# NTSB DEN04FA109: Beech 58P, N69CL, Fort Collins, CO, July 24, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 24, 2004, 12:07 local (18:07 UTC) - Place: Fort Collins, CO - Coordinates: 40.533054, -105.020835 - Nearby events: https://openairdocs.org/map.md?lat=40.5331&lon=-105.0208&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report September 13, 2005 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Fort Collins Police Department, Raytheon Aircraft Corporation, FAA Flight Standards District Office - NTSB case key (mKey): 59731 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN04FA109 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59731/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=59731 - Page: https://openairdocs.org/ntsb/DEN04FA109 ## Probable cause the loss of engine power for undetermined reasons, and the pilot's failure to maintain adequate airspeed which resulted in a stall/spin. Clouds and the pilot's diverted attention were contributing factors. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, climb - to cruise - reason for occurrence undetermined (cause) - 1 engine - Loss of control - in flight, climb - to cruise - airspeed - not maintained, pilot in command (cause) - stall/spin - inadvertent, pilot in command (contributing factor) - diverted attention, pilot in command - weather condition - clouds (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - residential area - terrain condition - roadway/highway ## Analysis The pilot obtained a "standard weather briefing," filed an instrument flight rules flight plan, and took off. Four minutes later, after several routine radio communications, the controller issued the pilot a radar vector. He did not acknowledge. The controller repeated the vector. There was a squelch break and in the background, a noise and tone could be heard. The pilot reported, "We have got some sort of malfunction going on here." Witnesses reported hearing an engine "sputtering" and losing power. The airplane emerged from a low overcast in a flat counterclockwise spin. The airplane impacted a street and driveway in a residential subdivision. On-scene investigation disclosed the landing gear and flaps were retracted. Both elevators were deflected up and jammed by impact. Subsequent examination of the airplane revealed the cockpit fuel selector handles were in the LEFT TANK-LEFT ENGINE/RIGHT TANK-RIGHT ENGINE positions. The left and right fuel selector valves, located in the wheel wells, were OFF and ON, respectively. Analysis of the ATC communications tape revealed two engines operating until the pilot reported the "malfunction," then which only one engine sound could be heard. A steady 1,000-hertz tone, similar to an aural stall warning system, was also heard. Both engines, turbochargers, and propellers were later disassembled and examined. No anomalies were noted. Neither propeller was feathered. On the day before the accident, the pilot had undergone recurrent ground and flight training, a flight review, and an instrument proficiency check in the airplane. Flight time totaled 5.3 hours. ## Factual narrative HISTORY OF FLIGHT On July 24, 2004, at 1207 mountain daylight time, a Beech 58P, N69CL, piloted by a private pilot, was destroyed when it impacted terrain in a residential area of Fort Collins, Colorado. Visual meteorological conditions (VMC) prevailed at the time of the accident. The personal cross-country flight was being conducted on an instrument flight rules (IFR) flight plan under the provisions of Title 14 CFR Part 91. The pilot and two passengers sustained fatal injuries. The flight originated from Fort Collins-Loveland Airport (FNL) at 1202, and was en route to Eppley Field (OMA), Omaha, Nebraska. According to Jet Center records, the airplane was serviced with 76.7 gallons of 100-LL aviation-grade gasoline prior to its departure from Fort Collins-Loveland Airport. According to FAA documents, the pilot telephoned the Denver (DEN) Automated Flight Service Station (AFSS) at 1037 and obtained a "standard weather briefing" for an IFR flight from FNL to OMA. When the briefing ended, the pilot filed an IFR flight plan. At 1151, the pilot inadvertently contacted Denver terminal radar control (TRACON) instead of the Denver AFSS. The controller obtained and issued the pilot his IFR clearance, and the pilot read it back correctly. At 1156, the pilot advised the controller he was ready for takeoff on runway 15. The controller said there would be a 20-minute delay due to inbound IFR traffic. The controller suggested that if the pilot would be willing to depart on runway 33, he could release him almost immediately. The pilot said he would taxi to and depart on runway 33. At 1202, the pilot said he was ready for takeoff. The controller "released" the flight and instructed the pilot to turn right to a heading of 350 degrees and climb and maintain 8,000 feet. The pilot was given an IFR clearance void time of 1205. At 1204, the pilot reported passing 5,800 feet. The controller advised the pilot that he was in radar contact. At 1205, the controller instructed the pilot to climb and maintain 8,000 feet and the pilot acknowledged. The controller then instructed the pilot to turn right to a heading of 080 degrees. The pilot acknowledged. At 1206, the controller instructed the pilot to turn right to a heading of 100 degrees. The pilot did not acknowledge. The controller repeated the instruction. There was a squelch break and in the background, noise and a tone could be heard. The controller then asked the pilot, "How do you hear?" The pilot answered, "We hear you loud and clear. We have got some sort of malfunction going on here." The controller asked if he was having communications difficulties. There was no reply from the pilot, nor were there any further communications. The controller then contacted the Fort Collins Police Communications Center and advised that the airplane was believed to have crashed northwest of Fort Collins. At 1207, the controller advised the pilot that radar contact had been lost. It was also at this time that the Fort Collins Police Communications Center received the first of numerous 9-1-1 calls. At 1244, the police department notified Denver TRACON and confirmed that the airplane had crashed in a Fort Collins neighborhood. Telephone interviews or written statements were taken from 16 witnesses. Witness 3 heard "an abrupt decrease in engine noise," and witness 7 heard "erratic revving of a plane motor, followed by the sound of a motor stalling. [It] sputtered four times before dying." Witness 4 heard "erratic engine noise." Witness 5 said the "engines were missing, sputtering, cutting to silence, then sputtering again." Witness 8 heard the airplane "lose an engine," and witness 11 said "the engine quit." Witness 12 said "the engines didn't sound normal...kind of higher pitched...like he was climbing. Engines were revved at high RPMs...[Then] the sound changed, [like] when a plane is diving to make a run." Witness 16 said the plane's engine sounded "like it was failing or under heavy load (higher RPM)," and witness 14 thought "the pilot had slowed the engine down." The airplane was seen to emerge from the overcast in a flat spin. Several witnesses (1, 6, 10, 16) said the airplane fell "straight down," and witness (10) added, "with no forward motion." Witnesses 1 and 7 said the airplane was spinning counterclockwise. Witness 3 said "it appeared the right hand engine propeller had stopped turning. Witness 4 said "one engine [was] dead (prop not spinning on starboard side)." This witness added, "The elevator on the aircraft was fully deflected in the up position during the descent and at impact." The airplane impacted the street and driveway in front of 3027 Stonehaven Drive. Fuel flowed underneath a parked automobile and into the storm drain. Seconds later, the fuel ignited and engulfed the airplane and the parked automobile and blew off four manhole covers. PERSONNEL INFORMATION The pilot, age 50, held a private pilot certificate with airplane single/multiengine land and instrument ratings, dated March 29, 2002. He also held and third class airman medical certificate, dated March 17, 2003, with the limitation, "must have available glasses for near vision." The pilot's two logbooks were examined. The first logbook contained entries from February 26, 1997, when he took his first flying lesson, to September 10, 2003. The second logbook contained entries from September 23, 2003, to July 28, 2004. He began taking multiengine instruction in a Beech 55 on November 6, 2001, and received an airplane multiengine land rating on March 29, 2002. He did not fly multiengine airplanes again until the following year. Between March 5 and 8, 2003, the pilot received 15 hours of instruction in a Beech 58P simulator from Simcom, including "pressurization, instrument emergency, single engine procedures, and high altitude descents." His logbook was endorsed as having satisfactorily completed "training requirements outlined in Advisory Circular 91-91H, paragraph 7(i)," and "an instrument proficiency check required by FAR 61.57(d)." After that, the only multiengine airplane the pilot flew was the Beech 58P, N69CL. On July 23, 2004, the day before the accident, the pilot received 5.3 hours of instruction from ATM (Aviation Training Management) of Vero Beach, Florida. The training included "preflight operations, line inspection, aircraft servicing, use of checklists, cockpit orientation, start, taxi, run up, takeoff, climb to altitude, normal operations, simulated emergency engine/electrical/cockpit fires, medium, steep bank 360's, unusual attitudes, partial panel operations, VOR radial intercept, track, hold, multiple instrument approaches, autopilot coupled approaches, go around, land, GPS operations, single engine operations." His logbook was endorsed as having satisfactorily completed "the recurrent ground and flight training," a "flight review required by FAR 61.56," and "and instrument proficiency check FAR 61.57(d)(2)." The pilot had accumulated the following flight time (in hours): Total time: 1,397.4 Pilot-in-command: 1,271.1 Instruction received: 119.4 Single engine: 1,153.2 Multiengine: 211.6 Cross-country: 852.7 Night: 46.6 Actual instruments: 80.4 Simulated instruments: 71.0 Simulator: 16.0 The pilot had logged 171.0 hours in the Beech 58P, N69CL, of which 16.0 hours were in a simulator, 2.3 hours were in simulated instrument conditions, and 31.4 hours were in actual instrument conditions. AIRCRAFT INFORMATION N69CL (s/n TJ-444), a model 58P Baron, was manufactured by the Beech Aircraft Corporation in 1984, and was registered to L-Petrel LLC, of Dover, Delaware. It was equipped with two Continental TSIO-520-WB(3) engines (s/n 248186-R, left; 274490-R, right), rated at 325 hp at 2700 rpm, driving two Hartzell all metal, 3-blade, full-feathering constant speed propellers (m/n 3AF32C511-C). The airframe, both engines, and both propeller ## Aircraft - Registration: [N69CL](https://openairdocs.org/deregistered/N69CL-2006-07-07), registration cancelled 2006-07-07, S/N TJ-444, built 1984 (OpenAirDocs) - Reported make and model: Beech 58P - Registry model: [Beech 58P](https://openairdocs.org/model/beech-58p) (registry code 1152744) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TJ-444 - Airframe hours: 2101 - Engines: Continental TSIO-520-WB 325 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Leo J. Schuster - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 20, 2004 - Departed: FNL, Loveland, CO - Destination: OMA, Omaha, NE - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; last flight review July 23, 2004; seat: left; toxicology performed; flight hours: 1,397 total, 32 in this make and model, 1,271 as pilot in command, 60 in the last 90 days, 28 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 1,100 ft broken - Temperature: 57 °F, dew point 48 °F - Altimeter: 30.45 inHg - Observed at: FNL, 9 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 (OpenAirDocs). - [Accident 20040724018749A](https://openairdocs.org/incident/20040724018749A), Jul 24, 2004: Beech 58P, Fort Collins, CO, Destroyed, 3 fatal. (-23) On July 24, 2004 at approximately 12:05 pm, N69CL a Beech baron 58P impacted the ground at the intersection of carrick road and stonehaven drive Fort… ## Docket (38 files) The files NTSB released with the investigation on December 27, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=59731. 13.9 MB in all. - Sound Spetrum Study- Air Traffic Control recording (item 1, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40219065&FileExtension=.PDF&FileName=Sound%20Spetrum%20Study-%20Air%20Traffic%20Control%20recording-Master.PDF - Supplement S (item 2, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229906&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - NTSB Report of Engine-Turbocharger Disassembly (item 3, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229907&FileExtension=.PDF&FileName=NTSB%20Report%20of%20Engine-Turbocharger%20Disassembly-Master.PDF - Witness Interview Notes and Statements (item 4, .PDF, 919 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408850&FileExtension=.PDF&FileName=Witness%20Interview%20Notes%20and%20Statements-Redacted.PDF - FAA Controller Statements (item 5, .PDF, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408854&FileExtension=.PDF&FileName=FAA%20Controller%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 6, .PDF, 237 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229910&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Weather Reports and Records (item 7, .PDF, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229911&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Transcript of Radio Communications (item 8, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408855&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - NTAP Data and Plots (item 9, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229913&FileExtension=.PDF&FileName=NTAP%20Data%20and%20Plots-Master.PDF - Excerpts from FAA Report of Aircraft Accident (item 10, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229914&FileExtension=.PDF&FileName=Excerpts%20from%20FAA%20Report%20of%20Aircraft%20Accident-Master.PDF - Daily Record of Denver TRACON (item 11, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408849&FileExtension=.PDF&FileName=Daily%20Record%20of%20Denver%20TRACON-Redacted.PDF - FAA Form 7230-7.2, Flight Progress Strip (item 12, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229916&FileExtension=.PDF&FileName=FAA%20Form%207230-7.2,%20Flight%20Progress%20Strip-Master.PDF - Excerpts from Fort Collins Police Department Incident Report (item 13, .PDF, 404 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229917&FileExtension=.PDF&FileName=Excerpts%20from%20Fort%20Collins%20Police%20Department%20Incident%20Report-Master.PDF - McCauley Propellers Disassembly Report (item 14, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408846&FileExtension=.PDF&FileName=McCauley%20Propellers%20Disassembly%20Report-Redacted.PDF - Fuel Invoice (item 15, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229922&FileExtension=.PDF&FileName=Fuel%20Invoice-Master.PDF - Raytheon Aircraft Corporation Safety Communique No. 249 (item 16, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229924&FileExtension=.PDF&FileName=Raytheon%20Aircraft%20Corporation%20Safety%20Communique%20No.%20249-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 17, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408856&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 18, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408835&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Reports (item 19, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229927&FileExtension=.PDF&FileName=Toxicological%20Reports-Master.PDF - Photo # 1 - 1209.15, airplane shortly after ground impact (item 20, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229929&FileExtension=.PDF&FileName=Photo%20%23%201%20-%201209.15,%20airplane%20shortly%20after%20ground%20impact-Master.PDF - Photo #2 - 1209.27. airplane suddenly bursts into flames (item 21, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229930&FileExtension=.PDF&FileName=Photo%20%232%20-%201209.27.%20airplane%20suddenly%20bursts%20into%20flames-Master.PDF - Photo #3 - 1210.19. Fuel flows down gutter into storm drain, igniting minivan and blowing off four manhole covers (item 22, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229932&FileExtension=.PDF&FileName=Photo%20%233%20-%201210.19.%20Fuel%20flows%20down%20gutter%20into%20storm%20drain,%20igniting%20minivan%20and%20blowing%20off%20four%20manhole%20covers-Master.PDF - Photo #4 - Left side of airplane (item 23, .PDF, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229933&FileExtension=.PDF&FileName=Photo%20%234%20-%20Left%20side%20of%20airplane-Master.PDF - Photo #5 - Front of airplane at 3027 Stonehaven Dr (item 24, .PDF, 714 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229934&FileExtension=.PDF&FileName=Photo%20%235%20-%20Front%20of%20airplane%20at%203027%20Stonehaven%20Dr-Master.PDF - Photo #6 - Right side of airplane (item 25, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229935&FileExtension=.PDF&FileName=Photo%20%236%20-%20Right%20side%20of%20airplane-Master.PDF - Photo #7 - Rear of airplane (item 26, .PDF, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229936&FileExtension=.PDF&FileName=Photo%20%237%20-%20Rear%20of%20airplane-Master.PDF - Photo #8 - Left engine and remains of propeller assembly (item 27, .PDF, 854 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229937&FileExtension=.PDF&FileName=Photo%20%238%20-%20Left%20engine%20and%20remains%20of%20propeller%20assembly-Master.PDF - Photo #9 - Right engine and remains of propeller assembly (item 28, .PDF, 850 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229939&FileExtension=.PDF&FileName=Photo%20%239%20-%20Right%20engine%20and%20remains%20of%20propeller%20assembly-Master.PDF - Photo #10 - Fuel selector handles (item 29, .PDF, 215 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229941&FileExtension=.PDF&FileName=Photo%20%2310%20-%20Fuel%20selector%20handles-Master.PDF - Photo #11 - Fuel selector valves from wheel wells (item 30, .PDF, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229958&FileExtension=.PDF&FileName=Photo%20%2311%20-%20Fuel%20selector%20valves%20from%20wheel%20wells-Master.PDF - Photo #12 - Power quadrant (item 31, .PDF, 610 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229943&FileExtension=.PDF&FileName=Photo%20%2312%20-%20Power%20quadrant-Master.PDF - Photo #13 - Magneto switches (item 32, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229946&FileExtension=.PDF&FileName=Photo%20%2313%20-%20Magneto%20switches-Master.PDF - Photo #14 - EDM-760 engine analyzer (item 33, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229970&FileExtension=.PDF&FileName=Photo%20%2314%20-%20EDM-760%20engine%20analyzer-Master.PDF - Photo #15 - Left elevator counterweight (item 34, .PDF, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229949&FileExtension=.PDF&FileName=Photo%20%2315%20-%20Left%20elevator%20counterweight-Master.PDF - Photo #16 - Matching counterweight with left stabilizer and elevator (item 35, .PDF, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229950&FileExtension=.PDF&FileName=Photo%20%2316%20-%20Matching%20counterweight%20with%20left%20stabilizer%20and%20elevator-Master.PDF - Photo #17 - Another view (item 36, .PDF, 169 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229951&FileExtension=.PDF&FileName=Photo%20%2317%20-%20Another%20view-Master.PDF - Photo #18 - Right elevator counterweight (item 37, .PDF, 612 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229952&FileExtension=.PDF&FileName=Photo%20%2318%20-%20Right%20elevator%20counterweight-Master.PDF - Photo #19 - Matching counterweight with right stabilizer and elevator (item 38, .PDF, 580 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229953&FileExtension=.PDF&FileName=Photo%20%2319%20-%20Matching%20counterweight%20with%20right%20stabilizer%20and%20elevator-Master.PDF From the NTSB's public API. 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