SEA06FA054

NTSB accident investigation · Beech 58P · Bow, WA · February 23, 2006

Accident · FatalField investigationFinal report
Date
February 22, 2006, 18:54 local (Feb 23, 2006, 02:54 UTC)
Place
Bow, WA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N469MDBeech 58P
Weather
Instrument (IMC) · Night/dark
Status
Completed · report March 26, 2007
Report
Approved by Office Director
Parties
Teledyne Continental Motors, Inc., Kelly Aerospace, FAA FSDO, Raytheon Aircraft Company
FAA report
20060222001629A
Case key
63265

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

On this page

Probable cause

The pilot's failure to maintain aircraft control during the climb to cruise. Contributing factors included a loss of engine power to the right engine folowing a turbocharger failure, instrument meteorological and dark night conditions.

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 engine powerClimb - to cruise
Exhaust system,turbocharger - failureFactor
1 engine
Loss of control - in flightClimb - to cruise
Aircraft control - not maintainedPilot in commandCause
Weather condition - low ceilingFactor
Light condition - dark nightFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

Approximately 11 minutes after takeoff on a night instrument flight rules flight plan, the pilot of the twin-engine airplane radioed air traffic control (ATC) that he was climbing out of 7,800 feet. Shortly thereafter, ATC received a "mayday" transmission followed by "lost an engine." Subsequently, radio communications and radar contact with the airplane were lost. Witnesses reported they observed the airplane in an unusually steep descent prior to impacting terrain. One witness stated he heard a high-pitched noise emanating from the airplane as it descended toward the ground. The wreckage was located in an open field adjacent to a highway. The main wreckage was located in the confines of a large impact crater approximately 15 feet in diameter and 6 feet deep. Dark night conditions with low ceilings prevailed at the time of the accident. Post-accident teardown and examination of both engines revealed no evidence of excessive wear or operational failure of internal engine components. Extensive damage, however, was noted to the right turbocharger assembly. Disassembly of the component revealed damage to the compressor wheel and compressor housing shroud. Circumferential scuffing and pockmarks were noted to the inner compressor housing, and impact type damage and smearing were noted to the individual compressor blades. Scuffing type damage was noted to the turbine wheel and corresponding turbine housing. Additional damage was noted to the turbine/compressor input shaft, and associated journals and bearings. Foreign material was found in the compressor housing and turbocharger after cooler. The material consisted of aluminum fragments, a rivet head, a piece of brass, paint chips, rubber, gasket material and dirt. The manufacturer of the turbo assembly examined the unit and reported the damage was consistent with FOD (foreign object damage) and lubricant starvation. The exact sequence of events leading to the failure of the turbocharger was not determined.

Factual narrative

History of flight

On February 22, 2006, about 1854 Pacific standard time, a Beech 58P Baron, N469MD, was destroyed when it collided with terrain subsequent to a reported loss of engine power during the initial climb out approximately two nautical miles south of Bow, Washington. The airplane was registered to H&W Management Services, Inc, of Carson City, Nevada, and was being operated by the pilot as an instrument flight rules (IFR) cross-country flight under the provisions of Title 14, CFR Part 91, when the accident occurred. The commercial pilot, the sole occupant of the airplane, was fatally injured. Night instrument meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) flight plan was in effect. The flight originated from the Bellingham Regional Airport about 1843 Pacific standard time, and was en route to the Ogden International Airport, Ogden, Utah.

Recorded air traffic control (ATC) communications between Seattle Air Route Traffic Control Center, and the pilot of N469MD, indicated the pilot radioed Seattle Center communicating that he was out of 7,800 feet. Seattle Center acknowledged the pilot and cleared the airplane to 15,000 feet. Shortly thereafter, Seattle Center received a "mayday" transmission followed by "lost an engine." Shortly after the transmission, radio and radar contact with the airplane were lost.

Witnesses reported they observed the airplane in an unusually steep descent prior to impacting terrain. One witness stated he heard a high-pitched noise emanating from the airplane as it descended toward the ground.

The wreckage was located in an open field adjacent to Highway 11. The main wreckage was located in the confines of a large impact crater approximately 15 feet in diameter and 6 feet deep.

Personnel information

The pilot held a private pilot certificate with an airplane single-engine land rating, a commercial certificate with a multi-engine land rating and a commercial instrument airplane rating. The pilot's most recent medical certificate (third-class) was issued on June 26, 2004. The certificate carried a limitation requiring the pilot to wear corrective lenses.

Comprehensive flight time logbooks for the pilot were not located. Documentation was located indicating the pilot completed a flight review (FAR 61.56) and an instrument proficiency check (FAR 61.57[d]) on October 22, 2005.

On the pilot's latest FAA Application for Airman Medical Certificate (Form 8500-8), dated June 26, 2004, the pilot listed 7,500 hours total pilot time and 150 hours total pilot time in the 6 months preceding the medical.

Aircraft information

The twin engine Beech Baron 58P, serial number TJ-331, was manufactured in 1978 and was certified as a normal category airplane. The airplane was equipped with two Teledyne Continental Motors (TCM) TSIO-520 engines, each rated at 310 horsepower. The airplane was approved for visual flight rules (VFR) and instrument flight rules (IFR) operations, as well as flight in icing conditions.

The airplane's last inspection, an annual inspection, was completed on December 16, 2005. Maintenance records showed the airplane's total time at inspection was 9,401 hours. The right engine's total time at inspection was 2,048 hours (621 since major overhaul); the left engine's total time at inspection was 3,476 hours (695 since major overhaul). A top overhaul of both engines was completed during the annual inspection.

Maintenance records showed that the last altimeter system and altitude reporting equipment test (in accordance with FAR 91.411) was completed on June 24, 2004.

Complete airframe, engine and propeller maintenance logbook records were not located for the accident aircraft.

Meteorological information

The closest weather observation facility to the accident site was the Skagit Regional Airport (KBVS), located approximately 4.6 miles south of the accident location at an elevation of 144 feet msl. The airport is equipped with an Automated Weather Observation System (AWOS). The following Meteorological Aerodrome Reports (METARs) were issued surrounding the period of the accident:

On February 22, at 1850, the METAR observation was, in part, winds from 180 degrees at 4 knots, visibility 8 statute miles, a few clouds at 2,000 feet, overcast skies at 3,500 feet, temperature 4 degrees C.

At 1910, the METAR observation was, in part, visibility 7 statute miles, scattered clouds at 100 feet, broken clouds at 2,500 feet, overcast skies at 3,400 feet, temperature 4 degrees C.

Communications

At 1851:02, the pilot of N469MD was instructed by Whidbey Approach to contact Seattle Center on frequency 134.95. The pilot acknowledged the ATC specialist and subsequently contacted Seattle Center stating he was through 7,800 for niner (nine) thousand. The ATC specialist then cleared the aircraft to 15,000 feet, and at 1851:38 the pilot acknowledged the clearance, stating, "we're up to one five thousand for niner mike delta."

At 1853:43, ATC received an unintelligible radio transmission containing "lost a" and "niner mike delta."

At 1853:48, ATC received a second transmission from the pilot who stated "mayday mayday just lost an engine a."

At 1853:53 and 1853:55, ATC received two additional transmissions believed to be from the pilot, however both were unintelligible.

This was the last known radio transmission from the pilot of the accident aircraft.

A complete ATC communication transcript and radar data are included in the public docket.

Flight recorders

The airplane was not equipped with flight data or cockpit voice recorders.

Wreckage and impact information

Personnel from the National Transportation Safety Board, Federal Aviation Administration, Teledyne Continental Motors and Raytheon Aircraft accessed the aircraft wreckage on February 23-24, 2006.

The crash site was located in an open field adjacent to the intersection of Highway 11 and Sunset Road, at 48 degrees 32.56 minutes' north latitude and 122 degrees 24.28 minutes' west longitude. The elevation at the crash site was approximately 11 feet above mean sea level (msl). The surrounding terrain was relatively flat and featureless.

The wreckage debris field encompassed an area approximately 348 feet in length (from south to north). The main wreckage was located in the confines of a large impact crater measuring approximately 15 feet in diameter and 6 feet deep. A majority of the wreckage was located in the immediate area of the impact crater. Numerous small pieces of system components and cockpit instrumentation were scattered from the crater to the end of the wreckage debris path.

The main wreckage included engines and propeller assemblies, fuselage, wing assemblies, and tail assembly. Impact forces destroyed the forward section of the fuselage and cockpit. A majority of the cockpit components and instrumentation were located in the crater and were severely fragmented. Both engine assemblies were separated from the airframe and located near the bottom of the crater. Both assemblies sustained extensive impact related damage. The 3-bladed McCauley propeller assemblies were located within the confines of the crater. Both sustained extensive impact related damage. The six propeller blades were separated from their respective hub assemblies and were located in the confines of the impact crater. Forward bending, leading edge damage, chord wise scratches and extensive overall deformation were noted to the propeller blades. The main wing assembly was located with the main wreckage and sustained extensive impact related damage and fragmentation. Extensive accordion type damage was noted to the leading edge of the wing structure. The entire wing assembly was severely fragmented and deformed. Both flap and aileron assemblies were attached to the wing structure and sustained impact

Aircraft

Registration
N469MD
Reported as
Beech 58P
Category
Airplane
Serial number
TJ-331
Airframe hours
9,401
Engines
Continental TSIO-520, 310 horsepower, reciprocatingContinental TSIO-520, 310 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Wallace FW Chang
Registered owner
H&W Management Services
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 1, 2005
Departed
BLI · Bellingham, WA
Destination
OGD · Ogden, UT
Flight plan
IFR

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
56
Injuries
Fatal
Certificates
Commercial, Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
October 1, 2005
Seat
Left
Toxicology
Performed
Flight hours
7,500 total

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
180° at 4 knots
Visibility
8 statute miles
Lowest ceiling
3,500 ft overcast
Temperature
39 °F
Altimeter
30.20 inHg
Observed at
KBVS, 4 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.