Sunday, September 22, 2019

Loss of Control in Flight: Ted Smith Aerostar 601, N7529S; fatal accident occurred December 10, 2017 near Miami Executive Airport (KTMB), Miami-Dade County, Florida

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Miramar, Florida
Lycoming; Williamsport, Pennsylvania

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 
 
http://registry.faa.gov/N7529S




William Rollo Carman

Location: Miami, FL
Accident Number: CEN18FA050
Date & Time: 12/10/2017, 1450 EST
Registration: N7529S
Aircraft: SMITH AEROSTAR 601
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On December 10, 2017, at 1450 eastern standard time, a Smith Aerostar 601 airplane, N7529S, collided with terrain shortly after takeoff from Miami Executive Airport (TMB), Miami, Florida. The pilot was fatally injured, and the airplane was destroyed by impact forces. The airplane was registered to the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which was originating at the time of the accident.

An employee of the flight school where the airplane was tied down stated that the pilot arrived about 1000 and began to preflight the airplane. About 1030, the pilot fueled the airplane, adding 105.2 gallons of 100LL aviation fuel. How the fuel was distributed between the airplane's three fuel tanks could not be determined. The pilot then taxied the airplane to the ramp in front of the flight school hangar where he kept a toolbox. The witness stated that the pilot was working on the airplane when he noticed a fuel leak and stated that he should have "fixed that" before he fueled the airplane. Both the employee and another witness stated that fuel was leaking from the aft fuselage belly area. They stated that the pilot had two or three 5-gallon orange buckets under the airplane to catch the fuel as he worked to stop the leak. Neither witness saw how much fuel was in the buckets or what the pilot did with the fuel. One witness asked the pilot if he fixed the problem, and the pilot responded that he had.

The pilot was cleared for takeoff from runway 31 at 1426; however, the pilot aborted the takeoff and landed the airplane back on the runway. The controller asked the pilot if he needed assistance, to which the pilot replied, "… not sure what happened just yet but so far so good." The pilot then requested to taxi back to the runway to take off again. The airplane was cleared to take off at 1447, and 32 seconds later, the pilot declared an emergency. The controller cleared the pilot to land on any runway.

Two pilots in an airplane waiting to take off from runway 31 stated that they did not notice anything unusual about the takeoff until they heard the pilot declare an emergency. They reported that the airplane was between 400 ft and 800 ft above the ground and in a left turn toward runway 9R. They stated that they thought the pilot was going to make it back to the runway, but then the left bank increased past 90° and the nose suddenly dropped. One of the pilots likened the maneuver to a stall/spin, Vmc roll, or snap roll-type maneuver. The airplane subsequently impacted a cornfield east of the approach end of runway 9R.

The following day, a 12-ft-by-16-ft stain was observed on the ramp where the airplane had been parked. One of the witnesses stated that the stain was from fuel that leaked out of the airplane.

Pilot Information

Certificate: Private
Age: 62, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 08/04/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 
Flight Time: 1000 hours (Total, all aircraft)

The pilot held a private pilot certificate with airplane single- and multi-engine land ratings. His most recent FAA first-class medical certificate was issued on August 4, 2015, with the limitation that he must wear corrective lenses. On the application for that medical certificate, the pilot reported 1,000 hours total flight experience, with 30 hours in the preceding 6 months. The medical certificate expired for all classes on August 31, 2017. The pilot's logbook was not available during the investigation and his flight time could not be determined. The pilot was not a certificated airframe and powerplant mechanic. 



Aircraft and Owner/Operator Information

Aircraft Make: SMITH
Registration: N7529S
Model/Series: AEROSTAR 601
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 61-0161-082
Landing Gear Type: Retractable - Tricycle
Seats:6 
Date/Type of Last Inspection:
Certified Max Gross Wt.: 6001 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time:
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series:IO-540-S1A5
Registered Owner: On file
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None 

The accident airplane was a six-place, turbo-charged twin-engine airplane with retractable landing gear. The airplane was powered by two Lycoming IO-540-S1A5 300-horsepower engines.

The pilot purchased the airplane on March 3, 1998, and had it advertised for sale at the time of the accident.

The last annual inspection recorded in the airframe, engine, and propeller logbooks was dated December 9, 2016. The airframe total time was listed as 3,571.7 hours. The left engine time since major overhaul (SMOH) was listed as 124.7 hours and the time SMOH for the right engine was 56.9 hours. The last entry in the airframe logbook was dated June 3, 2017, at which time the recorded airframe time was 3,576 hours.


Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dawn
Observation Facility, Elevation: TMB, 10 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1953 UTC
Direction from Accident Site: 90°
Lowest Cloud Condition: Clear
Visibility:   10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 13 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 340°
Turbulence Severity Forecast/Actual: 
Altimeter Setting: 30.21 inches Hg
Temperature/Dew Point: 16°C / 2°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Miami, FL (TMB)
Type of Flight Plan Filed: None
Destination: Miami, FL (TMB)
Type of Clearance: VFR
Departure Time: 1450 EST
Type of Airspace: Class C

Airport Information

Airport: MIAMI EXECUTIVE (TMB)
Runway Surface Type: N/A
Airport Elevation: 10 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Precautionary Landing 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 25.644444, -80.455833 

The accident site was located in a cornfield about 0.90 mile northwest of the approach end of runway 9R. There was an odor of fuel at the accident site. Aerial photographs taken 2 days after the accident showed an area of blight surrounding the accident site.

The wreckage came to rest on a heading of 210°. The empennage was reportedly folded over the fuselage area and pulled back by first responders. The pilot's seatbelt was cut by first responders during the extraction process. Both engines were buried 1.5 to 2 ft deep at a 45° angle. Portions of two propeller blades were visible on each engine.

The top of the cockpit was separated and the rest of the cockpit was destroyed. The throttle quadrant was separated from the surrounding structure. The fuel mixture and propeller levers were full forward. The throttle levers were broken off and the bases of the levers inside the quadrant were in the full-forward position. The instrument panel was fragmented. All of the fuel tank selector knobs and switches were either broken or missing, and their preimpact positions could not be determined. The left tank fuel quantity gauge indicated 10 gallons; however, the needle was loose. The fuselage tank gauge indicated 0 gallons and the needle was frozen in place. The right tank fuel quantity gauge indicated 12 gallons and the needle was frozen in place. The bladder fuselage fuel tank was ruptured.

The empennage was separated from the rest of the airplane. The vertical stabilizer, rudder, horizontal stabilizer, elevator, and respective trim tabs were intact and all remained attached to the empennage. The push-pull tubes for the elevator and rudder were disconnected and broken within the empennage.

The Janitrol heater was inside the empennage. The fuel line remained attached at the heater and the line was broken forward of the heater.

The fuel sump drain had broken out of the sump and was not located. The right side filter was clean. The left side filter contained a small amount of debris, which appeared to be cloth fibers. Examination of the fuel valves showed that the right main fuel valve was in the open position. The left main fuel valve, the left crossfeed valve, and the right crossfeed valve were in the closed position. The position of the valves was consistent with the fuel being shut off to the left engine and the right engine drawing fuel from the right fuel tank and the fuselage tank.

Examination of both engines did not reveal any mechanical failures or anomalies that would have precluded normal operation. The left engine fuel injection servo contained about 2 teaspoons of fuel and the right engine fuel injection servo contained about 2 ounces of fuel.

The fuel valves and fuel boost pumps were examined and functionally tested at the Aerostar facility in Hayden, Idaho. The fuel valves, with the exception of the left main valve, functioned normally when power was applied. The left main fuel valve was opened and internally intact. Power was again applied to the valve and the shaft of the motor drive gear was turned by hand. The motor began to operate intermittently; however, the gear housing immediately began to get hot.

The left engine fuel boost pump sustained internal impact damage, which prevented it from functioning when tested. The right engine fuel boost pump functioned when tested.

The airplane was equipped with an Insight GEM-1200 engine data monitor. The unit was sent to the National Transportation Safety Board Vehicle Recorder Laboratory for download. The unit records exhaust gas temperatures (EGT) and cylinder head temperatures (CHT). The unit sustained significant impact damage, which rendered it inoperable. The memory chip was removed from the unit and placed in a surrogate unit for download. The unit contained data from 12 flights, including the accident flight. Data was recorded every 6 seconds.

Data for all recorded flights showed that the left engine No. 5 CHT recorded a constant value of 32° Fahrenheit (°F) and the right engine No. 4 CHT recorded erratic values ranging from 32°F to 1382°F. These parameters were considered erroneous. The other data points were relatively consistent between both engines.

MEDICAL AND PATHOLOGICAL INFORMATION

The Miami-Dade County Medical Examiner's Department, Miami, Florida, performed an autopsy of the pilot. The reported listed the cause of death as blunt force trauma.

Toxicology tests performed at the FAA Forensic Sciences Laboratory were negative for carbon monoxide and cyanide. The testing was negative for drugs in the testing profile. Ethanol was detected in muscle tissue at 46 (mg/dL, mg/hg). Because ethanol was not detected in other tissue, the finding was consistent with postmortem production.

5 comments:

Anonymous said...

Doing your own maintenance ... even if illegal... Is a great way to save money.

RIP

Anonymous said...

With a leak requiring two or three buckets ? fuel dripping from the fuselage where that bladder tank was located ? was the bladder tank ruptered before the flight ? it all sounds a bit odd.

Anonymous said...

Just put 100 gallons of fuel in it- lucky that everything wasn't consumed by fire upon impact.

Anonymous said...

Sounds like he swapped out a fuel drain valve or cut the end off of a leaking rubber line.

Anonymous said...

Reading the attachments it looks like the left main fuel valve which is electrically operated was malfunctioning and was found in the closed position.

From the report:
The airplane fuel system contained four fuel shutoff valves and two electrical fuel pumps.
Three of the four fuel valves were found in the closed position. The right main fuel valve
was the only one found opened. With that configuration, the right engine would have
been receiving fuel from the right wing and the center fuselage tank, and the fuel would
have been shut off to the left engine.
ITT Aerospace fuel shutoff valves, p/n AV16B1900.
Left Crossfeed – Closed s/n J03363
Left Main – Closed s/n E34065 (Did not function when tested)
Right Crossfeed – Closed s/n E37605
Right Main – Open s/n E37565
The cannon plug wiring to each valve was checked for conductivity and all the wiring
functioned. The cannon plug mount on the left and right main valves was fractured from
impact damage. An alternate plug was used to attach the valves to an external power
source for functional testing.
All the valves functioned normally except for the left main valve. The slide mechanism
housing on the left main valve was opened and visually inspected. The slide mechanism
was intact. The motor brushes and commutator were intact. Power was again applied to
the valve and the shaft of the motor drive gear was turned by hand. The motor began to
operate intermittently; however, the gear housing immediately began to get hot.

I have a lot of time in Aerostars. A prefilght item is to cycle the valves before engine start to verify their functioning. Its easy to hear the valves operating. There is no visual conformation that the valve is actually open or closed only the indication by where the selector is set.

The second comment is that out off all the piston twins the Aerostar has more than enough power to continue a normal climb and pattern circuit after a engine failure. The wing profile is more like a jet so speed is critical. Keep it at blue line and the airplane climbs very well. There was no need for a panic turn back towards the departure runway after the plane was in the air. But like many accidents this pilot had was given two chances to save his life, in this case obvious ones and he ignored them both.