LAX97FA328

NTSB accident investigation · Beech C23 · Torrance, CA · September 21, 1997

Accident · FatalField investigationFinal report
Date
September 21, 1997, 10:34 local (17:34 UTC)
Place
Torrance, CA
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N543JLBeech C23
Weather
Visual (VMC) · Day
Status
Completed · report August 18, 2000
Report
Approved by Office Director
FAA report
19970921027609A
Case key
29633

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The failure of the pilot to attain and maintain adequate airspeed during the initial takeoff climb, which resulted in a stall/spin and subsequent collision with a building.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightTakeoff - initial climb
Airspeed(vs) - not maintainedPilot in commandCause
Stall/spin - inadvertentPilot in commandCause
In flight collision with objectDescent - uncontrolled
Object - building(nonresidential)

Analysis

Witnesses reported that after takeoff, the airplane never climbed beyond 150 to 200 feet above ground level. One witness reported the airplane's rotation and initial climb were normal until it achieved 100 feet, then it began to pitch nose up until the witness could clearly see the tops of the wings. The airplane then rolled to the right and descended vertically. The airplane collided with a three-story commercial office building about 2,000 feet from the departure end of the runway and was partially consumed by a postimpact fire. An audiocassette re-recording from the airport noise-monitoring site was examined to document any engine or propeller sounds that could be heard during the takeoff. A video recording that was recovered from the accident aircraft was also examined to document the takeoff distance and airborne pitch attitude/flight path of the airplane. The video recording began just as the aircraft was taking the runway for departure and appeared to continue uninterrupted until the airplane crashed. The audio track of the video was examined to document any engine or propeller sounds heard during the takeoff. Engine rpm was derived from both the audio track of the video recording and the noise-monitoring recording. The engine speeds derived from the video recording were between 2,250 and 2,430 rpm. Engine speeds derived from the noise monitoring station started at 2,750 and decreased to 2,510 rpm. Directly above the monitoring station there was no alteration in the measured frequency due to the Doppler shift. No dramatic changes were observed in the frequencies associated with the aircraft's engine. Examination of the engine did not disclose evidence of mechanical malfunction.

Factual narrative

History of flight

On September 21, 1997, at 1034 hours Pacific daylight time, a Beech C23, N543JL, collided with a commercial office building after takeoff from Zamperini Field, Torrance, California. The airplane was destroyed. The certificated private pilot and three passengers received fatal injuries. The airplane was operated as a personal flight by the pilot under the provisions of 14 CFR Part 91. The flight was originating from runway 29R and was destined for the Catalina Airport, Avalon, California. Visual meteorological conditions prevailed and no flight plan was filed.

Several witnesses were interviewed. One pilot/witness reported that he saw the airplane as he was driving to the airport. He observed the airplane depart at "an extremely low altitude, approximately 150 to 200 feet agl." He continued to watch the airplane and noted that he would be crossing under its flight path. The witness stated that "the elevator appeared to be in an extremely high position given the slow speed and altitude of the aircraft. The engine was not missing or making any irregular noises . . . . I immediately assumed he was grossly overweight. At this point I knew the pilot was in trouble." He looked over his shoulder to see where the airplane was headed and noticed a cloud of black smoke. He drove over and found that the airplane had collided with the office building.

Another witness reported that he first noticed the accident airplane flying westbound just after takeoff. He stated, "the tail of the plane was low in relation to the front of the plane. It was at that time I did not think the plane was going to stay in the air much longer." The airplane disappeared from his view due to surrounding buildings. He then saw smoke rising from an office complex. The witness reported that he later realized why the airplane had first captured his attention. He stated, "I watched about a dozen other planes take off and they were all at a higher altitude at the same point where I first observed the plane that crashed."

One other pilot/witness had been on a helipad waiting for a takeoff clearance at the time of the accident. He stated that the takeoff roll and initial rotation appeared normal, but when the airplane reached approximately 100 feet agl, it began to pitch up. He reported that the "pitch attitude was so high that I could clearly see the top of his wings." The airplane never seemed to gain altitude, but then banked to the right about a 20- to 30-degree bank angle. A few seconds later the witness observed a black cloud of smoke from the building area.

The local controller reported that the pilot had requested a straight-out departure from runway 29R. The controller suggested that the pilot perform a "right forty-five departure . . . for noise abatement reasons." He observed the airplane takeoff and cross the departure end of the runway. He then observed smoke about 1/4 mile west/northwest of the airport.

Personnel information

According to the Federal Aviation Administration (FAA) Airman Certification database, the pilot held a private pilot certificate with an airplane single engine land rating, as well as an instrument airplane rating. The original date of issuance for the private pilot certificate was May 07, 1985. According to the FAA Aeromedical Certification Division, the pilot held a third-class medical, dated October 22, 1996, with the noted restriction that he must wear corrective lenses.

The FAA Airman Certification database revealed that none of the passengers had ever held FAA airman certificates.

Aircraft information

A mechanic at the fixed-base operator (FBO) was interviewed. He reported that on Saturday, September 20, 1997, the accident pilot had planned to fly to Catalina Island with three passengers. The pilot left the FBO and returned some time later. He informed the mechanic that during the engine run-up at 2,000 rpm, with the parking brake set, the airplane "rotated" around the left brake, so he elected to return. The mechanic explained some of the possible causes of the problem and asked the pilot to bring the airplane back on Monday, September 22, 1997, since the shop was closed on the weekend.

According to the airplane's maintenance logbooks, the aircraft had last received an annual inspection on December 19, 1996. On the annual/100-hour inspection form, the engine static rpm was recorded as 2,200 rpm. The airplane's Pilot Operating Handbook (POH) lists the static rpm limits as 2,250 to 2,350 rpm. No corrective actions were noted on the inspection form. The mechanic who performed the inspection reported that he determined the aircraft to be in an airworthy condition.

Current weight and balance values were not obtained for the airplane. The delivery weight and balance values were used in calculating the airplane's accident gross weight and center of gravity (CG). The autopsy weights were used for the occupant weights. Three different weight and balance calculations were performed, since the occupant positions were not determined. A fuel loading of 50 gallons was used, based on a witness statement. According to the Beech representative, the weight and balance calculations showed that the airplane was near gross weight at takeoff, and the CG could have been as far forward as 114.09 inches, which is forward of the forward limit, or the CG could have been as far aft as 115.93 inches, which is a midrange CG value.

Wreckage and impact

The accident site was in a medical business park located north of the runway 29R extended centerline, and about 2,000 feet from the departure end of the runway. The airplane penetrated the third and second floors of the building, and came to rest inverted suspended in a hole in the first floor ceiling.

The empennage and the right wing were draped over a balcony railing, the left wing was inside the second floor office, and the fuselage was hanging from the first floor ceiling into the office directly below. Fire nearly consumed the fuselage, the left wing, and the first and second floor offices. The office sprinkler system flooded the remaining offices in the building.

The engine was observed lying inverted and lodged between the structure of the first and second floor of the office building. The two-bladed fixed pitch propeller remained attached at the crankshaft. The engine displayed thermal damage. Initial examination of the engine while still entangled with the attached wreckage did not reveal any evidence of catastrophic mechanical malfunction.

The left wing from the aileron outboard was consumed by fire. The flap remained attached to the wing. The wing fuel tank was consumed by fire. The aileron was not observed. The aileron flight control cables were continuous from the aileron bell crank attach fittings into the cabin.

The right wing was separated from the fuselage. The main spar was separated adjacent to the center wing spar splice and at the main landing gear strut. The inboard half of the flap remained attached to the wing, and the outboard half of the flap was consumed by fire. The wing fuel tank was consumed by fire. The outer 9 feet of the wing were separated from the airplane. The aileron remained attached to the outer wing panel. The aileron control cables remained attached to the aileron bell crank. The control cables were separated at the accident site by the recovery crew.

The fuselage sidewalls were consumed by fire. The lower cockpit and cabin floor area was partially consumed by fire. The cabin roof was separated from the fuselage and partially consumed by fire. The cockpit flight controls were intact from the cockpit aft to about FS 181, where they had been cut during the recovery process. The pitch trim mechanism was found melted and fused to the remains of the COMM Select Panel. The manual flap handle mechanism was examined. There was no evidence that the flap latch h

Aircraft

Registration
N543JL
Reported as
Beech C23
Category
Airplane
Serial number
M-1903
Airframe hours
3,460
Engine
Lycoming O-360-A4K, 180 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Shimpei Matsumoto
Registered owner
Mary M. Matsumoto
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · December 19, 1996
Departed
TOA
Destination
AVX · Avalon, CA
Airport
TOA · Zamperini Field, runway 29R, 5,000 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
35
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
300 total

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 64 °F
Altimeter
29.00 inHg
Observed at
TOA, 1 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.