# NTSB BFO94FA120: Beech 76, N6004E, Elizabeth, PA, June 28, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 28, 1994, 13:57 local (17:57 UTC) - Place: Elizabeth, PA - Coordinates: 40.600833, -78.760261 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.6008&lon=-78.7603&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed, report April 27, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 8853 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO94FA120 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8853/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=8853 - Page: https://openairdocs.org/ntsb/BFO94FA120 ## Probable cause 1) THE FAILURE OF THE PILOT-IN-COMMAND (CFI) TO PROVIDE ADEQUATE SUPERVISION OF THE DUAL STUDENT DURING A SIMULATED SINGLE-ENGINE APPROACH, AND 2) HIS FAILURE TO PERFORM REMEDIAL ACTION. THIS LED TO A LOSS OF AIRCRAFT CONTROL IN CLOSE PROXIMITY TO THE GROUND. CONTRIBUTING TO THE ACCIDENT WAS THE DUAL STUDENT'S FAILURE TO MAINTAIN MINIMUM CONTROLLABLE AIRSPEED AND A PROPER GLIDEPATH TO THE RUNWAY DURING THE APPROACH. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - vfr pattern - final approach - airspeed(vmc) - not maintained, dual student (contributing factor) - proper glidepath - not maintained, dual student (contributing factor) - remedial action - not performed, pilot in command(cfi) (cause) - supervision - inadequate, pilot in command(cfi) (cause) - emergency procedure - simulated, pilot in command(cfi) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - mountainous/hilly ## Analysis THE PRIVATE PILOT (DUAL STUDENT) HAD RECENTLY BEEN GRANTED PRIVATE PILOT PRIVILEGES IN MULTIENGINE AIRPLANES. HE REQUESTED THAT THE CERTIFIED FLIGHT INSTRUCTOR (CFI), FLY WITH HIM SO THAT HE COULD RECEIVE INSTRUCTION ON SIMULATED SINGLE-ENGINE OUT APPROACHES. THE AIRPLANE WAS OBSERVED FLYING LOW TOWARD THE RUNWAY ON FINAL APPROACH, THEN ROLLING TO THE RIGHT AND IMPACTING THE GROUND. WITNESS STATEMENTS AND AN EXAMINATION OF THE WRECKAGE INDICATED THAT THE AIRPLANE WAS ESTABLISHED FOR A SIMULATED SINGLE-ENGINE OUT APPROACH. NO PRE-IMPACT MECHANICAL DEFICIENCIES WERE FOUND WITH THE AIRPLANE AND ENGINES. ## Factual narrative HISTORY OF FLIGHT On June 28, 1994, about 1357 hours eastern daylight time, N6004E, a Beech BE-76, operated by O.T. Aviation, Inc., West Mifflin, Pennsylvania, impacted terrain in Elizabeth, Pennsylvania, and was destroyed during approach to runway 25 at the Rostraver Airport. The certified flight instructor (CFI) was seriously injured, the private pilot who was receiving instruction was fatally injured, and the rear seat passenger was fatally injured. Visual meteorological conditions prevailed and a flight plan was not filed. The instructional flight departed from the Allegheny County Airport, West Mifflin, at 1342 and was conducted under 14 CFR 91. According to the assistant manager of O.T. Aviation, who was present in the lounge/office area of O.T. Aviation on the day of the accident, the private pilot had called earlier in the day to schedule a flight simulator session for that afternoon. The assistant manager later learned after the accident that the person who received the call mistakenly scheduled the simulator under another name. This statement was corroborated by an examination of the operator's daily flight schedule. Another witness, a single-engine airplane flight instructor at O.T. Aviation, was also present in the lounge/office area on the day of the accident. He stated that when the private pilot arrived, he saw that someone else's name had been entered on the schedule. The private pilot said "I've got to fly today," and checked to see if there were any airplanes available to fly in lieu of the simulator. The flight instructor stated that the accident airplane, N6004E, a Beech "Duchess," was probably the only airplane available at the time, because it was "pretty busy" that day at the airport. The Duchess was parked in front of the office at the time the private pilot arrived because it had been prepared for flight by someone who had previously cancelled the flight; this was corroborated by the operator's flight schedule. Seeing that N6004E was available, the private pilot asked the flight instructor if he wanted to fly with him. The flight instructor stated that he could not because he wanted to wait for the person who had been mistakenly entered on the simulator schedule. The flight instructor then observed the private pilot ask another flight instructor, who had multiengine flight instructor privledges, if he would fly with him, but the multiengine flight instructor could not because he had another student scheduled. According to the multiengine flight instructor, the private pilot clearly asked him for "single engine work," and stated that the private pilot desired flight instruction involving practice approaches under simulated single-engine emergency procedures. After the multiengine flight instructor declined, he observed the private pilot ask the accident CFI if he "would like to go up and do some single engine work." The CFI said "yes." The multiengine flight instructor also stated that he heard the private pilot and CFI discuss what they would do during the flight. The discussion involved "upper air work" and "single engine work at Rostraver." The multiengine flight instructor stated that he was certain that "the whole purpose" of the flight was for instructional purposes, and he overheard the accident CFI tell the private pilot "I'm going to show you something you've never seen before." The multiengine flight instructor also stated that the passenger (seated in the left rear seat of the accident airplane) was in the lounge at the time of these conversations and decided to fly on the accident flight to observe. The accident CFI was interviewed in the hospital on August 19, 1994, after he had partially recovered from his serious injuries, and again on February 1, 1994, via telephone conversation. He stated that his memory of the accident flight ends at the time the airplane was about to taxi for takeoff at Allegheny County Airport. However, he did remember the events that led up to that time. According to the CFI, he arrived at the airport about noon on the day of the accident. He stopped in at the O.T. Aviation lounge to check if he was on the schedule for flight instruction. He saw the private pilot in the lounge area and the private pilot told him someone else was written into the schedule for the simulator during the time that he had previously requested. The CFI also recalled that he was going to monitor the private pilot during the simulator session, because the private pilot wanted to perform low approaches coming out of a 100-foot ceiling. An examination of the O.T. Aviation aircraft and flight instructor schedule (copy attached) for the day of the accident revealed that the CFI did not have any students scheduled. The examination also indicated that the private pilot was scheduled to fly a Piper PA-28 airplane at 1530; it was determined that the airplane was placed out of service and into maintenance prior to the scheduled time. Also, a name was entered for the flight simulator at 1300. The CFI stated that because someone else's name was written in the simulator schedule, the private pilot suggested that he and the CFI fly to Rostraver Airport in N6004E and have lunch there, figuring that when they returned, the simulator would be available. The CFI stated that he agreed, and that it was understood the flight would not be instructional and that he would be "just a passenger" on the flight. The CFI stated that he and the passenger stayed in the lounge and watched the first pilot perform a "thorough" pre-flight inspection that lasted about 20 minutes. The CFI observed the private pilot check the oil in both engines. No problems with the airplane were reported to the CFI by the first pilot. According to the CFI, the three occupants boarded the airplane and "... strapped in with the seat belts and shoulder harnesses." The private pilot went through the start-up checklist "... by the numbers..." and started both engines. The CFI stated that he did not perform any crewmember duties and was a "passenger" during this time. He stated that he remembered the private pilot contacting ground control and receiving clearance to taxi. The CFI stated that "...everything was operating normally..." at that point. After receiving the clearance, the private pilot said: "OK boys and girls, we're ready to taxi," or something similar. That is when the CFI's recollections of the accident flight end. According to the FAA Air Traffic Control (ATC) transcripts, the airplane received clearance to takeoff from runway 28 at the Allegheny County Airport at 1342 hours. No other pertinent radio communications were recorded by any FAA facility following the acknowledgement of the clearance. According to ATC personnel at the Pittsburgh International Airport, recorded radar data was not available at the time of the accident due to equipment and software modifications in progress. One witness, a pilot, was sitting on the rear deck of his home when he saw "... a twin engine, high tail, Duchess aircraft..." flying overhead about 1345. The witness's home is located about 2.5 miles southeast of the Rostraver Airport. The witness stated: My attention was directed to the east/southeast and the sound of an aircraft with a wooshing air sound (such as when an [aircraft] is losing altitude quickly). A ... Duchess ... was observed in a steep descent from what appeared to be about [3,500 to 4,000 feet above the ground] on a heading of approximately 290 degrees to 300 degrees. The [aircraft] appeared to level out, with landing gear extended, above normal pattern altitude for Rostraver [airport]. As it leveled, an engine could be heard backfiring, but I could not detect if one engine was feathered or off. The [aircraft] then powered ## Aircraft - Registration: [N6004E](https://openairdocs.org/deregistered/N6004E-1996-10-01), registration cancelled 1996-10-01, S/N ME127 (OpenAirDocs) - Reported make and model: BEECH 76 - Registry model: [Beech 76](https://openairdocs.org/model/beech-76) (registry code 1153005) (OpenAirDocs) - Category: Airplane - Serial number: ME-127 - Airframe hours: 1492 - Engines: Lycoming O-360 180 horsepower reciprocating - Damage: Destroyed - Flight: Instructional, Part 91 - Operator: O. T. Aviation, Inc. - Registered owner: Marshall Air Service, Inc. - Airworthiness certificate: Standard, Transport; Standard, Normal; Special, Experimental (Special) - Last inspection: 100 hour, April 28, 1994, 64 hours before - Departed: AGC, WEST MIFFLIN, PA - Destination: G08, ROSTRAVER, PA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; airline transport, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: right; flight hours: 5,533 total, 302 in this make and model, 44 in the last 90 days, 32 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 270° at 8 knots - Visibility: 12 statute miles - Lowest ceiling: 25,000 ft broken - Temperature: 77 °F, dew point 63 °F - Altimeter: 29.00 inHg - Observed at: AGC, 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 19940628017089A](https://openairdocs.org/incident/19940628017089A), Jun 28, 1994: Beech 76, Elizabeth, PA, Destroyed, 2 fatal. Crashed in wooded area. (.4)the private pilot (dual student) had recently been granted private pilot privileges in multiengine airplanes. He requested that the… ## Docket (28 files) The files NTSB released with the investigation on April 19, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=8853. 3.7 MB in all. - Supplement a (item 1, PDF, 2 pages, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534198&FileExtension=pdf&FileName=Supplement%20A-Master-Rel.pdf - Supplement b (item 2, PDF, 4 pages, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534375&FileExtension=pdf&FileName=Supplement%20B-Master-Rel.pdf - Supplement e (item 3, PDF, 2 pages, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534601&FileExtension=pdf&FileName=Supplement%20E-Master-Rel.pdf - Supplement I (item 4, PDF, 3 pages, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13533916&FileExtension=pdf&FileName=Supplement%20I-Master-Rel.pdf - Supplement k (item 5, PDF, 5 pages, 302 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13533774&FileExtension=pdf&FileName=Supplement%20K-Master-Rel.pdf - Supplement s (item 6, PDF, 1 page, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534378&FileExtension=pdf&FileName=Supplement%20S-Master-Rel.pdf - Pilot-operator aircraft accident report NTSB form 61201-2 (item 7, PDF, 6 pages, 394 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534122&FileExtension=pdf&FileName=Pilot-Operator%20Aircraft%20Accident%20Report%20NTSB%20Form%2061201-2-Master-Rel.pdf - Record of interview-william j brkovich (item 8, PDF, 2 pages, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534604&FileExtension=pdf&FileName=Record%20of%20Interview-William%20J%20Brkovich-Master-Rel.pdf - Witness statements (item 9, PDF, 13 pages, 587 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534125&FileExtension=pdf&FileName=Witness%20Statements-Master-Rel.pdf - Area map of accident site and witness locations (item 10, PDF, 1 page, 282 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534383&FileExtension=pdf&FileName=Area%20Map%20of%20Accident%20Site%20and%20Witness%20Locations-Master-Rel.pdf - ATC transcripts (item 11, PDF, 3 pages, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534128&FileExtension=pdf&FileName=ATC%20Transcripts-Master-Rel.pdf - FAA statement verifying lack of radar data (item 12, PDF, 1 page, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534132&FileExtension=pdf&FileName=FAA%20Statement%20Verifying%20Lack%20of%20Radar%20Data-Master-Rel.pdf - Operator airplane-instructor schedule for 06-28-91 (item 13, PDF, 2 pages, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13614008&FileExtension=pdf&FileName=Operator%20Airplane-Instructor%20Schedule%20for%2006-28-91-Master-Rel.pdf - Fuel-engine oil records (item 14, PDF, 6 pages, 262 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13614279&FileExtension=pdf&FileName=Fuel-Engine%20Oil%20Records-Master-Rel.pdf - Statement of party representatives to NTSB investigation (item 15, PDF, 1 page, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13614003&FileExtension=pdf&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master-Rel.pdf - Release of aircraft wreckage NTSB form 612015 (item 16, PDF, 2 pages, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13614421&FileExtension=pdf&FileName=Release%20of%20Aircraft%20Wreckage%20NTSB%20Form%20612015-Master-Rel.pdf - Toxicological report (item 17, PDF, 1 page, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13564956&FileExtension=pdf&FileName=Toxicological%20Report-Master-Rel.pdf - Photo 1 right-side profile view of main aircraft wreckage (item 18, PDF, 1 page, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13533936&FileExtension=pdf&FileName=Photo%201%20%20Right-side%20profile%20view%20of%20main%20aircraft%20wreckage-Master-Rel.pdf - Photo 2 front view of main aircraft wreckage-looking aft (item 19, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534691&FileExtension=pdf&FileName=Photo%202%20%20Front%20view%20of%20main%20aircraft%20wreckage-looking%20aft-Master-Rel.pdf - Photo 3 overall view of instrument panel and throttle quadrant note positions of throttle levers and mixture control (item 20, PDF, 1 page, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13533933&FileExtension=pdf&FileName=Photo%203%20%20Overall%20view%20of%20instrument%20panel%20and%20throttle%20quadrant%20%20Note%20positions%20of%20throttle%20levers%20and%20mixture%20co-Master-Rel.pdf - Photo 4 close-up view of auxiliary fuel pump switches note that left engine pump switch is on and right engine pump (item 21, PDF, 1 page, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534688&FileExtension=pdf&FileName=Photo%204%20%20Close-up%20view%20of%20auxiliary%20fuel%20pump%20switches%20%20Note%20that%20left%20engine%20pump%20switch%20is%20ON%20and%20right%20engine-Master-Rel.pdf - Photo 5 close-up view of engine gages note the differences between the readings from the left engine gages left hal (item 22, PDF, 1 page, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534779&FileExtension=pdf&FileName=Photo%205%20%20Close-up%20view%20of%20engine%20gages%20%20Note%20the%20differences%20between%20the%20readings%20from%20the%20left%20engine%20gages%20left-Master-Rel.pdf - Photo 6 right engine and propeller at accident site note some s-bending at blade tips also note crush damage to un (item 23, PDF, 1 page, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13533782&FileExtension=pdf&FileName=Photo%206%20%20Right%20engine%20and%20propeller%20at%20accident%20site%20%20Note%20some%20S-bending%20at%20blade%20tips%20%20Also%20note%20crush%20damage%20t-Master-Rel.pdf - Photo 7 left propeller at accident site note that it is detached from left engine also note blade tip damage (item 24, PDF, 1 page, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13533930&FileExtension=pdf&FileName=Photo%207%20%20Left%20propeller%20at%20accident%20site%20%20Note%20that%20it%20is%20detached%20from%20left%20engine%20%20Also%20note%20blade%20tip%20damage-Master-Rel.pdf - Photo 8 close-up view of right propeller after removal from right engine note s-bending at both blade tips (item 25, PDF, 1 page, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13533779&FileExtension=pdf&FileName=Photo%208%20%20Close-up%20view%20of%20right%20propeller%20after%20removal%20from%20right%20engine%20%20Note%20S-bending%20at%20both%20blade%20tips-Master-Rel.pdf - Photo 9 view of left propeller after removal from accident site notice blade tip damage (item 26, PDF, 1 page, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534642&FileExtension=pdf&FileName=Photo%209%20%20View%20of%20left%20propeller%20after%20removal%20from%20accident%20site%20%20Notice%20blade%20tip%20damage-Master-Rel.pdf - Photo 10 close-up view of a blade tip from left propeller note that tip is sheared off also note s-bending and cho (item 27, PDF, 1 page, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534685&FileExtension=pdf&FileName=Photo%2010%20%20Close-up%20view%20of%20a%20blade%20tip%20from%20left%20propeller%20%20Note%20that%20tip%20is%20sheared%20off%20%20Also%20note%20S-bending%20and-Master-Rel.pdf - Photo 11 close-up view of the other blade tip from left propeller note s-bending and chordwise scratching (item 28, PDF, 1 page, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13534682&FileExtension=pdf&FileName=Photo%2011%20%20Close-up%20view%20of%20the%20other%20blade%20tip%20from%20left%20propeller%20%20Note%20S-bending%20and%20chordwise%20scratching-Master-Rel.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.