# NTSB MIA06FA090: Beech B-60, N999DE, Gainesville, FL, April 16, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 16, 2006, 11:53 local (15:53 UTC) - Place: Gainesville, FL - Coordinates: 29.69, -82.271667 - Nearby events: https://openairdocs.org/map.md?lat=29.6900&lon=-82.2717&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report March 31, 2008 - Report: Approved by Office Director - Parties: Raytheon, Lycoming, FAA FSDO - NTSB case key (mKey): 63521 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA06FA090 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63521/pdf - Page: https://openairdocs.org/ntsb/MIA06FA090 ## Probable cause The loss of control for an undetermined reason. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - reason for occurrence undetermined (cause) - In flight collision with object, descent - uncontrolled - object - building(nonresidential) ## Analysis The airplane crashed into the terminal building following a loss of control on takeoff initial climb from runway 25. Witnesses reported that shortly after takeoff, the airplane banked sharply to the left, then it seemed to momentarily stabilize and commence a climb before beginning to roll to the left again. The airplane rolled to an inverted position, entered a dive, collided with the airport terminal building and exploded on impact. The entire airplane sustained severe fire and impact damage. Examination of the engines and propellers revealed no evidence of any discrepancies that would preclude normal operation. All the propeller blades displayed signatures indicative of high rotational energy at the time of impact, indicating that both propellers were rotating, not feathered, and the engines were operating at high power at the time of impact. Components of the autopilot system, specifically the pitch servo assembly and a portion of the roll servo assembly, were identified in the wreckage. The portion of the roll servo assembly found remained attached to a piece of skin torn from the airframe and consisted of the mounting bracket for the roll servo with the capstan bolted to the bracket, clearly indicating that this component had been reinstalled and strongly suggesting that the pilot reinstalled/reactivated all of the removed autopilot components the day before the accident. Maintenance personnel started an annual inspection on the airplane the month prior to the accident and found an autopilot installed in the airplane without the proper paperwork. The pilot explained to them that he designed and built the autopilot and was in the process of getting the proper paperwork for the installation of the system in his airplane. During the inspection, a mechanic found the aileron cable rubbing on the autopilot's roll servo capstan so the mechanic removed the roll servo along with the capstan. Additionally, mechanics disabled the autopilot's pitch servo and removed the autopilot control head. They were in the process of completing the inspection when the pilot asked for the airplane stating that he needed it for a trip. The pilot also asked that the airplane be returned to him without the interior installed. Two days before the accident, the airplane was returned to the pilot with the annual inspection incomplete. The autopilot control head, roll servo and capstan were returned to the pilot in a cardboard box on this date. A friend of the pilot reported that the day before the accident, the pilot completed reinstalling the seats and "other things" in order to fly the airplane the next day. It is possible that improper installation or malfunction of the autopilot resulted in the loss of control; however, the extent of damage and fragmentation of the entire airplane wreckage precluded detailed examination of the flight control and autopilot systems and hence a conclusive determination of the reason for the loss of control. ## Factual narrative HISTORY OF FLIGHT ` On April 16, 2006, about 1153 eastern daylight time, a Beech B-60 Duke, N999DE, registered to and operated by Ocem Avionics Inc., a company owned by the pilot, crashed into the terminal building following a loss of control on takeoff initial climb from runway 25 at Gainesville Regional Airport, Gainesville, Florida. Visual meteorological conditions prevailed, and no flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The private pilot and the two passengers received fatal injuries, and the airplane was destroyed. The flight was originating at the time of the accident. One witness stated that while driving north on Waldo Road, he observed the airplane, and upon liftoff, it banked sharply to the left. He stated that the airplane then seemed to stabilize and commence a climb to the east. He further stated that the airplane then began to roll to the left again and rolled into an inverted position. The airplane finally went into a sharp dive and impacted the west end of the terminal and exploded on impact. Another witness stated that she was a passenger in the front seat of an ambulance that was traveling north on Waldo Road, and as they passed the airport, her partner said "that was a bad takeoff." She looked and saw a low flying small airplane. She said she looked away and then shortly thereafter heard a loud bang, and upon looking again, saw a massive fireball erupting from the airport in the vicinity of the main gate. A witness in the back of the ambulance stated that she observed the accident airplane "flip and nose-dive into the airport terminal." According to an air traffic controller in the control tower, after clearing the airplane for takeoff, there were no further radio communications with the airplane. The controller said he last saw the accident airplane in wings level flight, about even with the Flight Service Station. He then changed from observing the accident airplane to observing two other aircraft in the area. When he next looked in the direction where he had last observed the accident airplane he saw smoke which he later learned was from the accident site. He stated that at no time had there been any indication that the accident airplane had experienced a problem. According to information obtained from University Air Center (UAC), a fixed base operator at the Gainesville Regional Airport, the pilot of the accident airplane had used the self serve tanks to purchase 31 gallons of fuel, and according to information obtained by detectives, the pilot was proceeding on a short personal flight. PERSONNEL INFORMATION The pilot, age 69, held a private pilot certificate, with airplane single and multiengine land and instrument ratings, issued on December 11, 1981. He also held an FAA third class medical certificate, issued on September 3, 2004, with the stated limitation that "the holder shall wear corrective lenses." The pilot's personal logbook was not obtained. According to information obtained from the pilot's last record of a medical examination, he reported having accumulated about 1,500 flight hours as of September 3, 2004. As of the time of the completion of this factual report, no information was obtained relative to the pilot's last flight review. AIRCRAFT INFORMATION N999DE was a Beech B-60 Duke, serial number P-447, which was manufactured in 1977. The most recent annual inspection of the airplane documented in the aircraft logbooks was performed on February 9, 2005. At the time of this inspection the airplane had accumulated about 2,901 hours. The airplane was equipped with two wing mounted Lycoming TIO-541 series, 380 horsepower engines, and at the time of the annual inspection on February 9, 2005, they had each accumulated about 1,266 hours since major overhaul. The left and right propellers were both 3-bladed constant speed Hartzell propellers, and both had last received major overhauls on September 20, 2004. According to information provided by UAC, their maintenance personnel started an annual inspection on the airplane on March 20, 2006. According to the director of maintenance for UAC, an autopilot was found installed in the airplane without the proper paperwork. The pilot told UAC that he designed and built the autopilot and was in the process of getting the proper paperwork for the installation of the system in his airplane. The pilot further told UAC that he had sold the design to a company called Chelton Aviation and was finishing up the research and development so the system could be installed on a number of different models of airplanes. During the inspection, a UAC mechanic found the aileron cable rubbing on the autopilot's roll servo capstan so the mechanic removed the roll servo along with the capstan. This maintenance action was documented as item 3 on a Work Order Discrepancy Form provided by UAC. Additionally, UAC reported that they disabled the autopilot's pitch servo and removed the autopilot control head. UAC was in the process of completing the inspection when the pilot asked for the airplane stating that he needed it for a trip. The pilot also asked that the airplane be returned to him without the interior installed. On April 14, 2006, UAC released the airplane to the pilot with the annual inspection incomplete. The autopilot control head, roll servo and capstan were returned to the pilot in a cardboard box on this date. A list of the repair items accomplished by UAC personnel and those remaining to be accomplished on the airplane when it was released to the pilot was provided by UAC. The list of 28 items accomplished included the following item related to the autopilot: "Performed conformity inspection for previously installed autopilot servo installation per engineering drawings and forms removed roll servo due to contact with aileron cables and disabled pitch servo. Autopilot control head removed to disable system due to no STC for B60." The list of 7 items remaining to be accomplished included the following items: "inspect carpet, seats, seat belts and misc. interior trim for proper installation", "Form 337 for pitch servo mounting", and "log book entries airframe engine and prop". A friend of the pilot stated that "University Air completed the inspection and released the aircraft to [the pilot] either Friday or Saturday. On Saturday night [the pilot] completed reinstalling the seats and other things in order to fly on Sunday when the accident occurred." A representative of Chelton Aviation reported that the company was not a participant in the pilot's effort to acquire FAA approval of the autopilot system installation in the airplane. The representative further reported that the company had begun to provide "drawing/documentation drafting support only of the component installation" at the pilot's request. Several Chelton Aviation documents were found with the airplane's maintenance records. One of these documents was numbered MS-012-09, dated March 15, 2006 and written by the pilot. In its Introduction section, the document stated, in part, "this report provides structural substantiation for installation of a Chelton Aviation Corp (CAC) AP-3C roll and pitch servos in Raytheon 60, A60, B60 aircraft. This document is in support of FAA Field Approval limited to the installation on aircraft Be B60 Serial N.P447, registration N999DE." METEOROLOGICAL INFORMATION Visual meteorological conditions prevailed at the time of the accident. The Gainesville Regional Airport 1153 surface weather observation was wind from 240 degrees at 11 knots, visibility 10 miles, sky condition clear, temperature 25 degrees C, dew point 16 degrees C, altimeter 30.00 inches. WRECKAGE AND IMPACT INFORMATION The airplane impacted the west end of the terminal building in the area of a baggage conveyor belt. As the airplane impacted the building and a parked vehicle, an explosion and fire ensued. During the impact sequ ## Aircraft - Registration: [N999DE](https://openairdocs.org/deregistered/N999DE-2013-02-25), registration cancelled 2013-02-25, S/N P-447, built 1977 (OpenAirDocs) - Reported make and model: Beech B-60 - Registry model: [Beech B-60](https://openairdocs.org/model/beech-b-60) (registry code 1153605) (OpenAirDocs) - Registry engine: [Lycoming TI0-541 series](https://openairdocs.org/engine/lycoming-ti0-541-series) (registry code 41536, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: P-447 - Airframe hours: 2901 - Engines: Lycoming TIO-541-E1C4 380 horsepower reciprocating; Lycoming TIO-541-E1C4 380 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Ocem Avionics Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2006 - Departed: GNV, Gainesville, FL - Destination: GNV - Airport: GNV, Gainesville Regional, runway 25, 4,158 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 1,500 total ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 61 °F - Altimeter: 30.00 inHg - Observed at: GNV ## 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 20060416007239A](https://openairdocs.org/incident/20060416007239A), Apr 16, 2006: Beech B60, Gainesville, FL, Destroyed, 3 fatal. (-23) Aircraft departed runway 25 at gnv requested a northeast departure. For unknown reasons at this time the aircraft banked left (to the south) entered what… 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.