Aircraft Accident/Incident Report

Lauderdale Lake, Florida 33309
Thursday, March 25, 1999 11:39 EST

NTSB Narrative Summary Released at Completion of Accident

The pilot was receiving a competency flight in the seaplane from an FAA inspector. The pilot was returning to their initial departure airport, descended to 1,000 feet, contacted the control tower for landing instructions, and was instructed to enter on a right base. Before he could acknowledge the landing instructions the engines started to make loud, rough, and unusual noises. The pilot informed the control tower that he was 2 miles south , declared an emergency, and stated he had a bad engine on the left side. The FAA inspector stated the pilot started the emergency procedure, the manifold pressure and rpm was fluctuating. The inspector could not determine the dead engine by the dead foot, dead engine method, because her rudder pedals were stowed. She pointed out a pasture and the pilot stated they were going to the water. She did not recall the pilot shutting down the engine or feathering the propeller. She could not recall the final seconds of the flight. The airplane collided with a tree, canal bank, and came to rest inverted in the canal. Examination of the airframe and flight control systems revealed no evidence of a precrash mechanical failure or malfunction. Examination of the left propeller revealed it was not feathered. The No. 6 front forward spark plug ignition lead was disconnected from the spark plug. The ignition lead shroud threaded coupling on the No. 4 front forward spark plug was unscrewed and the carbon wire was exposed. The left and right engines were removed from the airplane and transported to an authorized FAA approved repair station. The left engine was placed in an engine test cell. The engine was started, developed rated power, and achieved takeoff power. The spark plug lead was removed from the No.6 forward cylinder. The left magneto had a 125 rpm drop during the magneto check. The right magneto had a 75 rpm drop. The magneto drop exceeded the allowable drop indicated by the engine overhaul manual. The right engine was placed in a engine test cell. The engine was started, developed rated power, and achieved takeoff power. Review of the FAA inspectors FAA Form 4040.6 revealed she was not Event Based Current (EBC) for the 4th quarter of the Flight Standards EBC program, and she did not meet the EBC quarterly events required by the end of the 14-day grace period. FAA Order 4040.9 states for an FAA inspector to be eligible / assigned to perform flight certification job function they must be EBC current., and inspectors should not accept assignments without being in compliance with the FAA Order. Managers and supervisors should not assign inspectors who are not current. The FAA inspector's supervisor was aware that the inspector was not current. He contacted the FAA Safety Regulation Branch, FAA Southern Region Headquarters, and stated that FAA Southern Region indicated that the inspector could administer the checkride. FAA Southern Region stated at no time did they approve or agree to an operation outside the parameters of the FAR's, Inspector Handbook or FAA Order.

NTSB Probable Cause Narrative

The pilots failure to correctly identify an in-flight emergency (fluctuating manifold pressure and rpm due to a disconnected spark plug lead / unscrewed ignition lead shroud) and failure to complete the engine shutdown procedure once it was initiated (propeller not feathered). This resulted in a forced landing and subsequent in-flight collision with a tree, dirt bank and canal. Contributing to the accident was the FAA inspectors improper supervision of the pilot, and the improper supervision of the inspector by her supervisor, in his failure to follow written procedures / directives in assigning a non-current inspector to conduct a competency flight.

Event Information

Type of Event Accident
Event Date 3/25/1999
Event Day of the Week Thursday
Time of Event 1139
Event Time Zone Eastern Standard Time
Event City LAUDERDALE LAKE
Event State FLORIDA
Event Country --
Zipcode of the event site 33309
Event Date Year 1999
Event Date Month 3
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1153 Eastern Standard Time
Direction of event from weather observation facility (degrees) 50
Weather Observation Facility ID FXE
Elevation of weather observation facility 14
Distance of event from weather observation facility (units?) 2
Time Zone of the weather observation EST
Lighting Conditions Day
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 4700
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 86
Dew Point at event time (in degress fahrenheit) 78
Wind Direction (degrees magnetic) 140
Variable Wind Indicator Unknown
Wind Speed (knots) 10
Wind Velocity Indicator Unknown
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 30
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious 1
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 890
NTSB Notification Source --
NTSB Notification Date Mar 25 1999 12:00AM
NTSB Notification Time 1230
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Jul 25 2001 4:45AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N5548A
NTSB Number MIA99FA114
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? --
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion Ground
Aircraft Manufacturer's Full Name Grumman
Aircraft Model G-21A
Aircraft Series Identifier G-21A
Aircraft Serial Number 75-7661
Certified Max Gross Weight 8000
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 8
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Dec 8 1998 12:00AM
Airframe hours since last inspection 31
Airframe Hours 13136
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name TROPIC BIRD LANDING INC.
Aircraft Owner Street Address 875 MEADOWS ROAD SUITE 311
Aircraft Owner City BOCA RATON
Aircraft Owner State FL
Aircraft Owner Country
Aircraft Owner Zipcode 33486
Operator is an individual? --
Operator Name
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address
Operator City
Operator State
Operator Country
Operator Zip code
Operator Code
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Instructional
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code X-44
Departure City MIAMI
Departure State FL
Departure Country
Departure Time 1129
Departure Time Zone EST
Destination Same as Local Flt crash at destination city
Destination Airport Code FXE
Destination City
Destination State
Destination Country
Specific Phase of Flight Descent
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jul 25 2001 4:05AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --