Mastery Flight Training, Inc. 

Beech Weekly Accident Update archives

August 2008 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!

©2008 Mastery Flight Training, Inc.  All Rights Reserved

NEW REPORTS THIS WEEK

7/21 0930Z (0330 local):  A Be35 landed gear up during a middle-of-the-night landing attempt at Woods Cross, Utah.  The solo pilot wasn’t hurt and aircraft damage is “minor”.  Weather: “VFR”.  N2797T (D-8486) is a 1967 V35 registered since 2006 to a Sandy, Utah-based corporation.

(“Gear up landing”; “Night”)

7/23 1608Z (100 local):  On approach to land at Longmont, Colorado, a Be33’s engine failed and the aircraft landed short of the runway.  From the NTSB preliminary report: “According to the pilot, he was on final approach to runway 29. When he tried to adjust the power setting with throttle, the engine did not respond. He made a forced landing on uneven terrain short of the runway.”  Two aboard the Debonair were not injured.  Damage was “substantial” and weather was “VFR”.  The NTSB appears to suspect fuel starvation: “The pilot told FAA inspectors that when he departed Longmont on July 21, all fuel tanks were full (104 gallons). He flew to Salt Lake City, Utah. The next day, July 22, he flew to Wendover, Utah. The following day, July 23, he returned to Longmont. FAA inspectors reported both tip (auxiliary) tanks were ruptured. The left wing (main) tank was empty, and the right wing tank had 'some fuel.’ There was no fuel odor or stains on the ground.”  N7965M (CE-87) is a 1966 C33A registered since 2001 to a co-ownership in Loveland, Colorado.

(“Fuel starvation” [unless/until we hear otherwise]; “Substantial damage”—Local news shows the airplane after an apparently good, under control, off-airport, gear-up landing.  A log of the trip indicates the Bonanza had been in the air a little over two hours before the engine quit.  A C33A with tip tanks has a fairly complex fuel system that requires preflight planning of a fuel management scheme, in-flight monitoring to confirm a tank with adequate fuel is selected, and ensuring a main fuel tank contains sufficient fuel for approach, landing and if needed a go-around or missed approach and climbout.) 

7/26 1555Z (0955 local):  Two aboard a Be55 were not hurt when it landed gear up at Norfolk, Virginia.  The Baron has “minor” damage.  N955RH (TC-2095) is a 1977 B55 recently (September 2007) registered to a corporation in Poquoson, Virginia.

(“Gear up landing”; “Recent registration”)

7/28 1315Z (1015 local):  A Be95 “crashed while inbound with [an] unsafe gear indication,” a Carolina, Puerto Rico.  Two aboard the Travel Air avoided injury and damage is “minor”.  Weather: “few clouds” at 3000 feet, 4000 scattered, visibility 10 miles with a seven-knot wind.  N212GM (TD-529) is a B95A, year not reported, registered since 2002 to a corporation based in St. Thomas, Virgin Islands.

(“Gear collapse on landing—known mechanical system failure”—despite the unusual phraseology of the preliminary report’s description, given the minor damage incurred this sounds like a gear collapse and not some other type of “crash”).

7/28 1834Z (1134 local):  On takeoff the nose gear of a Be36 collapsed, at Bakersfield, California.  The solo pilot was not hurt and aircraft damage is “minor”.  Weather conditions were “not reported”.  N819LA (E-2689) is a 1994 A36 registered to an airline ab initio training program incorporated in Torrance, California.

(“Gear collapse on takeoff”—it’s likely this resulted from an inadvertent pilot activation of the landing gear switch during the takeoff portion of a touch-and-go…an operation the frequently correlates with landing gear-related mishaps.  There’s much to do during a touch-and-go, making it more likely the pilot may move the wrong control.  As we’ve seen before, squat switches may not protect you against this improper gear selection.  Instructors commonly recommend against touch-and-goes in retractable gear airplanes, especially during solo pilot operations.)

7/29 1351Z (0651 local):  “On landing,” a Be23 “bounced and skidded off the runway” at Flagstaff, Arizona.  The solo pilot was not hurt and damage is “minor”.  Weather:  “clear and 10” with a six-knot wind.  N23966 (M-1996) is a 1977 C23 registered since 2006 to a co-ownership in Glendale, Arizona.

(“Bounced landing”)

7/31 1700Z (1100 local):  A Be33’s engine failed on takeoff at Thompson Falls, Montana.  The pilot then landed gear up.  Three aboard were not injured despite “substantial” aircraft damage.  Weather was “clear and 10” with a seven-knot surface wind.  N668V (CD-92) is a 1960 35-33 recently (April 2008) registered to an individual in Surprise, Arizona.

(“Engine failure in takeoff”; “Substantial damage”; "Recent registration")

7/31 1945Z (1445 local):  The pilot of a Be33 reported an engine failure in flight, then force-landed in a field near Mokan, Missouri.  Four aboard were not hurt and there was no reported damage.  Weather was “not reported”.  N9348Y (CD-256) is a 1960 A33 registered since 1992 to a corporation in Naperville, Illinois.

(“Engine failure in flight”)

8/1 0014Z (2014 local 7/31/2008):  A Be35’s nose gear collapsed on landing at Miami, Florida.  The solo pilot was not injured; damage is “unknown” and prevailing weather “not reported”.  N7978D (D-5230) is a 1957 H35 registered since 2006 to a corporation in Miami.

(“Gear collapse on landing”)

8/1 1447Z (1047 local):  On landing at Morristown, New Jersey, a Be35’s nose gear collapsed.  Two aboard weren’t hurt; damage is “unknown” and weather “not reported”.  N2707V (D-83) is a 1947 Model 35 registered since 1987 to an individual in Toms River, New Jersey.

(“Gear collapse on landing”)

8/2 1800Z (1400 local):  A Be35 landed gear up at Bay City, Michigan.  Three aboard avoided injury despite “substantial” aircraft damage.  Sky conditions were 3400 scattered with 10 miles’ visibility; winds were calm.  N5430D (D-4945) is a 1957 H35 registered since 1986 to an individual in Beaver Island, Michigan.

(“Gear up landing”)

8/3 1510Z (1110 local):  A Be23 was “destroyed” by fire after the pilot “landed hard” and the “nose gear collapsed,” at Winter Haven, Florida.  The solo pilot avoided reportable injury.  Weather was “clear and 10” with an eight-knot surface wind.  N9194S (M- 1678) was a 1975 C23 recently registered to an individual in Callahan, Florida.

(“Hard landing”; “Aircraft destroyed”; “Recent registration”—some airplanes, such as this Beechcraft, are very nose-heavy when flown solo or with occupants only in the front seats [Of the four “hard landing” Beech mishaps reported so far this year, three involved Musketeers].  Nose-heavy airplanes tend to “run out of elevator” if permitted to get too slow on final approach; from this condition does not have control authority to resist a nose drop if the airplane flares or stalls too high above the runway. A hard landing might also result from failing to flare at all and “driving” the airplane into the ground.

Final approach airspeed control is vital in all types of airplanes and may be critical in some depending on their c.g. location and the size and location of their control surfaces.  Practice precise airspeed control for those unusual situations when it becomes critical in the airplane you’re flying, and be ready for a go-around if airspeed decays below your target in the final, stabilized portion of your approach.  Calculate not only your takeoff c.g. location but your expected landing condition c.g. also, to gauge the level of stability and controllability you’re likely to experience on landing and make decisions about close-to-the-edge conditions.  Remember the FAA guidelines for evaluating airspeed control on final is +10 knots above calculated approach speed, and -5 knots below the target speed.  Exceed that tolerance within, say, 500 feet of the ground, and the Practical Test Standards [and evidence from events like this and the double-fatality Lancair Legacy stall/crash at this year’s Oshkosh] strongly suggest you should immediately initiate a go-around instead of attempting to recover and continue the landing.)

8/5 1402Z (1002 local):  Two aboard a Be35 suffered “minor” injuries when their Bonanza crashed onto a road next to the runway immediately after taking off from Lockport, New York.  The airplane has “unknown” damage.  Weather: “few clouds” at 10,000, visibility 10 miles with a surface wind at four knots.  N5208C (D-2553) is/was a 1950 B35 registered since 2006 to a co-ownership based in Lometa, Texas.

(“Takeoff/unknown”)

UPDATES FROM NTSB: Incidents previously appearing in the Weekly Accident Update:

**6/27 F33A loss of control in a crosswind landing at Pine Mountain Lake, CA.  “The pilot reported that he performed a landing approach to runway 9 at Pine Mountain Lake Airport. During the landing flare, a wind gust blew the airplane off the runway centerline flight path. The airspeed was too low to perform a go-around, so he attempted to regain the runway centerline. The airplane touched down while moving laterally, and the landing gear became side loaded and collapsed. The airplane exited the runway and stopped. The wings sustained substantial damage.  The pilot reported gusts of 10 knots at the accident site.  Change “Weather not reported” to “VMC”**

**7/23 C33A engine failure on approach to Longmont, CO, cited above.**

FROM UNOFFICIAL SOURCES

A reader from Israel reports:  8/7 (time note reported):  “There was a fatal Bonanza accident at Haifa airport.  A civil A36 failed to go around and crashed into an abandoned shack. Three out of four crew members were killed, the fourth is severely wounded. From the information gathered so far it seems there was no problem with the aircraft and the engine was in full power during the crash. The investigation is still being carried out, I'll keep you updated when I know more.”  Aircraft registration and serial number are not known, and weather conditions appear not to have been a factor.

(“Landed long/failed to go around”; “Fatal”; and [I assume at least] “Substantial damage”—thanks, reader, for your report).

NEW REPORTS THIS WEEK

8/6 1315Z (0815 local):  On a “training” flight, a Be23 “landed hard and [its] gear collapsed,” at Augusta, Kansas.  Three aboard the Musketeer were not hurt despite “substantial” aircraft damage.  Weather conditions were “not reported” but local weather was VMC all day.  N24598 (M-1419) is a 1972 C23 registered since 1986 to a corporation in Wichita, Kansas.

(“Hard landing”; “Substantial damage”; “Dual instruction”—last week’s FLYING LESSONS report discussed the need for proper airspeed control on landing, and noted that [including this week’s event], of six total “hard landing” mishaps reported so far this year, four have been in Be23s.)

8/6 2130Z (1730 local):  During a “training” flight, a Be76’s landing gear collapsed on the runway at Winder, Georgia.  The two aboard were unhurt and damage is “minor”.  Weather: “VFR”.  N6716L (ME-326) is a 1980 Duchess registered since 1995 to a Chamblee, Georgia-based corporation.

(“Gear collapse on landing”; “Dual instruction”—another in the very common correlation between flight instruction and landing gear-related mishaps, this is a reminder to student and instructor alike that the risk of LGRMs is high during flight training.  As safety manager for the flight, the instructor should ensure the pilot maintains landing gear discipline.  Mastery Flight Training’s research suggests pilots should avoid touch-and-goes and instead make all landings to a full stop, even during training, and that reconfiguration [retracting flaps, etc.] should be delayed until the airplane is slowed to taxi speed or even stopped, giving the pilot [and instructor] time to positively identify cockpit controls before moving them.  Gear collapses from side loads sometimes also occur when the instructor “pulls an engine,” or simulates engine failure on the runway for purposes of training.  So instructor and student need to cover the proper Engine Failure on the Runway technique prior to practice in the airplane, and the MEI is responsible for ensuring all intentional “engine cuts” are done on wide runways with the airplane below 50% V_MC speed per recommendations in the FAA Practical Test Standards.  For more on avoiding pilot error LGRMs see the Mastery Flight Training DVD Those Who Won’t: Avoiding Gear Up and Gear Collapse Mishaps.)

8/10 1450Z (0750 local):  A Be35’s “engine failed and [the pilot] force landed in a field” near Oregon City, Oregon.  Three aboard were not hurt and the off-airport landing was executed with no damage to the airplane.  Weather was “few clouds” at 5000, 6500 broken 8000 broken, with 10 miles’ visibility and a seven-knot surface wind.  N8274D (D-5364) is a 1957 J35 registered since 1999 to a co-ownership in Yuma, Arizona.

(“Engine failure in flight”—and what sounds like a masterful job of getting down safely)

8/11 0030Z (1930 local 8/10/08):  A Be35’s nose gear collapsed on landing at Spirit Lake, Iowa.  The solo pilot was not hurt despite “substantial” aircraft damage.  Weather was “clear and 10” with a nine-knot wind.  N9839R (D-6367) is a 1060 M35 registered since 1999 to a co-ownership in Council Bluffs, Iowa.

(“Gear collapse on landing”)

8/11 0040Z (1640 local 8/10/08):  Two died when a Be55 “crashed into the side of a mountain” 47 miles from Biorka Island, Sitka, Alaska.  The Baron was “destroyed”.  Weather conditions were “not reported”.  N98HA (TC- 2111) was a 1978 B55 registered since 2005 to a corporation in Brevard, North Carolina.

(“Controlled flight into terrain—cruise flight/mountainous terrain” [at least for now]; “Fatal”; “Aircraft destroyed”—unconfirmed local reports suggest fuel starvation or exhaustion may have been a cause.)

8/12 1417Z (1017 local):  Three aboard a Be35 died when the Bonanza crashed “under unknown circumstances” into a mall parking lot at Easton, Massachusetts, while attempting the ILS 4R approach at Logan International Airport, Boston, Massachusetts.  The Bonanza was “destroyed” in a post-crash fire.  Weather was 1100 broken, 2000 broken, 5500 overcast, with visibility eight miles in light rain and an eight-knot surface wind.  N4615D (D-4807) was a 1956 G35 registered since 1992 to an individual in Brookfield, Connecticut.  

(“Loss of control on instrument approach” [see NTSB comments]; “Fatal”; “Aircraft destroyed”; “IMC” [at the altitude where control was lost]— ATC audio records indicate everything seemed normal until the Bonanza was directed to intercept the localizer.  It flew level through the localizer and was vectored for another intercept.  Shortly after the pilot acknowledged the re-intercept heading the controller issued a series of Low Altitude Alerts, radar indicating its altitude as low as 1200 feet in an area where 3000 feet was the assigned altitude.  The Bonanza’s “altitude went up and down, up and down, then off radar,” the controller later told an airline crew when asking if the crew heard an ELT signal [which it had not].

During vectors one controller asked the pilot what “level of priority” was assigned to the Angel Flight volunteer patient transportation flight.  The pilot responded “low,” meaning he at least said he felt no extra pressure to conclude the trip.  This does suggest, however, that [unless the controller was mistaken that such priorities exist] Angel Flight might at times assign a higher priority level to so-called “mission pilots”—a designation that might support acceptance of undue risk by suggesting the trip is something more than a Part 91 personal flight that just happens to be carrying a stranger with a medical condition, from a pilot decision-making standpoint.

NTSB held a live press conference [which I followed live] from the scene of the crash on Wednesday afternoon, August 13th.  In that briefing a Mr. Monville of NTSB said that preliminary information is the Bonanza was being vectored for the approach when the airplane went through several altitude "deviations".  According to the briefing, a witness on the roof of a building near the point of impact said the airplane was “circling” and “flying low,” passing between two mall buildings before “descending vertically” into the pavement.  A pilot-rated witness about half a mile from the crash reports the airplane “descended vertically” out of the base of the clouds, which the witness estimated to be at “800 feet”.  The engine sounded as if it “was running fine,” according to the pilot-rated witness.  “The airplane impacted right wing first, rotating 48º, then came to rest upright” as a post-crash fire erupted, Monville reported.

NTSB cautions that all information is preliminary.  It is investigating pilot history, aircraft maintenance records, and operations practices of Angel Flight, according to Monville.    He ended by saying that this and other fatal Angel Flight mishaps in recent weeks are focusing Federal attention on charitable air transportation organizations.

Loss of control followed a pattern consistent with pilot disorientation, such as when distracted in IMC.  A common error that could lead to such distraction is failure to load and arm an instrument approach into a GPS, with fixation on programming the GPS once the omission was discovered.  If the pilot was employing an autopilot in the Approach mode, which would be expected when on a vector to intercept the localizer, attempting to reprogram the GPS could provide unexpected autopilot responses to the interrupted signal. 

It’s not know whether this airplane was equipped with or using a GPS and/or an autopilot, but some GPS models require proper set-up even if using a traditional localizer and glideslope for approach guidance   Failure of one or more flight instruments may also be a possibility, if the pilot did not recognize the failure and was unable to successfully transition to partial-panel flight. Although some radio calls were missed, prompt and clear transmissions from the pilot up to very near the time the airplane descend below radar do not seem to suggest a medical or incapacitation issue. 

Notification by ATC that the pilot had flown through the localizer appears to have been the “trigger event” that led to loss of control; on the basis of my experience as an instructor pilot, if I had to guess [and that’s all it is, a guess], I’d say it’s far more likely that pilot distraction during a cockpit automation misprogramming issue, triggered by an unexpected continuation on altitude and heading through the localizer, was a proximate cause than a flight instrument that permitted precise flight up to the point of ATC’s call that the pilot had flown through the localizer failed at the moment the pilot was attempting to turn back on ATC’s direction.

Whether this is the cause of this mishap we may never know—remember, we don’t even know yet if the airplane had a GPS or an autopilot.  Regardless, it serves to point out the need for precise guidance for set-up of aircraft and navigational systems for an instrument approach.  My September 2008 Aviation Safety article is titled “Forget the Checklist”, and describes techniques for training to assure you do things right in those cases when there’s no time to reference a checklist.  But approach set-up is not one of those times; arguably briefing and configuring for an instrument approach carries the most critical need for referencing a printed checklist of any flight operation.  Yet almost no aircraft manufacturer provides an Approach checklist in its flight manual.  Just as well, because an Approach checklist would have to be highly customized to the individual airplane, updated as needed as pilot experience or panel upgrades change the flow of events.  The challenge, however, is to create a printed Approach checklist specific to the airplane you fly, and more importantly, to use it every time you prepare for an instrument approach.)

UPDATES FROM NTSB: Events previously appearing in the Weekly Accident Update:

** The 6/1 E18S loss of directional control on landing at Guyon, KS now has a final, “probable cause” report.  The National Transportation Safety Board determines the probable cause(s) of this accident as follows:  “The pilot's failure to maintain directional control during landing roll out. Contributing to the accident was the crosswind.”  Change “Weather not reported” to “VMC”.** 

** 6/5 Baron 58 wing explosion during the takeoff roll at Jackson, MS.  “According to the pilot, after being cleared for takeoff, he turned on the landing lights and strobes. During the takeoff roll, [at] about 50 knots, he glanced to check the engine gauges just before rotation. He then heard an "explosion" and could feel a thud in the rudder pedals (like he had hit a runway centerline light). He immediately looked up and saw the damage on the left wing with black smoke coming out a hole in the wing. He closed the throttles and started to slow the airplane. As the airplane was slowing down, fire was observed coming out of the wing. The pilot stopped the airplane, exited and put out the fire with the onboard fire extinguisher.

”Examination of the airplane found that about 37 inches of the outboard left wing and wing tip remained attached, but exhibited compression buckling and fire damage. The upper wing skin panel, located inboard of the wingtip, was bent upward, which sheared four rivets on four ribs. The landing light remained attached by the outboard side of the mounting bracket. The landing light ground and power leads exhibited sooting, and the protective plastic coating was destroyed by the fire, leaving the wires exposed. The ground wire remained connected and intact. The landing light power wire was separated and the exposed end of the wire exhibited melting, and there was evidence of arcing that existed along the base of the structure ("lightening hole") and adjacent interior upper wing skin.

”The left strobe light remained intact and attached to the cannon plug. It exhibited thermal damage and the shield was partially melted. The outboard leading edge fuel cell was removed to facilitate a leak check. The fuel cell was pressurized with a regulated air source and checked for external leaks. An air leak was found on the aft side of the fuel cap assembly, at the interior fuel placard mounting rivets. Upon further examination, the fuel full placard and rivets were found to be loose when moved by hand. No visible fuel leaks or staining was observed around the vents or sump drains of the airplane. The fuel pump or fuel strainer did not exhibit any leaks or staining.** 

** The 6/15 S35 fuel exhaustion event at Creola, AL now has a final, “probable cause” report.  The pilot reports he “climbed to his cruising altitude, and flew on the right main fuel tank until the fuel was exhausted. He switched the fuel selector to the left main fuel tank and requested a lower altitude from air traffic control (ATC). During the approved descent the engine lost power. He turned on the boost pump and the engine continued to windmill. The pilot stated that he did not engage the starter because he expected the engine to start. He switched the fuel selector back to the right main fuel tank, then left main fuel tank, and back to the right main fuel tank. The engine did not start and the left main fuel tank gauge indicated low. He checked the global position system for the nearest airport, cancelled his instrument flight plan with the air traffic controller, and continued direct to the airport, entering a left downwind while descending. The engine attempted to start and stopped.”  Three aboard the Bonanza suffered “minor” injuries.   

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:  “The pilot's inadequate fuel calculations resulting in a total loss of engine power due to fuel exhaustion.”** 

** The 6/26 A36 runway overrun on takeoff at Ryegate, MT now has a final, “probable cause” report.  “The pilot reported that prior to departure he checked the weather and performed a preflight inspection. He observed the direction of the windsock, and stated that it favored a takeoff from runway 23. He completed an uneventful run-up, and began the takeoff roll. Halfway down the turf runway he observed the airplane's airspeed to be indicating 60 knots. He stated that at this point on the takeoff roll he expected the airspeed to have reached 70 knots. The airplane continued to accelerate to 65 knots, and with the end of the runway approaching, the pilot 'forced' the airplane airborne and retracted the landing gear. The airplane settled to the ground and then collided with trees at the end of the runway. The pilot observed the wind direction after the accident, and noted that it was out of the northeast. He opined that the airplane had encountered a sudden wind shift or downdraft during the takeoff roll.”  One aboard the Bonanza suffered “minor” injuries. 

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: “The pilot's failure to abort the takeoff when the ground roll acceleration profile was determined to be insufficient for takeoff. Contributing to the accident was the shifting wind conditions.”** 

** The 6/27 F33A loss of directional control on landing at Groveland, CA, now has a final, “probable cause” report.  “During the landing flare, a crosswind gust blew the airplane off the runway centerline path. The airspeed was too low to perform a go-around, so the pilot attempted to regain the runway centerline. The airplane touched down while moving laterally, and the landing gear became side loaded and collapsed. The airplane slid off the runway and stopped.  The pilot reported gusts of 10 knots at the accident site.”

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:  “The pilot's inadequate compensation for the gusty crosswind conditions and failure to maintain proper alignment at touchdown resulting in a side load on the landing gear, which caused them to collapse.”** 

** 6/29 A23A fuel starvation event at Sheboygan, WI.  “The pilot reported that he departed with 30 gallons of fuel onboard. He estimated that the right and left fuel tanks contained 20 gallons and 10 gallons, respectively. The pilot reported that the accident flight was 2 hours 20 minutes in duration. While on final approach the engine lost power and the airplane impacted a 6 foot wide drainage ditch. The airplane sustained damage to the left wing, the lower fuselage structure, and the nose and left landing gear. Post accident inspection of the airplane showed that the right tank was empty and there was fuel present in the left tank. The pilot reported that he planned on a fuel burn rate of 8-1/2 gallons per hour. Using that fuel burn, the calculated fuel consumption for the accident flight was 19.8 gallons. The pilot said the accident could have been prevented if he had switched fuel tanks before the loss of engine power.”  Two aboard suffered “minor” injuries; remove “Serious injuries” from the record.**

** 7/1 A36 engine failure near Dwight, IL.  During initial descent the pilot selected the right fuel tank for the practice instrument approach procedure. Visual meteorological conditions prevailed at the time. The pilot performed a procedure turn to align with the instrument approach. The engine lost power while turning inbound onto the final approach course. The airplane was at 2,300 feet mean sea level (~1,600 feet above ground level) when the engine lost power. The pilot switched back to the left fuel tank but the engine did not respond. The pilot performed a forced landing onto Interstate Highway 55. During landing rollout the right wing impacted a mile-marker signpost. A post-accident investigation showed that the left and right fuel tanks were approximately 1/8 and 1/2 full, respectively. No anomalies were encountered during a post accident engine test run.”  Add “Substantial damage”.** 

** 7/8 Beech Staggerwing nose-over on landing at Hubbard, OR.  The pilot indicated that he believes he began braking slightly early, before the tail was firmly on the ground. As the airplane decelerated, the tail rose until the propeller impacted the ground. Thereafter, the airplane nosed over and stopped in an inverted attitude. The pilot indicated that the airplane and engine had no mechanical failures or malfunctions during the flight.  One aboard the flight suffered “minor injuries”.**

** 7/17 triple-fatality A36 collision with the glideslope antenna tower on takeoff from Tampa, FL.  “A witness stated he was driving southbound on I-75, adjacent to Vandenberg Airport. The accident airplane was observed taking off on the last one-third of the runway. The airplane landing gear was retracted, and the airplane drifted to the left off the side of the runway. The right wing tip of the airplane collided with a pole; and the airplane cart wheeled to the right, collided with the ground right side up, and immediately caught on fire. The witness reported a light rain and no noticeable wind.”** 

NEW REPORTS THIS WEEK

8/14 1432Z (1032 local):  A Be58 “crashed under unknown circumstances in a field near Marysville, Ohio,” killing the solo pilot.  The airplane has “unknown” damage.  Weather was “clear and 10” with unreported surface winds at the time of the mishap.  N715TB (TK-127) was a 1980 B58TC registered since 1980 to a corporation in Dublin, Ohio.

(“Takeoff/unknown”; “Fatal”; “Airplane destroyed” [from the news photo]—according to a local news report, the pilot “attempted to return to the Union County Airport around 10:30 Thursday morning because of a mechanical problem with his plane. But the…1980 multi-engine Beechcraft didn't make it and crashed in a soybean field near the runway, then burst into flames.”   The aircraft landed upright “less than a mile” from the runway, according to another report.  Although the pilot may have been returning for any number of possible reasons [instrument issues, door open in flight], the words “mechanical problem” in such reports usually denote something wrong with an engine.  The news photos are not sufficient to see the condition of the propellers to see whether the prop tips are bent forward [producing thrust during horizontal ground contact] or bent back [windmilling; not producing power].  The devastating fire indicates plenty of fuel was on board, although it’s not known whether fuel selectors were pointed to tanks with fuel, or if for some other reason fuel was contaminated or unable to make if from the tanks to the engines. 

Faced with a distraction event immediately after takeoff—even an engine failure—in almost all cases the best course of action is to climb straight ahead to pattern altitude if remaining power allows, before attempting any maneuver back to the airport.  If launching IFR into clouds you may want to climb ahead even higher, although safely doing so requires you pre-plan a safe climb route based on the climb gradient possible with partial power.

Even turboprops and jets, with tremendous power-to-weight ratios, have fatally crashed because the pilot was in too great a hurry to make it back to the runway.  It’s not loss of performance per se that has brought these airplanes down, but loss of pilot discipline to continue flying under the influence of distraction and imprudent action. 

Consider that, lightly loaded [as was this Baron] it still might take several miles to climb at “blue line” speed to pattern altitude [if in fact the “mechanical” problem was with an engine].  On every takeoff consciously commit yourself to climbing to a safe altitude before beginning any turns, if performance exists after you’re faced with an abnormality or emergency just after liftoff.)

8/14 1640Z (1240 local):  A Be55’s gear collapsed during a landing at Baltimore, Maryland.  Two aboard the Baron were not hurt; damage is “unknown”.  Weather was “few clouds” at 4500, 18,000 scattered, visibility 10 with calm surface winds.  N2057W (TE-24) is a 1965 C55 registered since 2000 to a co-ownership based in Ridgefield, Connecticut.

(“Gear collapse on landing”—although the record shows that most landing gear-related mishaps [LGRMs] appear to be pilot-induced, expert mechanics tell me they frequently find landing gear systems excessively worn, improperly rigged, or with up- and down-tensions far outside tolerances, either too loose [little resistance to folding up] or too firm [placing excessive stress on the gear, leading to fatigue damage].  As airplanes accumulate flight hours [in other words, fatigue exposure] decades-old prevailing wisdom about landing gear inspection and maintenance becomes less and les valid.  The old adage “if it ain’t broke, don’t fix it” does not work with retractable landing gear systems.  It take proactive maintenance before trouble occurs, not repairs or adjustments after a problem shows up, to avoid a mechanically induced gear collapse or gear up [i.e., broken and won’t go down] event.  Adhere to the manufacturer’s recommendations for landing gear inspection, servicing and component overhaul or replacement, as found in the aircraft maintenance/shop manuals and the Handling, Servicing and Maintenance section of the Pilot’s Operating Handbook.  Contact users groups and other experts on your landing gear system to learn what commonly breaks on your landing gear system, and how to proactively avoid failure.  Properly caring for your landing gear system may seem time-consuming and expensive, but consider the time lost and expense incurred if the landing gear system fails to fully extend, or collapses during takeoff or landing.)

8/18 1250Z (0850 local):  A Be35 landed gear up at Macon, Georgia.  The two aircraft occupants weren’t hurt and damage is “minor”.  Weather was “not reported”.  N8915A (D-2615) is a 1950 B35 registered since 1998 to an individual in Arlington, Texas.

(“Gear up landing”)

8/18 2100Z (1700 local):  A Be36 struck a deer on takeoff at Brooksville, Florida.  The two aboard the Bonanza were not hurt; damage is “unknown”.  Weather: “few clouds” at 6500, visibility 10 miles, with a four-knot surface wind.  N798GM (E-3184) is a 1998 A36 registered since 2005 to a Clearwater, Florida corporation.

(“Impact with object/animal during takeoff”)

UPDATES FROM NTSB: Events previously appearing in the Weekly Accident Update:

** 8/5 B35 collision with obstacles on takeoff from North Buffalo Suburban Airport, Buffalo, NY.  “The pilot stated…all of the airplane's fuel tanks were filled prior to departing on the accident flight. During the engine run-up and magneto check, he did not note any abnormalities. About the mid-point of runway 28, during the takeoff, the pilot stated that ‘something didn't feel right,’ and that the engine did not seem as if it were ‘making full power.’ He lifted the airplane off the runway at 65 [knots] indicated airspeed, and the airplane acted like it ‘was going to go.’ The airplane then settled back down, before it again ‘felt like it would go,’ so he then retracted the landing gear.

”Shortly thereafter, he noticed that the engine was losing power, and the tachometer was slowly decreasing from 2,600 rpm to 2,400 rpm. The pilot further noted that the power loss was gradual, and that the engine never ‘coughed’ during the entire accident sequence. Seeing that the trees at the end of the runway were ‘coming up quicker’ than the pilot wanted them to, he veered the airplane off the left side of the runway toward a road. The airplane continued to settle onto the ground, and the pilot reduced the throttle to idle. The airplane struck a road sign and fire hydrant, resulting in substantial damage to the fuselage, before coming to rest….  North Buffalo Suburban Airport [has] a single 2,830-foot long by 50-foot wide asphalt runway, with 50- to 65-foot-tall trees located 85 to 105 feet from the departure end of runway 28.”

Any failure to accelerate as planned or indication of engine hesitation or power loss on takeoff is grounds for immediately aborting the takeoff.  Once you’ve stopped safely you can troubleshoot the indications and, unless you find and correct an obvious cause, such as an improperly set mixture control or an out-of-detent fuel selector, take the airplane to a mechanic before attempting flight again.  Don’t let “get-home-itis” draw you into trying to continue the takeoff in the hopes everything will turn out okay, because [as in this case] abnormalities rarely cure themselves, and “hope” is not an effective risk management strategy.  Change “Takeoff/Unknown” to “Runway overrun—failure to abort takeoff” and add “Substantial damage”**

** 8/10 double-fatality B55 crash into a mountain near Sitka, Alaska.  The NTSB report describes a dream vacation that became an in-flight nightmare.  “Before arriving in Gustavus, [Alaska] the flight had departed Bellingham, Washington… about…1539 Alaska daylight time. The purpose of the stop in Gustavus was to purchase fuel before continuing on to Skagway, Alaska, the flight's final destination….

“NTSB…reviewed the air traffic control radio communication recordings…. The recordings revealed that about 2005 [about 4 ½ hours after takeoff] the pilot…ARTCC…and reported that he was about 14 miles southeast of Gustavus, at 6,000 feet msl. The pilot requested the GPS "Y" approach to Runway 29 at Gustavus, and his request was granted. About 2020 [4 hrs 41 minutes after takeoff] the pilot contacted [ATC] to report that he had landed at Gustavus, and that he wanted to cancel his IFR flight plan.

”About 2051, the pilot again contacted [ATC] to report that he had departed the Gustavus Airport, and said, in part: ‘I went into Gustavus to get fuel, but there's nobody there... I'm going to Sitka... I hope we have enough fuel.’”  [Again, “hope” is never an effective risk management tool—MFT].

“When [ATC] asked the pilot how much fuel he had remaining, he reported that he had ‘about an hour.’ The ARTCC specialist asked the pilot if he wanted to return to the Gustavus Airport, and the pilot responded by saying: ‘No, everything is locked up there.’ The ARTCC specialist then asked the pilot if he would like to go to the Juneau International Airport, or continue to Sitka Airport as he originally requested [The Juneau International Airport is about 41 miles east of the Gustavus Airport, and the Sitka Airport is about 95 miles south of the Gustavus Airport]. The pilot elected to go to Juneau.

”As the flight neared Juneau, while operating in instrument meteorological conditions (IMC), the ARTCC specialist issued the pilot a clearance for the Localizer-Type Directional Aid (LDA) approach to Runway 08. However, during the initial stages of the approach, the pilot appeared to be unsure about the LDA approach procedures, and he was unable to join the localizer for Runway 08. The ARTCC specialist instructed the pilot to discontinue the approach, and climb the airplane. The ARTCC specialist then asked the pilot if he wanted to try another approach to Juneau, return to Gustavus, or continue to Sitka. The pilot stated that he wanted to proceed to Sitka. When the ARTCC specialist asked the pilot how much fuel he had remaining, and the pilot said, in part: ‘...looks like we have about an hour... about an hour and ten minutes of fuel.’

”As the flight neared Sitka, about 2036 [sic, this should be 2136], the ARTCC specialist attempted to contact the pilot to request a better estimate of his remaining fuel, and initially there was no response. About 2038 [sic, 2138, or 5 hrs 59 minutes since refueling, including two departure climbs and a climb after abandoning the approach], the pilot's garbled response was: ‘Looks like we're having trouble with our left engine.’ No further communications were received from the accident airplane, and the airplane did not arrive at Sitka. The airplane was officially reported overdue at 2202….  An Alaska State Trooper that was dispatched to the accident site reported that when he arrived on scene, the airplane's fuel tanks were empty.”

These needless deaths teach several lessons:

·         Do not attempt to fly anywhere near the maximum endurance of your airplane when going into areas with few available airports, or when poor weather is widespread in the area of your destination.  “Poor weather” generally includes widespread IMC for an IFR-current pilot flying an IFR-capable airplane in daylight, or widespread Marginal VFR at night.  “Poor weather” consists of widespread Marginal VFR for pilots flying VFR, or any marginal VFR if flying visually at night.  You never know when some unforeseen event (worsening weather; a closed runway from an all-too-common gear up landing or some other event outside your control; animals you can’t scare off the runway; etc.) will close your intended airport, requiring you to fly to an alternate with the fuel you have remaining.  See the Categorical Outlook Flying weather go/no-go decision-making matrix, on the Tools for Flying Safety page of www.thomaspturner.net. 

·         If you have any doubt about the amount of fuel remaining in the tanks, land at the nearest suitable airport…whether or not you’ll immediately be able to refuel after you land.

·         If controllers begin to ask you about your fuel state, take that as a sign that you need to get on the ground NOW.

·         Carry extra food, water and survival gear in case you land at a remote airport expecting to top off, only to find the airport abandoned, employees gone for the day, the fuel pump broken, or fuel unavailable for any other reason.  Your life may depend on camping out until you can get more fuel…and in turn, on the sustenance and shelter you bring with you.

·         Consider the extra fuel burn from climbs and missed approaches when calculating fuel remaining in a low-fuel emergency.

·         If you find yourself aloft in a minimum fuel state reduce power for maximum range to get to the nearest airport.  Lean aggressively so long as your mixture continues to support smooth power.

·         If you ever find yourself saying “I hope this works out,” “I hope the weather improves,” “I hope I have enough fuel,” know that your subconscious is warning you “This probably won’t work out,” “the weather’s dangerous,” or “You’re running out of fuel”.  Heed your mind’s warning and choose the nearest airport accordingly.

Endurance (top) and Range (bottom) profiles for a 136-gallon B55 Baron.  Note that both maximum range and endurance result from very low power settings.  Range generally improves with altitude, assuming you’re not fighting headwinds and you don’t have to burn extra fuel to climb to a higher altitude.  Endurance decreases with altitude to the point where full throttle provides the manifold pressure needed for a given percentage of power, but then increases sharply. 

These charts assume a 25˚F rich of peak EGT power setting; a lean of peak EGT setting will reduce fuel flows dramatically, as well as reduce power approximately 10% compared to the same manifold pressure and RPM if leaned on the rich side of peak EGT. 

Note the times and distances derived from these charts include fuel burned during start, climb and one climb to altitude, with a 45-minute reserve remaining when the computed time/distance is reached.

I discussed (by email) this NTSB report with veteran Alaskan pilot Bill Compton, who has flown light piston airplanes over extremely long overwater distances numerous times.  Bill provides these insights:

Wow, Tom, what a tragic scenario.

I have long suspected that many fuel exhaustion and CFIT occurrences are related to uncertainty of fuel reserves.  How terrifying it must be to find oneself in weather, in a twin with uncertain fuel, unable to decipher an approach and pinning hopes on making it on luck to a destination probably beyond fuel range.

Max range procedures would be helpful in such a situation.

The LDA Rwy 8 approach at Juneau is not simple. Before it had a DME added to the LDA, it claimed an Alaska 727, a Lear, and an Air National Guard King Air.  [Minima are extremely high also, likely because of terrain clearance necessary on the missed approach—tt].

I would bet this accident could make a dynamite article for you. There probably is a combination of factors including: mountains, fuel uncertainty, inadequate fuel planning, pilot aging, instrument competency, hypoxia, confusion, failure to adequately assess the Juneau approach before departure, inadequate briefing before take off from Gustavus, poor decision making. It could stir up some insight for a lot of [pilots] used to lots of airports close together in non mountainous terrain.

Thanks, Bill, for your additions to the discussion.  Expect a more traditional article on this in a future issue of an aviation publication.  Change “Controlled flight into terrain—cruise flight/ mountainous terrain” to “Fuel exhaustion” and “Weather not reported” to “IMC”.**

NEW REPORTS THIS WEEK

8/23 1430Z (0930 local):  A Be35 landed gear up at Sherman, Texas.  The pilot, alone in the airplane, reports no injury; aircraft damage is “minor”.  Weather: “clear and 10” with calm winds.  N5355E (D-5882) is a 1959 K35 registered since May 2007 to an individual in Howe, Texas.

(“Gear up landing”)

8/23 1655Z (1255 local):  A Be55 landed gear up at Ocean City, Maryland.  The solo pilot wasn’t injured.  Damage to the Baron is “unknown”; weather was “few clouds” at 3700 feet, visibility 10 miles with a nine-knot surface wind.  N2031A (TE-741) is a 1969 D55 registered since 1979 to an individual in Frederick, Maryland.

(“Gear up landing”)

8/24 0445Z (2145 local 8/23/2008):  A Be35 landed gear up at Stockton, California.  The solo pilot was not hurt; damage is reported to be “minor”.  Weather conditions were “not reported”.  N354DG (D-5573) is a 1958 J35 registered since early 2007 to an individual in Stockton, California.

(“Gear up landing”)

UPDATES FROM NTSB: Events previously appearing in the Weekly Accident Update:

** 8/12 triple-fatality G35 loss of control while attempting to intercept an ILS approach course, at South Easton, MA. **

** 8/14 fatal 58TC apparent stall while attempting to return to land at Marysville, OH, with an unstated emergency condition that began almost immediately after takeoff.  Change “Takeoff/Unknown” to “Stall on landing—returning with unidentified urgency”. **

SUMMARY: Reported Hawker Beechcraft piston mishaps, year-to-date 2008:

Total reported:  150 reports 

Operation in VMC: 99 reports   (67%)  

Operation in IMC:    6 reports   (4%)  

Weather “unknown” or “not reported”:  45 reports

Operation at night:  12 reports  (8%) 

Surface wind > 15 knots:  13 reports  (9%)             

Fatal accidents: 18 reports   (12%)  

“Serious” injury accidents (not involving fatalities): 3 reports  (2%) 

“Substantial” damage: 50 reports   (33%)  

Aircraft “destroyed”:   17 reports   (11%)   

Recent registration (within previous 12 months):  25 reports   (17%)  

(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:

Be35 Bonanza  36 reports  

Be36 Bonanza  23 reports  

Be33 Debonair/Bonanza  19 reports  

Be58 Baron  15 reports   

Be55 Baron  12 reports  

Be76 Duchess  11 reports  

Be23 Musketeer/Sundowner 10 reports 

Be24 Sierra   5 reports 

Be95 Travel Air   5 reports  

Be18 Twin Beech  3 reports

Be65 Queen Air  3 reports 

Be50 Twin Bonanza  2 reports 

Be77 Skipper  2 reports  

Be17 Staggerwing  1 report

Be19 Sport  1 report

Be45 (T-34) Mentor  1 report   

Be60 Duke  1 report 

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

LANDING GEAR-RELATED MISHAPS (69 reports; 46% of the total) 

Gear up landing

28 reports (Be18; two Be24s; five Be33s; eleven Be35s; three Be36s; Be50; two Be55s; Be58; two Be76s)

Gear collapse (landing)

20 reports (two Be33s; four Be35s; Be36; Be50; two Be55s; three Be58s; Be60; two Be65s; two Be76s; two Be95s)

Gear up landing—known mechanical system failure

4 reports (Be33; Be35; Be45; Be76)

Gear collapse—pilot activation of gear on ground

5 reports (Be33; two Be35s; Be55; Be58)

Gear collapse (takeoff)

3 reports (Be18; Be36; Be58)

Failure of nose gear to extend due to mechanical failure

2 reports (Be65, Be76)

Gear collapse during taxi

2 reports (Be58; Be76)

Gear collapse on landing—known mechanical system failure

2 reports (Be55; Be95)

Gear collapse on landing: electrical failure/incomplete manual extension

1 report (Be45)

Gear collapse on landing—known incomplete electrical extension

1 report (Be58)

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

ENGINE FAILURE   (28 reports; 19% of the total) 

Engine failure in flight

11 reports (Be33; five Be35s; five Be36s)

Engine failure on takeoff

6 reports (two Be33s; Be36; Be55; Be77)

Fuel exhaustion

3 reports (two Be35s; Be55)

Engine failure on approach/landing

2 reports (Be23; Be35)

Partial power loss: fuel line leak

1 report (Be36)

Propeller overspeed

1 report (Be36)

Engine failure—fuel system malfunction

1 report (Be36)

Piston/cylinder failure in flight

1 report (Be35)

Propeller separation in flight

1 report (Be55)

Fuel starvation

1 report (Be33)

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

IMPACT ON LANDING  (26 reports; 17% of the total) 

Loss of directional control on landing

7 reports (Be18; Be19; two Be23s; Be33; Be36; Be77)

Hard landing

5 reports (four Be23s; Be35)

Loss of control on landing—strong, gusty winds

3 reports (two Be23s; Be58)

Landed long

2 reports (Be33; Be95)

Wing strike on landing

1 report (Be58)

Hard landing—strong, gusty wind

1 report (Be36)

Impact with animal while landing

1 report (Be76)

Impact with obstacle on landing

1 report (Be35)

Loss of control--attempted go-around in strong/gusty winds

1 report (Be55)

Landed short

1 report (Be35)

Nosed over on landing

1 report (Be17)

Bounced landing

1 report (Be23)

Landed long/failed to go around

1 report (Be36)

CAUSE UNKNOWN  (7 reports; 5% of the total)  

Takeoff/Unknown

2 reports (Be35; Be36; Be58)

Approach/Unknown

2 reports (Be33; Be36)

Crash/Unknown

2 reports (Be24; Be35)

Forced landing/Unknown

1 report (Be36)

MISCELLANEOUS CAUSES  (7 reports; 5% of the total) 

Taxied into obstruction

3 reports (Be33; Be76; Be95)

Pilot incapacitation—heart attack

1 report (Be58)

Bird strike on landing

1 report (Be33)

Gear door damage—ice accumulation

1 report (Be33)

Wing explosion—suspected fuel leak ignited by arcing electrical wiring

1 report (Be58)

IMPACT WITH OBJECT DURING TAKEOFF   (7 reports; 5% of the total) 

Impact with object/animal during takeoff

3 reports (two Be36s; Be58)

Loss of directional control during takeoff

1 report (Be76)

Collision with landing aircraft

1 report (Be36)

Blown tire/loss of directional control during aborted takeoff

1 report (Be24)

Runway overrun—failure to abort takeoff

1 report (Be35)

LOSS OF CONTROL IN FLIGHT   (5 reports; 3% of the total) 

Loss of control—single engine visual approach

3 reports (Be55; Be58)

Loss of control—airframe ice; in-flight break-up

1 report (Be35)

Loss of control on instrument approach

1 report (Be35)

STALL/SPIN   (4 reports; 3% of the total)

Stall--attempted go-around in strong/gusty winds

1 report (Be23)

Stall/Spin during turn in visual traffic pattern in strong/gusty winds

1 report (Be35)

Stall/Spin on takeoff

1 report (Be55)

Stall on landing—returning with unidentified urgency

1 report (Be58)

IN-FLIGHT CONTROL VIBRATION/ FLUTTER/ AIRFRAME SEPARATION  (2 reports; 1% of the total) 

In-flight break-up—probable pilot incapacitation

1 report (Be35)

In-flight tail vibration/flutter

1 report (Be35)

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!

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