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Beech Weekly Accident Update archives

June 2009 Reports

Official information from FAA and NTSB sources (unless otherwise noted). Editorial comments (contained in parentheses), year-to-date summary and closing comments are those of the author. All information is preliminary and subject to change. Comments on preliminary topics are meant solely to enhance flying safety. Please use these reports to help you more accurately evaluate the potential risks when you make your own decisions about how and when to fly. Please accept my sincere personal condolences if anyone you know was in a mishap. I welcome your comments, suggestions and criticisms. Fly safe, and have fun!

6/4/2009 Report

UPDATE

Regarding the 5/22 G36 bounced landing and gear collapse at Decatur, IL., a reader close to the situation reports the pilot had previously owned an F33A and therefore was experienced in Bonanzas, albeit at lighter weights and generally further aft centers of gravity. The pilot had completed an intensive pilot training program specific to the type on the day of the mishap, and was flying home after training. The reader feels that fatigue may have been a contributing factor.

(Fatigue is very poorly understood in aviation mishap prevention. The symptoms of fatigue are very similar to those of alcohol intoxication—impaired judgment and decision-making ability, hindered motor skills, reduced vision, and loss of consciousness. Perhaps some emerging studies in other disciplines and in motor vehicle accidents will benefit pilots as well.)

NEW REPORTS THIS WEEK

5/28 1745Z (1245 local): A Be17 “veered off runway 4 while landing at Southern Wisconsin Regional Airport,” in Janesville, Wisconsin. The solo pilot was not hurt and damage was “minor”. Weather was 1700 broken, visibility 10 miles, with surface winds from 320° at 11 gusting to 16 knots. N17985 (serial number 4807) is a 1943 D17S registered since 2006 to an individual in Middletown, Wisconsin.)

(“Loss of directional control on landing—strong, gusty wind”; “Wind”—The pilot was attempting to land in an 80° crosswind with winds gusting to half again the steady value. In the northern hemisphere when wind gusts at the surface it tends to change direction to its own left. A wind from 320° would become a wind from as much as 300° to 270° at the time of each gust, or 100 to 130 degrees off runway heading is landing on runway 4. In tailwiheel airplanes with most engines the propeller effects tend to turn the airplane to its left. This means that tailwheel airplanes usually are the least controllable with a left-quartering tailwind, which pushes the tail to the right and adds to the tendency to turn left. The pilot-in-command has the final say in runway selection, but there comes a point in any given combination of airplane/pilot/currency/conditions when we may have to pick a different runway or, in some cases, a different airport when the winds blow.)

UPDATES FROM NTSB

Events previously appearing in the Weekly Accident Update:

**5/15 double-fatality A36 crash at Beauregard, AL. Excepts from the report:

According to the passengers, they were flying at about 7,000 feet when the pilot told them that he was having engine problems. They stated that the pilot attempted to restart the engine with success but it stopped again after about 30 seconds. The [right] tip tank was breached but still contained about 4.5 gallons of fuel. The left wing main fuel tank bladder remained intact and was not leaking, approximately 1-quart of fuel was drained from this tank. The left wing tip tank was breached but still contained approximately .5 gallons of fuel. The fuel selector valve was selected to the right fuel tank. The fuel drain on the selector valve was opened and there was no fuel present. The fuel selector valve was removed and tested with no anomalies.

The report does not state how much fuel remained in the right tank, and there’s no way to know whether the selector was set to some other tank and then moved to the right-tank position during an attempted engine restart. But the lack of fuel in the selector valve strongly suggests fuel starvation, and the report of an engine stoppage, restart for a short run, and a second engine stoppage is consistent with many reports of fuel starvation and exhaustion. Unfortunately we frequently read where fuel tanks that were drained, intentionally or not, and the engine did not restart when another tank was selected. Change “Engine failure in flight” to “Fuel starvation”.) **

6/11/2009 Report

FROM UNOFFICIAL SOURCES

On or about 6/4: A reader called to report a Be36 suffered substantial damage when it impacted a hangar at an airport in rural Tennessee. According to the reader the airplane had recently been returned to service following repairs resulting from a gear collapse incident. During the restoration the engine was inspected and the propeller replaced, and the owner had the aircraft repainted and upgraded the avionics. Accepting the airplane from the avionics shop, the owner (a 10,000+ hour pilot) decided after engine start he had another question for the technicians. He exited the Bonanza with its engine still running; the unmanned airplane taxied across the ramp and into a hangar. It has damage to the propeller, nose section and wing leading edges. The airplane’s serial number and registration information are not available.

(“Unattended airplane with engine running taxis into obstruction”; “Substantial damage”—There is no situation that warrants leaving an airplane pilotless when its engine is running. There is trepidation among many pilots of fuel injected engines about “hot start” procedures that might make someone unwilling to shut down the engine for a short period of time. Learn the proper engine start procedures and patiently apply the checklist procedures, and you’ll replace this fear with knowledgeable command of the airplane’s systems.)

NEW REPORTS THIS WEEK

On or about 3/1/2009, time note reported: During taxi, a Be36’s nose gear collapsed, at Charleston, Missouri. The solo pilot wasn’t injured but damage is “substantial”. Weather conditions were not reported. N451S (E-1200) is a 1977 A36 registered since 2000 to a corporation in Charleston.

(“Gear collapse during taxi”; “Substantial damage”—although this incident occurred months ago, it was just posted on the FAA preliminary reports website this week.

What can cause a gear collapse during taxi? Possibilities include:

· Bending or mechanical failure of a landing gear component, especially a pushrod or rod end, from a sudden event or as the result of long-term use patterns or corrosion.

· A weak extension system, in this case an electric motor, that does not fully extend the landing gear.

· A weak electrical system that affects gear motor speed and does not permit complete extension from gear motor operation.

· Excessive side-load on the landing gear caused by attempting to turn at too great a speed.

· Inadvertent retraction of the landing gear by the pilot.

Regardless of the reason in this specific case, to prevent a similar occurrence:

· Check your landing gear system thoroughly during your preflight inspection.

· Insist on a complete and expert inspection of the gear system at annual, addressing all squawks.

· Adhere to manufacturers’ recommendations for inspection, overhaul or replacement of gear components on a time-in-service and/or calendar time basis.

· Occasionally time the gear extension and inspect and repair the system as necessary if the extension cycle becomes longer than normal.

· Have an expert mechanic inspect the system if you notice gear doors do not completely open or close, or for any other reason the landing gear does not look normal when on the ground.

· Run the alternate gear extension checklist as a back-up if extending the gear with a weak electrical system or slow-running motor.

· Slow to a walking pace before attempting taxi turns.

· Avoid any aircraft reconfiguration while moving. Positively identify the flap control and other switches before moving them, to prevent accidentally moving the landing gear switch.)

6/3 2125Z (1625 local): The “training” crew of a Be33 “landed and reported substantial damage,” at Midland, Texas. Pilot and instructor were unhurt. Weather: 5500 scattered, visibility 10 miles with a seven-knot surface wind. N33UB (CE-1496) is/was a 1990 F33A registered since 2004 to a collegiate flight training program in Midland.

(“Stall on final approach” [more in a moment]; “Substantial damage”; “Dual instruction—because the reason for this report was so cryptic I spoke with the chief instructor of the school in question. He reports the airplane “stalled about 60 feet up” on final approach. The instructor added power but did not reverse the sink rate before the Bonanza collided with the runway. The impact “warped the wings” and the airplane is likely “totaled”, according to the chief pilot.

By its nature landing occurs at a high angle of attack, which results in significant drag. If the airplane is allowed to get too slow the angle of attack may be so great that adding power alone does not arrest its descent. The training mission may have included a short-field landing practice, which makes this condition even more likely. It takes great discipline to add power and lower the nose to recover from an excessive rate of descent close to the ground. The preventive measure is to maintain proper airspeed control before you find yourself in this position. If the sink rate becomes excessive it may be best to initiate a go-around—power, attitude, speed and flaps—instead of trying to salvage the landing. A go-around even supports the training mission if this was intended to be a short-field lesson…part of a real-world short-field landing is knowing when speed and/or glidepath makes a go-around and a second attempt the wiser choice.)

6/5 0930Z (0430 local): During a predawn departure a Be35 pilot attempted to abort takeoff, colliding with trees at the end of the runway, at Decatur, Texas. The two aboard report no injury despite “substantial” aircraft damage. Weather conditions were not reported. N8636Q (D-7658) is a 1964 S35 registered since June 2008 to an individual in Decatur.

(“Runway overrun during attempted aborted takeoff”; “Substantial damage”; “Night”—A successful takeoff abort requires the pilot actively monitor the takeoff from the very beginning, and quickly abort if at any point the flight does not attain specific takeoff targets. The takeoff phases to consider are the:

· Pretakeoff phase: Is the airplane properly configured for takeoff with all Before Takeoff checks complete?

· Power phase. Is/are the engine(s) generating the expected level of power?

· Acceleration phase. Is the aircraft accelerating as expected, to lift off in the planned distance?

· Liftoff phase. Does the airplane lift off at the proper speed when and where planned?

· Initial climb phase. Does the airplane attaint the proper pitch attitude and initial rate of climb that’s expected?

If the airplane fails to achieve any of these performance targets, abort the takeoff right away, then take time to sort out the problem after you’ve safely come to a stop. Do you not have a good idea of the expected power output, acceleration, takeoff speed and distance, and initial climb attitude, speed and rate under the existing ground and atmospheric conditions at the airplane’s current weight? Takeoff planning is the epitome of the FAA’s Practical Test Standards completion criteria, that the pilot “demonstrate mastery of the aircraft with the successful outcome of each TASK performed never seriously in doubt.” If you don’t know what to expect from your airplane on takeoff you won’t know when it’s not achieving those goals, and you’ll be caught trying to “will” the airplane to become airborne and climb when preflight calculations and active monitoring during takeoff might have permitted an early, safe abort.)

6/9 1410Z (1010 local): A Be24 “landed with [its] gear not fully extended,” at Augusta, Maine. Two aboard the Sierra were not hurt and damage is “minor”. Weather was 2500 overcast, visibility 10 miles with a four-knot surface wind. N66293 (MC-674) is a 1979 C24R registered since 2006 to a corporation in Augusta.

(“Failure of landing gear to extend due to mechanical failure”—at least this is the most likely interpretation of the report)

UPDATES FROM NTSB

Events previously appearing in the Weekly Accident Update:

**There are no newly posted piston Beechcraft NTSB reports this week.**

SUMMARY: Reported Hawker Beechcraft piston mishaps, year-to-date 2009:

Total reported: 68 reports

Operation in VMC: 47 reports

Operation in IMC: 2 reports

Weather “unknown” or “not reported”: 16 reports

Operation at night: 9 reports

Surface wind > 15 knots: 10 reports

Fatal accidents: 6 reports

“Serious” injury accidents (not involving fatalities): 1 report

“Substantial” damage: 27 reports

Aircraft “destroyed”: 5 reports

Recent registration (within previous 12 months): 8 reports

(Note: FAA preliminary reports no longer identify the purpose of the flight involved in mishap. Consequently the number and percentage of Beech mishaps that occur during dual instruction will become less and less accurate over time. Since the late 1990s the percentage of Beech mishaps that take place during dual flight instruction has remained very consistently about 10%).

By Aircraft Type:

Be36 Bonanza 21 reports

Be35 Bonanza 15 reports

Be33 Debonair/Bonanza 8 reports

Be24 Sierra 6 reports

Be58 Baron 6 reports

Be55 Baron 4 reports

Be19 Sport 3 reports

Be17 Staggerwing 1 report

Be23 Musketeer/Sundowner 1 report

Be50 Twin Bonanza 1 report

Be56 Turbo Baron 1 report

Be60 Duke 1 report

Be76 Duchess 1 report

PRELIMINARY DETERMINATION OF CAUSE (all subject to update per NTSB findings):

LANDING GEAR-RELATED MISHAPS (32 reports)

Gear up landing

15 reports (two Be24s; two Be33s; five Be35s; four Be36s; Be50; Be56)

Gear collapse (landing)

9 reports (Be24; two Be33s; two Be35s; Be36; Be55; two Be58s)

Failure of landing gear to extend due to mechanical failure

3 reports (Be24; Be58; Be60)

Gear collapse during taxi

2 reports (Be24; Be36)

Gear collapse—retract rod failure after improper installation

1 report (Be36)

Wheel failure/separation

1 report (Be33)

Gear collapse on takeoff

1 report (Be35)

...for more on Landing Gear-Related Mishaps see these data and this commentary.

ENGINE FAILURE (12 reports)

Engine failure in flight

4 reports (Be19; Be35; two Be36s)

Engine failure on takeoff

3 reports (two Be35s; Be36)

Fuel starvation

3 reports (Be33; two Be36s)

Piston/cylinder failure in flight

1 report (Be35)

Loss of oil pressure

1 report (Be24)

...for more on fuel management-related mishaps see www.thomaspturner.net/Fuel.htm.

IMPACT ON LANDING (12 reports)

Loss of directional control on landing

3 reports (Be19; Be36; Be58)

Loss of directional control on landing—strong, gusty wind

1 report (Be17)

Hard landing

1 report (Be36)

Hard landing—airframe ice

1 report (Be58)

Landed short

1 report (Be35)

Landed long—runway overrun

1 report (Be33)

Collision with animal on landing

1 report (Be36)

Hard landing—simulated engine failure on takeoff (twin-engine airplane)

1 report (Be58)

Wingtip contact with the runway

1 report (Be58)

Hard landing—landing gear collapse (fixed gear)

1 report (Be19)

CAUSE UNKNOWN (3 reports)

Takeoff/Unknown

1 report (Be19)

Go-around/unknown

1 report (Be35)

Landing/unknown

1 report (Be76)

STALL/SPIN (3 reports)

Stall/loss of control during go-around

1 report (Be55)

Stall/spin during attempted aerobatics

1 report (Be55)

Stall on final approach

1 report (Be33)

CONTROLLED FLIGHT INTO TERRAIN (2 reports)

Airframe ice in cruise—unable to maintain altitude

1 report (Be36)

Attempted visual flight into IMC

1 report (Be36)

MISCELLANEOUS (2 reports)

Wheel/strut failure on landing—fixed gear airplane

1 report (Be23)

Unattended airplane with engine running taxis into obstruction

1 report (Be36)

IMPACT WITH OBJECT DURING TAKEOFF (2 reports)

Loss of directional control during takeoff—strong, gusty wind

1 report (Be55)

Runway overrun during attempted aborted takeoff

1 report (Be35)

LOSS OF CONTROL IN FLIGHT (1 report)

Loss of control: Attempted visual departure in IMC

1 report (Be36)

Recognize an N-number? Want to check on friends or family that may have been involved in a cited mishap? Click here to find the registered owner.

Please accept my sincere personal condolences if you or anyone you know was involved in a mishap. I welcome your comments, suggestions and criticisms. Fly safe, and have fun!

Thomas P. Turner, M.S. Aviation Safety, Master CFI

2008 FAA Central Region CFI of the Year

Mastery Flight Training, Inc.

mastery.flight.training@cox.net

There's much more aviation safety information at www.thomaspturner.net.

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