Un-airworthy airplane crashes

Aircraft: Beech 18. Injuries: 1 Fatal. Location: Miami Gardens, Fla. Aircraft damage: Destroyed.

What reportedly happened: The pilot held an ATP certificate and had in excess of 6,400 hours of flight experience. He was the president and director of operations for the company that maintained the airplane, which was kept outdoors when not flying. The local area had been experiencing large amounts of rain during the week before the accident.

During the accident investigation, investigators learned that the right engine of the Beech had been experiencing mechanical difficulties for months, which the pilot was aware of but continued to fly the airplane.

According to people familiar with the pilot, the pilot’s practice was to takeoff with the engine shuddering. He would circle his departure airport to gain altitude before heading to his destination.

On the night before the accident, the director of maintenance (DOM) replaced the No. 1 cylinder on the No. 2 engine, because the cylinder had developed a crack in the fin area and had oil seeping out of it. After the DOM performed the replacement, he did not do a compression check or check the magnetos.

Review of the airplane’s maintenance records did not reveal an entry for installation of the cylinder. The last entry in the maintenance records for the airplane was an annual and a 100-hour inspection, which had occurred about 11 months before the accident.

The Director of Maintenance told investigators that he did not know the total time on the airplane when the cylinder was replaced.

The accident happened shortly after take off. According to witnesses, the airplane did not sound like it was developing full power during the takeoff roll. The airplane climbed to about 100 feet, banked to the left and began losing altitude. The Beech crashed in a residential area and caught fire.

Examination of the wreckage revealed that the number 2 engine was not producing power at the time of the crash. There was no evidence that the pilot attempted to perform the manufacturer’s published single engine procedure, which would have allowed him to maintain altitude.

Further investigation of the number two engine revealed that the compression on four of the nine cylinders was below specification and the magnetos were not functioning correctly. Moisture and corrosion were discovered inside the magneto cases. The left magneto sparked internally in a random pattern when tested and its point gap was in excess of the required tolerance. The right magneto’s camshaft follower also exhibited excessive wear and its points would not open, rendering it incapable of providing electrical energy to its spark plugs.

Additionally, the main fuel pump could not be rotated by hand, and it exhibited play in the gear bearings, and corrosion was present internally.

Investigators suggested that had the Director of Maintenance performed a compression after the cylinder replacement it such checks would have likely revealed that four of the remaining cylinders were not producing specified compression, that the magnetos were not functioning correctly, and that further maintenance was necessary.

Review of the airplane’s maintenance records did not reveal an entry for installation of the cylinder. The last entry in the maintenance records for the airplane was an annual and a 100-hour inspection, which had occurred about 11 months before the accident.

Probable cause: 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.

NTSB Identification: ERA11FA274

This May 2011 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.