# NTSB LAX92FA161: Beech A33, N9367Y, Paradise, CA, April 3, 1992 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 2, 1992, 19:54 local (Apr 3, 1992, 03:54 UTC) - Place: Paradise, CA - Coordinates: 39.740348, -121.609466 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.7403&lon=-121.6095&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report June 30, 1993 - Report: Approved by Office Director - NTSB case key (mKey): 27417 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX92FA161 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27417/pdf - Page: https://openairdocs.org/ntsb/LAX92FA161 ## Probable cause THE STUDENT PILOT'S INADVERTENT USE OF THE MIXTURE CONTROL INSTEAD OF THE COWL FLAPS AT A CRITICAL PHASE OF FLIGHT, HIS MISUSE OF THE FLIGHT CONTROLS AFTER THE ENGINE FAILURE AND THE INSTRUCTOR'S INADEQUATE SUPERVISION OF THE STUDENT. CONTRIBUTING FACTORS IN THE ACCIDENT WERE: THE NON STANDARD LOCATION OF THE COWL FLAP PUSH PULL CONTROL, DUE TO AN IMPROPER AIRCRAFT MODIFICATION, THE DARK NIGHT LIGHT CONDITIONS WHICH IMPAIRED THE FLIGHT INSTRUCTORS ABILITY TO MONITOR THE STUDENT COCKPIT CONTROL MANIPULATIONS. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, go-around (vfr) - light condition - dark night (contributing factor) - visual/aural detection, pilot in command(cfi) (contributing factor) - mixture - inadvertent use, dual student (cause) - maintenance,modification - improper, other maintenance personnel (contributing factor) - acft/equip,inadequate control location, other maintenance personnel (contributing factor) - supervision - inadequate, pilot in command(cfi) (cause) - Loss of control - in flight, descent - emergency - elevator - improper use of, dual student (cause) - stall/mush - inadvertent, dual student (cause) - remedial action - not possible, pilot in command(cfi) (contributing factor) - altitude - inadequate - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE 60 HOUR STUDENT PILOT HAD A TOTAL OF 25 HOURS IN TYPE, ALL OF WHICH WERE DUAL. WITH HIS CURRENT FLIGHT INSTRUCTOR THE STUDENT RETURNED TO THEIR HOME BASE AIRPORT TO PERFORM A PREARRANGED GO-AROUND TO FINALIZE THEIR DUAL PERIOD FOR THE EVENING. AFTER THE APPROACH TO THE RUNWAY, THE INSTRUCTOR CALLED FOR THE GO-AROUND. AFTER THE CLIMB WAS ESTABLISHED AT ABOUT 500 FEET AGL HE CALLED FOR THE COWL FLAPS TO BE OPENED, AND MOMENTS LATER THE ENGINE SUDDENLY AND WITHOUT WARNING QUIT. THE INSTRUCTOR SAID THAT AFTER THE ENGINE QUIT THE STUDENT PULLED THE CONTROL YOKE ALL THE WAY BACK AND THE AIRCRAFT ENTERED A DEEP STALL. THE AIRPLANE HAD BEEN MODIFIED TO ACCOMMODATE AN ENGINE WITH MORE HORSE POWER WHICH REQUIRED THE INSTALLATION OF COWL FLAPS. THE FAA APPROVED STC MODIFICATION DRAWINGS REQUIRED THE PUSH-PULL CONTROL FOR THE COWL FLAPS TO BE LOCATED TO THE LEFT OF THE THROTTLE CONSOLE ON A SEPARATE SWITCH PANEL. THE ACTUAL LOCATION OF THAT CONTROL IN THE ACCIDENT AIRPLANE WAS FOUND TO THE RIGHT OF THE THROTTLE BELOW THE PROPELLER CONTROL AND NEXT TO ## Aircraft - Registration: [N9367Y](https://openairdocs.org/deregistered/N9367Y-1992-08-20), registration cancelled 1992-08-20, S/N CD262 (OpenAirDocs) - Reported make and model: BEECH A33 - Registry model: [Beech 35-A33](https://openairdocs.org/model/beech-35-a33) (registry code 1151404) (OpenAirDocs) - Category: Airplane - Serial number: CD-262 - Airframe hours: 4686 - Engines: CONTINENTAL IO-520-BA 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Desmet, Jeffrey G. - Registered owner: Desmet, Jeffrey G. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 23, 1991, 61 hours before ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; airline transport, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1; seat: right; flight hours: 2,500 total, 10 in this make and model, 1,700 as pilot in command, 90 in the last 90 days, 30 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point -0 °F - Altimeter: 29.00 inHg ## 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 19920402008289A](https://openairdocs.org/incident/19920402008289A), Apr 2, 1992: Beech 35A33, Paradise, CA, Destroyed, 1 fatal. Engine quit on practice go around. Fuel selector between idnets. Student caused stall. Possibly leaned by mistake ## Other investigations on N9367Y (3) 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. - [NTSB OAK71DVA31](https://openairdocs.org/ntsb/OAK71DVA31), Sep 27, 1970: Beech 35-A33 (N9367Y), Fresno, CA, substantial damage - [NTSB LAX66D0367](https://openairdocs.org/ntsb/LAX66D0367), Apr 25, 1966: Beech A33 (N9367Y), Barstow, CA, substantial damage - [NTSB UNK65X0407](https://openairdocs.org/ntsb/UNK65X0407), Oct 24, 1964: Beechcraft 35-A33 (N9367Y), Marseilles, IL, substantial damage 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.