# NTSB LAX91FA324: Beech 95-C55, N77CQ, Granada Hills, CA, July 23, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: July 22, 1991, 17:00 local (Jul 23, 1991, 00:00 UTC)
- Place: Granada Hills, CA
- Coordinates: 34.289405, -118.500534 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.2894&lon=-118.5005&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report July 31, 1992
- Report: Approved by Office Director
- Safety recommendations: Yes
- NTSB case key (mKey): 27015
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX91FA324
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27015/pdf
- Page: https://openairdocs.org/ntsb/LAX91FA324

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Airframe/component/system failure/malfunction, go-around (vfr)
  - flt control syst,elevator control - movement restricted (contributing factor)
  - directional control - not possible, pilot in command (cause)
  - physical strength overload, pilot in command (contributing factor)
  - autopilot/flight director - undetermined (cause)
  - autopilot - not understood, pilot in command (contributing factor)
  - inadequate transition/upgrade training, check pilot (contributing factor)
  - trim setting - not corrected, pilot in command (cause)
  - lack of familiarity with aircraft, pilot in command (contributing factor)
  - emergency procedure - not performed, pilot in command (cause)
  - inadequate training(emergency procedure(s)), flight instructor(on ground) (contributing factor)
- Loss of control - in flight, approach - vfr pattern - downwind
- In flight collision with object, descent - 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](https://openairdocs.org/deregistered/N77CQ-2013-06-27), registration cancelled 2013-06-27, S/N TE-299, built 1967 (OpenAirDocs)
- Reported make and model: BEECH 95-C55
- Registry model: [Beech 95-C55](https://openairdocs.org/model/beech-95-c55) (registry code 1152708) (OpenAirDocs)
- Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: TE-299
- Airframe hours: 3698
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 50; 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 (OpenAirDocs).

- [Accident 19910722029039A](https://openairdocs.org/incident/19910722029039A), Jul 22, 1991: Beech 9555, Van Nuys, CA, Destroyed, 3 fatal. Pilot reported control problems after being too high to land. Dived into building. Possible runway pitch trim.

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.

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