# NTSB WPR12LA178: Beechcraft A36TC, N3862C, Pendleton, OR, April 22, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: April 21, 2012, 17:17 local (Apr 22, 2012, 00:17 UTC) - Place: Pendleton, OR - Coordinates: 45.694999, -118.258056 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.6950&lon=-118.2581&mi=10 - Phase of flight: [Prior to flight](https://openairdocs.org/ntsb-phases/100) (OpenAirDocs' grouping) - Defining event: [Prior to flight: Aircraft servicing event](https://openairdocs.org/ntsb-events/020) - Highest injury: Serious injuries - Injuries: 1 serious, 2 uninjured - Status: Completed, report June 11, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 83451 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12LA178 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/83451/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=83451 - Page: https://openairdocs.org/ntsb/WPR12LA178 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech A36TC, 2 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=1151603), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech A36TC, 2 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=1151603), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Beech A36TC, 1 case](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=1151603), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01020000): Aircraft › Aircraft systems · Damaged/degraded; cases with it: [Beech A36TC, 1 case](https://openairdocs.org/ntsb-findings/01020000/cases.md?model=1151603), [All aircraft, 63 cases](https://openairdocs.org/ntsb-findings/01020000/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01020000): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Beech A36TC, 1 case](https://openairdocs.org/ntsb-findings/01020000/cases.md?model=1151603), [All aircraft, 63 cases](https://openairdocs.org/ntsb-findings/01020000/cases.md) - [Use of equip/info](https://openairdocs.org/ntsb-findings/02063000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A36TC, 2 cases](https://openairdocs.org/ntsb-findings/02063000/cases.md?model=1151603), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02063000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft servicing event](https://openairdocs.org/ntsb-events/020) (defining event); cases with it: [Beech A36TC, 1 case](https://openairdocs.org/ntsb-events/020/sequence.md?model=1151603), [All aircraft, 70 cases](https://openairdocs.org/ntsb-events/020/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36TC, 12 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151603), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N3862C-2012-07-25), registration cancelled 2012-07-25, S/N EA-227, built 1981 (OpenAirDocs) - Reported make and model: Beechcraft Corporation A36TC - Registry model: [Beech A36TC](https://openairdocs.org/model/beech-a36tc) (registry code 1151603) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: EA-227 - Airframe hours: 3699 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: serious; 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 ## 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 20120421006329A](https://openairdocs.org/incident/20120421006329A), Apr 21, 2012: Beech A36TC, Pendleton, OR, Substantial damage. The pilot did not install the left fuel tank cap correctly. At rotation on takeoff the pilot saw the fuel cap was hanging loose and fuel was poring from the… ## Docket (10 files) The files NTSB released with the investigation on April 19, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=83451. 16.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 420 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370085&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - FAA Tower Controller Statement (item 2, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40368042&FileExtension=.PDF&FileName=FAA%20Tower%20Controller%20Statement-Redacted.PDF - Beech Restraint System Testing (item 3, .PDF, 15 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400391&FileExtension=.PDF&FileName=Beech%20Restraint%20System%20Testing-Redacted.PDF - DuPont and Celanese- Sunlight Degradation (item 4, .PDF, 450 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391196&FileExtension=.PDF&FileName=DuPont%20and%20Celanese-%20Sunlight%20Degradation-Redacted.PDF - Materials Laboratory 15 - Factual Report 13-056 (item 5, .PDF, 10 photos, 613 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407166&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2013-056-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411631&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 356 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397236&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1. Airplane at Accident Site (item 8, .PDF, 6.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40368043&FileExtension=.PDF&FileName=Photo%201.%20Airplane%20at%20Accident%20Site-Master.PDF - Photo 2. Left Fuel Tank (item 9, .PDF, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40368044&FileExtension=.PDF&FileName=Photo%202.%20Left%20Fuel%20Tank-Master.PDF - Photo 3. Shoulder Harness (item 10, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370985&FileExtension=.PDF&FileName=Photo%203.%20Shoulder%20Harness-Master.PDF 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.