# NTSB ATL04FA038: Beech 55, N4482S, Griffin, GA, November 21, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 21, 2003, 12:45 local (17:45 UTC) - Place: Griffin, GA - Coordinates: 33.321666, -84.292221 - Nearby events: https://openairdocs.org/map.md?lat=33.3217&lon=-84.2922&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 13, 2005 - Report: Approved by Office Director - Parties: Atlanta FSDO - NTSB case key (mKey): 58382 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL04FA038 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58382/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58382 - Page: https://openairdocs.org/ntsb/ATL04FA038 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - all engines - maintenance,modification - improper, pilot in command (contributing factor) - fuel system,line - blocked(partial) (contributing factor) - fuel system - starvation (contributing factor) - Forced landing, descent - emergency - Loss of control - in flight, descent - emergency - procedures/directives - not followed, pilot in command (cause) - propeller feathering - not performed, pilot in command (cause) - In flight collision with object, descent - 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](https://openairdocs.org/deregistered/N4482S-2015-05-19), registration cancelled 2015-05-19, S/N TC1882 (OpenAirDocs) - Reported make and model: Beech 55 - Registry model: [Beech 95-B55 (T42A)](https://openairdocs.org/model/beech-95-b55-t42a) (registry code 1152706) (OpenAirDocs) - Category: Airplane - Serial number: TC-1882 - Airframe hours: 1960 - Engines: Continental IO-470L-21B 260 horsepower reciprocating; Continental 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: fatal; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20031121029209A](https://openairdocs.org/incident/20031121029209A), Nov 21, 2003: Beech 95B55, Griffin, GA, Destroyed, 1 fatal. (-23) Airplane, N4482S, BE-55, crashed after takeoff into a building off the airport. Airplane hit the roof of the stowe woodward building in Griffin, GA, and… ## Docket (15 files) The files NTSB released with the investigation on May 31, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58382. 12.1 MB in all. - Engine Log-Left (item 1, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386337&FileExtension=.PDF&FileName=Engine%20Log-Left-Redacted.PDF - Engine Log- Right (item 2, .PDF, 286 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386338&FileExtension=.PDF&FileName=Engine%20Log-%20Right-Redacted.PDF - FAA Form 337 & STC Attachments (item 3, .PDF, 441 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386339&FileExtension=.PDF&FileName=FAA%20Form%20337%20%26%20STC%20Attachments-Redacted.PDF - Hartzell Propeller Report (item 4, .PDF, 9.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219350&FileExtension=.PDF&FileName=Hartzell%20Propeller%20Report-Master.PDF - Inspection Report (item 5, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219352&FileExtension=.PDF&FileName=Inspection%20Report-Master.PDF - Propeller Log- Left (item 6, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386340&FileExtension=.PDF&FileName=Propeller%20Log-%20Left%20-Redacted.PDF - Propeller Log- Right (item 7, .PDF, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386341&FileExtension=.PDF&FileName=Propeller%20Log-%20Right%20-Redacted.PDF - STC SA579GL (item 8, .PDF, 448 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219355&FileExtension=.PDF&FileName=STC%20SA579GL-Master.PDF - STC SE443GL (item 9, .PDF, 405 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219356&FileExtension=.PDF&FileName=STC%20SE443GL-Master.PDF - STC SE552GL (item 10, .PDF, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219357&FileExtension=.PDF&FileName=STC%20SE552GL-Master.PDF - Toxicological Report (item 11, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219358&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Witness Statements (item 12, .PDF, 234 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386342&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Work Order (item 13, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386343&FileExtension=.PDF&FileName=Work%20Order-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 14, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386344&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Emergency Procedures (item 15, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232091&FileExtension=.PDF&FileName=Emergency%20Procedures-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.