LAX91FA324

NTSB accident investigation · Beech 95-C55 · Granada Hills, CA · July 23, 1991

Accident · FatalField investigationFinal report
Date
July 22, 1991, 17:00 local (Jul 23, 1991, 00:00 UTC)
Place
Granada Hills, CA
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N77CQBeech 95-C55
Weather
Visual (VMC) · Day
Status
Completed · report July 31, 1992
Report
Approved by Office Director
Safety recommendations
Yes
FAA report
19910722029039A
Case key
27015

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

A loss of directional control following an undetermined autopilot failure, during which the pilot failed to perform the emergency procedure to correct a mis-trim condition. Contributing to the accident was a perceived elevator control problem; the inability of the pilot to overpower the mis-trim condition; and a lack of understanding and training in autopilot systems and failures.

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.

Airframe/component/system failure/malfunctionGo-around (vfr)
Flt control syst,elevator control - movement restrictedFactor
Directional control - not possiblePilot in commandCause
Physical strength overloadPilot in commandFactor
Autopilot/flight director - undeterminedCause
Autopilot - not understoodPilot in commandFactor
Inadequate transition/upgrade trainingCheck pilotFactor
Trim setting - not correctedPilot in commandCause
Lack of familiarity with aircraftPilot in commandFactor
Emergency procedure - not performedPilot in commandCause
Inadequate training(emergency procedure(s))Flight instructor(on ground)Factor
Loss of control - in flightApproach - vfr pattern - downwind
In flight collision with objectDescent - uncontrolled

Analysis

During a visual approach to the airport, the tower controller noticed that the airplane was high, and instructed the pilot to go around and enter a right downwind. Repeated instructions to turn to downwind brought no response until a turn was finally initiated. At that time the pilot declared an emergency, reporting that he was holding full back elevator, trying to keep the airplane in the air, and that it looked like his elevators were stuck. The airplane continued away from the airport and entered a near vertical high speed descent into a storage building. Investigation revealed both elevator trim actuators at a 4 deg nose down trim position, and evidence indicates a 40 deg down elevator position. No malfunction of the engines or flight controls were found. The autopilot system control module was destroyed. The pilot had received 7 hours of training in the airplane, and had 20 hours total time in the airplane.

Aircraft

Registration
N77CQ
Reported as
Beech 95-C55
Category
Airplane
Serial number
TE-299
Airframe hours
3,698
Engine
Continental IO-520-C, 285 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Bargman, Stuart
Registered owner
Bargman, Stuart
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 20, 1991 · 16 hours before
Departed
SJC · San Jose, CA
Airport
VNY · Van Nuys, runway 16R, 8,001 × 150 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
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
555 total · 20 in this make and model · 20 in the last 90 days · 20 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 61 °F
Altimeter
29.00 inHg
Observed at
VNY, 4 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.