# NTSB LAX93FA097: Beech A35, N595B, Tulare, CA, January 21, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 20, 1993, 18:05 local (Jan 21, 1993, 02:05 UTC) - Place: Tulare, CA - Coordinates: 36.179832, -119.359184 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.1798&lon=-119.3592&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 4, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 27821 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93FA097 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27821/pdf - Page: https://openairdocs.org/ntsb/LAX93FA097 ## Probable cause THE INSTALLATION OF AN UNAPPROVED WING TIP FUEL TANK SYSTEM; AN INADEQUATE ANNUAL INSPECTION WHICH DID NOT NOTE, OR CORRECT, THE UNAPPROVED FUEL SYSTEM ADDITION; A WING TANK FUEL SELECTOR VALVE INSTALLATION WITHOUT ADEQUATE PLACARDS TO SHOW POSITION OR OPERATION; AND INCORRECT INSTRUCTIONS TO THE PILOTS BY THE OWNER AND MECHANIC ON POSITIONING FUEL SELECTOR VALVES WHICH LED TO INADVERTENT MISPOSITIONING BY THE PILOTS AND SUBSEQUENT FUEL STARVATION. IN ADDITION, THE PILOT AT THE CONTROLS FAILED TO MAINTAIN ADEQUATE AIRSPEED FOLLOWING THE POWER LOSS WHICH RESULTED IN AN INADVERTENT STALL/SPIN. A FACTOR WHICH CONTRIBUTED TO THE LOSS OF CONTROL WAS THE DARK NIGHT LIGHT CONDITION. ## 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 - fuel system - improper (cause) - maintenance,installation - improper, other maintenance personnel (cause) - maintenance,annual inspection - inadequate, other maintenance personnel (cause) - fuel system,selector/valve - inadequate (cause) - instructions,written/verbal - inadequate, other person (cause) - instructions,written/verbal - inadequate, other maintenance personnel (cause) - fluid,fuel - starvation (cause) - fuel tank selector position - inadvertent, pilot in command(cfi) - Loss of control - in flight, takeoff - initial climb - light condition - dark night (contributing factor) - airspeed(vs) - not maintained, pilot in command(cfi) (cause) - stall/spin - inadvertent, pilot in command(cfi) - In flight collision with terrain/water, takeoff - initial climb ## Analysis THE CFI IN THE RIGHT SEAT WAS GIVING DUAL TO THE LEFT SEAT CFI, WHO HAD NO EXPERIENCE IN TYPE. DURING THE INITIAL CLIMB, AT ABOUT 400-500 FT AGL, WITNESSES HEARD THE ENGINE LOSE POWER OR SURGE. THE AIRPLANE WAS SEEN TO ROLL TO ONE SIDE AND DESCEND STEEPLY TO IMPACT. THE AIRPLANE HAD BEEN EXTENSIVELY MODIFIED WITH AN UNAPPROVED WING TIP FUEL TANK SYSTEM ADDITION. THE FUEL SELECTOR VALVE FOR THE TIP TANKS DID NOT HAVE ANY PLACARDS SHOWING POSITION OR OPERATION. BOTH CFI'S HAD BEEN GIVEN INCORRECT INSTRUCTIONS ON HOW TO POSITION THE FUEL SYSTEM SELECTOR VALVES BY THE OWNER AND A MECHANIC WHO SIGNED OFF THE ANNUAL INSPECTION. POST-CRASH EXAMINATION REVEALED THAT THE STANDARD FACTORY FUEL SELECTOR WAS IN THE AUX POSITION, AND THE TIP TANKS FUEL SELECTOR VALVE WAS IN A HALF-ON/HALF-OFF POSITION. THE AIRPLANE ALSO HAD A POWERPLANT MODIFICATION FOR INCREASED HORSEPOWER AND OTHER AIRFRAME MODIFICATIONS, NOT ALL OF WHICH WERE DOCUMENTED OR APPROVED. THIS WAS THE FIRST FLIGHT SINCE THE ANNUAL INSPECTION. ## Aircraft - Registration: [N595B](https://openairdocs.org/deregistered/N595B-1996-02-23), registration cancelled 1996-02-23, S/N D1616 (OpenAirDocs) - Reported make and model: BEECH A35 - Registry model: [Beech A35](https://openairdocs.org/model/beech-a35) (registry code 1151504) (OpenAirDocs) - Category: Airplane - Serial number: D-1616 - Airframe hours: 4950 - Engines: CONTINENTAL E-225-8 225 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Rent And Lease Programs - Registered owner: Rent And Lease Programs - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 29, 1992, 1 hours before ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 41; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 7,100 total, 44 in this make and model, 117 in the last 90 days, 34 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 48 °F - Altimeter: 30.00 inHg - Observed at: VIS, 11 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 19930120000609A](https://openairdocs.org/incident/19930120000609A), Jan 20, 1993: Beech STC35, Tulare, CA, Destroyed, 2 fatal. Lost power and control on climbout. Fuel selector on aux tank. Appears fuel flow lost. Overcontrol using hand pump. 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.