# NTSB LAX94LA340: Beech D95A, N4835J, Oakdale, CA, August 28, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: August 27, 1994, 18:05 local (Aug 28, 1994, 01:05 UTC) - Place: Oakdale, CA - Coordinates: 37.799934, -120.740966 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.7999&lon=-120.7410&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 July 24, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28843 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94LA340 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28843/pdf - Page: https://openairdocs.org/ntsb/LAX94LA340 ## Probable cause IMPROPER IN-FLIGHT PLANNING/DECISION BY THE FLIGHT INSTRUCTOR (CFI), AND THE CFI'S INADEQUATE SUPERVISION BY NOT ASSURING THAT THE MINIMUM CONTROL SPEED (VMC) WAS MAINTAINED. A FACTOR RELATED TO THE ACCIDENT WAS: THE CFI'S LACK OF EXPERIENCE IN MULTI-ENGINE INSTRUCTIONAL TRAINING. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, go-around (vfr) - 1 engine - switched off - emergency procedure - simulated, pilot in command(cfi) - in-flight planning/decision - improper, pilot in command(cfi) (cause) - go-around - initiated - airspeed(vmc) - not maintained (cause) - supervision - inadequate, pilot in command(cfi) (cause) - lack of total experience in type operation, pilot in command(cfi) (contributing factor) - In flight collision with terrain/water, descent - uncontrolled ## Analysis THIS WAS THE STUDENT'S FIRST FLIGHT IN A MULTIENGINE FLIGHT TRAINING COURSE. AFTER 3 TAKEOFFS & LANDINGS AT THE AIRPORT, THE FLIGHT DEPARTED THE AREA, THEN RETURNED A FEW MINUTES LATER. WHEN THE CFI TRANSMITTED THEIR POSITION, A GROUND-BASED WITNESS (ALSO A MULTI-ENGINE CFI) HEARD THE SOUND OF A GEAR WARNING HORN IN THE BACKGROUND. THE WITNESS OPINED THAT THE FLIGHT WAS PRACTICING A SINGLE ENGINE APPROACH. THE WITNESS OBSERVED THE AIRCRAFT DESCEND TO ABOUT 30' AGL AS IT OVERFLEW THE APPROACH END OF THE RUNWAY, THEN ENTER A SHALLOW CLIMBOUT. BEFORE REACHING THE DEPARTURE END OF THE RUNWAY, THE AIRCRAFT ENTERED A LEFT BANK. THE BANK ANGLE GRADUALLY INCREASED UNTIL BECOMING VERTICAL, AND THE AIRCRAFT CRASHED INTO A FIELD NEXT TO THE AIRPORT. AN EXAM OF THE WRECKAGE REVEALED NO PREIMPACT MECHANICAL MALFUNCTION. THE LEFT & RIGHT FUEL TANK SELECTORS WERE FOUND IN THE 'OFF' & 'MAIN TANK' POSITIONS, RESPECTIVELY. THE LEFT PROPELLER APPEARED TO HAVE BEEN IN THE FEATHER POSITION, THE RIGHT PROPELLER WAS TWISTED & BENT. THE CFI HAD GIVEN ABOUT 8 HOURS TOTAL OF MULTIENGINE INSTRUCTION (TO ANOTHER STUDENT) DURING THE 2.5 WEEKS SINCE HAVING BEEN ISSUED A MULTIENGINE INSTRUCTOR PILOT CERTIFICATE. ## Factual narrative HISTORY OF FLIGHT On August 27, 1994, at 1805 Pacific daylight time, a Beech D95A, N4835J, operated by Diamond K. Aviation, Inc., collided with terrain and was destroyed by a postimpact fire during a go-around at the Oakdale (uncontrolled) Airport, Oakdale, California. Visual meteorological conditions prevailed and no flight plan was filed. The flight instructor (CFI) possessed a commercial pilot certificate and was seriously injured. The second pilot possessed a commercial pilot certificate and was receiving multiengine flight training. She sustained fatal injuries. The instructional flight originated from Oakdale at 1643. Another CFI, who was standing on the ground at the airport, witnessed the accident flight. This CFI was also a multiengine flight instructor and was familiar with the accident airplane. According to this CFI/witness, prior to the crash the accident airplane had performed three full stop landings at Oakdale. Then, the airplane departed the pattern. After several minutes, the airplane returned to the pattern. The witness heard the CFI transmit the airplane position. In the background of the transmission, the witness recalled hearing the sound of a gear warning horn. According to the witness, this indicated a throttle had been retarded and a single-engine approach may have been the intended maneuver which was in progress. The witness further reported that as the accident airplane flew in the downwind leg, he heard a popping sound from one of the engines. The witness attributed this sound to a low engine power setting. The witness saw the airplane on the base and final legs, and nothing unusual was noted. The airplane overflew the landing threshold and descended to about 30 feet above the runway, but it did not land. According to the witness, he then heard the sound of engine power increasing, saw the airplane initiate a shallow climb, and saw the landing gear being retracted. The airplane then began turning left and flying nearly perpendicular to the runway. At the same time, its left bank angle gradually steepened until reaching over 90 degrees. The airplane's nose lowered, and it collided into a field next to the airport. Within seconds, a fire was observed at the impact site. WRECKAGE AND IMPACT INFORMATION The airframe and engines were examined under the supervision of Federal Aviation Administration (FAA) personnel. The cockpit examination revealed the cowl flap switch for the left engine was in a position corresponding to the CLOSED position. The corresponding right engine cowl flap switch was found in the OPEN position. According to the witness, during simulated engine out operations, the cowl flaps are normally open on the engine developing power, and they are closed on the engine which is in the simulated zero thrust mode. The fuel selector for the left engine was found in the OFF position. The fuel selector for the right engine was found in the MAIN tank position. The right engine's propeller blades appeared to be in a high rpm (low-pitch) position, and the blades were bent and twisted. The left engine's propeller blades appeared to be in a feathered position, and the blades were not bent or twisted. No evidence of any preimpact mechanical failure was observed to any engine rotating or reciprocating components. Regarding airframe structure, all airframe components were accounted for at the accident site. The continuity of the flight control system was established. CREW INFORMATION On September 9, 1994, the husband of the deceased student pilot was interviewed via telephone by the National Transportation Safety Board. In pertinent part, he reported that on the day of the accident, his wife had commenced her multiengine flight training. She had been in good health, did not smoke or drink, and was not using medication. The evening before the accident flight she had received her customary amount of sleep. As of April 17, 1995, the Safety Board has not received any written statement from the surviving CFI. The FAA reported that a designated pilot examiner had issued the CFI a flight instructor certificate for multiengine land airplanes on August 9, 1994. Prior to the day of the accident, the CFI had provided multiengine flight training to one other student. The CFI's total experience as a multiengine instructor was between 7 and 8 hours of flight time. ## Aircraft - Registration: [N4835J](https://openairdocs.org/deregistered/N4835J-1997-01-21), registration cancelled 1997-01-21, S/N TD679 (OpenAirDocs) - Reported make and model: BEECH D95A - Registry model: [Beech D95A](https://openairdocs.org/model/beech-d95a) (registry code 1153408) (OpenAirDocs) - Category: Airplane - Serial number: TD-679 - Airframe hours: 3913 - Engines: LYCOMING IO-360-B1B 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Diamond K. Aviation, Inc. - Registered owner: S. Barkley, D. Noe, S. Critzer - Airworthiness certificate: Special, Restricted (Special); Standard, Normal - Last inspection: Annual, March 20, 1994, 61 hours before - Airport: O27, Oakdale, runway 28, 3,020 × 66 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 24; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: right; flight hours: 1,430 total, 75 in this make and model, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 90 °F ## 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 19940827023699A](https://openairdocs.org/incident/19940827023699A), Aug 27, 1994: Beech D95A, Oakdale, CA, Destroyed, 1 fatal. Simulated left engine out via fuel off prop feathered. Began go around. Climbing left turn. Rolled over. Dived in. ## Other investigations on N4835J (1) 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 MIA71FKJ43](https://openairdocs.org/ntsb/MIA71FKJ43), Mar 18, 1971: Beech D95A (N4835J), Birmingham, AL, 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.