Aviation Accident Summaries

Aviation Accident Summary ATL95FA021

MABLETON, GA, USA

Aircraft #1

N8933M

BEECH 95B55

Analysis

THE PILOT OBTAINED TWO WEATHER BRIEFINGS PRIOR TO DEPARTING ON THE CROSS-COUNTRY FLIGHT. FORECASTED EN ROUTE WINDS WHICH WERE HIGH WERE PROVIDED. THE PILOT DID NOT CHANGE HIS ESTIMATED TIME EN ROUTE WHEN HE FILED AN IFR FLIGHT PLAN. DESTINATION WEATHER WAS FORECASTED TO IMPROVE; HOWEVER, THE FSS SPECIALIST STATED THAT HE DOUBTED THERE WOULD BE IMPROVEMENT. DESTINATION WEATHER WAS NOT REQUESTED AGAIN UNTIL NEAR THE ARRIVAL AIRPORT. AT THE DESTINATION, A VOR APPROACH WAS ATTEMPTED, EVEN THOUGH WEATHER WAS BELOW MINIMUM DESCENT ALTITUDE. A MISSED APPROACH FOLLOWED, AND THE PILOT PROCEEDED TO THE ALTERNATE AIRPORT. EN ROUTE, HE REPORTED LOW FUEL. AN ILS APPROACH AT THE ALTERNATE ENDED IN A MISSED APPROACH WHEN THE PILOT REPORTED HE DID NOT SEE THE RUNWAY. WEATHER WAS AT MINIMUMS. DURING THE SECOND APPROACH TO THE ALTERNATE, THE PILOT REPORTED THAT ONE ENGINE HAD QUIT. THE SECOND ENGINE QUIT DURING AN ATTEMPT TO BEGIN A THIRD APPROACH. FOUR AND ONE-HALF GALLONS OF FUEL WERE DRAINED FROM THE AIRPLANE AT THE ACCIDENT SITE.

Factual Information

HISTORY OF FLIGHT On November 27, 1994, about 1803 eastern standard time, a Beech 95B55, N8933M, collided with trees and terrain during an uncontrolled descent at Mableton, Georgia about 1.5miles southeast of the Fulton County Airport. The airplane was operated by the owner/pilot under the provisions of 14 CFR Part 91, and instrument flight rules (IFR). Instrument meteorological conditions prevailed. An IFR flight plan was filed for the personal flight. The private, instrument and multi-engine rated, pilot was fatally injured, and the airplane was substantially damaged. Origination of the flight was Pennridge Airport, Perkasie, Pennsylvania, about 1259, on the same day. The pilot obtained two pre-flight weather briefings from Altoona Automated Flight Service Station (AFSS) and Williamsport AFSS at 0906 and 1216, respectively. Information regarding the freezing level, upper level icing, and upper level winds were specifically discussed by the AFSS specialist and the pilot. The airport forecasts for the destination area were for improving conditions to 2500 feet scattered cloud layers, and visibility exceeding seven miles. During the second weather briefing, the AFSS specialist noted that the current weather at Dekalb-Peachtree airport, about 30 miles northwest of Covington, Georgia, the destination, was ceiling, 300 feet overcast, with 1.5 miles visibility. The Atlanta International Airport had an indefinite ceiling, 100 feet obscured, with visibility 1/8 mile. The second specialist went on to note the forecast of improving weather and stated that "I wouldn't count on it if they're still down that low now." According to air traffic control records, the pilot requested additional weather information at 1636 from Atlanta Air Route Traffic Control Center (ARTCC). Information obtained from air traffic control indicated that the flight was routine until its arrival in the Atlanta metropolitan area. Upon arrival at the flight planned destination, Covington, Georgia, a VOR-DME approach to the Covington Airport an uncontrolled field, was executed, followed by a missed approach. The pilot requested to proceed to his alternate, Fulton County Airport. Prior to beginning an approach at Fulton County Airport, the pilot had reported that he had about 15-20 minutes of fuel remaining. An instrument landing system (ILS) approach to runway 8 was attempted. The pilot stated he did not see the runway environment. Following a missed approach, the flight was provided an airport surveillance approach. During the surveillance approach the pilot reported that an engine had quit. The surveillance approach was continued with the pilot never sighting the runway environment. Subsequently, radio and radar contact with the airplane was lost, about 1.5 miles west of the airport. The wreckage was located 1.5 miles, bearing 278 degrees from the airport. All of the wreckage debris was confined to an area approximately within the wingspan of the airplane. PERSONNEL INFORMATION The pilot obtained his private certificate in December 1986. An instrument rating was obtained in January 1992. On his application for the instrument rating he listed 893 total flight hours and 47 instrument flight hours. A multiengine rating was issued to the pilot in December 1993. He listed 1041 total flight hours, and 60 instrument flight hours, on the rating application. He listed four flight hours in the aircraft used for the multiengine flight check. N8933M was registered to the pilot in September 1993. The aircraft log indicated 921 total hours for the airplane in July 1993. The airplane's hour meter reflected 1076.5 hours at the accident site. The last entry in the pilot's log is dated October 25, 1992, and listed 22.1 total multiengine flight hours. Therefore, the pilot's multiengine flight hours are estimated to be 170 (1076.5-921=155.5+22.1=177.6). The pilot certificate issued to the pilot in December 1993, for the added multiengine rating, stated that the multiengine rating was for visual flight rules only. The designated examiners's report stated that the rating for which tested was "multiengine (private VFR)." A second class medical certificate was issued to the pilot on April 26, 1993. It contained a limitation that the holder must wear corrective lenses while exercising the privileges of the certificate. AIRCRAFT INFORMATION The airplane was registered to the pilot. An annual inspection was recorded in the aircraft log and was dated August 16, 1994. The aircraft total time on that date was listed as 5129.4 hours with a tachometer hour meter reading of 1024.2 hours. The left and right engine logbooks indicated an inspection on August 16 and August 18, 1994, respectively. The left engine log listed 963.7 hours since overhaul and the right engine log listed 2693.2 total engine hours. The aircraft records indicated that the propellers were overhauled on November 22, 1988. An entry in the aircraft log indicated that the altimeter, the static system, the automatic pressure altitude reporting equipment and the transponder were tested in July, 1991. 14 Code of Federal Regulations (CFR) Part 91.411 requires that each static pressure system, each altimeter instrument, and each automatic pressure altitude reporting system must be inspected within 24 calendar months, preceding the operation of the airplane in controlled airspace under instrument flight rules. Similarly, 14 CFR Part 91.413 requires that the transponder be inspected within the preceding 24 calendar months. METEOROLOGICAL INFORMATION At the time of the accident, and immediately preceding it, aircraft that were executing approaches to Dekalb-Peachtree Airport, about 15 Nmi northeast of the accident site, were missing the approach and landing at Fulton County Airport. The surface weather analysis at Fulton County at 1750 on November 27, 1994 was sky measured 300 feet overcast; visibility 3/4 mile in fog; temperature 47 degrees F.; dew point missing; wind 110 degrees at five knots; and altimeter setting 30.06 In. Hg. Another pilot, operating a Piper Cherokee, landed at Fulton County Airport after the accident had occurred. He reported that the cloud tops were about 3,000 to 4,000 feet. The cloud layer was solid until just above decision height, about 250 feet above ground level. He first observed the approach strobe lights to identify the runway environment. AIDS TO NAVIGATION Several aircraft completed an ILS approach to Fulton County Airport prior to and following N8933M. There were no pilot reports of problems with the localizer or glide slope signals. Additionally, the manager of the Fulton County Air Traffic Control Tower stated that proper operation of the ILS system was verified by airways facilities personnel. AIRPORT INFORMATION Runway 8 at the Fulton County Airport is equipped with High Intensity Runway Lights and a Medium Intensity Approach Light System with Runway Alignment Indicator Lights (MALSR). The decision height is 1,078 feet mean sea level, 270 feet above ground level. WRECKAGE AND IMPACT INFORMATION The airplane impacted in a wooded lot, adjacent to a residence. One propeller blade from the right propeller was separated from the airplane and located about 15 feet behind the right wing. About three feet of the outboard end of the right wing was separated from the airplane and located about 25 feet to the left rear of the left wing tip. The outboard portion of the left wing tip had pine bark trapped in the folds of chordwise accordion-like damage to the leading edge. A concave shaped indentation was co-located with the chordwise accordion-like damage. The remainder of the airplane lay, upright, within the confines of its fuselage length and wingspan. One tree had freshly broken limbs and was located about 15 feet on a 45 degree angle from the left wing tip leading edge. A second tree was topped, and was located about 25 feet, on a 45 degree angle, from the left wing tip trailing edge. The separated right wing tip was located at the base of this same topped tree. The nose of the airplane, forward of the windshield, was broken off downward. A crush line was observed in the underside of the fuselage, from the wing spar forward to the nose cone, consistent with a nose down impact of about 15 degrees. The landing gear was extended and partially buried in the soft ground, so that the airplane rested on the fuselage and wings. Flaps were fully extended, by reference to the position of the flap guide rollers in the flap guides. There were small indentations, less than six inches across, in the leading edge of the vertical and right horizontal stabilizers. The left horizontal stabilizer, rudder, and both elevators were undamaged. The left wing leading edge, forward of the spar, was crushed flat, and deformed as if the wing tip leading edge had been twisted up. The left propeller was broken off, fractured through the engine crankshaft, about two inches forward of the crankcase. The crankshaft had the appearance of the propeller having been bent down. The propeller remained in front of the engine with one blade exposed above the ground and two blades buried. When it was uncovered, one blade was found bent rearward about the mid-span point. Both remaining blades were essentially straight. About three feet of the right wing tip was separated from the airplane and was found as previously noted. The wing spar was bent aft in a broad arc from the point of separation inboard to the engine nacelle. The right engine was separated from the airframe mounts and was found inverted. One blade was broken out of the propeller hub and found as previously noted. The separated blade was bent and twisted spanwise, toward a low pitch position, about the blade's mid-point. About four inches of the tip of the blade that led the separated blade was bent toward a low pitch position. A tree was positioned at the radius formed by the right wing leading edge and the outboard side of the right engine nacelle. There were slash marks on the tree trunk beginning about 12 feet above the ground and continuing at intervals to a point about six feet above the ground. Continuity of the flight controls from the surfaces to the cockpit was established. Measurements of the trim tab extension rods indicated, according to the manufacturer's representative, zero deflection of the aileron, zero to two degrees right rudder deflection, and six to seven degrees of nose up trim. Available fuel from the airplane was captured in portable containers. Approximately two gallons of liquid were drained from the left auxiliary tank, and about 2.5 gallons of liquid was drained from the right auxiliary tank. The drained liquid was blue in color and had the odor and texture of aviation gasoline. After the airplane was removed from the accident site, fuel selector positions were verified by adding fuel to the main tanks, powering the boost pumps, and pumping the fuel through the selector to the engine main fuel fitting. The left fuel selector was found to be in the left main tank position, and the right fuel selector was found in the right auxiliary tank position. Both engines were removed and examined. The left engine, Continental IO-470-L(5) serial number 237767R, was rotated using the engine starter. Compression was verified at each cylinder by thumb pressure at one spark plug opening. Liquid, with the odor of aviation gasoline, was found when the fuel manifold valve was removed. The spark plugs exhibited normal wear and color, when compared with a manufacturer's wear chart. All spark plug leads sparked as the engine rotated. The piston crowns displayed normal combustion deposits, gray to tan coloration. The right engine, Continental IO-470-L, serial number CS192814-73-L-R, was also rotated using the engine starter. Again finger compression was noted at each cylinder, and the spark plug leads all sparked. A similar liquid was found when the fuel manifold valve was removed. The spark plugs and piston crowns were oil fouled (engine lay inverted at accident site). Avionics equipment was removed from the airplane and operated on a test bench. The Horizontal Situation Indicator MN DGO-90A, serial number 271, was found to be sensitive, providing a 1/2 face deflection at 90 microvolts, versus the standard 75 microvolts. The localizer and glide slope receiver, MN DG0-10, was mounted in a converter separated from the number 1 NAVCOM. It operated when placed on a test bench, as did the number two localizer receiver and both navigation/communication radios. MEDICAL AND PATHOLOGICAL INFORMATION A post mortem examination of the pilot was conducted by the Office of the Medical Examiner of Cobb County, Georgia, on November 28, 1994. The cause of death was listed as generalized trauma. Toxicological examinations of the pilot were conducted by the Federal Aviation Administration Toxicology and Accident Research Laboratory. The examination report indicated that no ethanol was detected in the blood and that 10.000 mg/dl ethanol was detected in the urine. No other drugs were detected. ADDITIONAL INFORMATION The aircraft wreckage, logs, and records were returned to the registered owner's insurance representative: Harry Brooks Carson-Brooks Incorporated 2300 Peachford Road Suite 1160 Atlanta, Georgia 30338

Probable Cause and Findings

The pilot's inadequate weather evaluation in that he failed to account for forecasted winds at altitude that resulted in an increased time en route and fuel exhaustion.

 

Source: NTSB Aviation Accident Database

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