CEN09FA430

NTSB accident investigation · Beech 35-A33 · Las Vegas, NM · July 10, 2009

Accident · Serious injuriesField investigationFinal report
Date
July 10, 2009, 10:15 local (16:15 UTC)
Place
Las Vegas, NM
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N4334WBeech 35-A33
Defining event
Emergency descent: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report January 7, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Albuquerque FSDO, Hawker Beechcraft, Teledyne Continental Motors
FAA report
20090710857479A
Case key
74254

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

On this page

Probable cause

The loss of engine power for undetermined reasons.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating)Aircraft › Aircraft power plant · MalfunctionBeech 35-A33: 2 casesAll aircraft: 497 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedBeech 35-A33: 3 casesAll aircraft: 2,247 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

After a cross-country visual flight rules flight of one hour and 40 minutes, the pilot was landing at an airport with a surface elevation of 6,877 feet mean sea level. While on downwind for landing the pilot extended the landing gear and flaps, and set the engine power at 1,700 rpm. A witness at the airport heard the engine “sputtering,” then the engine failed and restarted twice before he heard the engine fail completely. The pilot executed a forced landing to a field one mile south of the airport and the airplane flipped inverted during the impact with terrain. The airplane was substantially damaged by the impact forces and the post-impact fire. The two occupants were seriously injured. The investigation revealed that adequate fuel was present, with symmetrical fire damage to both wings. The engine was tested at the manufacturer's facility and during the first start the engine started normally on the first attempt without hesitation or stumbling. The engine rpms were advanced in steps to 1200 rpm and held for five (5) minutes to stabilize. The engine throttle was advanced to full open position and held for five minutes to stabilize. The engine throttle was rapidly advanced from idle to full throttle six times. Throughout the test phase, the engine accelerated normally without any hesitation or interruption in power and demonstrated the ability to produce rated horsepower.

Factual narrative

HISTORY OF FLIGHT On July 10, 2009, 1015 mountain daylight time, a Beech 35-A33, N4334W, lost power and attempted a forced landing in a field one mile south of the Las Vegas Municipal Airport (LVS), Las Vegas, New Mexico. A post impact fire ensued after the airplane nosed over during the forced landing. The airplane was owned and operated by a private individual, as a visual flight rules (VFR) flight, under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The airplane was substantially damaged. The pilot and one passenger were seriously injured. Visual meteorological conditions prevailed and no flight plan had been filed. The flight had originated from the St. Johns Industrial Air Park (SJN), St. Johns, Arizona, at 0735 mountain standard time and was destined for the LVS airport. The pilot had recently purchased the airplane in Arizona and was flying back to his home in Connecticut. After an overnight fuel stop at the SJN airport, he intended another fuel stop at the LVS airport before continuing eastbound. The pilot was on a downwind leg to land on the “long runway” at the LVS airport and had extended the landing gear and flaps with the engine at 1,700 revolutions per minute (RPM) as he began a descent. He did not remember the engine “failing”, but he remembered the airplane suddenly descending and then almost stalling just before impact. After the first impact, the nose gear “dug in” and the airplane flipped over on its back with an immediate post-impact fire. The pilot did not lose consciousness during the impact sequence and exited through the cabin door. The pilot reentered the burning wreckage and pulled out the unconscious passenger. A witness standing outside on the airport ramp said he saw the airplane to the west of the airport flying southbound at pattern altitude when he heard the engine “sputtering”. He heard the engine fail and restart twice before he heard the engine fail completely. When the airplane began a steep descent, the witness ran inside the airport terminal building to call 9-1-1. When the witness returned he saw a column of smoke and he drove his truck directly to the accident scene and assisted the two seriously injured occupants until emergency first responders arrived. PERSONNEL INFORMATION The pilot, age 42, held a private pilot certificate with a airplane single-engine land rating. He did not hold an instrument rating. The pilot was issued an unrestricted third-class medical certificate on December 7, 2006. The pilot completed the requirements for a biennial flight review (BFR) on May 24, 2008. The pilot’s log book was destroyed in the post impact fire and was not available during the investigation. The pilot estimated that he had a total of 195 hours of pilot experience with an estimated 25 hours of pilot experience in the accident airplane within the past 30 days. AIRCRAFT INFORMATION N4334W, serial number (S/N) CD-331, a model 35 A33, was manufactured by the Beech Aircraft Corporation in 1961. Itwas a low-wing, single engine land airplane. The airplane was originally delivered with a Continental IO-470-K engine, S/N 86031, rated at 225 horsepower. At the time of the accident it was powered by a Continental IO-470-J engine, S/N 089122, rated at 230 horsepower, driving a Hartzell 2-blade, constant speed, aluminum alloy propeller. The airplane was issued a standard airworthiness certificate on April 5, 1961, in the normal category. The airplane was registered to the owner on July 9, 2009. The airplane was configured with two seats in the cockpit area and two passenger seats in a second row. There was one cabin door next to the right front seat passenger. Each of the four seats was equipped with a seat belt with a “lift to release” type latch. The airplane was not equipped with shoulder harnesses (Because of the airplane's year of manufacture shoulder harness installation was not required). The aircraft maintenance records were destroyed in the post impact fire and were not available during the investigation. A few selected pages of recent maintenance record entries provided by an inspection authority mechanic show that the most recent annual inspection was completed on July 7, 2009, at a tachometer time of 4,931.1 hours, an aircraft total time of 8,406.1 hours, and an engine total time of 1,822.6 hours. METEOROLOGICAL INFORMATION At 1553, the automated surface observing system (ASOS) at the LVS airport, located approximately 1 miles north of the accident site, reported calm winds, visibility 10 statute miles, clear of clouds, temperature 27 degrees Celsius, dew point 07 degrees Celsius, and an altimeter setting of 30.34 inches of Mercury. The elevation of the reporting station is 6,877 feet mean sea level (MSL). The density altitude for these conditions is calculated as 9,452 feet. COMMUNICATIONS There was no record of communications with the accident airplane. AIRPORT INFORMATION The Airport/ Facility Directory, Southwest U. S., indicated that runway 14/32 at the LVS airport was 8,198 feet long and 75 feet wide. The runway surface was composed of asphalt. An additional runway 2/20 at the LVS airport was 5,004 feet long and 75 feet wide. The runway surface was composed of asphalt. WRECKAGE AND IMPACT INFORMATION The accident site was located in a dry dirt and rock field with rolling grassy terrain. The gradient from the first ground scar to the final resting location was estimated as a 6 degree down gradient. A handheld global positioning system (GPS) showed an accident site location of 35 degrees, 38 minutes, 4 seconds north latitude, and 105 degrees, 9 minutes, 8 seconds west longitude, at an estimated elevation of 6,790 feet MSL. Investigators from the Safety Board and the Federal Aviation Administration (FAA) examined the wreckage at the accident scene on July 14, 2009. The debris path from the initial impact ground scar to the main wreckage was measured on a magnetic bearing of approximately 347 degrees. All wreckage debris was foundwithin a distance of 290 feet to the northwest from the initial impact ground scar. The distance and direction from the main wreckage to the approach end of runway 02 at the LVS airport was estimated at 5,200 feet on a magnetic bearing of 16 degrees. The initial impact ground scars were consistent with landing gear impacts and continued to the northwest for a distance of approximately 35 feet. Part of one nose gear door was observed 15 feet to the left and 35 feet to the north of the first ground scar. The next ground scars began 100 feet to the northwest with intermittent ground scars continuing for 120 feet. The ground scars were absent for the next 20 feet to the point where the main wreckage was observed. The airplane came to rest inverted with the tail aligned approximately 340 degrees and the front end of the fuselage aligned approximately 160 degrees. Both wings were still connected to their respective attach points. The ailerons, flaps, elevators and rudder were still connected to their respective attach points. The cockpit, cabin area, rear fuselage, and most portions of both wings sustained thermal damage. Documentation of controls and gauge indications in the cockpit was not possible because of thermal damage that consumed most non steel components in that area. All three landing gear were observed in the extended position. The nose gear strut piston was fractured and separated just below the cylinder. The fracture surfaces of the nose gear piston showed a rough granular appearance. The exact position of the flaps could not be confirmed because of the thermal damage, but they visually appeared to be partially extended. Flight control continuity was confirmed from the forward cockpit floor to both ailerons, the elevator, and the rudder. Cable continuity was also confirmed from the cockpit floor to the elevator trim tabs. Examination of the engine revealed it was partially separated from the firewall with sections of the engine mount bent and detached. Some thermal damage was observed to the rear of the engine. The propeller remained attached to the crankshaft and the spinner had crushing damage to one side of the spinner. One propeller blade had a bend of approximately 70 degrees to the rear and the other blade had a bend of approximately 15 degrees to the rear. Examination of the airframe and flight control system components revealed no evidence of pre-impact anomalies that would have precluded normal operations. PATHOLOGICAL INFORMATION A forensic toxicology test on the pilot was not performed. TESTS AND RESEARCH Investigators from the Safety Board, FAA, Hawker Beechcraft Corporation, and Teledyne Continental Motors examined the engine at the Teledyne Continental Motors facilities in Mobile, Alabama, on October 21, 2009. The engine exhibited impact damage concentrated at the throttle body and engine mounts. The spark plugs were removed for inspection and exhibited a black sooty deposit. The cylinders were inspected with a bore scopeand there were combustion deposits present in the combustion chamber and on the piston head. There was oil and corrosion present on the cylinder bore. The cylinder head combustion chamber, intake and exhaust valve faces, piston head and cylinder bore exhibited normal operating signatures. The cylinder bore finish was steel. The magnetos as received exhibited impact damage and both had signatures of movement from the damage. The magnetos were timed to the proper (22 degree BTDC) specification. After documentation of the damage substitute parts to replace impact damaged parts were installed and the engine was prepared for installation in an engine test cell. The engine was not disassembled prior to the engine run. During installation in the test cell the engine was fitted with a test club propeller. The engine experienced a normal start on the first attempt without hesitation or stumbling in observed RPM. The engine RPM was advanced in steps to 1200 RPM and held for five (5) minutes to stabilize. The engine throttle was advanced to full open position and held for five (5) minutes to stabilize. The engine throttle was rapidly advanced from idle to full throttle six times. 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 pre-impact anomalies of the engine were observed that would have precluded normal operations. ADDITIONAL INFORMATION The airplane was equipped with 63 gallon usable capacity fuel system (70 gallon total capacity). According to the Beechcraft Debonair 35-A33 Pilot’s Operating Handbook and Airplane Flight Manual, the fuel system consisted of a 25 gallon capacity rubber fuel cell in each wing leading edge, and two auxiliary 10 gallon capacity fuel cells in the wings outboard of the wheel wells. Both auxiliary fuel cells are connected to a common port in the fuel selector valve, and both feed simultaneously when the fuel selector is set to AUX.

Aircraft

Registration
N4334W
Reported as
Beech 35-A33
Category
Airplane
Serial number
CD-331
Airframe hours
8,406
Engine
Continental IO-470-J, 230 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 7, 2009
Departed
SJN · St Johns, AZ
Destination
LVS · Las Vegas, NM
Airport
LVS · Las Vegas Municipal Airport, runway 32, 8,198 × 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
41
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
May 24, 2008
Seat
Left
Flight hours
195 total · 25 in this make and model · 50 in the last 90 days · 25 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 45 °F
Altimeter
30.34 inHg
Observed at
KLVS, 1 nm away

Docket · 26

The files NTSB released with the investigation on October 18, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.0 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 477 KBPilot Interview on August 25, 2009Item 2 · .PDF · 25 KBAircraft Maintenance - Partial Record Showing Most Recent Annual Inspection on July 7, 2009 at 8,406.1 hours Total TimeItem 3 · .PDF · 297 KBAircraft Maintenance - Partial Record Showing a 50 Hour Inspection Completed on January 29, 2009 at 4,928.8 hours Tach TimeItem 4 · .PDF · 22 KBWitness Interview - John Aragon at LVS AirportItem 5 · .PDF · 24 KBWitness Statement - Gary Liston at SJN AirportItem 6 · .PDF · 99 KBWitness Interviews - FAA Interviews of James Butler and Gary ListonItem 7 · .PDF · 89 KBMap 1 - View of Area Around Las Vegas NM (from Skyvector.com)Item 8 · .PDF · 122 KBMap 2 - Google Earth View of 35:38:04 N - 105:09:08 W - Overhead ViewItem 9 · .PDF · 138 KBMap 3 - Google Earth View of 35:38:04 N - 105:09:08 W - Angle View From the SouthItem 10 · .PDF · 129 KBWeather SummaryItem 11 · .PDF · 603 KBPhoto 1 - Showing Ground Scars and Main Wreckage - Viewer Looking to the North Northwest (FAA Photo)Item 12 · .PDF · 131 KBPhoto 2 - Showing Inverted Airplane With Right Wing on the Right Side of Photo - Viewer Looking Northwest (FAA Photo)Item 13 · .PDF · 1.3 MBPhoto 3 - Showing Right Wing of Inverted Airplane - Viewer Looking West (FAA Photo)Item 14 · .PDF · 787 KBPhoto 4 - Showing Right Rear View of the Inverted Airplane - Viewer Looking Southwest (FAA Photo)Item 15 · .PDF · 747 KBPhoto 5 - Showing Tail - Viewer Looking South Southeast (FAA Photo)Item 16 · .PDF · 663 KBPhoto 6 - Showing Damage to Left Wing - Viewer Looking Northeast (NTSB Photo)Item 17 · .PDF · 119 KBPhoto 7 - Closeup View of Cabin Area - Viewer Behind Left Wing Looking Southeast (FAA Photo)Item 18 · .PDF · 976 KBPhoto 8 - Showing Engine and Propeller in situ - Inverted Right Wing is on Viewer's Right - Viewer Looking Northeast (FAA Photo)Item 19 · .PDF · 804 KBPhoto 9 - Generic Photo of a Similar Beech 35 A33 (Internet Photo)Item 20 · .PDF · 22 KBReports from Local Agencies - 9-1-1 Emergency Call Center Incident Log - Showing Initial Call Time at 1015 MDTItem 21 · .PDF · 324 KBReports from Parties to the Investigation - Teledyne Continental Motors (With 20 Embedded Photos)Item 22 · .PDF · 890 KBStatement of Party Representatives to NTSB InvestigationItem 23 · .PDF · 54 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 24 · .PDF · 29 KBThree View Sketch of Airplane - Showing Cabin Door (From Airplane Flight Manual)Item 25 · .PDF · 45 KBEstimated Fuel Consumption Calculations - In Several Different ConditionsItem 26 · .PDF · 42 KB

FAA reports on this event · 1

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