NTSB Factual Report

HISTORY OF FLIGHT

On December 22, 2010, at 1446 central standard time, a Beech C24R, N5293M, impacted a building and several unoccupied parked vehicles prior to coming to rest in a parking lot one-half mile northwest of the Chicago Executive Airport (PWK), Wheeling, Illinois. The private pilot was seriously injured and the passenger was fatally injured. The privately owned airplane was substantially damaged by impact forces and post impact fire. The flight was being conducted under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed. The reported destination for the flight was the Schaumburg Regional Airport (06C), Schaumburg, Illinois.

The airplane had been operated by Chicago Executive Flight School and had been sold to a private individual in October 2010. The pilot, who was also an airframe and powerplant mechanic, flew into PWK with three other people on the day of the accident to pick up the airplane for a new owner. The pilot and one of the other three people were to fly the accident airplane back to Jacksonville, Illinois, with an en route stop at 06C. The accident airplane was going to be one of a flight of two airplanes, with the other airplane being the one that the pilot flew in up to PWK.

The pilot reported the airplane was parked outside on the ramp and he cleared the snow off of it while a mechanic installed the battery. He then started the airplane and taxied to the fixed base operator to have the airplane de-iced and fueled. The pilot then performed an aircraft pre-flight during which he sumped the fuel tanks. The pilot stated the fuel sample he drained did not contain any water and that instead of dumping the fuel on the ramp he put it back in the fuel tank as advised by line personnel. He stated that he performed an engine run-up on the ramp and the airplane operated normally. The pilot used a typical small fuel sample cup when he sumped the fuel tanks.

A mechanic who worked for the flight school that sold the airplane stated he installed the battery when the pilot arrived to pick up the airplane. He stated the pilot started the engine and allowed it to run for 5 to 10 minutes prior to taxiing the airplane to another area of the airport to be fueled and de-iced. The mechanic stated he then heard the pilot having trouble starting the engine, so he went outside and instructed the pilot on how to start a fuel injected engine that was already hot. He did not notice any anomalies with the way the engine sounded.

At 1436, the pilot of requested a taxi clearance for both airplanes and air traffic control cleared the airplanes to taxi to runway 34. The pilot stated he ran the engine up two more times while waiting for takeoff. He stated the engine performed normally. At 1444, the accident airplane was cleared for takeoff on runway 34 at the intersection of runway 06. The intersection takeoff resulted in the pilot having 4,200 feet of useable runway.

The pilot stated he retracted the landing gear at an altitude of 50 to 75 feet above ground level (agl), and the flaps at an altitude of about 200 feet agl. During an interview the pilot recalled that the airplane began to sink when he retracted the flaps, so he decided to return to the airport. During the turn back toward the airport, the engine began to vibrate and lose power. He stated he could feel the vibrations in the control yoke. He then lowered the landing gear in preparation for an emergency landing.

In his written statement the pilot stated the takeoff was normal until the engine began to lose power when he reached an altitude of 200 to 300 feet agl. He reported he leveled the wings and noticed the engine vibration changed so he radioed the control tower that he needed to return to the airport. At 1446, the pilot declared an emergency with the control tower and stated he was turning around because there were “all kinds” of vibrations and the airplane was “losing power quick.” This was the last radio transmission from the airplane. Air traffic cleared the pilot to land on any surface. The pilot stated he began a left turn, was unable to maintain altitude, and the airplane descended into the parking lot.

The airplane contacted the roof of a two-story office building prior to descending into an adjacent parking lot.

Several witnesses observed the airplane during the takeoff. These witnesses described the airplane’s maximum altitude as being between 50 and 200 feet agl. They described the airplane as being in a nose high attitude with the wings rocking. The airplane entered a left turn, the left wing suddenly dropped, and the airplane began a descent. The witnesses then lost sight of the airplane as it descended toward the building. One witness stated the airplane’s wings and pitch attitude leveled as it descended toward the building. The witnesses stated the landing gear remained extended and the flaps were retracted. Witnesses who heard the airplane stated the engine sounded normal during the takeoff. The mechanic who watched the takeoff stated the engine sounded “strong.”

A line person who worked for the local fixed based operator stated that a mechanic had to start the airplane when the pilot was unable to get the engine started. He stated that the engine did not sound right when the mechanic got it started. He stated he heard what sounded like “burbles.” This witness did not witness the takeoff or accident.

PERSONNEL INFORMATION

The pilot, age 36, held a private pilot certificate for airplane single-engine land, and a third-class airman medical certificate issued March 17, 2008. The medical certificate contained a limitation for corrective lenses. The pilot’s last flight review was completed on January 9, 2009. The pilot also held an airframe and powerplant mechanic certificate.

A review of the pilot’s logbooks revealed the last entry was made on July 12, 2010. As of that date the pilot had recorded a total flight time of approximately 1,170 hours. The pilot’s logbooks indicated that of the total time, 12 hours were in multi-engine airplanes and about 1 hour was in a helicopter. On the accident report form completed by the pilot he reported having 1,132 hours of total flight time of which 1,112 were in single-engine airplanes. Although not identified in the pilot’s logbooks that were provided, he reported having 3.5 hours of flight time in a Beech C24R.

AIRCRAFT INFORMATION

The four-seat, low-wing, retractable-gear airplane, serial number MC-572, was manufactured in 1978. It was powered by a Lycoming IO-360-A1B6 200-hp engine equipped with a McCauley model B3036C429 constant speed propeller.

The aircraft maintenance records were on board the airplane at the time of the accident. The records sustained fire damage which resulted in portions of the records being illegible. A review of the legible maintenance logbook records showed the last airframe and engine annual inspection was completed on October 29, 2010, at a recorded tachometer time of 2,951.31 hours. This record also recorded the installation of the overhauled engine.

The airframe and engine logbooks contained entries dated February 14, 2008, that the airframe and engine received a Ferry Flight inspection following a gear up landing. The airframe and engine total times were listed as being 2,908.9 hours at this inspection.

An entry in the logbooks dated September 24, 2009, indicated an annual inspection had been completed at a tachometer time of 2,909.77 hours. The engine logbook indicated that new main bearings, new gaskets, new spark plugs and ignition harness, and new engine isolator mounts were installed at this time. The entry also indicated the cylinders, crankshaft, and magnetos were inspected.

An entry in the engine logbook dated November 24, 2009, at a total time of 2,923.7 hours indicated that an overhauled propeller governor and a new propeller governor gasket was installed because of an oil leak. Another entry dated May 7, 2010, indicated that another propeller governor was installed on the engine. The tachometer reading at this time was listed as 2,948 hours.

An entry in the engine logbook dated June 18, 2010, indicated that the engine had been removed for overhaul. The tachometer time was listed as 2,961 hours and the time since overhaul was listed as being 1,545 hours.

An entry regarding what was accomplished during the engine overhaul was dated September 9, 2010. This entry contained the information, “Installed overhauled LW15472 fuel pump s/n AA26207.”

According to the mechanic at the flight school, the airplane was involved in a propeller strike approximately two years prior to the accident and a new propeller was installed on the airplane. The airplane was then flown 25 to 50 hours and metal shavings were found in the engine oil, so the engine was sent out for overhaul. The engine was received back from the overhaul, but there were still problems with the induction system, the starter, and other “discrepancies.” He continued to work on the airplane and believed that he had all the issues resolved. The airplane had been flown about 1 hour after the overhauled engine was installed. He stated that at some point the airplane was sold and there were several delays of the new owner picking up the airplane. He stated he charged the battery and ran the airplane several times during the delay period and that the engine operated normally during these engine runs. He stated that to his knowledge there was not a pre-buy inspection performed on the airplane.

The owner of the flight school stated they received the overhauled engine back around October 2010. He stated they were not able to start the engine and they discovered that the wrong starter had been returned with the engine from the overhaul shop. The correct starter was installed, but the engine was running rough. They then discovered that there was a plug missing from the bottom of the engine. They installed the plug and several engine runs were performed and he flew the airplane for about one hour. He stated that by the end of October, early November, the issues were resolved and the engine was in good running condition.

The airplane sat out on the ramp for at least one month prior to the accident flight. The airplane was topped off with 19.8 gallons of fuel prior to takeoff. The line person who fueled the airplane stated he did not notice any ice, frost, or snow on the airplane. Nor did he notice any standing water around the fuel caps.

The mechanic that performed the engine overhaul stated that after the engine was overhauled, he was contacted by the flight school that owned the airplane and was told the engine was running rough, especially at low idle. He stated he offered suggestions regarding troubleshooting the problem. He suggested they check the fuel injectors for clogging, check for a missing intake plug, and/or send the fuel injector out for overhaul.

METEOROLOGICAL INFORMATION

A review of the recorded surface observation weather data from PWK, revealed the conditions at 1452 were winds from 020 degrees at 11 knots; visibility 10 miles; ceiling 3,500 broken; temperature 2 degrees Celsius; dew point minus 2 degrees Celsius; and altimeter 30.33 inches.

WRECKAGE AND IMPACT INFORMATION

The airplane initially contacted the roof of an office/warehouse building located on the corner or Wolf and Hintz Roads. The building was approximately 40 feet high. The roof of the building consisted of snow covered gravel. Three elongated impact marks, the longest of which was about 25 feet, were visible on the roof. One of the track marks continued to the edge of the roof where the nose gear impacted a raised portion of the building’s façade. The nose gear was located on the roof next to the façade and the left wing tip was also located on the roof.

The airplane then descended into a parking lot adjacent to the building where it damaged five parked cars. The airplane ultimately contacted the trunk area of one of the cars. This car was pushed about 20 feet and rotated 90 degrees from where it was originally parked. The nose of the airplane came to rest alongside the trunk of the car and the right wing was up against the right side of the car.

The airplane and engine sustained fire damage with the structure between the firewall and the aft fuselage partially consumed by fire. Examination of the recovered airframe and flight control system components revealed no evidence of preimpact mechanical malfunction. All three landing gear were separated from the airplane with portions of the gear still attached to their trunnions. The left main landing gear actuator was in the extended position. The number of exposed threads on the flap actuator corresponded to 1 degree of flap extension. The stabilator trim actuator was measured suggesting the airplane was trimmed slightly nose up.

The engine remained attached to the engine mounts, three of which had been pulled out of the firewall. The engine sustained impact and fire damage with most of the fire damage occurring to the accessory section of the engine. The magnetos sustained fire damage and could not be tested.. Engine continuity and cylinder thumb compression were established.

The fuel servo was removed from the engine. The servo could not be tested due to the amount of fire damage and a teardown was accomplished. The inside and outside of the fuel inlet filter screen were coated which what appeared to be a melted substance that had solidified. It was noted that the plastic spacer and aligner for the mixture control valve was missing and presumed to have melted resulting in the substance found on the inlet screen. The inlet screen was cut in half and a foreign piece of material was found inside the screen. The material was opaque and cylindrical in shape. It matched the inside diameter of the metal fitting at the end of the screen. This material was sent to the National Transportation Safety Board (NTSB) Materials Laboratory for examination.

The propeller remained attached to the engine. Approximately 18-inches of one propeller blade were separated from the remainder of the blade and the separated portion was not located. The tips of the two remaining blades exhibited gouges and scrapes. Both blades exhibited slight twisting. Examination of the fractured propeller blade revealed mechanical bending and mechanical surface damage consistent with impact damage. A propeller teardown was performed and it revealed that the propeller had sustained heavy impact damage. By aligning internal impact marks it was determined that the propeller was most likely on the low pitch stop at the time of impact.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the passenger on December 23, 2010, by the Cook County Medical Examiner’s Office, Chicago, Illinois. The cause of death was reported as smoke inhalation and thermal injuries.

The Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma performed a Forensic toxicology on specimens from the passenger by. The toxicology report listed 16 percent Carbon Monoxide detected in blood and 0.46 (ug/ml) Cyanide was detected in blood.

ADDITIONAL INFORMATION

The NTSB’s Materials Laboratory examination of the material found inside the fuel servo fuel inlet screed revealed material appeared to by polymeteric. The material was off-white and opaque with darkened/browned areas. The material also contained some areas where bubbles had been trapped, giving it the appearance of a material that had been exposed to high heat. Further examination revealed the material was most likely polyacetal. Polyacetal, also known as polyoxymethylene, is a thermoplastic that can be found in some fuel system components.

The majority of the engine-driven fuel pump was destroyed by the postimpact fire; however, the base of the pump remained attached to the accessory case. The numbers 15472 were stamped into the base of the pump. There was no serial number visible on the base. Part number 15472 is a low pressure fuel pump that delivers a fuel pressure between 4 and 6 psi. According to Textron Lycoming Engines, the IO-360-A1B6 engine installed on the a

NTSB Probable Cause

The installation of the wrong engine-driven fuel pump, which resulted in a loss of engine power during takeoff, and the pilot's subsequent decision to turn back toward the airport at an insufficient altitude to complete the maneuver. Contributing to the accident was the pilot’s failure to maintain airspeed, which resulted in a loss of aircraft control.