NTSB Factual Report

HISTORY OF FLIGHT

On August 23, 1993, about 1450 eastern daylight time, a Cessna T337G, N5CP, registered to Cheetah Express, Inc., crashed shortly after takeoff from the Ormond Beach Municipal Airport, Ormond Beach, Florida, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for the flight. The airplane was destroyed by postcrash fire and the private-rated pilot, the sole occupant, was fatally injured. The flight originated from the Ormond Beach Municipal Airport, Ormond Beach, Florida, about 1445.

The airplane had been painted and the day before the accident flight, the accident pilot asked the owner of the paint shop to fly the airplane to Sanford, Florida. The owner, who is an FAA certificated airframe and powerplant mechanic started both engines and discovered that the rear engine would only develop 1500 rpm. Several combinations of changes in the mixture control, fuel boost pump, and fuel selector valve positions were unsuccessful to restore full rated rpm (2800). When the mixture control was in the full rich position, the engine would "...flood out and would only run smooth when the mixture was near idle cutoff...." Each magneto drop was even between 100 and 150 rpm. The front engine operated normally. He advised the accident pilot that he would not fly the airplane.

At about 1000 on the day of the accident, 20.0 gallons of fuel were added, 10 gallons each to the main fuel tanks. There were no reported problems with any of the other airplanes who were refueled by the truck. According to the mechanic who started both engines the day before, the auxiliary tip tanks were empty and each wing fuel tank gauge indicated about 1/2 full.

The accident pilot arrived in Sanford, Florida, about 1230, and according to the mechanic, performed a thorough preflight of the airplane. Another individual who is a pilot witnessed the accident pilot check the flight controls for freedom of movement and correct position, with no discrepancies noted by the witness. He heard the paint shop owner tell the pilot about the rear engine problem and then observed the accident pilot in the left seat of the airplane. He heard both engines start and stated that the front engine sounded normal but the rear engine ran rough. He then left the ramp and did not observe the airplane take off. According to the mechanic, the accident pilot then shut down both engines after the rear engine backfired. The mechanic concluded that several fuel injector nozzles were plugged and advised the pilot that he would clean them. The accident pilot advised him that he would get the best power available from the rear engine and rely on the front engine to get airborne. If there was a problem once airborne, he would feather the rear engine propeller, secure the engine and continue the flight.

According to the mechanic, he observed the airplane climbing slowly and he then heard a sound described as an "afterfire" followed by total silence. According to a witness who lives near the crash site, she observed the airplane flying southbound very low in a nose-high attitude, then observed the airplane bank to the right. After the airplane completed 90 degrees of the turn, she then observed the nose of the airplane pitch up abruptly followed by the airplane pitching nose down. She then lost sight of the airplane due to obstructions.

PERSONNEL INFORMATION

Information pertaining to the pilot is contained in the First Pilot Information section. Additionally, on June 10, 1993, the pilot obtained his multiengine land rating issued on his private pilot certificate. The application for this rating indicates that his total flight time in the airplane used for the flight test was 2 hours. The airplane used was a Piper PA-23-150.

According to FAA records, on May 26, 1993, the pilot was issued a private pilot certificate with an airplane single engine land rating. The application for this rating indicates that the pilot's total flight time at that time was 179 hours.

Review of the pilot's logbook revealed that he stopped logging flight time in December 1981. At that time he had accumulated 138.4 hours, none of which in complex aircraft. All flight time logged was in single engine airplanes.

AIRCRAFT INFORMATION

Information pertaining to the airplane is contained in the Aircraft Information section and Supplements A & B. The airframe, engines, and propellers logbooks were not located. According to a memorandum signed by Mel, the annual inspection of the airplane was accomplished in April 1983, and no ferry permit was required.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site revealed evidence that the airplane impacted the ground nose and left wing low then nosed over and was destroyed by postcrash fire.

Examination of the flight controls revealed no evidence of aileron, rudder, or elevator preimpact failure or malfunction. The flaps were fully extended but the landing gear was retracted. The engines were removed for further examination.

Examination of the front engine revealed that the propeller was separated from the engine due to a broken crankshaft just aft of the crankshaft propeller mounting flange. Examination of the fracture surfaces of the crankshaft revealed signatures consistent with overload failure. Components of the ignition system and fuel injection system were heat damaged. The left magneto was separated from the accessory case but the right was attached. The engine driven fuel injection pump drive shaft was intact. The crankshaft could not be rotated, therefore, the engine was disassembled which revealed no evidence of preimpact failure or malfunction. The fuel line from the engine driven fuel injector pump to the fuel air mixture control assembly was disconnected from the later and about 1/2 ounce of water leaked onto the floor. The water was recovered and retained for analysis.

The rear engine was placed on a test stand and started after replacement of the fuel manifold valve, fuel air mixture control assembly, engine driven fuel injection pump, ignition harness, and magnetos. The engine operated no more than 1800 rpm. The actual fuel injection nozzles with lines attached were placed in separate jars and an auxiliary fuel pump was turned on. Fuel flow from each nozzle was not equal.

MEDICAL AND PATHOLOGICAL

Postmortem examination of the pilot was conducted by Ronald L. Reeves, M.D., of the Daytona Beach, Florida, Medical Examiners Division. The cause of death was listed as multiple blunt force trauma.

Toxicological testing was performed on specimens by the Daytona Beach Medical Examiners division. The results were positive in the urine for caffeine, nicotine, nicotine metabolite, and benzodiazepines (.17 UG/ML). The carbon monoxide level in the blood was 5 percent.

Toxicological testing was also performed on specimens submitted to the FAA Civil Aeromedical Institute (CAMI). The results were negative for carbon monoxide, cyanide, volatiles, and tested drugs. The results were positive for alpha-hydroxyalprazolam, and cyclobenzaprine which were detected in the urine.

According to FAA medical certification personnel, the pilot did not have a waiver issued by the FAA which allowed the pilot to exercise the privileges of his pilot and medical certificates while using the drugs detected by CAMI.

FIRE

Examination of the airplane revealed no evidence of in- flight fire or explosion. According to police department personnel, bystanders used a garden hose in an attempt to extinguish the fire. According to the fire department report, 1,500 gallons of water and 5 gallons of foam were used to extinguish the fire.

ADDITIONAL DATA/INFORMATION

The water which leaked from the disconnected fuel line was sent to a laboratory for further examination. Examination of the sample revealed that it contained 11,541 parts per million sodium chloride, which is about 1/3 the amount found in sea water. The pH was 6 when tested with pH indicating paper. There was insufficient quantity for additional tests.

The wreckage was released to Mr. Walter E. Culbreth on March 15, 1994.

NTSB Probable Cause

WATER CONTAMINATION IN THE FUEL, WHICH RESULTED IN LOSS OF POWER IN THE FRONT ENGINE AS THE PILOT WAS ATTEMPTING FLIGHT WITH A KNOWN PROBLEM IN THE REAR ENGINE, AND FAILURE OF THE PILOT TO MAINTAIN ADEQUATE AIRSPEED, WHICH RESULTED IN AN INADVERTENT STALL. FACTORS RELATED TO THE ACCIDENT WERE: INADEQUATE MAINTENANCE/INSPECTION OF THE AIRPLANE, PARTIALLY BLOCKED FUEL NOZZLES IN THE REAR ENGINE, AND OPERATION OF THE AIRPLANE BY THE PILOT WITH A KNOWN DEFICIENCY.