FTW98FA276

The pilot reported to Salt Lake City ARTCC that 'I've lost an engine and the cockpit is filling with smoke.' Five minutes later the pilot reported that 'my cylinders are all blown, I've got smoke comin' through.' He stated that he would shut off the electrical power as soon as the landing gear was down. A witness observed N3861K appear from behind a one-story building flying 'what appeared to be straight up in the air, and then it veered sharply to the right, then went straight down.' The airplane had been modified with a turbonormalizing system and the installer recommended that the tailpipe be removed for internal inspection of the turbocharger every 100 hours. Postaccident examination of the turbine exhaust flange revealed a 3-inch portion was missing and the fuel selector was found on the right main fuel tank. Several items from the airplane were found outside the postimpact fire area and they exhibited fire damage: the cabin entrance door, the cargo door, a passenger's shoe, and the engine cowling. The firewall had an 18 inch hole burned through it. Toxicology tests on the pilot revealed that fluoxetine (trade name Prozac, a non-approved drug for flight status) was present in his blood.

History of flight

On June 19, 1998, at 2021 mountain daylight time, a Beech A36, N3861K, was destroyed following an in-flight fire and subsequent impact with terrain while on approach to Nephi Municipal Airport, Nephi, Utah. The instrument rated private pilot and his passenger were fatally injured. The aircraft was being operated by the owner under Title 14 CFR Part 91. Visual meteorological conditions prevailed for the cross-country flight which originated from Las Vegas, Nevada, 1 hour, 39 minutes before the accident. No flight plan had been filed.

According to FAA documents, N3861K departed North Las Vegas Airport at 1842. The pilot contacted Nellis Air Force Base Approach Control at 1845 and requested VFR flight following. At 1920, when N3861K was handed off to Salt Lake City Center ARTCC, the pilot reported that he was at 13,500 feet (see attached transcriptions of voice recordings). At 2009, the pilot said, "bonanza three eight six one kilo, I've lost an engine and, uh, between Delta and Provo." The pilot also reported that his cockpit was "filling with smoke."

At 2014, the controller asked the pilot if he had "run through the [aircraft's] emergency checklist already." The pilot responded, "Ah, my cylinders are all blown, I've got smoke comin' through." The controller said "Can't read anything, ok, um supervisor here says you may want to shut down all your electrical power uh that might help you out a bit. If you've got the airport you don't need to talk to me right now." The pilot replied, "Uh six one kilo roger, and uh I'll shut off the electrical as soon as I, uh, get the gear down." One minute later, the pilot reported that he had "three [landing gear] down." At no time did the pilot declare an emergency or inform the controller that N3861K was a single engine airplane.

A witness reported that he observed the north bound airplane appear from behind a one-story building (located approximately 1,000 feet from the witness) "heading what appeared to be straight up in the air, and then it veered sharply to the right, then went straight down." The airplane impacted the terrain at Nephi Municipal Airport, 264 nm from its departure point, and postimpact fire destroyed the airplane. At 2021, the Juab County Sheriff's Department received a 911 call informing them of the accident at the airport.

Personal information

The pilot's most recent FAA Part 61 required flight review was dated February 8, 1997. His last FAA third class medical was issued on July 21, 1997. He purchased N3861K in December 1992, and had accumulated approximately 950 hours of flight experience in it at the time of the accident.

Aircraft information

The airplane was a single engine, six seat airplane that was manufactured by Beech Aircraft Company in 1981. It had accumulated approximately 2,228 hours of flight time at the time of the accident. In July 1994, the pilot had the airplane modified by installing a turbonormalizing system (an approved STC modification, see attached documents) and wing tip fuel tanks. The airplane's last annual inspection was on June 30, 1997, and it was scheduled for its next annual inspection during the week after the accident. The last entry in the airframe maintenance logbook was January 19, 1995, and it was for an oil change. A representative from Aerleon, Inc., a maintenance facility in North Las Vegas, Nevada, reported that they had been documenting their work on N3861K on "peel-off insert" paper, and were leaving them in the airplane for the pilot. None of these "peel-off insert" papers with maintenance documentation on them were ever located.

FliteCraft Turbo, Inc., the company that installed the turbonormalizing system in N3861K, published a maintenance and trouble shooting manual for the turbonormalizer (see attached document). In the periodic inspection chart, under 100 hour inspection procedures for the turbocharger, it states "remove tailpipe and ducting, inspect turbine for coking, carbonization, oil deposits, and turbine impeller for damage. Inspect compressor wheel for damage, rubbing on housing, and free rotation." No documentation was located which indicated that this periodic inspection had been performed. Installation instructions of the tailpipe and ducting included specific torque pressures to be used (see attached document) for reattaching the V-band clamps. FliteCraft Turbo further recommends that after the V-bands are attached, the aircraft should be flown and all V-bands be retorqued.

The airplane was equipped, for high altitude flying, with a supplemental oxygen system for its occupants. No documentation was found which indicated the system had been serviced with oxygen or periodic inspections performed.

The last fuel purchase for N3861K was six days before the accident (June 13, 1998) and records indicate that it had been topped-off with 60.9 gallons of 100LL. The airplane had a total fuel capacity of 120 gallons and an estimated 35 gallons were used for this flight. No documentation was located to indicate if N3861K had been flown between the last refueling and the accident flight.

Wreckage and impact information

The airplane impacted the terrain near mid field of runway 34 and approximately 220 feet east of the runway's edge (N39 degrees 44.503 minutes, W111 degrees 52.066 minutes). The terrain was a flat alfalfa field with vegetation approximately 12 inches high. The ground scar from the initial impact point extended approximately 185 to 190 degrees. The initial impact point was approximately 12 to 18 inches wide and contained pieces of green len. The main wreckage was found inverted and was located approximately 95 feet from the initial ground scar point (see attached wreckage diagram). The engine was found separated from the fuselage and in an upright position (see Test and Research for engine tear-down results). All the fuel and oil lines were found burned and/or broken. All the airplane's flight control components were accounted for, but control cable continuity could not be established due to impact damage and postimpact fire.

The landing gear was found in the down position. The nose wheel landing gear had separated from the aircraft (located half way to the initial ground scar point) and showed no signs of fire damage. Examination of the flaps indicated that the flaps were down 20 degrees; however, the flap actuator had been damaged by fire to the extent that the flap position could not be definitively determined. The propeller, spinner, and crankshaft flange were found approximately 20 feet from the beginning ground scar point. The spinner was pushed straight back and exhibited no signs of rotation (see photograph). The propeller blade marked "A" showed no signs of chordwise striations and the midsection was straight with the second half bent forward approximately 5 degrees. The propeller blade marked "B" exhibited some chordwise striations in the form of mud streaks across the blade. It exhibited approximately 20 degrees of twist and was bent back approximately 20 degrees.

A small fire extinguisher was found in the unburned grass and its gauge indicator needle was found in the discharge position. No fire extinguisher safety pin was located. The fuel selector was found on the right main tank.

Medical and pathological information

An autopsy on the pilot was performed by Dr. Maureen J. Frikke, a forensic pathologist, at the State of Utah, Department of Health, Salt Lake City, Utah, on June 20, 1998.

Toxicology tests were performed on the pilot by FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma. According to CAMI's report, the pilot's carbon monoxide, cyanide, and ethanol test results were negative. Fluoxetine, norfluoxetine, ephedrine, phenylpropanolamine, and salicylate were found in the pilot's blood (see attached CAMI toxicological report). NTSB's Medical Officer,