NTSB Factual Report

HISTORY OF FLIGHT

On February 28, 2000, at 1455 Eastern Standard Time, a Cessna 337, N53HS, was destroyed during collision with trees and terrain following an uncontrolled descent from cruise flight in Prince Frederick, Maryland. The certificated private pilot/owner was fatally injured. Visual meteorological conditions prevailed for the personal flight that originated at Eagle Neck, Georgia (1GA0), approximately 1100, destined for Edgewater, Maryland (ANP). No flight plan was filed for the flight conducted under 14 CFR Part 91.

On January 21, 2000, the pilot/owner flew the airplane from Edgewater, Maryland, to Hinesville, Georgia, purchased fuel, and then continued to Eagle Neck, Georgia. The pilot owned homes in Edgewater and Eagle Neck. Examination of the pilot's records did not reveal any subsequent flights until the day of the accident.

A Safety Board Investigator interviewed witnesses at a construction site approximately 1/4 mile east of the crash site. According to one interview summary:

"[The witness] used a model airplane to demonstrate what he saw. He held the airplane model up to the sky in the position of where he first saw the accident airplane. He situated the model so it was in an approximate 90 degree left bank. He then moved the model from his left to right (southeast to northwest) across the skyline in a descent. He described the accident airplane as "moving really, really fast" and continued to emphasize throughout the interview at how fast the airplane was moving.

"[The witness] said he saw the aircraft descend beyond the tree line and said he knew the airplane was going to crash. He heard the aircraft hit the trees and waited to see smoke, which he stated never happened. [The witness] also stated he never heard any engine noise and his impression was that "the aircraft ran out of gas." [The witness] thought the airplane was headed toward one of the two local airstrips. [The witness] explained there were two airstrips located northwest of his position."

A second witness at the same site stated:

"[The witness] stated the wind was blowing 'hard'. He was working at a home site when he saw the airplane flying low approximately 50-100 feet above the trees towards the northwest. He noticed the aircraft's wings were rocking and, 'the aircraft was moving really fast and was out of control.'

"With an aircraft model, [the witness] demonstrated that the aircraft was in an approximate 90 degree left bank as it descended. He said he did not think the pilot was flying the aircraft. [The witness] drove to the location of the accident and arrived approximately 15 minutes later. On-site he noticed no smoke, no odor of fuel, and said the aircraft was 'a pile of rubble'.

"When questioned about the engine noise, [The witness] stated it was smooth and without interruption."

According to an interview summary prepared by a Federal Aviation Administration (FAA) inspector, several witnesses provided similar accounts of the airplane's flight prior to the crash. They each described a steep bank angle, high airspeed, and two witnesses described an increase in power prior to contact with the trees. One witness said the airplane "sounded like it was missing."

In a telephone interview, a Chief Petty Officer, the radar chief at the Patuxent Naval Air Station, described the movement of a radar target that matched the time and course of the accident airplane. The target disappeared from the scope at the time and place the accident was reported.

According to the Petty Officer, the target crossed the Tappahannock Municipal Airport, Tappahannock, Virginia, at 2,500 feet and 110 knots ground speed, on an approximate heading of 025 degrees. According to the Chief:

"Approximately 10 minutes later, the airplane target exhibits altitude excursions down to 1600 [feet], up to 17-18 [hundred feet], down to 1,500, and back up to 23-2,400 [feet]. Then, the target started descending in a right turn to the east. The right turn continued and the target dropped off about 1,300 [feet]."

The accident occurred during the hours of daylight approximately 38 degrees, 29 minutes north latitude, and 76 degrees, 36 minutes west longitude.

PILOT INFORMATION

The pilot held a private pilot's certificate with ratings for airplane single engine land and multi-engine land. The pilot was issued an FAA third class medical certificate on March 30, 1998.

An examination of two pilot logbooks revealed the books were labeled #1 and #3. No book #2 was located. The pilot's total flight experience could not be determined. Total flight experience was not carried forward to book #3; neither were the times totaled at the bottom of each page. The last entry in book #3 was dated April 17, 1994.

Examination of book #3 revealed that entries for flights in N53HS began April 30, 1993. The pilot logged receipt of 1.5 hours of dual instruction on that date, and 2 hours of dual instruction in the airplane on May 5, 1993. The pilot logged no other instruction in N53HS. He logged 17.2 hours of solo time in N53HS before he was issued a multi-engine rating.

The pilot logged 6.4 hours of dual instruction in a Piper PA-23-160 beginning March 26, 1994. He completed his multi-engine examination in a Piper PA-23-160 on April 6, 1994.

The pilot's last known biennial flight review was completed April 6, 1994.

In a telephone conversation, the pilot's daughter said that the pilot reported to his insurance company 2,265 hours of flight experience, 600 hours of which were in multi-engine airplanes. She said the report to the insurance company was made in 1998.

AIRCRAFT INFORMATION

Examination of aircraft records revealed the pilot/owner purchased the airplane on July 8, 1991.

Examination of maintenance records revealed the airplane was on an annual inspection program. The most recent annual inspection was performed October 16, 1998. The mechanic who recorded the inspection in the logbook did not record compliance with mandatory inspections, maintenance procedures, and Airworthiness Directives (AD). The same mechanic recorded the previous annual inspection 16 months prior on June 16, 1997. Again, no compliance with mandatory inspections, maintenance procedures, or ADs was noted.

The last documented compliance with any Airworthiness Directives was dated March 17, 1989.

A review of FAA records revealed the mechanic who performed the most recent annual inspection could not exercise the privileges of an IA (Inspection Authority) after March 31, 1998, and that he was the subject of an investigation for releasing an airplane for flight without complying with mandatory Ads. According to the mechanic's FAA records:

"[The FAA] never received response to letter of investigation, which was received by [mechanic] on 2/18/98. On 3/26/98, checked with [FAA inspector], of the IAD (EA27) FSDO office, to which [mechanic] is assigned, and verified that he did not renew his IA. They will notify this office if he does attempt to renew after March 31. [Mechanic's] mental faculties have been confirmed to be less than perfect, by people who know him within the industry, due to advanced age and Alzheimer's. Closed out the investigation with a warning letter mailed out 4/10/98."

According to a letter from an FAA inspector who examined the airplane's maintenance records:

"[The mechanic] did the last few annual inspections. He showed no compliance of any AD's that were due. Also a Mr. Douglas Brown did two annual inspections in 1995 and 1996, again no compliance with any AD's. We have looked into the FAA record system and have found that Brown's certificate number does not exist at all. This information is based on the information found in the aircraft's log books."

According to FAA records, an airworthiness condition notice was issued to N53HS on April 30, 1997. In a telephone interview, an FAA airworthiness inspector stated that he issued the notice based on the general condition of the airplane, but specifically due to "numerous fasteners that were rusty and should be replaced." The inspector said that the pilot/owner responded to the notice, and stated that due to his age and health, he would no longer fly N53HS. The inspector closed the action against N53HS on July 25, 1997, based on the conversation with the pilot/owner.

However, a review of the pilot/owner's flight log and fuel records revealed that he continued to fly N53HS after April 30, 1997. Further, an entry in the maintenance logbook reflected the completion of an annual inspection on June 16, 1997, after the condition notice was issued, and prior to its closure.

Examination of the aircraft logbooks revealed that from January 4, 1995, until the date of the accident, only 4 entries were made in the maintenance logbooks. Each reflected completion of an annual inspection with no discrepancies noted. In the 5 years prior to the accident, no entries were made to reflect the performance or completion of any scheduled or unscheduled maintenance.

Examination of the Emergency Locator Transmitter (ELT) at the scene revealed the battery expiration date was July 1994.

METEOROLOGICAL INFORMATION

Winds reported at the Patuxent Naval Air Station, 17 miles southeast of Prince Frederick were from 320 degrees at 15 knots gusting to 20 knots.

Winds aloft at Richmond, Virginia, were from 320 degrees at 32 knots at 3,000 feet and from 320 at 45 knots at both 6,000 and 9,000 feet.

WRECKAGE INFORMATION

The wreckage was examined at the scene on February 29 and March 1, 2000, and all major components were accounted for at the scene. There was no odor of fuel or evidence of fire. The wreckage path was approximately 230 feet long and was oriented 290 degrees magnetic. Several angular cut tree trunks and branches were found along the wreckage path.

The wings, tailbooms, engines, and the elevator were separated from the airplane. The cockpit and cabin areas were destroyed. Cockpit panel instruments were destroyed and scattered along the wreckage path.

Control continuity could not be established.

The aft propeller was still attached to the aft engine. The #1 blade was loose in the hub. The #1 blade displayed S-bending, leading edge gouging, and chordwise scratching. The #2 blade was solid in the hub. The blade displayed aft bending, leading edge gouging, and chordwise scratching.

The propeller spinner backing plate behind the hub displayed rotational scoring, and the rivet heads around the circumference were shaved flat.

The forward propeller was separated from its engine. The #1 propeller blade was intact with a slight bend at the tip. Tree bark and green pollen transfers were smudged against the face of both blades. The #2 blade was loose in the hub. It was bent and twisted at the tip and the trailing edge displayed several dents.

The forward propeller dome had a symmetrical, concave dent in the front with wood embedded. The dome and propeller hub displayed fore and aft scratching with no rotational scoring.

The aft engine muffler displayed numerous holes due to corrosion and repair welds across every seam.

The fuel tanks from the airplane's left side were compromised. Examination of these tanks revealed no trapped fuel and no odor of fuel.

The main fuel tanks from the airplane's right side were also compromised and revealed no trapped fuel or fuel odor. The right auxiliary and right sump tanks were intact. A section of the right wing and the top of the auxiliary tank were removed to examine the tank's contents. Examination of the tank revealed a quantity of fuel inside. The fuel was drained and measured 2 1/4 gallons. The sump tank was drained and yielded 12 ounces of fuel.

The fuel selector valves and the auxiliary fuel pump switches were all found in the "Off" position.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of the Chief Medical Examiner, Baltimore, Maryland, performed an autopsy on the pilot on February 29, 2000.

The FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on April 28, 2000.

ADDITIONAL INFORMATION

The fuel system consisted of two main tanks and one auxiliary tank per wing. According to the Cessna 337 Owner's Manual:

"The main fuel system is composed of two main fuel tanks (46 gal. usable each wing) in each outboard wing panel and one sump tank in the lower portion of each boom... Fuel is normally fed from the left wing tanks and front selector valve to the front engine, and from the right wing tanks and rear selector valve to the rear engine. It is possible, however, to feed either engine from either main fuel tank."

With the auxiliary fuel tanks installed, the airplane's total fuel capacity was 131 gallons.

In a telephone interview, the pilot/owner's wife was discussing the pilot's fuel management practices when she stated, " One of the fuel gauges was broken, but you knew that." When asked which gauge was broken, she said, "One of the main tanks, the one on the bottom." Later, the pilot's wife said it was an auxiliary tank fuel gauge that was broken. When asked which side, right or left, she said, " I don't remember, but it was one of the main tanks."

The pilot's wife further stated that the fuel quantity system had been inoperative since the previous summer. She said, "He was talking about getting a whole different system put on. He was waiting to have it annualed."

Examination of fuel records and the pilot's personal fuel log revealed the airplane was last serviced with 101 gallons of fuel on January 21, 2000, at 3,332.9 aircraft hours in Hinesville, Georgia. The airplane was then flown to Eagle Neck, Georgia. At the accident site, the Aircraft Hours meter showed 3,337.3 aircraft hours.

According to a representative of the Cessna Air Safety Group, the switch that activated the Aircraft Hours meter worked in a similar fashion to the stall-warning switch. Above 40 miles per hour, the switch was activated. Therefore, engine operation at start-up, ground idle, taxi, and initial takeoff roll was not measured.

In the Emergency Procedures section of the Cessna 337 Owner's Manual, the procedure Engine-Out During Flight was as follows:

1. Power-Increase as required.

2. Determine inoperative engine (check power response to throttle movement).

3. Cowl flaps-Open on operative engine.

4. Mixture-Adjust for new power setting (if used).

Before securing inoperative engine:

1. Check fuel flow; if deficient, turn on auxiliary fuel pump.

NOTE

If the fuel selector valve handle is on "AUXILIARY TANK", switch to "MAIN TANK".

2. Fuel quantity indicators-Check and switch to opposite tank if necessary.

3. Ignition switches-Check

If corrective action was taken, engine will restart. If it does not, secure it as follows:

1. Mixture-Idle cut-off.

2. Propeller-"FEATHER"

3. Turn off auxiliary fuel pump, alternator and ignition switches and fuel selector valve.

4. Cowl flaps-"CLOSED"

The single-engine service ceiling for the airplane at maximum gross weight with the aft engine operating was 10,200 feet. The maximum single-engine rate of climb in the same configuration was 450 feet per minute.

The airplane wreckage was released to a representative of the owner's insurance company on March 1, 2000.

NTSB Probable Cause

was the pilot's failure to maintain control of the airplane after a loss of engine power on one engine. Factors in the accident were the pilot/owner's failure to follow the published emergency procedure, his inadequate fuel management, and his intentional flight with known deficiencies which included an inoperative fuel quantity system.