ATL04FA038

NTSB accident investigation · Beech 55 · Griffin, GA · November 21, 2003

Accident · FatalField investigationFinal report
Date
November 21, 2003, 12:45 local (17:45 UTC)
Place
Griffin, GA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N4482SBeech 55
Weather
Visual (VMC) · Day
Status
Completed · report September 13, 2005
Report
Approved by Office Director
Parties
Atlanta FSDO
FAA report
20031121029209A
Case key
58382

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

A loss of engine power due to the pilot's failure to follow the engine failure after liftoff emergency procedure to feather the left engine propeller resulting in a loss of control during climbout, and the subsequent collision with a commercial building. A factor was the fuel starvation of the left engine due to debris in the fuel line.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine powerTakeoff - initial climb
All engines
Maintenance,modification - improperPilot in commandFactor
Fuel system,line - blocked(partial)Factor
Fuel system - starvationFactor
Forced landingDescent - emergency
Loss of control - in flightDescent - emergency
Procedures/directives - not followedPilot in commandCause
Propeller feathering - not performedPilot in commandCause
In flight collision with objectDescent - uncontrolled
Object - building(nonresidential)

Analysis

According to the company's chief maintenance inspector, the purpose of the flight was to conduct a maintenance test flight of the airplane on recently installed equipment the pilot/ mechanic had just completed. Before engine start-up the pilot/ mechanic conducted a pre-flight of the airplane, and then taxied out to the ramp and ran the engine up to full rpm three consecutive times before the test flight. The pilot taxied to runway 32, and proceeded to add full power for take-off. As the airplane began to rotate for climb out the engines sounded like they began to "backfire". The engines continued to make this sound as it climbed out. The airplane climbed approximately 200 feet and the left wing pitch down. The airplane descended under the tree line and a "loud explosion" was heard. The airplane collided with a building a quarter mile from the departure end of runway 32. Post-accident examination of the cabin section, main fuselage, and wing assemblies revealed that they were fire damaged. All flight control and communication instruments were fire damaged. Post-accident examination of blades from both propeller assemblies revealed rotational scoring. Post-accident examination of the propellers revealed both propellers were rotating and not in the feathered position. There were no pre-impact mechanical anomalies noted with the propeller blades. Review of the maintenance work order revealed that a Shadin Digilfo-L fuel flow indicator and fuel flow transducers on the right and left engines were installed by the pilot/mechanic prior to the flight. Post-accident examination of left fuel flow transducer serial number 130436 revealed it was charred, and the inlet hose coupler was not as tight as the outlet hose coupler. Fuel was poured into the inlet side of the transducer, and the outlet flow was restricted. The fitting on the inlet side was removed and the inlet was inspected. Debris was found around the inlet orifice. . After removing the debris from the Fuel flow transducer, fuel was again poured into the inlet and fuel exited the outlet without restriction to flow. Post examination of the right fuel flow transducer serial number 130437 revealed it was intact with no visible damage, and both hose couplers were tight. Fuel was poured into the inlet side of the transducer, and the fuel exited the outlet side of the transducer without visible restriction to flow.

Factual narrative

History of flight

On November 21, 2003, at 1245 eastern standard time, a Beech Baron 55, N4482S, registered and operated by River Chase Development Aviation Co. collided with a building during climb-out at Spaulding County Airport, Griffin, Georgia. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The airplane was substantially damaged and the pilot was fatally injured. The flight departed Spaulding County Airport on November 21, 2003 at 1240.

According to the company's chief maintenance inspector, the purpose of the flight was to conduct a maintenance test flight of the airplane on recently installed equipment the pilot/ mechanic had just completed. Before engine start-up the pilot/ mechanic conducted a pre-flight of the airplane, and then taxied out to the ramp and ran the engine up to full rpm three consecutive times before the test flight. The pilot taxied to runway 32, and proceeded to add full power for take-off. As the airplane began to rotate for climb out the engines sounded like they began to "backfire". The engines continued to make this sound as it climbed out. The airplane climbed approximately 200 feet and the left wing pitch down. The airplane descended under the tree line and a "loud explosion" was heard.

According to other witnesses, as the airplane flew overhead the engines sounded as though they were "sputtering" as it climbed out. The airplane began to roll into a left bank, and descended below the tree line. Shortly after a "loud explosion" was heard.

There was no distress call heard from the pilot at time of the accident. The airplane collided with building ¼ mile from the departure end of runway 32.

Personnel information

Review of pilot records revealed the pilot was issued a commercial pilot certificate on May 14, 1982, with ratings for airplane single-engine land, multiengine land, instrument airplane, and glider aero tow. Review of records revealed the pilot held an aircraft mechanic certificate with ratings for airframe and power plant. The pilot held a second-class medical certificate issued on April 22, 2003, valid when wearing corrective lenses. Review of the pilot experience form indicated that the pilot accumulated a total of 2,500 flight hours. The pilot's logbook was not recovered for review.

Aircraft information

Review of airplane logbooks indicated the last recorded annual inspection was conducted on November 04, 2002; the total tachometer time was 1690. The altimeter system, static pressure system, and transponder were inspected on April 24, 2001 and were found in compliance.

Meteorological information

The nearest weather reporting facility at the time of the accident was Macon, Georgia. The 1253 surface weather observation was: clear, visibility 10 miles, temperature 22 degrees Celsius, dew point temperature 04 degrees Celsius, winds calm, altimeter reading of 30.13.

Wreckage and impact information

Examination of the wreckage site revealed, the airplane came to rest on top of a commercial building approximately ¼ mile from the end of runway 32. The wreckage debris path extended approximately 60 feet in length along the top of the roof. The initial point of impact was approximately 30 feet high at the edge of the commercial building. Approximately 30 feet along the wreckage debris path a vent duct displayed six propeller slash marks followed by a hole in the roof of the building where the right engine came to rest. Approximately 25 feet forward of the propeller damaged vent duct the airplane fuselage came to rest on the roof of the building. Wreckage debris was spread over an area of approximately 25 yards in diameter.

Post-accident examination of the cabin section of the airplane, and the main fuselage revealed that they were fire damaged. All flight control and communication instruments were fire damaged.

Post-accident examination of the right wing assembly revealed the right wing was connected to the fire damaged fuselage by the main spar. The outboard section of the right wing assembly was distorted aft. A six-foot section of the left wing assembly came to rest in the parking lot of the building. The left wing section was distorted and fire damaged. The left wingtip was located approximately 25 feet aft of the initial impact point. The left and right horizontal stabilizers, and vertical stabilizer were fire damaged. Flight control cables were fire damaged and located within the wreckage debris. Cable ends with the respective flight control cables were attached. The flight control chains for the elevator trim and control wheel interconnect chains were found intact.

Post-accident examination of the left engine revealed that it was fire damaged. The left propeller and crankshaft-mounting flange were broken free of the crankshaft. The crankshaft was turned through approximately 290-degrees of rotation. Gear and valve train continuity was confirmed. Compression and suction was obtained on all cylinders. The external examination of the left engine revealed that all external components were fire damage. Post-accident examination of the spark plus revealed that they were intact and the barrels were fire damaged. The top spark plug electrodes were normal when compared to the Champion Aviation Check-A-Plug.

Post-accident examination of the right engine revealed that the external components of the engine were intact, and sustained damage. The engine was examined, and it was determined that it would be prepared for a field test run. The engine was started and ran at idle. After warm up, the throttle was advanced to 1700 rpm and a magneto grounding check was performed. The throttle was advanced to full power, reduced to idle and shut down with the mixture. At the conclusion of the field test run the no mechanical anomalies were noted that would have prevented the engine from developing power prior to the accident. The engine was also test run at the factory test cell. Throughout the test phase, the engine accelerated normally without any hesitation, stumbling or interruption in power, and demonstrated the ability to produce rated horsepower. No mechanical anomalies were noted at the conclusion of the factory test run.

Post-accident examination of blades from both propeller assemblies revealed rotational scoring. Post-accident examination of the propellers revealed both propellers were rotating and not in the feathered position. There were no pre-impact mechanical anomalies noted with the propeller blades.

Medical and pathological information

The Division of Forensic Sciences Georgia Bureau of Investigation State of Georgia conducted postmortem examination of the pilot, on November 22, 2003. The cause of death was fire-related injuries including smoke inhalation. The Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma performed postmortem toxicology of specimens from the pilot. The results were negative for carbon monoxide, cyanide, and ethanol.

Additional information

Review of the Beechcraft Baron B55 pilot operating manual emergency procedures section states: After Engine failure on lift-off and in-flight; requires immediate pilot response of the following procedures in order to continue fight.

1. Landing Gear and Flaps- UP

2. Throttle (inoperative engine)- Closed

3. Propeller (inoperative engine)- Feather

4. Power (operative engine)- As Required

5. Airspeed- Maintain speed at engine failure (100 KTS (115 mph) max.) until obstacles are cleared.

Review of the maintenance work order revealed that a Shadin Digilfo-L fuel flow indicator and fuel flow transducers on the right and left engines were installed by the pilot/mechanic prior to the flight. The fuel flow transducers were installed in accordance with supplemental type certificate (STC) SA579GL and SE552GL.

Post examination of left fuel flow transducer serial number 130436 revealed it was

Aircraft

Registration
N4482S
Reported as
Beech 55
Category
Airplane
Serial number
TC-1882
Airframe hours
1,960
Engines
Continental IO-470L-21B, 260 horsepower, reciprocatingContinental IO-470L-21B, 260 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Flight test · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 4, 2002 · 90 hours before
Departed
6A2 · Griffin, GA
Destination
6A2 · Griffin, GA
Airport
6A2 · Griffin Spalding Airport, runway 32, 3,701 × 75 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
47
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
2,500 total · 50 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 39 °F
Altimeter
30.12 inHg
Observed at
FFC, 10 nm away

Docket · 15

The files NTSB released with the investigation on May 31, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.1 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.