# NTSB MIA95FA154: Beech 58, N4403Q, Orlando, FL, June 23, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 23, 1995, 09:16 local (13:16 UTC) - Place: Orlando, FL - Coordinates: 28.55017, -81.299896 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.5502&lon=-81.2999&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report October 13, 1995 - Report: Approved by Office Director - ADs cited in the narratives: [AD 93-16-15](https://openairdocs.org/ad/93-16-15) (OpenAirDocs) - NTSB case key (mKey): 37655 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA95FA154 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37655/pdf - Page: https://openairdocs.org/ntsb/MIA95FA154 ## Probable cause THE FAILURE OF THE PILOT-IN-COMMAND TO INSURE THE LANDING GEAR WAS RETRACTED FOLLOWING LOSS OF POWER IN ONE ENGINE RESULTING IN THE AIRCRAFT BEING UNABLE TO CLIMB AND CLEAR TREES IN THE AIRCRAFT'S FLIGHT PATH. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, takeoff - initial climb - 1 engine - accessory drive assy,drive shaft - incorrect - maintenance,compliance with ad - not performed, company maintenance personnel - accessory drive assy,drive shaft - worn - fuel system,pump - disengaged - In flight collision with object, emergency landing after takeoff - emergency procedure - not complied with, pilot in command (cause) - gear retraction - not selected, pilot in command (cause) - climb - not possible (cause) - object - tree(s) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis SHORTLY AFTER TAKEOFF ON RWY 7, THE PILOT REPORTED TO FAA CONTROLLERS HE HAD AN ENGINE FAILURE. THE CONTROLLERS OBSERVED THE LANDING GEAR RETRACT AT THIS TIME AND THEN IMMEDIATELY EXTEND. WITNESSES OBSERVED THE ACFT AT TREE TOP LEVEL MAKING A TURN TO THE NORTH WITH THE LANDING GEAR DOWN AND THE LEFT ENGINE SHUTDOWN AND THE PROPELLER FEATHERED. THE ACFT DESCENDED AND STRUCK THE TOP OF A TREE WITH THE WINGS LEVEL. THE ACFT THEN ROLLED TO THE RIGHT 90 DEGREES AND STRUCK THE GROUND. THE ACFT THEN CARTWHEELED AND SLID BACKWARDS INTO A TREE WHERE IT CAME TO REST. EXAMINATION OF THE LEFT ENGINE SHOWED THE ENGINE DRIVEN FUEL PUMP DRIVE COUPLING WAS ROUNDED OFF AND NOT TURNING THE PUMP. THE DRIVE COUPLING WAS TOO SHORT FOR THE MODEL FUEL PUMP DRIVE SHAFT. A 1993 FAA AIRWORTHINESS DIRECTIVE THAT CALLS FOR CHECKING FOR THE PROPER LENGTH DRIVE COUPLING HAD NOT BEEN COMPLIED WITH. THE FLIGHT MANUAL FOR THE ACFT STATES THAT THE FIRST ACTION TO BE PERFORMED BY THE PILOT AFTER ENGINE FAILURE IS TO RAISE THE LANDING GEAR. THE MANUAL ALSO STATES THAT SINGLE ENGINE PERFORMANCE IS PREDICATED ON THE LANDING GEAR BEING RETRACTED. ## Factual narrative HISTORY OF FLIGHT On June 23, 1995, about 0916 eastern daylight time, a Beech 58, N4403Q, registered to Bazeco, Inc., and operated by Air Orlando Charter, Inc., collided with trees and then the ground shortly after takeoff from Orlando Executive Airport, Orlando, Florida, while on a 14 CFR Part 135 air taxi flight. Instrument meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The aircraft was destroyed and the airline-transport rated pilot and one passenger were fatally injured. The flight was originating at the time of the accident. After takeoff the pilot reported to the FAA Orlando Executive Airport Control Tower Local Controller that "we've got an engine failure we are declaring an emergency." A short time later the pilot reported "we're going to go down." Witnesses observed the aircraft at about 100 feet altitude, shortly after liftoff from runway 7. A backfire was heard and the left wing raised up making a witness believe the left engine had failed. The landing gear was observed to retract at this time followed shortly by the landing gear being extended. The aircraft climbed slowly. As it passed over the lake at the departure end of the runway it was observed that the left propeller was not turning and the landing gear was down. The aircraft made a left turn to a northerly heading and was just above tree top level at this time. The aircraft then hit the top of a tree with the wings level, rolled to the right about 90 degrees, and descended hitting the ground right wing first. The aircraft then cartwheeled and slid backwards into a tree, where it came to rest. A postcrash fire erupted and consumed the aircraft. PERSONNEL INFORMATION Information on the pilot is contained under pilot information and in attachments. AIRCRAFT INFORMATION Information on the aircraft is contained under aircraft information, in the section on Test and Research, and in logbook records attached to this report. WEIGHT AND BALANCE INFORMATION Calculations showed the aircraft weighed about 5,076 pounds at the time of the accident. The center of gravity was about 79.7 inches aft of the datum. The maximum allowable takeoff weight for the aircraft is 5,400 pounds and the center of gravity limits at that weight are 78 to 86 inches aft of the datum. METEOROLOGICAL INFORMATION Instrument meteorological conditions prevailed at the time of the accident. Additional meteorological information is contained under weather information. WRECKAGE AND IMPACT INFORMATION The aircraft came to rest in the front yard of house at 5587B Lehigh Avenue, Orlando, Florida. Examination of the crash site showed the aircraft hit the top of about a 60 foot tall tree while in a wings level attitude, while on a northerly heading. The aircraft then descended and hit the ground right wing first at a point 275 feet past the tree. The aircraft then cartwheeled and slid backwards into a tree where it came to rest. All components of the aircraft which are necessary for flight were located on or around the main wreckage. Continuity of all flight controls cables was established. The landing gear was in the extended position. The wing flaps were in the retracted position. The left propeller was in the feathered position and the propeller spinner had no rotational damage. The right propeller was in the low pitch, high rpm position and the spinner had twisting damage consistent with rotating during ground impact. Examination of the left engine showed that the engine rotated freely. Continuity was established in the crankshaft, camshaft, valve train, and all accessory drives of the engine assembly. Each cylinder produced normal compression. Each magneto was set to the proper timing and operated normally after the accident. Each spark plug had coloring consistent with normal operation. Examination of the engine fuel system showed each of the components contained uncontaminated 100LL fuel and there was no evidence of malfunction of the throttle body, fuel metering unit, fuel manifold, or fuel injectors. The engine driven fuel pump drive coupling was found rounded at the fuel pump end and would not rotate the pump. Examination of the right engine showed the engine rotated freely. Continuity was established with the crankshaft, camshaft, valve train, and all accessory drives. Each cylinder developed normal compression. The right magneto produced a normal spark. The left magneto rotated normally but would not spark. The left magneto condenser and wires had sustained heat damage. The spark plugs had color consistent with normal engine operation. Examination of the engine driven fuel pump, throttle body, metering unit, manifold, and injectors showed no evidence of precrash malfunction. Each of these had sustained fire damage. The drive coupling for the engine driven fuel pump had a normal appearance. MEDICAL AND PATHOLOGICAL INFORMATION Post-mortem examination of the pilot was performed by Julia V. Martin, M. D., Associate Medical Examiner, Orlando, Florida. The cause of death was attributed to cerebral laceration, contusion, and hemorrhage due to comminuted skull fractures due to blunt trauma. No findings which could be considered casual to the accident were reported. Post-mortem toxicology tests on specimens obtained from the pilot were performed by SmithKline Beecham Clinical Laboratories, Leesburg, Florida. The tests were negative for ethanol alcohol, carbon monoxide, basic, acidic, and neutral drugs. Post-mortem examination of the passenger was also performed by Dr. Martin. The cause of death was attributed to acute respiratory failure, due to inhalation of super-heated air, due to a plane crash with fire. Post-mortem toxicology tests were performed by SmithKline Beecham Clinical Laboratories. The tests were positive for less than 10 percent carbon monoxide. The tests were negative for ethanol alcohol, basic, acidic, and neutral drugs. For additional medical and pathological information see Supplements K and toxicology reports. TESTS AND RESEARCH Examination of the left engine driven fuel pump drive coupling was performed by representatives of Teledyne Continental Motors. The coupling was identified as part number 631263 and measured 1.25 inches in length. All four corners of the coupling end which fits into the pump had been sheared off about .050 inches. Smeared metal at one end of each sheared off corner was consistent with a clockwise coupling rotation direction. The coupling appeared to be slipping in the pump shaft. See attached Teledyne Continental reports. The engine driven fuel pump drive coupling was the subject of Teledyne Continental Motors Mandatory Service Bulletin M93-9, dated March 10, 1993. Accomplishment of this Service Bulletin was made mandatory by FAA Airworthiness Directive 93-16-15 dated September 27, 1993 and amended December 14, 1993. This Service Bulletin and AD Note require inspection of the engine driven fuel pump and drive coupling to prevent fuel pump drive shaft disengagement and loss of engine power. If an older style fuel pump drive shaft is installed on the fuel pump then the old style coupling (part No. 631263) which is 1.25 inches in length may be used. If a new style fuel pump drive shaft is installed the a new drive coupling (part No. 653359) which is 1.37 inches in length must be used. Examination of the left engine driven fuel pump showed it had a new style drive shaft (part No. 646176) and the old style drive coupling (part No. 631263). This is not an acceptable combination in accordance with Service Bulletin M93-9. The right engine driven fuel pump was found to have the old style drive shaft (part No. 643689) and the old style drive coupling (part No. 631263). This is an acceptable combination in accordance with Service Bulletin M93-9. Logbook records showed the e ## Aircraft - Registration: [N4403Q](https://openairdocs.org/deregistered/N4403Q-2014-10-29), registration cancelled 2014-10-29, S/N TH-809, built 1977 (OpenAirDocs) - Reported make and model: BEECH 58 - Registry model: [Beech 58](https://openairdocs.org/model/beech-58) (registry code 1152740) (OpenAirDocs) - Category: Airplane - Serial number: TH-809 - Airframe hours: 6109 - Engines: CONTINENTAL IO-520-CB 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Operator: Air Orlando Charter, Inc. - Registered owner: Bazeco, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 13, 1995, 1 hours before - Departed: ORL - Destination: JAX, JACKSONVILLE, FL - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 6,700 total, 500 in this make and model, 6,500 as pilot in command, 20 in the last 90 days, 8 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 190° at 6 knots - Visibility: 4 statute miles - Lowest ceiling: 700 ft broken - Temperature: 79 °F, dew point 75 °F - Altimeter: 30.00 inHg - Observed at: ORL, 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 (OpenAirDocs). - [Accident 19950623020759A](https://openairdocs.org/incident/19950623020759A), Jun 23, 1995: Beech 58, Orlando, FL, Destroyed, 2 fatal. Lost left engine on climbout. Failed to clean up or climb. Turned into bad engine. Hit trees. Fuel pump had failed. 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.