CHI04FA290

NTSB accident investigation · Beech B95A · Burlington, WI · September 30, 2004

Accident · FatalField investigationFinal report
Date
September 30, 2004, 16:30 local (21:30 UTC)
Place
Burlington, WI
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N1703YBeech B95A
Weather
Visual (VMC) · Day
Status
Completed · report May 30, 2006
Report
Approved by Office Director
Parties
FAA Milwaukee FSDO, Precision Airmotive, Raytheon Aircraft, Hartzell Propeller
FAA report
20040930029299A
Case key
60257

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 improper maintenance of the fuel servo resulting in a loose adjustment nut and subsequent failure of the fuel injection servo which led to a complete loss of power on the right engine. Other causes were the pilot's failure to obtain or maintain minimum controllable airspeed which resulted in an uncommanded roll and subsequent impact with the ground.

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 engine powerTakeoff - initial climb
Fuel injection control/system - loose part/bolt/nut/clamp/etcCause
Maintenance - improperOther maintenance personnelCause
Fuel injection control/system - failure,totalCause
Loss of control - in flightTakeoff - initial climb
Airspeed(vmc) - not obtained/maintainedPilot in commandCause
Aircraft control - not maintainedPilot in commandCause
In flight collision with objectDescent - uncontrolled
Object - tree(s)
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The airplane was destroyed when it impacted terrain following a loss of control after takeoff. A witness observed the airplane takeoff and then make a right turn that increased in bank angle until the airplane impacted the ground. Examination of the airplane's control system revealed no pre-impact abnormalities. Examination of the left engine revealed no pre-impact abnormalities. An examination and subsequent test run of the right engine revealed that the engine would not operate continuously with the installed fuel servo. A flow test of the fuel servo showed that the fuel flow was not within the manufacturer's specifications. Disassembly of the fuel servo showed that the fuel regulator nuts were loose and not the same as those originally supplied by the manufacturer. The measured drag torque of the regulator nuts was below the manufacturer's minimum specifications. An overhaul tag indicated that the fuel servo had been previously overhauled. A search of the aircraft records for the previous 5 years showed no record of the fuel servo being overhauled.

Factual narrative

History of flight

On September 30, 2004, about 1630 central daylight time, a Beech B95A, N1703Y, piloted by a commercial pilot, was destroyed when it impacted trees and terrain after takeoff from runway 11 (4,300 feet by 75 feet, asphalt), at the Burlington Municipal Airport (BUU), Burlington, Wisconsin. The 14 CFR Part 91 flight was operating in visual meteorological conditions without a flight plan. All three occupants of the airplane were fatally injured. The flight was originating at the time of the accident and was en route to the Westosha Airport, Wilmont, Wisconsin.

According to a witness, the airplane departed using runway 11 and was observed to make a right turn that increased in bank angle until the airplane impacted the ground. The airplane came to rest at the rear edge of a residential property near the airport. On October 1, 2004, the airplane was recovered from the accident site to a hangar at BUU where further examination was conducted.

Personnel information

The pilot seated in the left pilot station held a commercial pilot certificate issued by the Federal Aviation Administration (FAA). The certificate included single engine land, multi-engine land, and instrument airplane ratings. The pilot had received his commercial multi-engine land rating on March 9, 2003. He also held a flight instructor certificate with single engine and instrument airplane ratings. The pilot held a FAA first class medical certificate issued on April 15, 2004. The medical certificate listed the limitation, "must wear corrective lenses". A review of pilot logbooks bearing the name of this pilot indicated that he had accumulated 1,508.2 hours total flight experience and 146.3 hours of multi-engine experience as of the last entry dated September 28, 2004. The logbook listed 243.3 hours accumulated in the last 90 days, of which, 50.4 hours were in multi-engine airplanes. Of those 50.4 hours, 48.4 hours were in the accident airplane.

The pilot rated occupant seated in the right pilot station held a FAA commercial pilot certificate. The certificate included single engine land, multi-engine land, and instrument airplane ratings. He also held a flight instructor certificate with single engine, multi-engine and instrument airplane ratings. He held a FAA first class medical certificate issued on November 18, 2002. The medical certificate listed the limitation, "must wear corrective lenses".

Aircraft information

The airplane was a twin-engine Beech model B95A, serial number TD-498. This model, also known as the Travel Air, is a low-wing monoplane with an aluminum primary structure and retractable landing gear. Two wing-mounted Lycoming model IO-360-B1A engines powered the airplane. Each fuel-injected engine was rated for 180 horsepower. The accident airplane was manufactured in 1962 and was configured to seat 4 occupants.

A review of the maintenance records showed that the airplane had undergone an annual inspection on November 1, 2003. The airplane had accumulated 7,934.7 hours total time in service at the time of the annual inspection. According to the recording hour meter readings from the accident site and the annual inspection entry, the airplane had accumulated an additional 202.3 hours since the annual inspection.

According to maintenance records, the left engine, serial number L1526-51, had accumulated 1,941.4 hours since overhaul as of the annual inspection on November 1, 2003. The last recorded overhaul was performed on October 1, 1977.

According to maintenance records, the right engine, serial number L1525-51, had accumulated 1,262.3 hours since overhaul as of the annual inspection on November 1, 2003. The last recorded overhaul was performed on May 26, 1990.

Meteorological information

The BUU weather at 1636 was recorded as: Winds 170 degrees at 6 knots; Visibility 10 statute miles; Sky condition clear; Temperature 23 degrees Celsius; Dew point 2 degrees Celsius; Altimeter setting 29.98 inches of mercury.

Wreckage and impact information

The airplane impacted the ground at the rear of a residential property adjacent to a marsh area. Using a global positioning system receiver, the wreckage location was determined to be at 42 degrees, 41.140 minutes north latitude, 88 degrees, 17.664 minutes west longitude. The airplane came to rest in a nose low attitude with the aft portion of the airplane resting on trees. The forward fuselage was crushed rearward to the leading edge of the wing root. The leading edges of the wings were crushed rearward. A linear impact scar was found adjacent to the wing leading edges. The right wing outboard of the engine nacelle was separated and impacted around a tree. All of the tail surfaces remained attached to the aircraft. The left engine, propeller, cowl and firewall were partially separated from the nacelle just aft of the firewall. The right engine, propeller and cowl remained attached to the nacelle. Subsequent to these observations, the airplane was removed from the accident site and placed in a hangar for further examination.

The aircraft control system was examined. Continuity of the rudder, aileron, and elevator control cabling was confirmed from the cockpit to the respective control surfaces. All of the flight control surfaces remained attached to the mating portions of the airframe. The flaps and landing gear were found in the retracted position.

The left engine was inspected in a hangar after removal from the accident site. The engine remained attached to the firewall. The propeller and spinner remained attached to the engine. The spinner was crushed in a spiral shape. Both propeller blades were bent aft. The fuel servo was separated from the mounting flange. Both magnetos remained attached to the accessory section of the engine. The crankshaft was rotated by hand and continuity of the crankshaft, camshaft, and accessory gears was confirmed. Compression and suction was confirmed on all cylinders during crankshaft rotation. Spark was confirmed from each magneto lead while the engine crankshaft was rotated. During rotation of the crankshaft, oil was noted being pumped out of the hose fitting that had been disconnected from the oil cooler. Fuel was found in the fuel lines from the fuel pump to the fuel servo and from the fuel servo to the flow divider. The flow divider diaphragm was found intact.

The right engine was inspected in a hangar after removal from the accident site. The engine remained partially attached to the firewall. The propeller and spinner remained attached to the engine. The spinner was crushed on one side. One of the propeller blades was bent slightly forward and the other blade was bent slightly aft. The fuel servo remained attached to the engine. Both magnetos remained attached to the accessory section of the engine. The crankshaft was rotated by hand and continuity of the crankshaft, camshaft, and accessory gears was confirmed. Compression and suction was confirmed on all cylinders during crankshaft rotation. Spark was confirmed from each magneto lead while the engine crankshaft was rotated. During rotation of the crankshaft, oil was noted being pumped out of the hose fitting that had been disconnected from the oil cooler. Fuel was found in the fuel lines from the fuel pump to the fuel servo and from the fuel servo to the flow divider. The flow divider diaphragm was found intact.

The right engine was retained in order to attempt an engine run in a test facility. Details of the engine test run are in the "Tests and Research" section of this report.

The propeller manufacturer under the direct supervision of a Federal Aviation Administration inspector conducted examinations of the propellers from both engines. The installed propellers were hydraulically actuated with oil pressure from the propeller governor driving the propeller blades toward low pitch. The propeller incorporates a

Aircraft

Registration
N1703Y
Reported as
Beech B95A
Category
Airplane
Serial number
TD-498
Airframe hours
7,934.7
Engines
Lycoming IO-360-B1A, 180 horsepower, reciprocatingLycoming IO-360-B1A, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Gns LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 1, 2003 · 202.3 hours before
Departed
BUU · Burlington, WI
Destination
WI10 · Wilmot, WI
Airport
KBUU · Burlington Muni, runway 11, 4,300 × 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
48
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 1, 2003
Seat
Left
Toxicology
Performed
Flight hours
1,508 total · 243 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 36 °F
Altimeter
29.97 inHg
Observed at
KBUU

Docket · 21

The files NTSB released with the investigation on February 24, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 22.9 MB in all.

Witness Statements and Record of InterviewItem 1 · .PDF · 213 KBHartzell Propeller ReportItem 2 · .PDF · 3.3 MBPrecision Airmotive Corporation ReportItem 3 · .PDF · 130 KBToxicological ReportItem 4 · .PDF · 93 KBStatement of Party Representatives to NTSB InvestigationItem 5 · .PDF · 323 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 6 · .PDF · 68 KBPhoto 1. Front-right Quarter View of Wreckage at Accident SiteItem 7 · .PDF · 1.4 MBPhoto 2. Front View of Wreckage at Accident SiteItem 8 · .PDF · 1.3 MBPhoto 3. Left Side View of Wreckage at Accident SiteItem 9 · .PDF · 1.3 MBPhoto 4. View of Right Engine at Accident SiteItem 10 · .PDF · 1.2 MBPhoto 5. View of Left Engine at Accident SiteItem 11 · .PDF · 1.2 MBPhoto 6. View of Instrument Panel at Accident SiteItem 12 · .PDF · 1.3 MBPhoto 7. View of Instrument Panel at Accident SiteItem 13 · .PDF · 1.3 MBPhoto 8. Front View of Aircraft After Removal From Accident SiteItem 14 · .PDF · 1.3 MBPhoto 9. Front-right View of Aircraft After Removal From Accident SiteItem 15 · .PDF · 1.2 MBPhoto 10. Right View of Aircraft After Removal From Accident SiteItem 16 · .PDF · 1.2 MBPhoto 11. View of Right Engine After Removal From AircraftItem 17 · .PDF · 1.2 MBPhoto 12. View of Left Engine After Removal From AircraftItem 18 · .PDF · 1.2 MBPhoto 13. Photo of Fuel ServoItem 19 · .PDF · 1.2 MBPhoto 14. Photo of Engine on Test StandItem 20 · .PDF · 1.3 MBPhoto 15. Photo of Running Engine on Test StandItem 21 · .PDF · 1.2 MB

FAA reports on this event · 1

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