DEN04FA087

NTSB accident investigation · Raytheon A36 · Gilcrest, CO · June 7, 2004

Accident · FatalField investigationFinal report
Date
June 7, 2004, 16:50 local (22:50 UTC)
Place
Gilcrest, CO
Injuries
2 fatal, 1 serious
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N6162ERaytheon A36
Weather
Visual (VMC) · Day
Status
Completed · report January 24, 2005
Report
Approved by Office Director
Parties
Raytheon Aircraft Company, Teledyne Continental Motors, Inc., FAA Flight Standards District Office, Honeywell
FAA report
20040607011049A
Case key
59412

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 inadequate in-flight planning/decision by his failure to switch fuel tank selector position which resulted in fuel starvation. Also causal was the pilot's failure to maintain airspeed which resulted in a stall.

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 powerCruise - normal
In-flight planning/decision - inadequatePilot in command
Fluid,fuel - starvationFactor
Fuel tank selector position - not possiblePilot in command
Fuel tank selector position - reset/repositionedPilot passenger
Forced landingDescent - emergency
Loss of control - in flightDescent - emergency
Airspeed - not maintainedPilot in commandFactor
Stall/mush - inadvertentPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

Witnesses driving north on the highway observed the airplane flying low to the ground, in a northerly direction. According to one witness, the airplane's wings rocked from side to side and then the airplane pitched up. The airplane's nose dropped and the airplane impacted in a right wing low attitude. The airplane came to rest in a sod field approximately 1/4 mile east of the highway. One witness who had exited his vehicle noted a strong fuel smell. The surviving passenger stated that the "airplane shuttered, and a lot of the alarms on the plane started going off." The passenger estimated that they were approximately 500 feet agl and had been attempting to climb. According to the passenger, the pilot "could [not] reach the switch for the gas tanks" so the front seat passenger switched it. The passenger was not sure if they tried to start the engine. She heard the front seat passenger make the mayday call and could not recall anything after the impact.

Factual narrative

History of flight

On June 7, 2004, approximately 1650 mountain daylight time, a Raytheon Aircraft Company A36, N6162E, piloted by a private pilot, was destroyed when it impacted terrain approximately 2 miles south of Gilcrest, Colorado. Visual metrological conditions prevailed at the time of the accident. No flight plan had been filed for the local personal flight being conducted under the provisions of Title 14 CFR Part 91. The private pilot and the student pilot passenger in the front seat were fatally injured. The rear passenger received serious injuries. The flight departed Vance Brand Airport (2V2), Longmont, Colorado, approximately 1630.

Witnesses driving north on U.S Highway 85 observed the airplane flying low above the ground in a northerly direction. According to one witness, the airplane's wings rocked from side to side and then the airplane pitched up. The airplane's nose dropped and the airplane impacted the terrain in a right wing low attitude. The airplane came to rest in a sod field approximately 1/4 mile east of the highway. One witness exited his vehicle to help those on board the airplane. While approaching the wreckage, he noted a strong odor of fuel.

The owner of Airwest Flight Center in Longmont, Colorado, said he heard a mayday call at the approximate time of the accident. He said he heard, "Mayday, Mayday, Beechcraft N (witness could not recall the N number} east of Longmont, going down, 3 souls on board."

In a hospital interview and subsequent telephone interviews to clarify the submitted written statement, the surviving passenger stated that the flight had departed from Longmont approximately 20 to 30 minutes prior to the accident. They had flown over the pilot's home and were en route to Greeley when the accident occurred. The passenger stated that the front seat passenger, the pilot's daughter, expressed a wish to fly the airplane. She remembered she was "typing in the autopilot," and she recalled the pilot correcting her, "GXY, not GYX," or words to that effect (GXY is the 3-letter designator for the Greeley-Weld County Airport, located about 18 miles north of the accident site). As soon as she disengaged the autopilot, the "airplane shuttered [sic], and a lot of the alarms on the plane started going off." The passenger estimated that they were approximately 500 feet agl and had been attempting to climb. According to the passenger, the pilot "could [not] reach the switch for the gas tanks" so the front seat passenger switched it. The passenger was not sure if they tried to start the engine. She heard the front seat passenger make a mayday call and could not recall anything after the impact.

Personnel information

The pilot held a private pilot certificate with an airplane single engine land rating, which was issued April 27, 2004. The pilot held a third class medical certificate, dated January 9, 2004, with the limitation "must wear corrective lenses." According to the pilot's logbook, he received endorsements for complex and high performance airplane operations on April 1, 2001. The pilot had logged approximately 139 hours total time, 75 of which was in the accident airplane.

The front seat passenger held a student pilot certificate, which was issued on January 9, 2004. This third class medical certificate contained the limitation "must wear corrective lenses." According to her flight instructor, she had logged approximately 40 hours in a Cessna 172S and had soloed on May 14, 2004. He said he had never flown with her in the A36 and to the best of his knowledge, she had never flown in the airplane.

Aircraft information

The airplane, a Raytheon A36 "Bonanza" (s/n E-3492), was certified in the utility category on March 5, 2003. The airplane was equipped with an IO-550-B, 300 horsepower Teledyne Continental Motors, Inc. engine (s/n 695995). The engine was driven by a 3-bladed, constant speed Hartzell propeller. In addition, the airplane was equipped with retractable landing gear and flaps. The pilot purchased the airplane in January 2004 from Stevens Aviation in Broomfield, Colorado. Stevens Aviation also maintained the airplane. Although the aircraft maintenance logbooks were never located, Stevens Aviation records indicate an annual inspection was accomplished on April 6, 2004. At that time, the airframe and engine had accrued 95.2 hours total time.

Meteorological information

According to the Fort Collins-Loveland routine aviation weather report (METAR), 15 miles northwest of the accident site, the weather at the time of the accident was: Wind, 120 degrees at 7 knots; visibility, 10 statute miles (or better); sky condition, clear; temperature, 93 degrees F.; dew point, 30 degrees F.; altimeter, 29.64 inches of mercury. Density altitude was calculated to be between 8,244 and 8,631 feet at ground level.

Wreckage and impact information

The National Transportation Safety Board's (NTSB) on scene investigation began on June 7, 2004.

The accident site was located on level terrain in a turf farm, approximately 0.25 miles east of U.S. Highway 85, at 40 degrees, 15.434 minutes north latitude, and 104 degrees, 48.151 minutes west longitude. The accident site elevation was at 5,740 feet msl.

The initial impact point was located approximately 160 feet south of the main wreckage. This point was defined by a series of small ground scars that extended for 20 feet. Within the first ground scar were right wing tip lens fragments. The impact heading was approximately 010 degrees.

Approximately 25 feet from the initial impact point was a 10 foot long ground scar and several adjacent ground scars, consistent with propeller blade strikes. The debris field extended from the initial impact point north for approximately 160 feet. Within the debris field were the propeller assembly, the right front seat headrest, windscreen Plexiglas and fiberglass fragments, and the glare shield. The main wreckage was oriented on a heading of 118 degrees. The main wreckage consisted of the empennage, fuselage, both wings, and the engine. Between the initial impact point and the main wreckage, the sod was discolored to a shade of brown.

The left wing tip and aileron were unremarkable. The inboard leading edge of the wing was wrinkled. The trailing edge of the wing acted in the manner of a scoop and was covered in sod. The left fuel bladder had not been compromised and approximately 1 gallon of fuel was recovered. The left main landing gear had collapsed towards the fuselage. The left main landing gear door was found closed, underneath the collapsed left gear. The landing gear turnbuckle was extended and the flap jackscrew was retracted. According to the Raytheon Aircraft investigator, these would indicate that the landing gear was down and the flaps were up.

The engine cowling was torn off and the engine was separated from its mounts. The entire propeller assembly was located approximately 80 feet south east of the main wreckage. The propeller was sheared off at its attachment bolts.

The right wing was bent and crushed from the wing tip to the attachment point at the fuselage. Both the right aileron and flap were bent. The right main landing gear door was found closed and the right main landing gear had been bent out towards the wing tip. The right wing fuel bladder was compromised and no fuel was recovered.

The cabin door was torn open. The windscreen was fragmented and the instrument panel was crushed in towards the cabin.

The airplane's flight instruments showed the following indications:

Turn Coordinator: Right wing low/full left ball

Air Speed Indicator: Zero

Attitude Indicator: 50 degrees right bank/40 degrees nose down

Vertical Speed Indicator: 600 feet descent

Altimeter: 5,740 feet msl.

Kollsman window: 29.65 inches

The airplane's engine instruments showed the following indications:

Vacuum gauge: Zero

Tachometer: Zero

Fuel flow: Zero

Oil temperature: Zero

Oil pres

Aircraft

Registration
N6162E
Reported as
Raytheon A36
Category
Airplane
Serial number
E-3492
Airframe hours
95
Engine
Teledyne Continental IO-550-B, 300 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Standard, Utility
Last inspection
Annual · April 6, 2004 · 43 hours before
Departed
2V2 · Longmont, CO

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
45
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
April 27, 2004
Seat
Left
Toxicology
Performed
Flight hours
139 total · 75 in this make and model · 43 as pilot in command · 5 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 34 °F
Altimeter
29.61 inHg
Observed at
FNL, 17 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.