# NTSB LAX95LA040: Beech 95-B55, N1898W, Santa Monica, CA, November 23, 1994 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 22, 1994, 20:12 local (Nov 23, 1994, 04:12 UTC) - Place: Santa Monica, CA - Coordinates: 34.010833, -118.460571 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.0108&lon=-118.4606&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report June 22, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 28984 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95LA040 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28984/pdf - Page: https://openairdocs.org/ntsb/LAX95LA040 ## Probable cause fuel starvation to both engines due to the CFI's inadequate fuel consumption calculations during the flight, and his failure to ensure that adequate fuel existed in the main tanks to complete the traffic pattern circuit. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, takeoff - initial climb - all engines - fuel consumption calculations - inadequate, pilot in command(cfi) (cause) - fluid,fuel - starvation (cause) - refueling - not performed, pilot in command(cfi) (cause) - Forced landing, emergency landing after takeoff - Wheels up landing, landing - flare/touchdown - wheels up landing - intentional, pilot in command(cfi) ## Analysis THE CFI AND STUDENT HAD DEPARTED SANTA MONICA AT 1356 ON A CROSS-COUNTRY CHECKOUT WITH FULL FUEL TANKS. TAKEOFFS, LANDINGS, AND/OR INSTRUMENT APPROACHES WERE MADE AT 6 DIFFERENT LOCATIONS THROUGHOUT THE FLIGHT. THE CFI KNEW THE AIRCRAFT HAD INACCURATE FUEL GAUGES. AFTER FLYING FOR 5.3 HOBBS-METER-HOURS, WHILE USING FUEL FROM A COMBINATION OF AUX AND MAIN TANKS, THEY RETURNED TO SANTA MONICA. BOTH PILOTS REPORTED THAT THE MAIN TANKS' FUEL GAUGES INDICATED AT OR ABOVE THE 'YELLOW ARC.' THE CFI AUTHORIZED ONE FINAL TRAFFIC PATTERN CIRCUIT. WHILE CLIMBING TO 1,000 FT, ONE OF THE ENGINES STARTED RUNNING ROUGH THEN QUIT. SECONDS LATER, POWER WAS ALSO LOST ON THE SECOND ENGINE. THE CFI TOOK CONTROL, REVERSED COURSE, AND GLIDED TO THE RUNWAY WITH THE LANDING GEAR INTENTIONALLY RETRACTED TO INCREASE THE LIKLIHOOD OF REACHING THE AIRPORT. THE AIRCRAFT WAS DESTROYED BY THE POSTCRASH FIRE. ## Factual narrative HISTORY OF FLIGHT On November 22, 1994, at 2012 Pacific standard time, a Beech 95-B55, N1898W, operated by Cloverfield Aviation, Inc., made a forced landing at the Santa Monica Municipal Airport, Santa Monica, California. The airplane was substantially damaged during the landing, and thereafter it was destroyed by fire. Neither the certificated commercial pilot, who was receiving a checkout in the airplane, nor the airline transport certificated flight instructor (CFI) was injured. In part, the checkout (instructional flight) consisted of airplane familiarization including single-engine and multiengine flying procedures, and instrument flying. Visual meteorological conditions prevailed. The flight originated from Santa Monica at 1356. On November 23, 1994, the National Transportation Safety Board interviewed both pilots via telephone. According to the pilots, prior to commencing the flight all of the airplane's fuel tanks were completely full of fuel. The pilots reported that the airplane held 136 usable gallons of fuel. The CFI subsequently reported that after takeoff, a series of practice approaches and/or landings were performed at Bakersfield, Shafter, and Porterville. While at Porterville, the engines were shut down and he and his student exited the airplane and had lunch. No fuel was added to the airplane. After returning to the airplane, the instructional lesson was continued. Additional approaches and/or landings were made at Visalia, Fresno-Chandler, Madera, and Santa Monica. The CFI further reported that the landing at Santa Monica was uneventful. Runway 21 was used. In the CFI's completed "Aircraft Accident Report, NTSB Form 6120.1/2," he made the following statement regarding the events which then occurred: "I wanted the student to have two more night landings before we shut down, so we taxied to runway 3 (the active at the time), reorganized the cockpit, and requested closed traffic. Tower cleared us for right closed traffic, we took off and completed one pattern with a full stop landing. We taxied back once again to runway 3, held short, requesting one more closed pattern. At this time the Hobbs read 5.3 hours of total elapsed time and the fuel gauges were several needle widths above yellow arcs on the main tank quantity gauges, indicating that there was approximately 30 gallons of total usable fuel remaining. This would be adequate for one pattern and still have our 45-minute night reserve upon landing. When cleared for takeoff, we departed runway 3 as before for a right pattern. At approximately 1000 feet, while beginning a right turn, we experienced an engine failure. . . . I had not failed an engine on him, and I immediately took over on the controls and rolled out on crosswind. As I was beginning to verify full power and all drag retracted, the other engine failed." The CFI additionally reported that he was in command of the flight, and he made an immediate decision to reverse course and attempt to land on runway 21. The CFI stated he informed the control tower that power was lost. In order to increase the likelihood of reaching the runway, the landing gear and flaps were kept retracted. Within a few seconds of the airplane having slid to a stop on the runway, a fire was observed near the belly of the airplane. FUEL MANAGEMENT AND AIRCRAFT INFORMATION According to the CFI, no mechanical problems were experienced with the engines. In the CFI's completed "Aircraft Accident Report," he also wrote the following statement regarding fuel management: "Fuel was burned enroute out of the aux. tanks as much as possible as a standard operating practice to ensure that usable fuel at the end of the flight would all be in the same place - the mains. The 'Cruise' checklist which we perform at every enroute level off, prompt us to consider fuel selectors at which point we switch to aux. tanks if we have not already done so in the climb. While it is common in this procedure to actually run aux. tanks dry enroute, this did not occur on our flight. We fully expected to run them dry on the leg from Madera to Santa Monica, and by Burbank Aux Tank gauges read 'empty', but it was necessary at that point to configure for the approach and complete the 'Before Landing' checklist, so we switched to the Mains for the remainder of the flight. . . . It is my conclusion that the nature of the accident, insofar as the engine failures is concerned, is a function of the available fuel (30 gallons) not reaching the engines. . . ." Regarding the accuracy of the airplane's fuel gauges, the CFI reported the following: "When the airplane was checked out at dispatch we were also aware of a discrepancy regarding the accuracy of the fuel gauges. This discrepancy was on the dispatch book ever since the airplane had come on line with us and was repeatedly deferred at every 100-hour inspection. Those of us who flew the airplane regularly had operational experience with the gauges, and it was understood that the gauges were inaccurate and unreliable in the upper end (half) of their travel; then, at about mid tanks, the floats seemed to stabilize allowing the needles to come down normally and evenly for the rest of their travel. . . ." SECOND PILOT (STUDENT) STATEMENT The Safety Board requested and received a statement from the pilot who was receiving instruction during the accident flight. In pertinent part, the student reported the following events occurred during the last takeoff: ". . .[The CFI] told me to taxi for another take-off from Rwy 3. We reached the hold-sort line, and I conducted the pre-takeoff check as before. The fuel gauges indicated at the top of the yellow arc. We received take off clearance at 8:10 pm, and I began the take-off roll, accelerated to 95 mph and rotated. I selected gear up quickly, and controlled pitch attitude to maintain 123 mph. My left hand was on the yoke and my right hand was on the throttles. I noticed the [CFI's] hand move down to the fuel selector panel, and began to mentally prepare for a simulated engine-out emergency. I counted off in my head, waiting for one engine or the other to sputter. Exactly when I expected it, one of the engines began to run rough and the plane yawed slightly. I countered with rudder, and moved my right hand to the mixtures, beginning the simulated emergency response. We were at about 1000 ft AGL, and I was in a right bank entering right crosswind, and it was not obvious which engine was failing. Almost right away, however, the sound of sputtering became 'stereo,' and the yaw force neutralized. I realized that we had a problem with both engines, and simultaneously the [CFI] called that he 'had the airplane'." The second pilot also reported to the Safety Board that, at the direction of the CFI, he immediately took his hands off the airplane's controls. The CFI proceeded to land the airplane. A fire was observed within seconds after coming to a stop on the runway. The fire was initially small, but after a few minutes it spread. By the time the fire department arrived it had engulfed the cockpit. FLIGHT TIME INFORMATION Following the accident the Federal Aviation Administration (FAA) coordinator examined the airplane and records associated with its operation. The FAA coordinator reported to the Safety Board that the airplane's Hobbs hour recording meter indicated the total time the airplane had been operated since originally departing Santa Monica for the instructional lesson was approximately 5.4 hours. The student reported that he observed the Hobbs hour meter after the crash. According to the student, the total elapsed Hobbs meter time from engine start to crash was actually 5.5 hours. COMMUNICATION In pertinent part, the following transmissions were recorded by the FAA Santa Monica Air Traffic Control Tower during communications between control tower personnel (SMO); (1) the acciden ## Aircraft - Registration: [N1898W](https://openairdocs.org/deregistered/N1898W-1997-03-25), registration cancelled 1997-03-25, S/N TC1570 (OpenAirDocs) - Reported make and model: BEECH 95-B55 - Registry model: [Beech 95-B55 (T42A)](https://openairdocs.org/model/beech-95-b55-t42a) (registry code 1152706) (OpenAirDocs) - Category: Airplane - Serial number: TC-1570 - Airframe hours: 3881 - Engines: CONTINENTAL IO-470-L21 260 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Cloverfield Aviation, Inc. - Registered owner: Bob Yari - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, November 18, 1994, 15 hours before - Departed: SMO - Airport: SMO, Santa Monica Municipal, runway 21, 4,987 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; airline transport, 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: 3,956 total, 106 in this make and model, 3,579 as pilot in command, 137 in the last 90 days, 61 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 340° at 10 knots - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 23 °F - Altimeter: 30.00 inHg - Observed at: SMO ## 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 19941122038779A](https://openairdocs.org/incident/19941122038779A), Nov 22, 1994: Beech 95B55, Santa Monica, CA, Destroyed. Departed on closed pattern with gauges near yellow. Below fuel safety level. Both engines quit. Burned on runway. 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.