during the run-up, the pilot did not like the run-up on the rear engine and they readjusted the settings until 31 inches of manifold and a fuel burn of 20 gallons per hour was achieved. After the adjustment, the run-up appeared to be normal; however, due to the lateness of the day and the sun setting the pilot elected to "test fly" the airplane the following day. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted a tree approximately 60 feet agl, power lines, and then another tree about 25 feet agl prior to coming to a rest in a cow pasture that was approximately 1,000-feet long and 200-feet wide. The accident flight path was oriented on a 076 degree heading and the debris path began just prior to the final tree strike and terminated 227 feet past and was approximately 98 feet wide. The final tree strike was located 186 feet from a power pole and power line which ran nearly perpendicular to the debris path. The accident location was 5,373 feet and 215 degrees from the midfield point of the departure runway. According to local authorities, upon arrival at the accident site the top line of the power line was severed.
Examination of the debris path revealed that the nose gear strut and the right front seatbelt and shoulder harness were imbedded in the tree approximately 25 feet agl. The seat belt remained latched but was separated from the aircraft structure. The left and right wing remained attached to each other via the cross control cable and the roof of the cabin area. Both wings came to rest inverted about 75 feet from the final tree strike. The tail section and rudders were imp...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA13FA131