NYC08FA143

NTSB accident investigation · Beech BE-76 · Rome, GA · March 21, 2008

Accident · FatalField investigationFinal report
Date
March 21, 2008, 16:25 local (20:25 UTC)
Place
Rome, GA
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N184AABeech BE-76
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report May 12, 2009
Report
Approved by Office Director
Parties
Lycoming Engines, Hawker Beechcraft, Hartzell Propeller Inc., FAA/FSDO
FAA report
20080321836809A
Case key
67701

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 flight instructor's failure to maintain aircraft control while maneuvering during a simulated engine failure. Contributing to the accident was the flight instructor's lack of total experience as a multiengine flight instructor.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: engine out controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech 76: 1 caseAll aircraft: 35 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotBeech 76: 11 casesAll aircraft: 9,295 casesProbable cause
Experience/qualifications: total experience in positionPersonnel issues › Experience/knowledge · Instructor/check pilotBeech 76: 1 caseAll aircraft: 19 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot was receiving instruction toward a multiengine airplane rating from a certificated flight instructor (CFI). The training syllabus for the flight included introduction to engine failures on takeoff and initial climb, as well as approaches and landings with an inoperative engine. The airplane was observed climbing at slow rate of speed after takeoff. When the airplane reached an altitude of 600 to 800 feet, it began a left turn, consistent with a return to the airport, which was followed by a nose-down descent toward the trees. The airplane impacted in a field and a postcrash fire consumed the majority of the airplane, forward of the empennage. Examination of the wreckage did not reveal evidence of any preimpact malfunctions. The CFI had accumulated about 111 hours of total multiengine flight experience, all in the same make and model as the accident airplane. He received his CFI rating about 3 weeks prior to the accident and had accumulated about 60 hours of multiengine flight experience as a CFI.

Factual narrative

History of flight

On March 21, 2008, about 1625 eastern daylight time, a Beech BE-76, N184AA, was substantially damaged when it impacted terrain while maneuvering after takeoff from the Richard B. Russell Airport (RMG), Rome, Georgia. The certificated flight instructor and the certificated private pilot were fatally injured. Visual meteorological conditions prevailed and no flight plan had been filed for the instructional flight that was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91.

The airplane was operated by a flight school and based at the Dekalb-Peachtree Airport (PDK), Chamblee, Georgia. The private pilot was receiving instruction toward a multiengine airplane rating. The training syllabus for the flight included introduction to engine failures on takeoff and initial climb, as well as approaches and landings with an inoperative engine. The airplane departed PDK about 1530.

A witness at RMG observed the airplane climbing after takeoff from runway 19, a 6,000-foot-long, 150-foot-wide, asphalt runway. He stated the airplane seemed to be "struggling" and was climbing at a very slow rate of speed. The airplane reached an altitude of 600 to 800 feet, and began a left turn, consistent with a return to the airport. The airplane then began a nose first descent toward the trees, southeast of the airport.

The airplane impacted in a field surrounded by small trees and shrubs, and came to rest upright, on a heading of approximately 040-degrees.

Personnel information

The flight instructor, age 34, held a commercial pilot and flight instructor certificate with ratings for airplane single-engine, airplane multiengine, and instrument airplane. The flight school reported that the flight instructor had accumulated approximately 827 total hours of flight experience, which included 111 hours in multiengine airplanes, all in the same make and model as the accident airplane.

The flight instructor received his multiengine flight instructor rating on February 29, 2008. The flight school reported that at the time of the accident, he had accumulated about 60 hours of multiengine flight experience as an instructor.

The flight instructor held a Federal Aviation Administration (FAA) first class medical certificate, which was issued on October 1, 2007.

The private pilot, age 24, held a private pilot certificate with an airplane single-engine land and instrument rating. He had accumulated 182 total hours of fight experience, which included about 7 hours of multiengine flight experience, all in the same make and model as the accident airplane, which he began flying on March 11, 2008.

The private pilot held an FAA first class medical certificate, which was issued on November 14, 2007.

Aircraft information

The airplane was manufactured in 1981, and equipped with a Lycoming O-360-A1G6D (left engine) and a LO-360-A1G6D (right engine), each with a 2-bladed Hartzell series propeller assembly.

Review of maintenance records revealed that the airplane's most recent 100 hour inspection was performed on March 4, 2008. At the time of the inspection, the airplane had been operated for about 5,210 total hours.

The right and left engines were overhauled on January 6, and February 4, 2005; respectively. They had both been operated for about 850 hours at the time of the most recent 100 hour inspection.

The airplane's most recent annual inspection was performed on May 10, 2007, at a total time of about 5,025 hours.

A pilot who flew the airplane as part of a commercial multiengine check ride on the morning of the accident reported that the airplane was flown for 3.5 total hours without any discrepancies noted.

Meteorological information

The weather reported at RMG, at 1653, was: wind from 180 degrees at 6 knots, visibility 10 statute miles, sky clear, temperature 22 degrees Celsius (C), dew point -3 degrees C, altimeter 30.06 inches of mercury.

Wreckage and impact information

All major portions of the airplane were accounted for at the accident site. A postcrash fire consumed the majority of the airplane forward of the empennage. Flight control continuity was confirmed from the ailerons, elevator and rudder control surfaces to the forward cockpit area. The fuel selector valve in each wing was observed selected to its respective engine. Measurement of the flap actuator jackscrew corresponded to a 0 to 5 degree flap setting, and measurement of the rudder trim corresponded to a 5 degree, nose left position. The landing gear was observed in the retracted position.

Subsequent additional examination of rudder and elevator assemblies by an NTSB investigator did not reveal evidence of any preimpact discrepancies.

The right engine was observed upright, canted nose down and to the left, and sustained fire damage. The right engine initially could not be rotated via an accessory drive gear. After the accessory case and oil sump were removed, the engine rotated freely via the crankshaft gear bolt. Valve train continuity and thumb compression was attained on all cylinders. The engine driven fuel pump, fuel hoses, dual magneto and ignition harness could not be examined due to fire damage. The carburetor was fire damaged; however, it was disassembled. The float was destroyed, but the float hinge pin and needle assemblies were intact. All spark plugs were removed. Their electrodes were intact and gray in color. A lighted borescope examination of all cylinders did not reveal any abnormalities. The oil pump rotated freely; however, gears located in the accessory section exhibited thermal discoloration and did not rotate freely.

The right propeller and crankshaft flange were separated and partially buried in the ground in front of the engine. One blade contained torsional twisting, leading edge gouges, and chord-wise scratches. The other blade was curled aft approximately 10 degrees.

The left engine was observed upright, canted nose down about 30 degrees, and sustained fire damage. The left engine initially could be rotated via the propeller about 10 degrees. After the accessory case and oil sump were removed, the engine crankshaft rotated freely. Valve train continuity and thumb compression were obtained on all cylinders. The carburetor, engine driven fuel pump, fuel hoses, dual magneto and ignition harness, could not be examined due to fire damage. All spark plugs were removed. Their electrodes were intact and gray in color. A lighted borescope examination of all cylinders did not reveal any discrepancies. The oil pump housing was discolored consistent with heat damage and the pump could not be rotated. Disassembly of the oil pump did not reveal any damage to the gears, gear shafts or housing.

The left propeller remained attached to the engine. Both propeller blades were oriented about 10 to 15 degrees from the feathered (high pitch) position. Both blades rotated to the feathered position after the spinner dome was removed. One blade was not damaged and the other blade was bent aft approximately 90 degrees at mid-span.

A subsequent teardown of the left propeller assembly was conducted under the supervision of an NTSB investigator. According to a representative from the propeller manufacturer, examination of the propeller counterweights and spinner was consistent with the left propeller impacting in a low pitch position.

Medical and pathological information

An autopsy was performed on the flight instructor on March 25, and on the private pilot on March 24, 2008, by a Georgia Bureau of Investigation, Division of Forensic Sciences medical examiner. The autopsy reports for both pilots listed the cause of death as "multiple blunt trauma due to an airplane crash."

Toxicological testing conducted on both pilots by the FAA Forensic Toxicology Research Team, Civil Aerospace Medical Institute was negative for drugs and alcohol.

Aircraft

Registration
N184AA
Reported as
Beech BE-76
Category
Airplane
Serial number
ME-400
Airframe hours
5,210
Engines
Lycoming O-360-A1G6D, 180 horsepower, reciprocatingLycoming LO-360-A1G6D, 180 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Aviation Atlanta
Registered owner
Aviation Atlanta
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 4, 2008 · 40 hours before
Departed
RMG · Rome, GA
Airport
RMG · Richard B. Russell, runway 19, 6,000 × 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
34
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
February 29, 2008
Seat
Right
Toxicology
Performed
Flight hours
827 total · 111 in this make and model · 690 as pilot in command · 257 in the last 90 days · 89 in the last 30 days · 5 in the last 24 hours
Role
Student pilot
Age
24
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
182 total · 7 in this make and model · 77 in the last 90 days · 31 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 27 °F
Altimeter
30.05 inHg
Observed at
RMG

FAA reports on this event · 1

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