WPR12LA178

NTSB accident investigation · Beechcraft A36TC · Pendleton, OR · April 22, 2012

Accident · Serious injuriesLimited investigationFinal report
Date
April 21, 2012, 17:17 local (Apr 22, 2012, 00:17 UTC)
Place
Pendleton, OR
Injuries
1 serious, 2 uninjured
Damage
Substantial damage
Phase of flight
Prior to flight
Aircraft
N3862CBeechcraft A36TC
Defining event
Prior to flight: Aircraft servicing event
Weather
Visual (VMC) · Day
Status
Completed · report June 11, 2014
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20120421006329A
Case key
83451

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 pilot's failure to maintain an adequate glidepath for landing, which resulted in a collision with terrain short of the runway. Contributing to the accident was the pilot's failure to secure the left-side fuel cap before departure. Contributing to the pilot's injuries was the broken shoulder harness.

Findings · 6

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: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech A36TC: 2 casesAll aircraft: 809 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · PilotBeech A36TC: 2 casesAll aircraft: 440 casesProbable cause
Fuel systemAircraft › Aircraft systems · Inadequate inspectionBeech A36TC: 1 caseAll aircraft: 181 casesProbable cause
AircraftAircraft › Aircraft systems · Damaged/degradedBeech A36TC: 1 caseAll aircraft: 63 cases
AircraftAircraft › Aircraft systems · FailureBeech A36TC: 1 caseAll aircraft: 63 casesProbable cause
Use of equip/infoPersonnel issues › Task performance · PilotBeech A36TC: 2 casesAll aircraft: 111 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 pilot reported that the airplane had been refueled before the flight and that the fuel had expanded during the day due to heat, which resulted in fuel draining from the vent. The pilot loosened the fuel caps to facilitate draining excess fuel from the tank; however, he forgot to resecure the left-side cap after he finished draining the fuel. Shortly after takeoff, the pilot reported to an air traffic controller that one of the airplane's fuel caps was not secure and requested permission to return to the airport for landing. However, the pilot did not maintain an adequate glidepath during the approach, and the airplane impacted terrain short of the runway. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. During the impact sequence, the pilot's shoulder harness webbing separated, resulting in a serious injury. Examination showed that the webbing met the original load requirements as specified by the manufacturer, and no photodegradation was evident.

Factual narrative

The NTSB's safety alert "Check Your Restraints" notes the importance of restraint systems in preventing injuries and provides resources for inspecting restraint systems for wear and damage. The safety alert can be found at http://www.ntsb.gov/doclib/safetyalerts/SA_027.pdf. On April 21, 2012, at 1717 Pacific daylight time, N3862C, a Beechcraft Corporation A36TC, registered to Hermiston Aviation Inc. and operated by the pilot collided with terrain short of the runway at Eastern Oregon Regional Airport, Pendleton, Oregon. The commercial pilot sustained serious injuries and the two passengers were not injured. The airplane was substantially damaged. The pilot was operating the airplane under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed. According to emergency response personnel, the pilot had departed Pendleton and radioed to the air traffic control tower controller that one of the airplane's fuel caps was not secured. The pilot was returning to the airport when the airplane impacted terrain short of runway 16. The pilot stated that the airplane had been refueled prior to the flight. It was a warm day with the tank full of fuel and the heat resulted in fuel draining from the vent. The pilot loosened the fuel cap to aid in ridding the tank of the excess fuel. Upon departure, the left wing fuel cap departed from the fuel tank. As the pilot returned to land, he did not maintain an appropriate glide path during final approach and the airplane collided with terrain on the approach end of runway 16. The pilot indicated there were no mechanical malfunctions or failures during the flight, and the engine continued to operate until impact with the terrain. Post accident examination of the airplane revealed that the pilot's shoulder harness separated during the accident sequence resulting in serious injuries. The shoulder harness was dated September of 1980 and was installed when the airplane was manufactured. The pilot's shoulder harness and lap belt were examined by a metallurgist from the NTSB Materials Laboratory. The separation point on the shoulder harness belt showed that some filaments contained mushroomed ends, consistent with a relatively high loading rate. Under such conditions, the loading of the filament produces heat which softens the filament and causes it to fracture. The shoulder harness was also examined using a Fourier Transform Infrared (FTIR) spectrometer. The test was indicative of negligible photodegradation of the webbing. Additionally, the restraint system was examined at Beechcraft with a representative from the Federal Aviation Administration. Sections of the shoulder harness were tensile tested and exceeded the proof load strength of 1,666 pounds, with an ultimate static load strength of 2,500 pounds.

Aircraft

Registration
N3862C
Reported as
Beechcraft A36TC
Category
Airplane
Serial number
EA-227
Airframe hours
3,699
Engine
Continental TSIO-520, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 14, 2012 · 10 hours before
Departed
PDT · Pendleton, OR
Destination
HRI · Hermiston, OR
Airport
PDT · Pendleton, runway 16, 4,341 × 60 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
63
Injuries
Serious
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
January 30, 2012
Seat
Left
Flight hours
13,000 total · 7,500 in this make and model · 12,600 as pilot in command · 67 in the last 90 days · 15 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 54 °F
Altimeter
30.00 inHg
Observed at
PDT

Docket · 10

The files NTSB released with the investigation on April 19, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 16.7 MB in all.

FAA reports on this event · 1

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