LAX00FA151

NTSB accident investigation · Beech B36TC · Fullerton, CA · April 11, 2000

Accident · FatalField investigationFinal report
Date
April 11, 2000, 12:07 local (19:07 UTC)
Place
Fullerton, CA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N6791PBeech B36TC
Weather
Visual (VMC) · Day
Status
Completed · report April 15, 2003
Report
Approved by Office Director
Parties
Teledyne Continental Motors, Raytheon Aircraft Company, Federal Aviation Administration
FAA report
20000411012679A
Case key
48932

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 failure to maintain adequate airspeed while in the traffic pattern, which resulted in an inadvertent stall/spin. Contributing factor was the pilot's diverted attention with the loss of engine power from his inadvertent activation of the auxiliary fuel pump, and the open cabin door.

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.

Miscellaneous/otherTakeoff - initial climb
Door - not secured
Door - openFactor
Loss of engine power(total) - nonmechanicalApproach - vfr pattern - downwind
Fuel boost pump selector position - inadvertent activationPilot in commandFactor
Fuel system - excessive flow/output
Loss of control - in flightApproach - vfr pattern - base turn
Airspeed - not maintainedPilot in commandCause
Diverted attentionPilot in commandFactor
Stall/spin - inadvertentPilot in commandCause
In flight collision with objectDescent - uncontrolled
Object - wire,transmission
Object - residence

Analysis

The single engine airplane impacted a house after experiencing a loss of control while returning to land. The commercial pilot reported to air traffic controllers that the cabin door came open during takeoff. The pilot was attempting to return the airplane to the departure runway when the air traffic controller heard the pilot's voice say, "Emergency, I've got . . ." Witnesses observed black smoke emanating from the exhaust stack. One witness observed the airplane flying low and slow at a high angle of attack with the landing gear extended. He then observed the airplane stall and spin, rotating 1.5 times before losing site of the airplane. Another witness, who was located near the accident site, stated the engine stopped making noise prior to the accident. The airplane impacted a power line and home in a residential area. No anomalies were noted with the airplane and engine that would have prevented its operation; however, the engine did display signatures of operation with an excessively rich mixture. The auxiliary fuel pump, which was unguarded and located adjacent to the landing gear selector switch, was found in the HI position. Operation with the auxiliary fuel pump in the HI position, with an operative engine-driven fuel pump, can result in a complete loss of engine power once the pilot reduced power for landing.

Factual narrative

History of flight

On April 11, 2000, at 1207 hours Pacific daylight time, a Beech B36TC single engine airplane, N6791P, impacted utility lines and a residence after experiencing a loss of control while returning to land following takeoff at the Fullerton, California, airport. The aircraft was destroyed during the impact sequence and post crash fire. The commercial pilot, who was the sole occupant, received fatal injuries. The aircraft was being operated as a personal flight by the pilot/owner under 14 CFR Part 91 when the accident occurred. The flight originated from the Fullerton Municipal Airport at 1203, and was destined for Van Nuys, California. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed.

The Air Traffic Control Tower (ATCT) local controller at Fullerton Municipal Airport reported that on takeoff, the pilot radioed that the aircraft door had opened and he was requesting permission to return for landing. The pilot was cleared for a left downwind approach to runway 24 and was told he would be number two to land behind a Cherokee that was on the downwind leg. The controller then asked the pilot if he had an emergency, to which the pilot replied, "no emergency." The pilot acknowledged his clearance and reported he was looking for the traffic. He subsequently reported he had the Cherokee in sight.

The controller reported he then heard the same voice say "Emergency, I got . . ." There were no further transmissions reported from the pilot.

Witnesses on the ground reported the aircraft was seen trailing dark smoke immediately after takeoff. Witnesses at locations along the downwind portion of the approach reported seeing grayish or light smoke. A witness near the accident site reported he heard the engine sounds stop prior to the crash. Another witness, who was a 9,500-hour Beech A36 pilot, reported he observed the airplane in a steep climb with a trail of black smoke from the exhaust, as if "the mixture was richer than necessary." He added that the aircraft stopped climbing and he lost sight of it behind trees; however, he observed the airplane again on the downwind leg approximately 600-800 feet above ground level. The witness stated the nose of the aircraft was high and the airplane was slow. As the airplane started its turn to base, it entered a 1.5-turn spin and crashed. This witness reported the landing gear were down and the flaps were up.

Personnel information

The commercial pilot held single engine, multiengine, and instrument airplane ratings. He was issued a second-class medical certificate on March 10, 1999, with no limitations. According to Federal Aviation Administration (FAA) records, the pilot reported having accumulated 2,182 total flight hours on his last medical certificate application. The pilot was the registered owner of the aircraft since December 1985.

Aircraft information

The airplane was manufactured and issued an airworthiness certificate in January 1984, and utilized a Continental TSIO-520-UB six-cylinder, turbocharged engine and a 3-bladed McCauley propeller. The aircraft maintenance records were not located; however, the insurance adjuster provided endorsements and inspection checklists from the aircraft's last annual inspection, which took place on September 3, 1999. At the time of the last annual, the airplane and engine had accumulated a total of 1,028.7 hours.

The airplane was equipped with an auxiliary fuel pump, which is controlled by a switch located adjacent to the landing gear selector handle. The auxiliary fuel pump switch has three positions; OFF, LO, and HI. The LO position is used for priming the engine during hot starts and to supply a low boost to the fuel flow during all flight conditions. The HI position is used for priming the engine during cold starts and also to provide an alternate source of fuel pressure in the event the engine-driven fuel pump fails. According to the pilot operating handbook (POH), the "HI boost must not be used during the flight unless the engine-driven fuel pump has failed. The increased pressure of the HI boost will overdrive the fuel control unit producing abnormally high fuel flows, which, in turn, will cause engine roughness. In some cases, engine combustion my cease." The auxiliary fuel pump is not equipped with a position guard.

The POH also describes an "UNLATCHED DOOR IN FLIGHT" situation by indicating that "If the cabin door is not properly latched, it may open in flight. This may occur during or just after takeoff. The door will trail open approximately 3 inches but the flight characteristics of the airplane will not be affected, except the rate of climb will be reduced. Return to the field in a normal manner. If practical, during the landing flare-out have a passenger hold the door to prevent it swinging open."

Wreckage and impact information

The airplane impacted power lines and a home in a residential area less than 1 mile southeast of the airport. The airplane came to rest within the home and erupted in flames upon impact, extensively damaging both the house and airplane. Review of photographs taken at the accident scene revealed that the majority of aircraft wreckage came to rest in the living room of the house.

Examination of the wreckage revealed that the flaps were found in the retracted position and the landing gear was found extended. The cabin door latch was examined and no damage or distortion was noted.

The engine sustained impact and fire damage, and was found separated from the airframe, and the propeller assembly was found separated from the engine. The propeller hub was shattered and the three propeller blades sustained varying degrees of fire and impact damage. Two of the three propeller blades displayed chordwise scratching, one of which sustained leading edge gouges. The third blade was bent aft and had approximately 8 inches of its tip missing, and displayed a leading edge gouge near its fracture surface. The number 2 rocker arm cover was partially melted from the cylinder exposing the rocker arms. The vacuum pump, starter, oil filter adapter, both magnetos, and propeller governor were found separated from the engine accessory section. The alternator was separated from its mounting pad. The fuel control housing was found melted away. The fuel pump was burned and its hoses were charred. The fuel pump was removed and its drive coupler was intact. An examination of the spark plugs by a NTSB investigator revealed that the plugs appeared sooted and black. According to the Champion Spark Plug Check-A-Plug chart, this spark plug condition and coloration is consistent with a rich air/fuel mixture.

The engine was sent to the manufacturer's facility in Mobile, Alabama, where it was examined at a later date. The engine turbocharger was sent to the manufacturer's facility in Torrance, California, where it too underwent examination at a later date.

Tests and research

On April 13, 2000, the turbocharger was disassembled and inspected at the manufacturer's facility under the observation of an FAA inspector. The turbocharger assembly sustained extensive fire damage and the compressor housing was broken. The impeller blades were found bent in the opposite direction of rotation near their tips and score marks were noted on the inside of the housing. No anomalies were noted that would have prevented its operation.

On September 14, 2000, the engine was examined by a Safety Board investigator, an aircraft manufacturer air safety investigator, and engine manufacturer representatives. Disassembly of the engine revealed that there was no metallic debris in the oil sump noted and the pickup tube screen was clear. The engine oil pump was disassembled and the gears were coated with oil and did not display any significant signatures. All of the cylinder head components were found intact. The cylind

Aircraft

Registration
N6791P
Reported as
Beech B36TC
Category
Airplane
Serial number
EA-404
Airframe hours
1,028.7
Engine
Teledyne Continental TSIO-520-UB, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
William Garvin Lofton, III
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · September 3, 1999
Departed
FUL · Fullerton, CA
Destination
VNY · Van Nuys
Airport
FUL · Fullerton Municipal, runway 24, 3,121 × 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
50
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
2,182 total

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 6 knots
Visibility
6 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 57 °F
Altimeter
30.03 inHg
Observed at
FUL, 1 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.