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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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March 16, 1990 · Butler Aerostar 601 Aerostar 6 · N7443S

Lake Butler, FL

Overview

Report Status
Probable Cause
Event Type
Accident
Date
March 16, 1990
Injury Outcomes
1 injury (1 minor injury)
Location
Lake Butler, FL
Aircraft
Butler Aerostar 601 Aerostar 6
Tail Number
N7443S
Injuries
Minor
Aircraft Damage
Destroyed
NTSB Number
MIA90FA090

Shortly after leveling off at 14,000 ft the left engine quit. The pilot diverted to Tampa, and 34 minutes later the right engine quit. During the subsequent forced landing the airplane collided with the roof of a covered sidewalk and then trees. Teardown of the left engine revealed that the seal between the exhaust flange & turbocharger was not installed; bolt clamp was finger tight. Heat had melted wiring harness & mag grounding leads insulation; both 'P' leads were grounded. Pilot stated that after losing the left engine he initiated a left tank to right engine crossfeed, and after 20 minutes of single engine flight in this configuration the right engine quit. Flight manual states to land as soon as possible in case of one engine failure. In addition, it warns that when flying on one engine & crossfeeding fuel, absolute coordinated flight must be maintained to prevent unporting of the tank's fuel pickup tube when the tank is not full.

NTSB Probable Cause

INFLIGHT FAILURE OF THE LEFT ENGINE WHICH WAS CAUSED BY INADEQUATE MAINTENANCE AND INSPECTION BY COMPANY MAINTENANCE PERSONNEL RESULTING IN HEAT DAMAGED MAGNETO LEADS AS A RESULT OF A MISSING EXHAUST FLANGE-TO-TURBOCHARGER SEAL. IN ADDITION, THE INFLIGHT POWER LOSS OF THE RIGHT ENGINE WAS CAUSED BY THE PILOT'S FAILURE TO FOLLOW THE PROCEDURES IN THE AIRPLANE OPERATING HANDBOOK AND LAND AS SOON AS POSSIBLE RESULTING IN FUEL STARVATION OF THE RIGHT ENGINE. DARKNESS WAS A RELATED FACTOR.

Full Narrative

SHORTLY AFTER LEVELING OFF AT 14,000 FT THE LEFT ENGINE QUIT. THE PILOT DIVERTED TO TAMPA, AND 34 MINUTES LATER THE RIGHT ENGINE QUIT. DURING THE SUBSEQUENT FORCED LANDING THE AIRPLANE COLLIDED WITH THE ROOF OF A COVERED SIDEWALK AND THEN TREES. TEARDOWN OF THE LEFT ENG REVEALED THAT THE SEAL BETWEEN THE EXHAUST FLANGE & TURBOCHARGER WAS NOT INSTALLED; BOLT CLAMP WAS FINGER TIGHT. HEAT HAD MELTED WIRING HARNESS & MAG GROUNDING LEADS INSULATION; BOTH 'P' LEADS WERE GROUNDED. PILOT STATED THAT AFTER LOSING THE LEFT ENG HE INITIATED A LEFT TANK TO RIGHT ENGINE CROSSFEED, AND AFTER 20 MINUTES OF SINGLE ENG FLIGHT IN THIS CONFIGURATION THE RIGHT ENG QUIT. FLIGHT MANUAL STATES TO LAND AS SOON AS POSSIBLE IN CASE OF ONE ENG FAILURE. IN ADDITION, IT WARNS THAT WHEN FLYING ON ONE ENG & CROSSFEEDING FUEL, ABSOLUTE COORDINATED FLIGHT MUST BE MAINTAINED TO PREVENT UNPORTING OF THE TANK'S FUEL PICKUP TUBE WHEN THE TANK IS NOT FULL.

Flight

Event TypeAccident
Event Time22:45 EST
Nearest Airport0nm N
Runway0
Runway Length0
Runway Width0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftButler Aerostar 601 Aerostar 6
Tail NumberN7443S
Aircraft CategoryAir
DamageDestroyed
Operating RulePart 135
Engines2
Engine TypeReciprocating
Engine DetailsLycoming · IO-540-AA1A5 · Reciprocating · 290
Seats2

People & Injuries

Injury Summary1 injury (1 minor injury)
Fatal0
Serious0
Minor1
Uninjured0
Total1
Crew 1Age 26 · First Class

Conditions

ConditionsVMC
LightDark Night
Wind120° @ 4 kt
Visibility7 sm
CeilingNone
Temperature / Dew Point70 F / 57
Altimeter30.00 inHg
Observation Time03:58
Weather SourceWFAC

Appendix: Source Data