CHI98FA068

NTSB accident investigation · Beech C35 · Evansville, IN · December 17, 1997

Accident · FatalField investigationFinal report
Date
December 17, 1997, 14:54 local (20:54 UTC)
Place
Evansville, IN
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N782DBeech C35
Weather
Visual (VMC) · Day
Status
Completed · report April 15, 1999
Report
Approved by Office Director
FAA report
19971217039069A
Case key
10725

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

Improper maintenance by the use of a loose fitting unapproved fuel line, which resulted in fuel starvation and the loss of engine power.

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
Maintenance - improperPilot in commandCause
Aircraft preflight - inadequatePilot in commandCause
Fuel system - starvationCause
Fuel system,line fitting - looseCause
Fuel system,line - unapproved part
In flight collision with terrain/waterEmergency descent/landing
Unsuitable terrain or takeoff/landing/taxi area - selectedPilot in commandCause

Analysis

The airplane hit the tops of trees located about 280 feet from the impact site on the side of a highway berm. The descent angle measured eight degrees. The left wing hit two small trees located 17 feet in front of the initial ground scar. The airplane spun around and came to rest 9 feet from end of the initial ground scar. No propeller ground scars were found. One propeller blade was undamaged. The other blade was undamaged except it had 4 inches of chordwise scratching on the backside of the blade. The examination of the airplane revealed flight control and engine continuity. The fuel system on the engine had been converted to a fuel injection system. The fuel in the airplane was autogas. A green hose was found connecting the fuel line at the fire wall to the engine driven fuel pump. The fuel line was marked, 'GATES 6C5D FLEXLINE 5/16 INCH 1500 PSI MAX HYD WP MADE IN USA.' The manufacturer of the green hose reported it was a common hose used for petroleum products such as transmission fluid or anti-freeze. The manufacturer reported it had not made aviation hoses for many years. Inspection of the green hose revealed that the B nut attached to the fire wall was loose. A witness reported that the pilot performed maintenance on the airplane, although he was not an Airframe and Powerplant mechanic.

Factual narrative

History of Flight

On December 17, 1997, at 1454 central standard time, a Beech C35, N782D, was substantially damaged when it impacted the terrain about 1/3 mile south of the Skylane Airport, Evansville, Indiana. The airplane struck a road embankment after it experienced a loss of power during climbout after a touch and go. The private pilot was fatally injured. The 14 CFR Part 91 flight had departed the Skylane Airport on a local flight. Visual meteorological conditions prevailed and no flight plan had been filed.

No witnesses observed the airplane depart Skylane Airport. Air traffic control at Evansville Regional Airport reported that prior to the accident, the airplane had proceeded to Skylane Airport from 30 miles to the west of airport. No witnesses from the Skylane Airport observed the airplane land or perform touch and goes.

Witnesses reported seeing the airplane flying south from the airport at a low altitude. They reported seeing the airplane flying low over the trees and hitting trees prior to impacting the ground. The witnesses reported the airplane spun around after it impacted the ground and ended up facing the northeast.

The pilot initially survived the impact and was taken to a local hospital. He was pronounced dead at 1945 on December 17, 1997.

Personnel Information

The pilot was a private pilot with a single engine land rating. He held a Third Class Medical Certificate. He had a total of about 725 hours of flight time. 225 hours were in the make and model of the accident aircraft. There was no record in the pilot's logbook indicating that he had flown within the last 90 days.

Aircraft Information

The airplane was a single engine Beech C35, serial number D-3051. The airplane seated four and had a gross weight of 2,900 pounds. The engine was a 225 horsepower Continental E-225-8. A Bendix fuel injection system was installed on the engine and a Supplemental Type Certificate (STC) was recorded in the aircraft's logbooks. The last annual inspection was conducted on July 19, 1997. The airplane had flown 21 hours since the last inspection.

A green hose used as a fuel line was found attached to the fuel line at the engine firewall and attached to the engine driven fuel pump. The identification on the green hose was as follows: "GATES 6C5D Flexline 5/16 INCH 1500 PSI MAX HYD WP MADE IN USA." An aviation "B" nut was attached to each end of the green hose.

Meteorological Conditions

At 1534, weather conditions reported at the Evansville Regional Airport were VFR. The sky was clear with 10 miles visibility. The temperature was 49 degrees Fahrenheit, and the dew point was 37 degrees Fahrenheit. The winds were 310 degrees at 4 knots.

Wreckage and Impact Information

The airplane wreckage was located about 1/3 mile south of the departure end of runway 18 at Skylane Airport on a heading of 183 degrees from the airport.

The wreckage path indicated that the airplane hit the top of trees located about 280 feet north of the impact site. The airplane struck two small trees that were about 17 feet north of the initial ground impact scar. The two trees were about 8 feet 4 inches apart. The airplane's left wing's leading edge had a tree branch imbedded in it, and another impact mark was located about 8 feet 4 inches outboard of the tree branch.

The airplane struck the slope of the road embankment of Highway 66 which ran east and west. The airplane impacted the slope on a heading of about 180 degrees. The airplane spun around and came to rest about 9 feet from the end of the initial ground scar. The airplane remained upright and the airplane's heading was about 070 degrees. There were no propeller mark ground scars evident at the impact site.

Both wings remained attached to the fuselage. The left wing exhibited impact damage which corresponded to the tree impacts. The right wing did not have any impact marks on its leading edge. A 45 degree buckle on both sides of the empennage was evident midway between the rear window and the stabilizers. There was no apparent damage to the stabilizers or ruddervators. None of the glass of the side windows was cracked or broken. The one piece pilot's windshield was intact except for about a 4 inch triangular section that had broken out of the windshield on the lower left side.

One propeller blade did not indicate any chordwise scratching, bending, or leading edge damage. The other blade exhibited about 4 inches of chordwise scratching on the backside of the blade at the outboard tip.

Continuity of the aircraft control surfaces, engine and propeller controls, and the airframe fuel system was verified.

The examination of the engine revealed drive train continuity and compression. The spark plugs were normal in color. Both magnetos were spark checked and the leads were spark checked except for two leads that suffered impact damage.

The fuel selector was in the right main tank position. Fuel samples were taken from both main tanks and an auxiliary tank located in the empennage. The fuel samples were sent to a laboratory for examination.

The green fuel line from the airframe firewall to the engine driven fuel pump was disconnected at the engine driven fuel pump end. No fuel was in the line. No fuel was in the fuel line from the engine driven fuel pump to the fuel servo. The fuel line from the fuel line to the fuel servo to the distributor balve was removed at the servo and it contained fuel. The steel lines from the distributor valve to the injectors were removed and some contained fuel and some did not.

When the green fuel line was removed from the firewall fitting on the airframe, the fitting was discovered to be loose.

Medical and Pathological Information

An autopsy was performed on the pilot at the Vanderburgh County Coroner's Office, Evansville, Indiana.

A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute. The report indicated the following results:

No Carboxyhemoglobin detected in blood.

No Cyanide detected in blood.

No Ethanol detected in viteous fluid.

0.025 (ug/ml, ug/g) Diphenhydramine detected in blood.

Diphenhydramine was detected in urine.

Chlorpheniramine was detected in urine.

Diphenhydramine and Chlorphenirmine are used in over-the-counter antihistamine drugs.

Tests and Research

The Bendix fuel injection system was inspected and bench tested. The fuel servo benched tested normal, although a bent mixture control shaft and arm prohibited testing of all parameters. The flow divider ran normally. The residual fuel in the servo smelled like automotive fuel.

The fuel pump was benched tested and it operated normally.

The fuel from the left and right main tanks, the fuel sump, and the auxiliary fuselage tank was tested. The fuel was determined to be automobile gasoline. The fuel in the left and right tanks matched the fuel found in the fuel sump.

The green hose that was used as a fuel line was identified as a hose manufactured by the Gates Rubber Division. A representative of the company reported that the company had not made aviation hoses for many years. He identified the "GATES 6C5D" hose as a rubber, steel belted hose used for petroleum based products. He reported that typical uses would be for transmission or anti-freeze hoses. He reported that the hose was very common and could be found in many makes and models on all types of equipment.

Additional Information

A witness reported that the pilot did much of the maintenance on his own aircraft, although the pilot was not an Airframe and Powerplant (A&P) mechanic. The witness reported an authorized mechanic would check the maintenance the pilot had performed.

Parties to the investigation included Raytheon Aircraft Company and the Federal Aviation Administration.

The wreckage and the aircraft logs and the pilot logs w

Aircraft

Registration
N782D
Reported as
Beech C35
Category
Airplane
Serial number
D-3051
Airframe hours
5,287
Engine
Continental E-225-8, 225 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Charles A. Keown
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 19, 1997 · 21 hours before
Departed
3EV
Airport
3EV · Skylane Airport

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
53
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
650 total · 140 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 37 °F
Altimeter
30.00 inHg
Observed at
EVV, 4 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.