# NTSB ATL89FA106: Beech H35, N5403D, Knoxville, TN, March 16, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: March 16, 1989, 16:00 local (21:00 UTC)
- Place: Knoxville, TN
- Location: 35.9606° N, 83.9207° W: Placed by OpenAirDocs: center of Knoxville, TN, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=35.9606&lon=-83.9207&mi=10
- Phase of flight: [Unknown](https://openairdocs.org/ntsb-phases/990) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report August 22, 1990
- Report: Approved by Office Director
- NTSB case key (mKey): 7881
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL89FA106
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/7881/pdf
- Page: https://openairdocs.org/ntsb/ATL89FA106

## Probable cause

THE PILOT'S CONTINUED OPERATION OF THE AIRPLANE WITH A KNOWN MECHANICAL DEFECT IN THE ENGINE CARBURETOR/FUEL SUPPLY SYSTEM AS EVIDENCED BY THE PAST HISTORY OF ENGINE STOPPAGE DURING GROUND OPERATION. CONTRIBUTING TO THE ACCIDENT WAS THE PILOT'S PERFORMANCE OF UNAUTHORIZED MAINTENANCE ON THE AIRCRAFT AND ITS SYSTEM.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(total) - nonmechanical, unknown
  - fuel system,carburetor - contamination (cause)
  - maintenance - inadequate, pilot in command (cause)
  - operation with known deficiencies in equipment - misjudged, pilot in command (cause)
  - maintenance,major repair - performed, pilot in command (contributing factor)
  - lack of total experience in type of aircraft, pilot in command
- In flight collision with terrain/water, descent - emergency
  - terrain condition - water

## Analysis

IT WAS REPORTED THAT THE PILOT/OWNER AND THE PAX HAD SPENT THE DAY INSTALLING AN AIR-OIL SEPARATOR KIT ON THE AIRPLANE. AFTER THE INSTALLATION BY THE TWO UNCERTIFICATED MECHANICS, THEY DEPARTED THE LOCAL ISLAND AIRPORT SOMETIME AFTER 1500 EDT. AT ABOUT 1605, THE AIRPLANE WAS OBSERVED TO LAND ON THE RIVER SHORT OF THE AIRPORT SURFACE. BOTH OCCUPANTS EXITED THE AIRPLANE AND SWAM TOWARD SHORE. THE PILOT MADE IT TO SHORE BUT HIS PAX WAS HAVING PROBLEMS SO HE SWAM BACK OUT TO HELP. BOTH OCCUPANTS SANK IN THE 48 DEGREE WATER AND THEIR BODIES WERE RECOVERED LATER. AFTER RECOVERY, THE ENGINE WAS DRIED OUT AND A TEST RUN PERFORMED. SOME CONTAMINATION WAS FOUND IN THE PRESSURE CARBURETOR. THE ENGINE HAD A HISTORY OF STOPPING ON THE GROUND.

## Aircraft

- Registration: [N5403D](https://openairdocs.org/deregistered/N5403D-2013-04-09), registration cancelled 2013-04-09, S/N D-4873, built 1956 (OpenAirDocs)
- Reported make and model: BEECH H35
- Registry model: [Beech H35](https://openairdocs.org/model/beech-h35) (registry code 1151520) (OpenAirDocs)
- Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: D-4873
- Airframe hours: 3602
- Engines: CONTINENTAL O-470-G(1) 240 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: W. T. Christian
- Registered owner: Robert M Melia
- Airworthiness certificate: Standard, Utility
- Last inspection: Annual, September 2, 1988, 66 hours before

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 51; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 815 total, 12 in this make and model, 735 as pilot in command

## Weather

- Conditions: Visual (VMC), Day
- Wind: 20° at 10 knots
- Visibility: 15 statute miles
- Lowest ceiling: none
- Temperature: 66 °F, dew point 30 °F
- Altimeter: 30.00 inHg
- Observed at: TYS, 9 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 19890316003949A](https://openairdocs.org/incident/19890316003949A), Mar 16, 1989: Beech H35, Knoxville, TN, Substantial damage, 2 fatal. Engine quit while circling to land. Ditched in river.

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.

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