NYC00IA131

NTSB incident investigation · Beech BE-58 · Windsor Locks, CT · May 9, 2000

Incident · No injuriesIncident investigationFinal report
Date
May 8, 2000, 21:37 local (May 9, 2000, 02:37 UTC)
Place
Windsor Locks, CT
Injuries
1 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N9044VBeech BE-58
Weather
Visual (VMC) · Night/dark
Status
Completed · report April 6, 2001
Report
Approved by Office Director
FAA report
20000508023359I
Case key
49138

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

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Probable cause

Inadequate screw length information provided by the manufacturer, which allowed an inadvertent installation of a holding screw that was too long, and the subsequent fracture of the switch/circuit breaker. Factors included a short circuit of the beacon motor, and the location of the holding screw position within the electroluminescent panel.

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.

FireClimb
Electrical system,circuit breaker - fractured
Maintenance,adjustment - inadvertentCompany maintenance personnel
Information insufficientManufacturerCause
Electrical system,circuit breaker - shortedCause
Acft/equip,inadequate designManufacturerFactor
Electrical system,electric motor - shortedFactor

Analysis

The pilot smelled smoke after takeoff. He returned to the airport, landed, and taxied to the ramp. During the postflight inspection, the rotating beacon power wire was found to be burnt, the entire length of the airplane. The initiating event was suspected to be a failed beacon motor, which then initiated a short circuit; however, it was not positively confirmed. Further inspection revealed that a holding screw for the electroluminescent panel had contacted the rotating beacon switch/circuit breaker, and fractured the switch. The switch/breaker was attached to a solid buss bar behind the panel, and the screw position was directly below the toggle portion of the switch. The manufacturer's parts catalog called for the use of a specific screw, but did not give a dash number for the screw's length.

Factual narrative

On May 8, 2000, at 2137 Eastern Daylight Time, a Beech BE-58, N9044V, operated by U.S. Check, suffered minor damage from an electrical fire, shortly after departing Bradley International Airport (BDL), Windsor Locks, Connecticut. The certificated commercial pilot was not injured, and visual meteorological conditions prevailed at the time of the incident. An instrument flight rules flight plan was filed for the flight, between Bradley and Stewart International Airport (SWF), Newburgh, New York. The cargo flight was conducted under 14 CFR Part 135.

According to a Federal Aviation Administration (FAA) inspector, the pilot smelled smoke after takeoff. The airplane returned to Bradley, landed, and taxied to the ramp. During the postflight inspection, the rotating beacon power wire was found to be burnt, the entire length of the airplane. Further inspection revealed that a holding screw for the electroluminescent panel had contacted the rotating beacon switch/circuit breaker, and fractured part of the unit. The switch function was determined to still operate properly, but the circuit breaker had failed. The initiating event was suspected to be a failed beacon motor, which then initiated a short circuit; however, it was not positively confirmed.

The switch/breaker was attached to a solid buss bar behind the panel, and the screw in question was one of five used to hold the panel in place. Each of the four other screws was located at a corner of the panel, while the fifth screw was located directly below the toggle portion of the switch. The Beechcraft Illustrated Parts Catalog called for the use of an AN5158632R screw, but did not give a dash number for the screw's length.

The FAA inspector submitted safety recommendations to the FAA Recommendation and Quality Assurance Division, AAI-200, for a fleetwide inspection of existing switches, for the manufacturer to revise the parts catalogue to reflect screw length, and for the manufacturer to move the screw position on future airplanes.

Aircraft

Registration
N9044V
Reported as
Beech BE-58
Category
Airplane
Serial number
TH216
Airframe hours
11,213
Engine
Continental IO-540, 285 horsepower, reciprocating
Damage
Minor damage
Fire
In-Flight
Flight
Part 135
Registered owner
Airnet System, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 4, 2000 · 42 hours before
Departed
BDL
Destination
SWF · Newburgh, NY
Flight plan
IFR
Airport
BDL · Bradley International, runway 33, 6,846 × 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
31
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
1,400 total · 130 in this make and model · 1,370 as pilot in command · 200 in the last 90 days · 85 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
20° at 6 knots
Visibility
8 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 68 °F
Altimeter
29.00 inHg
Observed at
BDL

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.