LAX05LA215

NTSB accident investigation · Beech BE76 · Glendale, AZ · June 23, 2005

Accident · Minor injuriesLimited investigationFinal report
Date
June 22, 2005, 18:00 local (Jun 23, 2005, 01:00 UTC)
Place
Glendale, AZ
Injuries
3 minor
Damage
Destroyed
Phase of flight
Approach
Aircraft
N5274MBeech BE76
Weather
Visual (VMC) · Day
Status
Completed · report February 26, 2007
Report
Approved by Office Director
Parties
Raytheon Aircraft Company, Federal Aviation Administration
FAA report
20050622015789A
Case key
61781

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 flight instructor's decision to attempt a single engine go-around with multiple aircraft system failures, and his improper in-flight decision to pass up one airport for landing and continue the flight to the home base airport with known mechanical deficiencies.

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.

In flight collision with terrain/waterGo-around (vfr)
1 engine - switched off
In-flight planning/decision - inadequatePilot in command(cfi)Cause
Go-around - initiatedPilot in command(cfi)Cause
Descent - not correctedPilot in command(cfi)
Aircraft performance,engine out capability - exceeded
Terrain condition - ground

Analysis

The airplane impacted level terrain during an attempted single engine go-around. During a training flight, the certified flight instructor (CFI) was demonstrating single engine maneuvers with the left engine shutdown. The first attempt to restart the engine was unsuccessful. During subsequent attempts to start the engine, the CFI and pilot under instruction (PUI) could smell burning insulation and saw a trace of smoke from behind the instrument panel, followed by a loss of electrical power to most of the aircraft systems. The CFI decided to return to their departure airport (home base), and overflew a closer airport that had an 8,500-foot-long runway. Upon arrival at their home base, the CFI did not declare an emergency; instead he requested a straight-in approach due to single engine operations. The CFI attempted to extend the landing gear but he did not get a down and locked indication for the nose gear. He queried the tower controller as to whether or not the landing gear was down, and the controller informed him it was not down and issued instructions for the CFI to abort the landing. The CFI initiated a go-around and tried to circle around to land on the opposite runway. Although the CFI was able to extend the landing gear, he was unable to maintain altitude. He declared an emergency just before impacting an open dirt field 1/4-mile north of the runway. Post accident investigation showed that the propeller on the left engine was half in feather and half out. No mechanical malfunctions or failures were found during the examination of the wreckage.

Factual narrative

History of flight

On June 22, 2005, about 1800 mountain standard time, a Beech BE76, N5274M, impacted level terrain during an attempted go-around at Glendale Municipal Airport (GEU), Glendale, Arizona. Makarion Institute of Aeronautics (MIA) was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI), the commercial pilot undergoing instruction (PUI), and one passenger sustained minor injuries; the airplane was destroyed during the post impact fire. The local instructional flight departed Glendale about 1700. Visual meteorological conditions prevailed, and no flight plan had been filed. The approximate global positioning system (GPS) coordinates of the primary wreckage were 31 degrees 32.05 minutes north latitude and 112 degrees 17.25 minutes west longitude.

The National Transportation Safety Board investigator-in-charge (IIC) interviewed the CFI who related that the training flight was to indoctrinate the PUI with the Beech BE76 (Duchess). After demonstrating a couple of single engine maneuvers with the left engine shutdown, they attempted to restart the engine but were unsuccessful. During the subsequent attempts to start the engine they could smell burning insulation and saw a trace of smoke coming from behind the right side of the instrument panel. The CFI said he performed the emergency procedures for an electrical fire in flight as specified in the Federal Aviation Administration (FAA) approved flight manual. During the checklist, he found the number 2 electrical bus circuit breaker had popped. With a loss of all of the aircraft radios and instruments except for the number 1 radio/GPS and the fuel gauges, he decided to return to GEU.

While flying back to GEU they transitioned past Phoenix Goodyear Airport (GYR), Goodyear, Arizona. The CFI contacted GYR tower, and requested and received clearance to transition Goodyear's airspace.

When the CFI contacted GEU tower he requested a straight in approach to runway 01 due to single engine operations. The CFI reported that he did not declare an emergency or request priority handling due to the electrical problems and inability to restart the left engine. On final, the CFI attempted to extend the landing gear by use of the manual extension procedures. He observed that the nose gear down indicator failed to illuminate. The CFI contacted GEU tower and asked them if the nose gear was down. The controller told him that the nose wheel did not appear to be down and directed the CFI to go around. The CFI aborted the landing and tried to circle around to land on runway 19. The CFI said he was finally able to extend the landing gear, and declared an emergency because the airplane was not able to maintain altitude. The airplane landed about 1/4-mile north of runway 19 in an open dirt field. After the CFI, PUI, and the passenger exited the airplane the grass caught fire and the post impact fire consumed the airplane.

Personnel information

Certified Flight Instructor (CFI)

A review of FAA airman records revealed that the CFI held an airline transport pilot certificate with ratings for airplane single and multiengine land; and a certified flight instructor (CFI) certificate with ratings for airplane single and multiengine land, and instrument airplane. He also held a private pilot (foreign based) certificate with ratings for airplane single engine land and instrument airplane.

The CFI held a first-class medical certificate issued on June 28, 2004, with the limitation that he must wear corrective lenses.

The pilot reported a total flight time of 2,100 hours. He logged 108 hours in the last 90 days, and 19 hours in the last 30 days. He had an estimated 200 hours in the accident make and model, and had completed a biennial flight review on March 14, 2005.

Pilot Under Instruction (PUI)

A review of FAA airman records revealed that the PUI held a commercial pilot certificate with ratings for airplane single and multiengine land, and airplane single engine sea, and instrument airplane. He also held a flight instructor certificate with ratings for airplane single engine land and instrument airplane.

According to FAA records, the PUI held a first-class medical certificate issued in December 2004, with the limitation that he must wear corrective lenses.

The PUI reported he had a total flight time of 908 hours. He logged 120 hours in the last 90 days, and 60 in the last 30 days. He had no prior flight time in the accident make and model. He completed a biennial flight review on February 22, 2004.

Aircraft information

The airplane was a Beech BE76 (Duchess), serial number ME-24. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 5,658.9 hours at the last 100-hour inspection, dated May 19, 2005. The tachometer read 509.9 at the last inspection, and the Hobbs hour meter read 2,112.1. On June 16, 2005, a repair was performed replacing the ball joints on the nose gear doors, and replacement of a bolt and a nut on the right main landing gear torque links. Some fiberglass repairs were also performed. At that time, the tachometer read 565.4; the Hobbs meter read 2,175.6. On June 22, 2005, the number 2 Navigation-indicator was repaired. At that time, the tachometer read 584.5; the Hobbs hour meter read 2,197.7. The operator reported a total airframe time of 5,748 at the time of the accident.

The left engine was a Lycoming, O-360-A1G6D, serial number L-24652-36A. Total time recorded on the engine at the last 100-hour inspection was 5,671.8 hours; time since major overhaul was 1,556.6 hours. The operator reported a total time of 5,798 hours at the time of the accident, with 1,633.4 hours since the last major overhaul.

The right engine was a Lycoming, O-360-A1G6D, serial number L-124-71A. Total time recorded on the engine at the last 100-hour inspection was 5,670.2 hours; time since major overhaul was 1,611.1 hours. The operator reported a total time of 5,747 hours at the time of the accident, with 1,687.9 hours since the last major overhaul.

Both the left and right propellers were inspected during the 100-hour inspection.

Examination of the maintenance records did not reveal any unresolved maintenance discrepancies against the airplane prior to departure.

Meteorological information

The airport weather observation station issued an aviation routine weather report (METAR) for Glendale at the time of the accident. It stated: winds variable at 4 knots; visibility 20 statute miles; skies were reported as few clouds at 15,000 feet and a scattered cloud layer at 20,000 feet; temperature 43 degrees Celsius; and altimeter 29.67 inHg.

Airport information

The Airport Facilities Directory (A/FD) indicated that runway 01 and runway 19 were both 7,150 feet long and 100 feet wide. The runway surfaces were asphalt. Runway 01 had a displace threshold of 700 feet. Runway 19 had a displace threshold of 1,000 feet. The A/FD reported a right-hand traffic pattern for runway 01, and a left-hand traffic pattern for runway 19. Additional remarks indicated that there were high-tension power lines 1/4 mile west and parallel to the runway.

Tests and research

The Safety Board IIC examined the wreckage at Air Transport, Phoenix, Arizona, on June 23, 2005. Raytheon was a party to the investigation.

Investigators manually rotated the left engine's crankshaft via the propeller. The crankshaft rotated freely, and the valves moved approximately the same amount of lift in firing order. The gears in the accessory case turned freely, and thumb compression was obtained on all cylinders in firing order.

Investigators manually rotated the left engine's magnetos, and both magnetos produced spark at all posts for each cylinder. Investigators visually observed that the starter for the left engine was still in engaged.

The Raytheon representative dete

Aircraft

Registration
N5274M
Reported as
Beech BE76
Category
Airplane
Serial number
ME-24
Airframe hours
5,748
Engines
Lycoming O-360AIG6D, 180 horsepower, reciprocatingLycoming O-360-AIG6D, 180 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Registered owner
Makarion Enterprises, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 1, 2005 · 27.2 hours before
Departed
GEU · Glendale, AZ
Airport
GEU · Glendale Municipal Airport, runway 01, 7,150 × 100 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
27
Injuries
Minor
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 1, 2005
Seat
Right
Flight hours
2,100 total · 200 in this make and model · 1,940 as pilot in command · 108 in the last 90 days · 19 in the last 30 days · 5 in the last 24 hours
Role
Student pilot
Age
25
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
February 1, 2004
Seat
Left
Flight hours
908 total · 0 in this make and model · 800 as pilot in command · 120 in the last 90 days · 60 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 4 knots
Visibility
20 statute miles
Lowest ceiling
None
Temperature
109 °F, dew point 37 °F
Altimeter
29.67 inHg
Observed at
GEU

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.