# NTSB LAX03FA057: Beech 95, N8212D, Tucson, AZ, January 1, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 1, 2003, 12:12 local (19:12 UTC) - Place: Tucson, AZ - Coordinates: 32.14941, -110.930953 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.1494&lon=-110.9310&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 3 serious - Status: Completed, report June 28, 2006 - Report: Approved by Office Director - Parties: Beech Aircraft, Textron Lycoming, Hartzell Propellers, Federal Aviation Administration - NTSB case key (mKey): 56275 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03FA057 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56275/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56275 - Page: https://openairdocs.org/ntsb/LAX03FA057 ## Probable cause a loss power in the right engine due to an excessively rich mixture that was the result of the pilot's failure to secure the priming control prior to takeoff. Also causal was the pilot's failure to follow the single engine procedures specified in the operating manual for this aircraft, and, his failure to attain and maintain the correct airspeeds for single engine operation, and to maintain directional control. A factor was the pilot's lack of total experience in multiengine aircraft. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, takeoff - initial climb - preflight planning/preparation - improper, pilot in command (cause) - 1 engine - fuel system,primer system - not secured (cause) - powerplant controls - not set, pilot in command (cause) - Loss of control - in flight, takeoff - initial climb - aborted takeoff - not performed, pilot in command (contributing factor) - lack of experience, pilot in command (contributing factor) - procedures/directives - not followed, pilot in command (cause) - airspeed(v2 min) - not attained, pilot in command (cause) - directional control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane veered and rolled to the right after liftoff, and then went nose first into the ground. As the airplane took off, witnesses on the airport heard an engine "pop", which sounded to them like a backfire. The right wing dropped and then the airplane's nose went down and into the ground. Controllers in the Air Traffic Control Tower observed the airplane liftoff and begin a turn to the right at midfield, though they thought that the altitude, which they estimated at 60 to 80 feet, was very low. The airplane also appeared to be going slow as the airplane kept turning to the right and the nose pitched continuously up. The controllers then saw the right wing drop followed by the nose as the airplane went straight down. The landing gear was in the down and locked position, and the flaps were in the up position. The rudder trim was in the neutral position. Examination of the left engine and propeller found signatures consistent with engine rotation, and the left propeller was not feathered. Internal evidence in the right propeller revealed that it was operating at a high blade angle consistent with operation at low speed. The right engine spark plugs for cylinders 1, 2, and 4 were sooty and black, while the plugs in cylinder 3 were gray. The starting primer system is plumbed to cylinders 1, 2, and 4; the cockpit control for the right engine primer system was unlocked and extended about 1/4-inch. The pilot obtained his multiengine rating 3 weeks prior to the accident. and had a total of 20 hours in multiengine airplanes, which were all in this make and model. The owner's manual noted that liftoff airspeed was 85 while the safe single engine speed was 100 miles per hour (mph) indicated airspeed (IAS), which is still below best single engine rate of climb airspeed. The manual specified that at 100 mph or greater, the pilot could follow normal single engine procedures. Below this airspeed, the pilot had to attain it either through altitude loss or by making a landing. The manual instructed the pilot to land straight ahead and stop with loss of power in one engine below 90 mph at 100 feet, or below 100 mph at 50 feet. ## Factual narrative HISTORY OF FLIGHT On January 1, 2003, at 1212 mountain standard time, a Beech 95, N8212D, collided with terrain during departure from runway 6R at Ryan Airfield, Tucson, Arizona. The private pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The pilot and two passengers sustained serious injuries and one passenger sustained fatal injuries. The airplane was destroyed. Visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 32 degrees 08.48 minutes north latitude and 111 degrees 10.16 minutes west longitude. The flight was the first of two local sightseeing flights for relatives of the pilot. Family members who observed the accident provided statements to the Pima County Sheriff's Department. The pilot had completed an uneventful 2-hour flight the previous day. As they watched the airplane takeoff, one family member heard a pop, which sounded like a backfire. The right wing dipped; then the airplane's nose went down and into the ground. The local controller (LC) and ground controller (GC) in the air traffic control tower (ATCT), which was down approximately 1/4 the length of the runway, observed the takeoff. Other witnesses were also in the tower. The LC said that the pilot of N8212D called in ready for departure. He cleared the pilot for departure on runway 6 right with a right turn on departure. Everything looked good until the airplane began to turn. He thought that it didn't look right. The airplane was low and at midfield. It was a normal turn except that is was way low. The airplane was past the windsock and about 60 to 80 feet above ground level (agl). The airplane kept turning and had a continuous pitch up. The right wing dipped and then looked like it went straight down. He was now looking at the top of the cabin. He then saw a big dust cloud. He immediately started making notifications. The airplane still looked fairly normal at the taxiway. The GC reported that the LC asked what the pilot was doing as the airplane was between taxiways 3 and 4. The airplane was veering off the runway and wasn't very high. The airplane was rolling to the right. It stayed in a rolled position and climbed a little more. After crossing the taxiway, it appeared to go straight up, and then the nose went down. It hit and the back end came back down. It went from very nose high to very nose low. Other witnesses in the ATCT stated that the airplane appeared to be going slow as it lifted off. It banked right, but continued straight. It then turned hard right, pitched up, and then the nose pitched down. After the airplane hit the ground, it bounced back and pivoted. First responders reported that the pilot had opened his window and secured the master switch. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a private pilot certificate with airplane single and multiengine land ratings. The pilot held a third-class medical certificate issued on November 15, 2002. It had the limitations that the pilot shall wear corrective lenses. The pilot obtained his multiengine certificate on December 7, 2002. The FAA indicated that the pilot had a total time of 630 hours. He had 20 hours in multiengine airplanes, which were all dual instruction in make and model. AIRCRAFT INFORMATION The airplane was a Beech 95, serial number TD-8. A repair station at Marana Air Park provided records, which indicated that they completed an annual inspection on May 24, 2002. On the airworthiness directive compliance record, they noted a total airframe time of 3,726.9 hours, and a Hobbs hour meter reading of 501.7. The Hobbs meter read 532.5 at the accident scene. The airplane had a Textron Lycoming O-360-A1A engine, serial number L-120-36, installed on the left side. Total time on the engine at the last annual inspection was 2,804.9 hours with 64 hours since major overhaul. The airplane had a Textron Lycoming O-360-A1A engine, serial number L-117-36, installed on the right side. Total time on the engine at the last annual inspection was 2,634.1 hours with 22.8 hours since major overhaul. Fueling records at Tucson Airport Authority established that the airplane was last fueled on December 30, 2002, with the addition of 46 gallons of 100 LL octane aviation fuel. The fuel tanks contained a placard, which indicated that the main tanks held 19 gallons each, and the auxiliary tanks held 31 gallons each. The fuel selector valves were in the left and right main positions. Recovery personnel drained 19 gallons of fuel from the right main tank, and 5 ounces of fuel from the right auxiliary tank. They drained 5 gallons from the left main tank, and 6 ounces from the left auxiliary tank. Fuel leaked from the left wing lines during recovery. METEOROLOGICAL INFORMATION The closest official weather observation station was Tucson (TUS), Arizona, which was 12 nautical miles east of the accident site. The elevation of the weather observation station was 2,643 feet mean sea level (msl). A routine aviation weather report (METAR) for TUS was issued at 1155. It stated: skies clear; visibility 10 miles; winds calm; temperature 54 degrees Fahrenheit; dew point 31 degrees Fahrenheit; altimeter 30.14 inches of mercury. COMMUNICATIONS The airplane was in contact with Ryan ATCT Center on frequency 125.8. AIRPORT INFORMATION The Airport/ Facility Directory, Southwest U. S., indicated Tucson Ryan runway 6R was 5,500 feet long and 75 feet wide; the runway surface was asphalt. The field elevation was 2,417. WRECKAGE AND IMPACT INFORMATION The National Transportation Safety Board investigator-in-charge (IIC) and investigators from the FAA and Beech examined the wreckage at the accident scene. An investigator from Textron Lycoming joined them for examination of the wreckage in the owner's hangar. An investigator from Hartzell Propellers examined the propellers at Air Transport, Phoenix, Arizona, on January 29, 2003, under the supervision of a Safety Board investigator. The IIC estimated that the airplane came to rest about 200 feet beyond the 4,000-foot marker and southeast of Taxiway B. The terrain surface surrounding the runways and taxiways was hard dirt with patches of grass. The area between the runway and taxiway had a slight dip. The first identified point of contact (FIPC) was a ground scar, which contained green lens fragments. The debris field from the FIPC to the main wreckage was along a magnetic bearing of approximately 140 degrees. The main wreckage pointed on a magnetic bearing of 050 degrees, and was about 77 feet from the FIPC. About 15 feet from the FIPC along the debris path was a slash mark with blue paint along its smooth edge. About 5 feet further was the separated right propeller. About 10 feet further into the debris field was the separated left propeller, which was buried to the back of the flange. The propellers' tips had blue stripes that were approximately 2-inches wide with adjacent white and then red stripes of similar dimensions. The nose of the airplane crushed up and aft. The engines separated from the airframe except for some hoses and cables. The IIC supervised severance of the lines and placement of the inverted engines onto pallets. MEDICAL AND PATHOLOGICAL INFORMATION The Pima County Sheriff's Department reported that all of the victims had their seat belts fastened. The pilot sustained facial lacerations. The victim in the front right seat, who sustained fatal injuries, had the lap belt appropriately fastened; there was no shoulder harness. They observed severe head trauma during the autopsy that they attributed to contact with the instrument panel. TESTS AND RESEARCH The landing gear was in the down and locked position. The airframe representative determined that the flaps were in the up positio ## Aircraft - Registration: [N8212D](https://openairdocs.org/deregistered/N8212D-2013-04-01), registration cancelled 2013-04-01, S/N TD-8, built 1957 (OpenAirDocs) - Reported make and model: Beech 95 - Registry model: [Beech 95](https://openairdocs.org/model/beech-95) (registry code 1153402) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TD-8 - Airframe hours: 3726 - Engines: Lycoming O-360-A1A 180 hp reciprocating; Lycoming O-360-A1A 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Leland E. Oliver - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2002, 31 hours before - Departed: RYN, TUCSON, AZ - Airport: RYN, Ryan, runway 6R, 5,500 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: serious; private; airplane ratings: multi-engine land, single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 630 total, 20 in this make and model, 527 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 30 °F - Altimeter: 30.13 inHg - Observed at: TUS, 12 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 20030101000189A](https://openairdocs.org/incident/20030101000189A), Jan 1, 2003: Beech 95, Tucson, AZ, Destroyed, 1 fatal. (.19) On January 1, 2003, at 1212 mountain standard time, a Beech 95, N8212D, collided with terrain following a loss of control during departure from runway 6R… ## Docket (19 files) The files NTSB released with the investigation on April 5, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56275. 3.1 MB in all. - Witness Statements (item 1, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257801&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 2, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257802&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Photo 1-Accident Site (item 3, .PDF, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257803&FileExtension=.PDF&FileName=Photo%201-Accident%20Site-Master.PDF - Photo 2-Right Prop (item 4, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257804&FileExtension=.PDF&FileName=Photo%202-Right%20Prop-Master.PDF - Photo 3-Right Prop 2 (item 5, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257805&FileExtension=.PDF&FileName=Photo%203-Right%20Prop%202-Master.PDF - Photo 4-Left Prop in Ground (item 6, .PDF, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257806&FileExtension=.PDF&FileName=Photo%204-Left%20Prop%20in%20Ground-Master.PDF - Photo 5-Main Wreckage Front View (item 7, .PDF, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257807&FileExtension=.PDF&FileName=Photo%205-Main%20Wreckage%20Front%20View-Master.PDF - Photo 6-Main Wreckage Left Side View (item 8, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257808&FileExtension=.PDF&FileName=Photo%206-Main%20Wreckage%20Left%20Side%20View-Master.PDF - Photo 7-Main Wreckage Rear View (item 9, .PDF, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257809&FileExtension=.PDF&FileName=Photo%207-Main%20Wreckage%20Rear%20View-Master.PDF - Photo 8-Main Wreckage Nose Right Side (item 10, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257810&FileExtension=.PDF&FileName=Photo%208-Main%20Wreckage%20Nose%20Right%20Side-Master.PDF - Photo 9-Right Engine Front View (item 11, .PDF, 179 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257811&FileExtension=.PDF&FileName=Photo%209-Right%20Engine%20Front%20View-Master.PDF - Photo 10-Left Engine Front View (item 12, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257812&FileExtension=.PDF&FileName=Photo%2010-Left%20Engine%20Front%20View-Master.PDF - Photo 11-Rudder Pedals (item 13, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257813&FileExtension=.PDF&FileName=Photo%2011-Rudder%20Pedals-Master.PDF - Hartzell Report (item 14, .PDF, 198 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257816&FileExtension=.PDF&FileName=Hartzell%20Report-Redacted.PDF - Precision Report-Carburetor Exam (item 15, .PDF, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257818&FileExtension=.PDF&FileName=Precision%20Report-Carburetor%20Exam-Redacted.PDF - AD Record (item 16, .PDF, 293 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257819&FileExtension=.PDF&FileName=AD%20Record-Redacted.PDF - Fueling Records (item 17, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257820&FileExtension=.PDF&FileName=Fueling%20Records-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 18, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438186&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 19, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257822&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.