Aviation Accident Summaries

Aviation Accident Summary DEN04FA038

Cedar City, UT, USA

Aircraft #1

N9679R

Beech B95

Analysis

The check ride flight departed from the airport at 1120. At approximately 1400, the airplane was reported overdue, and the local flight school launched some airplanes to initiate a search. According to radar data, the airplane appeared to be maneuvering at an altitude that varied between 8,200 feet msl and 9,000 feet msl and a groundspeed that varied between 40 knots and 200 knots. The last radar position at 1141:03 indicated an altitude of 8,900 feet msl and a ground speed of 6 knots. An on scene examination of the airplane revealed no anomalies.

Factual Information

HISTORY OF FLIGHT On January 12, 2004, at 1142 mountain standard time, a Beech B95, N9679R, piloted by a commercial pilot applicant, was destroyed when it impacted terrain 16 miles north west of Cedar City Municipal Airport, (CDC) Cedar City, Utah. A post impact fire ensued. Visual meteorological conditions prevailed at the time of the accident. The local check ride was being conducted under the provision of Title 14 CFR Part 91 without a flight plan. The designated examiner and commercial rated examinee were fatally injured. The flight departed at 1120. According to the owner of the airplane, he had flown down from Provo, Utah, with the examinee, and another student on the morning of the accident. Two check rides with the designated examiner were scheduled. The first check ride flight departed from CDC at 1120. At approximately 1400, the airplane was reported overdue, and the local flight school launched several airplanes to initiate a search. One of the search airplanes observed a column of smoke, which led them to the smoldering airplane at approximately 1600. According to the National Track Analysis Program (NTAP) data, the airplane appeared to be maneuvering at an altitude that varied between 8,200 feet msl and 9,000 feet msl and at a groundspeed that varied between 40 knots and 200 knots. The last radar contact was made at 1141:03 at an indicated altitude of 8,900 feet msl and a ground speed of 6 knots. PERSONNEL INFORMATION The designated examiner held an airline transport pilot certificate with a multiengine rating, single engine land with commercial privileges, and a flight instructor's certificate with single, multiengine, and instrument ratings. He was issued a third class medical certificate on July 9, 2002. This certificate was under special issuance due to hypertension and a coronary artery bypass. The certificate contained no limitations. According to the last medical examination, the designated examiner estimated his flight time at 26,000 hours. The examinee held a commercial certificate with airplane single engine land and instrument ratings. He was issued a first class medical certificate on September 17, 2001. The certificate contained the limitation "corrective lenses must be worn." According to the examinee's flight instructor, he had logged approximately 300 hours, eight of which were in multiengine airplanes. All of the examinee's multiengine experience was logged in the accident airplane. AIRCRAFT INFORMATION The airplane was a Beech B95, manufactured in 1960. It was equipped with two Lycoming O-360-A1A engines. Each engine was equipped with a Hartzel, 2-blade, full feathering, constant speed propeller. The owner/operator of the airplane purchased it in October of 2003. Approximately 250 hours had been flown on the airplane between the time of purchase and the time of the accident. WRECKAGE, RECOVERY, AND DOCUMENTATON The NTSB arrived at the scene at approximately 1300 on January 13, 2004 and began the on scene investigation. The wreckage was located at 37 degrees 51.933 minutes north latitude and 113 degrees, 18.990 minutes west longitude; 16.4 statue miles north, north west of CDC. The airplane was located in an open, grassy, snow covered field at an elevation of 5,192 feet msl. The longitudinal axis of the airplane was oriented on a heading of 330 degrees. There were no ground scars, no debris field, and all of the airplanes major components were located at the accident site. The front cockpit area and instrument panel was consumed by fire. The rear cabin area was charred and partially consumed by fire. The windscreen was fragmented. Fragments were found in front of and to the right and rear of the wreckage. There was no debris or windscreen fragments found to the left or left rear of the wreckage. The empennage on the right side was crushed inward and torn from the top of the empennage to the bottom, along the side. From the empennage, rear, rudder continuity was established. Elevator continuity was not established. The right horizontal stabilizer was wrinkled 14 inches inboard from the tip. The left elevator wrinkled. The wing flaps are operated by one flap motor and two flex shafts. According to the flex shaft position, the flaps were approximately 30 degrees. The flap lever in the cockpit was found in the "half way" position. The landing gear lever was found in the down or gear extended position. This lever is spring controlled and has a detent or locked position. On scene information indicated that the gear was down prior to impact. The outboard engine mount on the left engine was broken. The inboard engine mount was bent to the right. The engine cowling was charred. The nose cone on the left engine showed aft crushing. The propeller blades on the left engine were labeled L-A and L-B for identification purposes only. Both blades appeared to be in the feathered position and were unremarkable. The left aileron was charred on the inboard edge. Aileron continuity was not established due to impact damage. The outboard edge of the aileron and the left wing were bent. The right wing leading edge was wrinkled. The riveting popped along the leading edge of the wing and the right fuel tank was compromised. The right flap was charred and partially consumed by fire. Several diagonal wrinkles were noted on the right elevator. The right inboard fuel tank was compromised and consumed by fire. Aileron continuity was not established due to impact damage. The right inboard fuel tank was compromised and consumed by fire. The right outboard fuel tank ruptured aft. Directly behind this rupture, a four-foot inboard section of the aileron and a small portion of the right flap were consumed by fire. The right engine mounts were crushed/bent outboard. The right engine cowling was charred. The wing locker was charred and partially consumed by the fire. For identification purposes, the propeller blades were labeled R-A and R-B. Blade R-A was pointing straight up and unremarkable. Propeller blade R-B was bent back, underneath the engine and cowling and separated at the propeller hub. The nose cone on the right engine showed straight crushing. A field examination of the engines was conducted at the scene. Engine continuity was established on the left engine. Due to impact damage, continuity was not established on the right engine. The left engine propeller appeared to be feathered and the blades were parallel with the leading edge of the wing (horizontal). MEDICAL & PATHOLOGICAL INFORMATION An autopsy was performed on both pilots at the State of Utah, Department of Health, Office of the Medical Examiner, in Salt Lake City, Utah, on January 13, 2004. No evidence of physical incapacitation or impairment that would have been causal to the accident was found. Toxicology was performed on the examinee. According to the CAMI (Civil Aero Medical Institute), report # 200400015001, the results were negative for cyanide, carbon monoxide, and ethanol. Doxylamine (found in Unisom Nighttime Sleep Aid) and pseudoephedrine (found in Sudafed) were detected in the liver and pseudoephedrine was detected in the kidneys. TESTS AND RESEARCH Both propeller blades were sent to Hartzell Propeller for further examination. According to their report, the left propeller "had a light mark caused by contact between the link arm and bottom side of the counterweight. This mark occurred at a blade angle in the operating range," indicating that the blade was not fully feathered. Fracture surfaces from the hub pilot tube on the right propeller indicated, "the blade was at a very low blade angle" at the time of impact. Hartzell concluded that because of the negligible damage to the left blade, "it appeared to have no power at the time of impact. The right propeller appeared to have low power or no power at the time of impact." ADDITIONAL DATA Parties to the investigation include the Federal Aviation Administration and Lycoming Engines. According to the aircraft owner and flight instructor, the airplane fuel tanks contained 5 hours of fuel. The flight duration from Provo, Utah, was 1 hour and 20 minutes long. According to the flight instructor, the examinee had flown to CDC the morning of the accident. During the flight, the instructor heard the left engine surge and noticed it began to "cool." The instructor verified that the engine was not running and initiated emergency procedures. During his checklist, he noted that the left engine fuel selector was in the off position. The flight instructor selected the main tank and the engine restarted immediately. The Commercial Pilot Practical Test Standards state that "Examiners shall select an entry altitude that will allow the single engine demonstrations TASK to be completed no lower than 3,000 feet agl or the manufacturer's recommended altitude, whichever is higher. At altitudes lower than 3,000 feet agl, engine failures shall be simulated by reducing throttle to idle and then establishing zero thrust." According to the aircraft owner and flight instructor, the examiner usually conducted the simulated engine failure towards the beginning of the check ride. The Commercial Pilot Practical Test Standards state that the applicant must demonstrate VMC in the following configuration "landing gear retracted, flaps set for takeoff, cowl flaps set for takeoff, trim set for takeoff, propellers set for high RPM, power on critical engine reduced to idle, power on operating engine set to takeoff or maximum available power."

Probable Cause and Findings

the pilot in command's (examinee) failure to maintain airspeed which resulted in a stall. Contributing to the accident was the inadequate supervision by the designated examiner.

 

Source: NTSB Aviation Accident Database

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