NEWPORT, OR, USA
N990EC
Beech A-36
While descending to the destination airport, the airplane broke out of the clouds about 600 feet above the ground and the pilot cancelled his IFR flight plan. Immediately after descending out of the clouds, witnesses reported that the engine began to 'sputter,' then quit. They observed the airplane impact level terrain during a rapid rate of descent. Examination of the wreckage revealed that the vernier mixture control was found in the idle cutoff position, and the throttle was found in a cruise power position. The airplane also had an additional manual turbocharger vernier control, and it was found partially engaged. The pilot received serious head injuries and stated that he cannot remember the accident flight. He had logged 11 hours in the accident airplane during the 105 days preceding the date of the accident. He had not flown the accident airplane, or any other turbocharged airplane with similar cockpit controls, prior to that time. He had flown eight consecutive flights in airplanes that had dissimilar cockpit controls prior to the accident flight and subsequent to his last flight in type.
HISTORY OF FLIGHT On October 25, 1995, about 1315 Pacific daylight time, N990EC, a Beech A-36, operated by the Ben-ko-matic Brush and Equipment Company and Prestige Care, Inc., Portland, Oregon, collided with terrain during a forced landing near Newport, Oregon, and was substantially damaged. The forced landing was precipitated by a loss of engine power during approach. The commercial pilot and his two passengers were seriously injured. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the operation. The business flight departed from Portland, Oregon, at 1224 and was destined for Newport. The flight was conducted under 14 CFR 91. According to information received from an FAA Automated Flight Service Station and the operator of the airplane, the pilot obtained a weather briefing and filed an IFR flight plan on the morning of the accident for a business flight from the Portland International Airport to the Newport Municipal Airport. After two operator employees and the pilot boarded the airplane, it departed from Portland at 1224 uneventfully. At 1312, the pilot cancelled his IFR flight plan with Air Traffic Control (ATC) as he approached Newport. No distress calls or indications of any problems were recorded by ATC during the flight. According to numerous ground witnesses (statements attached), the airplane was observed flying beneath the cloud ceiling from the north over Yaquina Bay. The airplane "appeared to be in trouble" and the wings were "wobbling." The witnesses also heard "loud popping" and "backfiring" from the airplane. One witness stated that the engine was "cutting out." The airplane continued to fly toward the south side of the bay while descending. It was observed about 200 feet above sand dunes when it banked to the west "into the wind." The airplane "suddenly [lost] forward momentum and fell to the ground." One of the eyewitnesses photographed the crash sequence (photographs attached). The pilot sustained serious head injuries and stated that he does not recall the accident flight. He stated that the last event he remembered was receiving a weather briefing prior to the accident flight. The passenger seated in the right front seat of the airplane stated that he remembered the pilot had reported to ATC that he was 9.2 miles north of the airport. As the airplane flew over Yaquina Bay, the airplane "lost power or powered down." The passenger stated that the pilot "dropped the landing gear and made many adjustments," but the engine never regained power. The other passenger, seated in the rear of the airplane, stated that she "heard the propeller stop or slow down" almost immediately after the airplane descended out of the clouds. She then observed the pilot "hunched over the wheel/controls, quickly making adjustments," and she heard the right front seat passenger tell the pilot that he saw a road to the right. She then heard the pilot say "oh no," and the airplane subsequently "dropped." The accident occurred during the hours of daylight at a location of 44 degrees, 36.5 minutes North and 124 degrees, 03.4 minutes West. PERSONNEL INFORMATION The pilot, age 41, was a certificated commercial pilot with ratings for single-engine land and multiengine land airplanes. He was also a certified flight instructor with ratings for single-engine land airplanes and instrument airplanes. According to FAA records, the pilot was issued an FAA Second Class Medical Certificate on March 7, 1995, with the limitation that he "must wear glasses for near and distant vision." According to the pilot's personal logbook, he had accumulated 1,400 hours of total flight time, including 1,254 hours of pilot-in-command time, 151 hours of flight instruction given, 225 hours in multiengine airplanes, and 458 hours of instrument time. Entries in the logbook (attached) indicated that the pilot had flown the accident airplane on five previous flights for a total of 11 hours and 11 landings during the 105 days preceding the accident. He had not flown the accident airplane prior to that time. Entries in the logbook also indicated that the pilot had flown eight consecutive flights in Cessna and Piper airplanes prior to the accident flight and subsequent to his last flight in type. The majority of the pilot's logged flight time occurred in airplanes that were not manufactured by Beech and were not turbocharged. AIRCRAFT INFORMATION The airplane, a 1975 Beech model A-36, was a six-seat, low-wing aircraft with retractable landing gear, a constant-speed propeller, and a fuel-injected, turbocharged engine. It was owned and operated by the Ben-ko-matic Brush & Equipment Company and Prestige Care, Inc., Portland, for business purposes. The airplane's original Continental model IO-520-BA had been converted to a model TSIO-520-DB. The conversion involved the installation of two Rayjay turbochargers as per an FAA-approved Supplemental Type Certificate (STC). Both turbochargers had manually-controlled wastegates that were tied into a single vernier cockpit control. The cockpit control was located directly beneath the propeller control, and about 5 inches to the right of the fuel mixture control. Advancing the turbocharger wastegate cockpit control forward causes both wastegates to close, thus initiating turboboosting. The airplane's fuel system consisted of two 40-gallon rubber fuel cells located in each wing leading edge with a flush type filler cap, associated supply/return/vent lines, a selector valve with right/left/off detents, an electrically-driven auxiliary fuel pump used for starting and emergency operation, a mechanically-driven injection pump, a fuel metering control unit, and a fuel manifold. Fuel metering is controlled by the pilot via a vernier mixture control located in the cockpit. Pulling the mixture control to the full aft position cuts off the fuel supply to the engine. The mixture control knob is red in color. Engine power is controlled by a throttle control located in the cockpit. Advancing the control forward increases engine power output. The control knob is black in color and is located directly above the mixture control. The arrangement of the throttle, mixture, and turbocharger controls differs from standard single-engine airplanes manufactured by Cessna and Piper. The arrangement also differs from earlier A-36 models and other Beech single-engine models. An examination of the airplane's engine and airframe logbooks revealed no unresolved discrepancies prior to departure the day of the accident. The logbooks indicated that the airframe and engine had received an annual inspection on February 24, 1995; the inspection occurred about 128 operating hours prior to the accident flight. The most recent entry in the logbook was dated August 24, 1995, and reported the installation of a digital fuel flow computer with no discrepancies noted. The airplane had logged a total of about 2,977 operating hours since its manufacture. The engine received a major overhaul on February 14, 1994, and was rebuilt after accumulating 2,720 operating hours. According to fueling receipts and airplane documents retrieved by the FAA, the airplane had been fueled with 51.9 gallons of 100 low lead aviation fuel on October 22, 1995. A comparison between the most recent recorded engine tachometer time in the airplane's flight log and the tachometer time displayed at the accident site revealed that the airplane had flown 0.9 hours since its last refueling. METEOROLOGICAL INFORMATION The following surface observations were recorded at the Newport Municipal Airport about 3 minutes after the accident: Cloud ceiling 600 feet broken; visibility 5 miles; temperature 55 degrees F; dewpoint 53 degrees F; winds from 190 degrees at 18 knots gusting to 25 knots; light rain and fog. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the accident site on the evening of the accident, October 25, 1995, and again on the following day. The on-scene examination was conducted by an FAA aviation safety inspector from Hillsboro, Oregon. An additional examination was conducted by the Safety Board on February 22, 1996, at Northwest Aircraft Salvage, Everett, Washington. The airplane came to rest in wet, sandy soil along level terrain. The right side of the airplane sustained greater damage than the left side. No evidence of a ground fire was noted. The wreckage remained intact and was found within it's own preimpact dimensions. An odor of fuel was detected near the wreckage. All primary and secondary flight control surfaces were accounted for at the accident site. The electrically-driven flaps were found in the retracted position. No evidence was found to indicate a flight control deficiency. The engine and propeller remained attached to the airframe. The right wing was partially separated from the fuselage and exhibited evidence of impact damage. The right main landing gear strut had been forced upward into the wing. Both main landing gear and the nose gear were found in the extended position and were damaged. The cockpit mixture control was found in the idle cutoff position. The throttle control was found in the full forward position. The propeller control and turbocharger control were partially pulled aft. The fuel selector valve control was found in the LEFT MAIN tank position. The auxiliary fuel pump switch was found in the OFF position. An examination of the right wing fuel tank revealed evidence of about 10 to 15 gallons of fuel. The left wing fuel tank had less than 1 gallon of fuel. Both fuel caps were found secured to their respective tanks. Some fuel lines had been compromised. The fuel supply line emanating from the firewall and ending at the injection pump, and the fuel line connecting the injection pump to the fuel metering control unit were both loosened by investigators at the accident site; no fuel was found in these lines. The fuel line connecting the fuel metering control unit to a fuel flow transducer was compromised. About 1 teaspoon of fuel was found in the fuel line connecting the transducer to the fuel manifold. Both main fuel tank bladders were removed from the wings and inspected. Both bladders were intact, uncompromised, and contained no blockages. All of the airplane's fuel lines were subjected to air pressure and were found to be unobstructed. The electrically-driven auxiliary fuel pump and fuel selector valve were functionally tested with no anomalies noted. The fuel metering control unit had separated from the engine and was later removed for additional testing. No preimpact mechanical discrepancies associated with the airplane's fuel system were found. Then engine and propeller were examined at the accident site. An external examination did not reveal evidence of preimpact catastrophic mechanical failure. Some sparkplugs were removed from the engine and appeared in clean, operable condition. The engine was removed from the fuselage for additional testing. ADDITIONAL TESTING The engine was functionally tested (test sheet attached) by the Safety Board on January 18, 1996, at facilities located in Mobile, Alabama. The following items were repaired or replaced prior to the test: three engine mount legs, oil sump quick drain, left exhaust crossover pipe, no. 5 cylinder induction tube, turbocharger induction ducts, throttle body, and fuel metering control unit. A slaved throttle assembly of the same part number and calibration was installed in lieu of the damaged unit from the accident airplane. Engine start-up was immediate. The engine ran smoothly at high revolutions per minute (rpm), and stalled at low rpm. It was determined that the engine's fuel injection pump pressure was insufficient to sustain the engine at the idle power setting. The pump's fuel flow adjustment screw was advanced one rotation and the test was resumed. The engine then idled with no anomalies noted. The engine was run up to 2,100 rpm without boost from the turbochargers. The wastegates were then wired closed and the engine reached full rated manifold pressure prior to full throttle. The fuel metering unit from the accident airplane was bench tested by the Safety Board (test sheet attached) on April 1, 1996, at facilities located in Mobile, Alabama. The results of the test revealed that the unit was able to provide flow rates within production specifications. ADDITIONAL INFORMATION Published Operating Procedures. The normal descent checklist (attached) found in the FAA approved airplane flight manual for the Beech A-36 states that the fuel mixture control should be "enrich[ed] as required" and the throttle adjusted "as required." The normal before landing checklist states that the mixture control should be "full rich." The emergency checklist (attached) for engine failure in flight states that the auxiliary fuel pump should be selected to the "on" (or "high" as published in the Rayjay STC supplement) position, and the mixture control should be "full rich, then lean as required." The emergency checklist for landing without power states that the fuel selector valve should be selected to "off." and the mixture should be in the "idle cut-off" position. Wreckage Release. The aircraft wreckage was released to Mr. Edward F. Stewart, Assistant Vice President, United States Aviation Underwriters, Seattle, Washington, on April 30, 1996. Mr. Stewart is representing the registered owner of the airplane.
the pilot's inadvertent shut-off of the fuel mixture control. Factors contributing to the accident were: the pilot's failure to perform adequate remedial action to regain engine power, his lack of familiarity with the accident airplane, and his failure to obtain/maintain a proper descent rate during the forced landing.
Source: NTSB Aviation Accident Database
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