Accident Details
Probable Cause and Findings
Improper maintenance of the fuel injector nozzles and the pilots’ failure to abort the takeoff during the takeoff roll. Contributing to the accident was the mechanic’s decision to return the airplane to service with the engine unable to attain its full rated power.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn October 21, 2022, about 1845 eastern daylight time, a Beech A24R, N8020R, was destroyed when it was involved in an accident near Keene, New Hampshire. The flight instructor and commercial-rated pilot were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
According to the recorded audio from the common traffic advisory frequency (CTAF) at the Dillant/Hopkins Airport (EEN), Keene, New Hampshire, about 1842, one of the pilots broadcast that the airplane was taking runway 02 for departure. About 2 minutes later, one of the pilots broadcast that the flight was departing from runway 02 and would remain in the airport traffic pattern.
Video from the airport showed that the airplane began the takeoff from the approach end of runway 02. Several witnesses (including pilots and a mechanic) who were located on the airport reported that the engine sounded abnormal, with one reporting that it never sounded smooth the entire time the airplane was on the runway or while airborne. The airplane rotated when the flight was about 3,311 ft down the 6,201-ft-long runway and climbed to about 25 ft above ground level. A pilot-rated mechanic stated that when the flight was airborne over the runway, he heard a momentary power reduction followed by a power advance.
Witnesses reported that after takeoff, the flight continued in a very shallow climb, climbing to between 50 ft and no higher than about 200 ft when the flight was near the intersection of runways 02/20 and 14/32, which was about 5,200 ft down the runway. The flight continued in a wing and nose-level attitude while several witnesses, who were located northwest of the departure end of the runway, reported that the “poor” engine sound continued. A witness located about .5 nautical mile north-northeast from the departure end of runway 02 reported the airplane was flying not much higher than 50 ft above ground level when it flew by him. He reported hearing “pop pop pop” sounds in quick succession, like backfiring. The airplane cleared his neighbor’s house and then cleared a tree line; at that point the popping sound stopped, but then continued 3 seconds later. While descending, the sound from the engine got louder. He heard the impact and ran to the accident site. There was no distress call made by either pilot on the CTAF.
The airplane impacted into a storage building attached to an apartment building, resulting in a postcrash fire. There were no reported ground injuries. AIRCRAFT INFORMATIONThe airplane was equipped with a three-bladed, constant-speed, single-acting McCauley propeller that was installed in accordance with Supplemental Type Certificate SA496CH. The Federal Aviation Administration (FAA) Approved Airplane Flight Manual Supplement associated with the propeller installation specified that there was no performance change as compared to the originally installed propeller, and that the rated full power rpm was 2,700 rpm.
Section VIII, Handling, Service and Maintenance, of the Pilot’s Operating Handbook and FAA Approved Airplane Flight Manual (POH/AFM), specified the static rpm range during a power check to be between 2,650 and 2,700 rpm. The performance section of the POH/AFM indicated that from a paved, level, dry surface runway, based on the environmental conditions at the time, the approximate ground roll distance at 2,750 pounds was about 1,224 ft. A note in the chart specified that for each 100 pounds below 2,750 pounds, to subtract 8 percent from the distances.
Before the accident flight, the accident airplane was last flown on September 4, 2021, over 13 months before the accident flight. The pilot in the left seat during that flight reported that he was interested in possibly purchasing a similar make and model airplane as the accident airplane. He, therefore, flew two flights in the accident airplane. Once on August 28, 2021, for 1.3 hours, and during the second flight on September 4, 2021, which lasted 1.2 hours. He reported that the airplane flew normally during the first flight and for the first 2 legs on September 4th. However, he reported that the airplane did not perform normally during the third leg of flight (The right front pilot during the September 4th flight was the accident flight instructor, and the passenger in one of the rear seats was the left seat pilot during the accident flight). During the taxi for takeoff on the third leg of flight, the engine sounded like it might have a fouled spark plug or bad magneto. During takeoff, the airplane did not accelerate as expected and the right seat pilot took the controls and aborted the takeoff. The right seat pilot did another run-up and magneto check and decided to attempt another takeoff. The left front pilot reported that the airplane did not get airborne until between 2,200 to 2,500 ft down the runway; the airplane was climbing about 100 ft per minute and nearly hit a tree on departure. The right seat pilot continued to climb by making “zig zag” turns up the valley until they cleared a ridgeline and landed uneventfully at the destination airport, EEN. The left front pilot described the flight as the “worst flight of my life.”
The owner/operator of the airplane reported that before the accident flight the airplane had not been flown since the September 2021 event and had been stored in a hangar. She, and one of the operator’s mechanics, indicated that the issue associated with the September 2021 flight was a plugged fuel injector.
The airplane’s last annual inspection was completed on October 19, 2022. The mechanic reported that the fuel injector nozzles were cleaned as part of the annual inspection. Additional engine work consisted of replacing five spark plugs and re-timing the magnetos. Each differential compression check was greater than 75 psi when checked at 80 psi. The mechanic who performed a full-power post-maintenance engine run earlier on the day of the accident reported the maximum rpm attained was between 2,300 and 2,375 rpm. A postmaintenance check flight was not performed after the annual inspection; the accident flight was the first flight flown after the annual inspection.
Lycoming Service Bulletin No. 1414B, and Lycoming Service Instruction No. 1275C specified instructions for cleaning, and removing, cleaning, reassembly, and then testing of the fuel injector nozzles, respectively. AIRPORT INFORMATIONThe airplane was equipped with a three-bladed, constant-speed, single-acting McCauley propeller that was installed in accordance with Supplemental Type Certificate SA496CH. The Federal Aviation Administration (FAA) Approved Airplane Flight Manual Supplement associated with the propeller installation specified that there was no performance change as compared to the originally installed propeller, and that the rated full power rpm was 2,700 rpm.
Section VIII, Handling, Service and Maintenance, of the Pilot’s Operating Handbook and FAA Approved Airplane Flight Manual (POH/AFM), specified the static rpm range during a power check to be between 2,650 and 2,700 rpm. The performance section of the POH/AFM indicated that from a paved, level, dry surface runway, based on the environmental conditions at the time, the approximate ground roll distance at 2,750 pounds was about 1,224 ft. A note in the chart specified that for each 100 pounds below 2,750 pounds, to subtract 8 percent from the distances.
Before the accident flight, the accident airplane was last flown on September 4, 2021, over 13 months before the accident flight. The pilot in the left seat during that flight reported that he was interested in possibly purchasing a similar make and model airplane as the accident airplane. He, therefore, flew two flights in the accident airplane. Once on August 28, 2021, for 1.3 hours, and during the second flight on September 4, 2021, which lasted 1.2 hours. He reported that the airplane flew normally during the first flight and for the first 2 legs on September 4th. However, he reported that the airplane did not perform normally during the third leg of flight (The right front pilot during the September 4th flight was the accident flight instructor, and the passenger in one of the rear seats was the left seat pilot during the accident flight). During the taxi for takeoff on the third leg of flight, the engine sounded like it might have a fouled spark plug or bad magneto. During takeoff, the airplane did not accelerate as expected and the right seat pilot took the controls and aborted the takeoff. The right seat pilot did another run-up and magneto check and decided to attempt another takeoff. The left front pilot reported that the airplane did not get airborne until between 2,200 to 2,500 ft down the runway; the airplane was climbing about 100 ft per minute and nearly hit a tree on departure. The right seat pilot continued to climb by making “zig zag” turns up the valley until they cleared a ridgeline and landed uneventfully at the destination airport, EEN. The left front pilot described the flight as the “worst flight of my life.”
The owner/operator of the airplane reported that before the accident flight the airplane had not been flown since the September 2021 event and had been stored in a hangar. She, and one of the operator’s mechanics, indicated that the issue associated with the September 2021 flight was a plugged fuel injector.
The airplane’s last annual inspection was completed on October 19, 2022. The mechanic reported that the fuel injector nozzles were cleaned as part of the annual inspection. Additional engine work consisted of replacing five spark plugs and re-timing the magnetos. Each differential compression check was greater than 75 psi when checked at 80 psi. The mechanic who performed a full-power post-maintenance engine run earlier on the day of the accident reported the maximum rpm attained was between 2,300 and 2,375 rpm. A postmaintenance check flight was not performed after the annual inspe...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA23FA033