CHI03LA063

NTSB accident investigation · Beech A36 · Grand Rapids, MI · February 1, 2003

Accident · No injuriesLimited investigationFinal report
Date
February 1, 2003, 08:00 local (13:00 UTC)
Place
Grand Rapids, MI
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5677XBeech A36
Weather
Instrument (IMC) · Day
Status
Completed · report September 30, 2003
Report
Approved by Office Director
Parties
FAA-Grand Rapids, Michigan-FSDO
FAA report
20030201002649A
Case key
56478

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

The pilot's failure to maintain aircraft control which resulted in the overload of the aircraft. Spatial disorientation, an inoperative turn coordinator, and the pilot's misinterpretation of the flight instruments were contributing factors.

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 control - in flightCruise
Electrical system,circuit breaker - disengagedFactor
Flight/nav instruments,turn and bank indicator - inoperativeFactor
Weather condition - low ceilingFactor
Flight/navigation instrument(s) - misjudgedPilot in command(cfi)Cause
Aircraft control - not maintainedPilot in command(cfi)Cause
Spatial disorientationPilot in command(cfi)Factor
Abrupt maneuverDescent - uncontrolled
Airframe - overloadCause
Pull-up - abruptPilot in command(cfi)Cause
Airspeed - highPilot in command(cfi)Factor

Analysis

The airplane received substantial damage during a high speed pull-up while recovering from an unusual attitude after a loss of control during an instrument training flight in actual instrument meteorological conditions. The ceiling was reported to be overcast at 700 feet above ground level. The airplane subsequently returned to the departure airport. The certified flight instructor who was on-board the airplane reported that pre-departure checks of the flight instruments were normal. He said that, during the flight the gyroscopic flight instrument became unusable. A postaccident examination revealed that the turn coordinator circuit breaker was in the open position. Further testing revealed no detectable defects in the gyroscopic flight instruments and instrument pressure system.

Factual narrative

On February 01, 2003, about 0800 eastern standard time, a Beech A36, N5677X, piloted by a certified flight instructor (CFI) and dual student, sustained substantial damage during a recovery from an unusual attitude after a loss of control during instrument flight. The non-instrument rated dual student held a private pilot certificate with a single engine land rating. The 14 CFR Part 91 training flight was operated in instrument meteorological conditions (IMC) with an instrument flight plan. No injuries were reported. The flight originated from the Gerald R. Ford International Airport (GRR), Grand Rapids, Michigan, about 10 minutes prior to the loss of control. The destination has not been determined.

The weather reporting station located at the departure airport recorded the ceiling and visibility as overcast ceiling at 700 feet above ground level, and 7 statute miles respectively. The report was taken about 4 minutes prior to the accident.

The CFI reported that prior to departure checks of the engine and flight instruments were normal. He stated that the takeoff was uneventful. Shortly after takeoff the airplane entered IMC. The CFI said he noticed that the airplane was in a 30 degree bank and he applied right aileron to correct. He said that a subsequent scan of the turn coordinator showed wings level. He said that another scan of the attitude indicator showed a bank angle in excess of 60 degrees. The CFI stated that he assumed control of the airplane and determined that the gyroscopic instruments were not usable. According to the CFI, the airplane exited IMC in an unusual, high speed, nose down, left bank attitude and the he used right aileron and up elevator to recover. The CFI regained control below the overcast and returned to the departure airport. The airplane was substantially damaged due to the pull up during recovery.

A postaccident examination of the airplane was conducted. The wings, horizontal stabilizer skins were wrinkled. Further examination revealed that the wing and horizontal stabilizer spars were damaged. During the examination, the turn coordinator circuit breaker was found in the open position. A run up and taxi test confirmed that the primary and backup instrument pressure systems were operational. The pressure gyroscopic instruments functioned without noticeable defect during the test. Additionally, the turn coordinator circuit breaker was reset and no noticeable defects in operation were found during the test.

Subsequent to the taxi testing, the artificial horizon indicator (AHI) was removed for further examination. Bench testing of the AHI was performed by a certified repair station under the supervision of a Federal Aviation Administration official. The testing of the AHI revealed that the unit was in an airworthy condition.

Aircraft

Registration
N5677X
Reported as
Beech A36
Category
Airplane
Serial number
EZ797
Engine
Continental IO 550B, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Larry L. Brown
Registered owner
Hole Shot Racing Inc.
Airworthiness certificate
Standard, Utility
Last inspection
Annual · December 2, 2002 · 14 hours before
Departed
GRR · Grand Rapids, MI
Destination
Unknown
Flight plan
IFR
Airport
KGRR · Gerald R. Ford International

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
37
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
1,230 total · 16 in this make and model · 1,160 as pilot in command · 87 in the last 90 days · 25 in the last 30 days · 0 in the last 24 hours
Role
Pilot
Injuries
None

Weather

Conditions
Instrument (IMC) · Day
Wind
300° at 9 knots
Visibility
7 statute miles
Lowest ceiling
700 ft overcast
Temperature
32 °F, dew point 30 °F
Altimeter
29.88 inHg
Observed at
GRR

Docket · 4

The files NTSB released with the investigation on July 30, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 687 KB 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.

Other investigations on N5677X · 1

Matched to the same aircraft by N-number and date.