Firefighters gather for Survival Flight training: Allen Park, Michigan

Published: Sunday, June 02, 2013  
By Dave Herndon, The News Herald

ALLEN PARK — Firefighters from both Allen Park and Melvindale gathered in the parking lot of the Southfield Lease Properties Wednesday for training with the Survival Flight crew from the University of Michigan Medical Center.

“It was a great training opportunity,” Melvindale Fire Chief Steven Densmore said. “Having a helicopter land on the scene is a pretty unique situation.”

Densmore said that the training was especially necessary because the hospital has recently purchased two new helicopters with a third one on the way soon.

“The landing zone is different for every size and weight chopper,” he said. “So it was good to get the training with the new equipment.”

The new helicopters that the hospital purchased are Eurocopter’s with twin turbine engines. They are capable of getting from Ann Arbor to any scene Downriver in about 20 minutes. The time includes the preflight checks and loading any special equipment that is needed for a specific call.

The class that the crew taught to the local firefighters was specifically about how to set-up a landing zone and the basics of where to be while the helicopter is landing.

“They had to show us what to do to help them land,” Allen Park Fire Chief Doug LaFond said. “They showed us where we could be, and where we shouldn’t be to avoid being in the pilot’s blind spots when he is landing.”

LaFond said that the Survival Flight crews are not needed often, but in the case of a “mass casualty” situation or a major burn victim would trigger calling them in. A mass casualty event would be something like a major car crash with multiple critical patients.

According to LaFond in that situation local ambulances would take patients to hospitals like Detroit Receiving or Oakwood Hospital and Medical Center, while the Survival Flight crews would take patients to hospitals farther away to “spread the load,” and not overwhelm any one hospital.

Another reason that a helicopter crew might be called in would depend on traffic flow and time of day. LaFond said that during a rush hour accident it might be more effective to call in the Survival Flight rather than try to traverse rush hour traffic.

“With a critical patient there are often as many as 10 staff members used to care for them,” he said. “So we don’t like to take to many patients to the same hospital all at once.”

The Survival Flight helicopters are staffed with a pilot, most of which have military flight training backgrounds, and two flight nurses that have been cross trained as paramedics that can give emergency care during transport.

University of Michigan Hospital has bee providing Survival Flight services since 1983.

The crew is expected back later this summer for a second training class for the rest of the Allen Park department, as well as members of other departments that will be invited.

Story, Video, Photos:  http://www.thenewsherald.com

Pittsburgh International Airport (KPIT) restaurants short on food safety: Inspection reports show persistent problems at Airmall

While the Pittsburgh International Airport long ago lost its status as a hub for a major airline, the facility more recently has become a standout in a more dubious category -- as a hotbed for food safety violations.

A Pittsburgh Post-Gazette review of inspection reports for 19 restaurants at the airport found that together they racked up some 270 critical violations over the past two years. Critical violations are the most serious types of problems that put people at risk for foodborne illnesses. The restaurants also accumulated roughly 230 lesser infractions.

The reports by the Allegheny County Health Department also showed seven "administrative" actions, a fairly rare occurrence in which persistent problems trigger a visit from a health department supervisor to press the need for corrective action.

"It sounds like more violations than we want to have," interim health department director Ronald Voorhees said when asked about the newspaper's findings.

He said the department would conduct a review to determine the need for "additional actions to improve the situation."

The Airport Group, a policy group affiliated with the labor union Unite Here, last month expressed concerns about food safety conditions at the airport during a board meeting for the Allegheny County Airport Authority. (Unite Here does not represent workers at food concessions at the Pittsburgh airport.)

The group presented board members with an analysis identifying 271 violations at airport restaurants since the beginning of 2012, a shorter period of time than the newspaper's review, including 132 critical violations.

By comparison, inspection reports for the similarly sized Mineta San Jose International Airport showed 146 violations at a nearly identical number of facilities over roughly the same time frame, with just two violations termed "major" by inspectors there, Airport Group analyst Ian Mikusko said.

"We wanted to alert the Allegheny County Airport Authority about the number of violations so it could take positive action to ensure the safety of food available to the airport's passengers," Mr. Mikusko said.

When asked about the newspaper's findings and the concerns of the Airport Group, the airport authority issued an email statement saying it was "proud of the track record of Airmall's food and beverage operators and of the hardworking food service workers who make the program a success."

Airmall USA, which manages the retail space at the airport, also released a statement via email saying it "takes great pride in managing and maintaining a clean, safe food and beverage operation."

Both the airport authority and Airmall emphasized that "no airport eatery has any outstanding issues" with the health department.

The health department can issue a yellow "Consumer Alert" sticker or shut down a restaurant for uncorrected critical food safety violations but has not done so at any restaurant at the airport.

Such actions are rare. Last year, the county issued nine consumer alerts and four closures among the roughly 7,000 food facilities it oversees.
McDonald's located in the main area of the terminal known as the center core was hit with the most critical violations of any restaurant over the two-year period with 32 and tied with two other restaurants for prompting the most visits by inspectors at nine. County health inspectors are supposed to inspect restaurants once per year but come more often if there are severe or persistent problems.

Critical violations included undercooked burgers, holding food at unsafe temperatures and cross-contamination problems when employees handling raw meat were observed touching clean items, including a seasoning bottle and trays meant for cooked burgers.

The popular fast-food outlet also accumulated the most noncritical violations, 41, for less serious infractions such as food service employees wearing acrylic nails and excessive debris on the floor.

The restaurant's owner, Iftakhar Malik, attributed the high number of violations to a high volume of business.

"We serve the most customers," he said.

"We do not serve any food that should not be served. We serve safe food. Every product we make has a time and temperature on it and when it's expired" it is thrown out, he said.

Mr. Malik said the undercooked Quarter Pounders and Angus burgers that an inspector found last year represented "one complaint in one year."

Still, inspection reports show a similar violation about a month later at another McDonald's outlet that Mr. Malik owns, located in Concourse B. That outlet was inspected five times and accumulated 19 critical violations.

"If we were doing something real serious, they will tag you," Mr. Malik said, referring to the health department's consumer alert program.

l Charley's Steakery, also in the center core, accumulated the second highest number of critical violations at 31, including 10 recorded during a single inspection in June 2012.

The sub shop was repeatedly cited for not having at least one worker on duty certified in safe food-handling practices -- which has been a county requirement since 1993 -- and for holding foods at unsafe temperatures, including during the facility's most recent inspection in April.

Owner Drew Janis said he considers food safety the most important aspect of serving the public, that he welcomes the input from inspectors and that all violations have been corrected.

"I've been there for 21 years at the airport. We are very careful about things and run a very clean operation," he said, adding that he and his general manager took the county's food safety course but let the certification lapse. He said they were planning to be recertified.

At Nature's Kitchen in the center core, inspectors visited nine times, finding 25 critical violations, the third highest among the 19 restaurants. Repeat violations twice triggered a meeting with a health department supervisor, the most of any restaurant at the airport.

On nearly every visit, multiple foods inside coolers were too warm. The facility also was cited multiple times for not having a certified food safety manager and not keeping food hot enough on the steam table.

Inspectors found a similar number of problems at a second Nature's Kitchen location in Concourse D.

The general manager for Nature's Kitchen did not return telephone calls seeking comment.

At a Subway shop in Concourse B, an inspector visited six times, recording 18 critical and nine noncritical violations that prompted a visit from a health department supervisor in January.

Critical problems included meats being held at unsafe temperatures, improper sanitization and an employee observed blowing her nose and then putting on plastic gloves without washing her hands.

"That employee is no longer with us," said Mike Patel, owner of that facility and another Subway in Concourse A, where a supervisor also paid a visit in January.

"We have fixed all the problems we had," Mr. Patel said.

Although the vast majority of airport restaurants had multiple critical violations, a few stood out for exceptionally good performance. Among the three full-service T.G.I. Friday's locations at the airport, there wasn't a single critical violation and just two noncritical infractions recorded over the past two years.

"Certainly the goal of the inspection process is to decrease the number of violations as close to zero as possible," the health department's Dr. Voorhees noted.

Unless customers logged onto the county health department website, they had no way of knowing how the airport restaurants were doing.

The department has been working on implementing an A-B-C rating system that would post scores on restaurant doors. Part of the reason is to help people quickly interpret inspection reports and make it easier for them to make informed dining decisions.

Supporters say that in addition to grades helping customers make on-the-spot choices, the specter of having to post a poor score is a strong motivator for restaurants to be vigilant about food safety and to act quickly to fix health code violations.

"Certainly the hope is that it improves food safety throughout the county. That's the goal," Dr. Voorhees said.

The department was ready with a draft proposal for grading restaurants early last month, but the plan was put on hold pending the appointment of a permanent director, which was announced Friday as Karen Hacker of the Cambridge Health Alliance in Massachusetts, effective in September.

The next step would be to test the system in the field before presenting it to the Allegheny County Board of Health. The plan would then go to Allegheny County Council for consideration.

Any grading plan would be long in coming.

Some two years ago, the board unanimously approved an A-B-C rating system that had been in the works for many months but scuttled it after an outcry from prominent local restaurant owners who called it unnecessary, unfair and potentially damaging to their businesses.

That plan also was criticized by a food safety expert at the Center for Science in the Public Interest in Washington, but for a different reason. She said it was too lenient on restaurants, making it virtually useless as a guide for consumers when choosing a place to eat.

Annoying aircraft flies over John Carroll graduation: Police investigating -- Bel Air, Maryland

Members of the John Carroll School Class of 2013 send their caps skyward as they celebrate after receiving their diplomas during Saturday's graduation ceremony. 

A single-engine plane made an unexpected appearance during The John Carroll School's commencement ceremony Saturday afternoon, flying over the graduates sitting on the school's athletic field.

The identity of the pilot of the small aircraft could not be immediately confirmed Saturday, but the plane made repeated wide circles over the graduates seated on the Gerry Gray Memorial Field, the spectators in the stands and the school buildings behind them.

The plane was not low enough to glimpse its identifying tail number, but the engine noise was loud enough to occasionally drown out the words of graduation speaker Vickie Ensor Bands.

Bands, a 1975 graduate of John Carroll, did not stop her speech, however.

Some graduates and parents were perturbed by the appearance of the aircraft on the special day.

"It was very disrespectful of the parents and students who put so much into this," said Deborah Caperna, of Dundalk, whose son Anthony was one of 169 members of John Carroll's Class of 2013.

She and her son said as they posed for pictures after the ceremony that the pilot did not stop everyone from enjoying the commencement.

"It could have thunderstormed," Caperna said. "It wouldn't have made a difference; God is good, always."

Graduate Jennifer Kreis declined to comment on the plane's appearance.

"It's really exciting," she said of graduating. "I can't believe that our four years are over, and I really love John Carroll and my classmates."

Campus Minister Patti Murphy Dohn said after the ceremony school officials had no comment.

Bel Air Police Chief Leo Matrangola wrote in an e-mail Saturday evening that the town Police Department had received a complaint about the plane, and officials planned to follow up with the "complainant" and the Federal Aviation Administration.

Story and Comments/Reaction: http://www.baltimoresun.com

Homemade ultralight declared not airworthy; builder disputes decision, vows to fly: Cape Fear Regional Jetport/Howie Franklin Field Airport (KSUT), Oak Island, North Carolina

Norman Lewis stands next to the Brockenhiemer 2 in front of his house in Southport in 2012.

By Brian Freskos, Star News 
Published: Thursday, May 30, 2013 at 7:46 p.m.
Last Modified: Thursday, May 30, 2013 at 11:27 p.m.
 

Norman Lewis almost reached the clouds. But he hit a snag.

Officials at the Cape Fear Regional Jetport recently laid out a series of criteria that Lewis must meet before embarking on long-planned flight to the Bahamas in his homemade, self-designed ultralight aircraft. For all practical purposes, that means Lewis is grounded, for now at least.

“They want me to tear my plane apart for no reason,” the 44-year-old fumed. “They want me to jump through hoops only so they can give the end-result answer they have up their sleeves.”

Lewis labored over his aircraft for a year and a half with the intent of making the several hundred miles-long flight to Grand Bahama Island. But the airport sees his endeavor as posing a serious safety risk, so much so that officials refuse to let him fly until Lewis proves he can make the journey, alive.

The airport’s safety adviser, a former Federal Aviation Administration crash investigator named Lyle Streeter, appeared before the governing board on Thursday to outline the steps that Lewis needed to take before lifting off. They included proving the aircraft meets federal specifications for ultralights, allowing an engineer to inspect its structural soundness, and completing flight lessons.

“It’s not a personal issue. We applaud him as an aviator,” said airport director Howie Franklin. “But people’s lives are at stake here.”

The dispute opens a window into the close-knit aviation world, where desires are sometimes at odds with goodwill, and liabilities impede ambition. 

Under law, ultralight aircraft must seat only one person, weigh less than 254 pounds, and travel no faster than 55 knots (63 mph). No pilot’s license is required to fly one.

Lewis’ aircraft looks like a torpedo with wings, a shiny metal cap around the nose. It rides atop go-cart wheels, is about as long as two men lying down and runs on a gasoline generator engine modified for better horsepower. A homemadefuel gauge – a metal rod stuck into a piece of cork that floats on the gasoline in the 5-gallon tank – protrudes up in front the windshield.

Aviation has been Lewis’ lifelong interest. He flew with his father as a boy. And though he took flight lessons in the late 1980s and early 1990s, he never got his pilot’s license.

It took Lewis 18 months of nose-grinding work to complete the ultralight, sweating and smoking cigarettes in his garage on N.C. 133 in Southport.

When complete, Lewis stowed the plane in a hangar at the Cape Fear Regional Jetport about a month ago and began making final preparations to fly to Grand Bahama Island, with a stopover in Boca Raton, Fla.

A rift emerged after Franklin, the airport director, saw Lewis on a television news channel saying he planned to take off that weekend. Concerned about the aircraft’s fly-ability, Franklin asked Streeter, two workers from the maintenance shop and another ultralight specialist for their opinion.

The unanimous verdict: “It’s not airworthy,” Franklin said. “It is extremely questionable whether it can sustain any flight whatsoever.”

That decision does not sit well with Lewis, who said the airport is overreaching its authority by regulating ultralight flight, which does not fall under the FAA’s purview.

“I did some pretty good engineering on this thing,” he said, walking around the aircraft, which now is parked in front of his house. “Anybody who looked at my airplane and said it couldn’t fly is a fool.”

For Lewis, this is but a setback. The plan now is to find another runway.

Story, Photo, Comments/Reaction:  http://www.starnewsonline.com

Collision During Takeoff: Beechcraft A36 Bonanza, N999PK; accident occurred May 28, 2013 in Mountainaire, Arizona

Aviation Accident Final Report - National Transportation Safety Board 

The National Transportation Safety Board traveled to the scene of this accident. 

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Scottsdale, Arizona

Continental Motors Inc; Mobile, Alabama

Hartzell Propeller; Piqua, Ohio

Beechcraft; Wichita, Kansas

Beechcraft/Textron Aviation; Wichita, Kansas

Investigation Docket - National Transportation Safety Board:

https://data.ntsb.gov/Docket

https://registry.faa.gov/N999PK

Location: Mountainaire, Arizona 

Accident Number: WPR13FA244

Date and Time: May 28, 2013, 11:43 Local

Registration: N999PK

Aircraft: RAYTHEON AIRCRAFT COMPANY A36

Aircraft Damage: Destroyed

Defining Event: Collision during takeoff/land 

Injuries: 2 Fatal

Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The pilot had purchased the Beechcraft airplane about 18 months before the accident and based it at his home airport, which was located at an elevation of about 80 ft mean sea level (msl). The pilot flew the Beechcraft to an airport that was at an elevation of about 7,100 ft msl. A few days after his arrival, he returned to the airport for his planned departure and spent about 15 minutes asking the fixed base operator owner, who was also a pilot, multiple questions about the route to his next planned destination. According to the owner, he was surprised by the nature of the pilot's questions, his lack of basic aeronautical information knowledge for area restrictions, and his lack of formal planning for his flight.

No witnesses reported anything unusual about the engine start or taxi. At the time the pilot was cleared by the air traffic control tower controller for takeoff, the airport density altitude was about 9,000 ft. No ground witnesses reported observing anything unusual with the takeoff, but a Cessna 172 pilot who was behind the Beechcraft reported that the Beechcraft's climb-out was slow. Shortly after his own takeoff, about 75 seconds after the Beechcraft, the Cessna pilot asked the tower controller about the Beechcraft's situation and intentions because the Cessna was already well above the Beechcraft. This prompted the controller to ask the Beechcraft pilot if he needed assistance, and the pilot responded that he was climbing "very slowly" and would remain near the airport. Shortly after that, the Cessna pilot saw the Beechcraft impact trees. The accident site was about 3 miles southeast of the airport at an elevation about 300 ft below that of the departure airport. A postimpact fire obscured or destroyed a significant amount of evidence.

Review of the Beechcraft's published performance data revealed that, for the given conditions, the airplane should have been able to successfully depart the airport and climb at a rate of about 500 feet per minute.

Most of the engine components and all of the propeller components that survived the accident, displayed no evidence of preimpact mechanical deficiencies. The engine cylinder conditions were indicative of a history of generally lean operation. In addition, the No. 5 cylinder exhaust valve's appearance was consistent with excessively lean operation for an undetermined period of time, and the fuel injector nozzle for that cylinder was found to be partially occluded. Excessively lean operation will reduce engine power output, and will manifest itself as abnormally high exhaust and cylinder head temperatures and possible engine roughness. Further, if the No. 5 cylinder's injector was occluded for the flight, it would have resulted in overly lean operation of and reduced power output from that cylinder, yielded higher exhaust and cylinder head temperatures, and likely manifested itself as engine roughness. (Some witnesses close to the impact site reported that the engine was making "popping" noises.) Although the airplane was equipped to monitor, display, and record temperatures for each cylinder, it could not be determined whether the pilot monitored that display, and fire damage prevented the recovery of that data from the engine monitor. Further, there was insufficient evidence to determine the source of the injector's occlusion, quantify its effects on engine power output, determine its relation to the condition of the exhaust valve, or determine if it was present for the takeoff or an artifact of the postimpact fire.

Although the engine was developing power at impact, there was insufficient evidence to quantify the actual power output for the climb or at the time of impact. There was also insufficient evidence to determine whether the pilot ensured that the throttle and propeller controls were set to and remained in their appropriate positions for the departure or whether the pilot adjusted the mixture properly (not overly lean).

It is likely that the pilot lifted off prematurely at a speed lower than the prescribed value and was unable to accelerate or climb the airplane once it exited the ground effect regime. Because the surrounding terrain and the impact point were lower than the elevation of the airport, the pilot was able to continue to fly the airplane before crashing. This scenario is at least partially corroborated by the pilot's reported lack of preparation for the flight, which could have included a lack of performance planning. This scenario is also partially corroborated by the observed repetitive minor banking of the airplane, which often occurs when an airplane is flying very slowly.

A premature liftoff or a climb attempt at a speed significantly below the prescribed value would place the airplane in a situation where the power required for level flight was very near to or exceeded the available power. A recovery would require the pilot to lower the nose in order to accelerate the airplane to obtain a positive rate of climb. Such an action is counterintuitive when low to the ground and requires accurate problem recognition, knowledge of the correct solution, and sufficient terrain clearance to

accomplish.

During the departure, the pilot reduced his options by deciding to turn to the east instead of continuing straight ahead to the south. Review of topographic data revealed that a four-lane highway was located just beyond the south end of the runway, and was situated in a north-south valley that descended to the south. However, instead of tracking over that highway, which could have been used as an off-airport emergency landing site, and its descending valley, which provided increasing terrain clearance, the pilot opted to turn east, toward higher, wooded terrain. Although that turn was consistent with both a left traffic pattern (in order to remain close to the airport as the pilot reported to the air traffic controller), and toward the pilot's on-course heading, by making that turn, the pilot reduced the likelihood of a partially or fully successful outcome to the flight.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot's inability to maintain a climb after departure in high-density altitude conditions, which resulted in a collision with trees and terrain. Contributing to the accident were the pilot's decision not to track the four-lane highway just beyond the departure runway, which he could have used as an alternate landing site; his premature rotation of the airplane; and degraded engine performance that affected the airplane's climb ability. 

Findings

Aircraft Climb rate - Attain/maintain not possible

Environmental issues High density altitude - Effect on operation

Personnel issues Decision making/judgment - Pilot

Personnel issues Incorrect action performance - Pilot

Aircraft (general) - Damaged/degraded

Environmental issues Tree(s) - Not specified

Environmental issues Mountainous/hilly terrain - Not specified

HISTORY OF FLIGHT

On May 28, 2013, about 1143 mountain standard time, a Beechcraft A36, N999PK, was destroyed when it impacted trees and terrain in the Coconino National Forest adjacent to Mountainaire, Arizona, shortly after takeoff from Flagstaff Pulliam airport (FLG), Flagstaff, Arizona. A large post-impact fire ensued immediately. The owner/private pilot and the one passenger received fatal injuries. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight.

According to relatives of the pilot, he based the airplane at McClellan Airfield (MCC) Sacramento, California. The pilot and his wife (the passenger) departed MCC on the morning of May 25, 2013, and arrived at FLG that same day. According to personnel and documentation from a fixed base operator (FBO) at FLG, the couple rented a car the day they arrived, and returned the car to the FBO about 1100 on the day of the accident. On their return, the pilot requested that 20 gallons of fuel be loaded into each of the main tanks, and then queried the FBO owner for about 15 minutes about route and other considerations for a flight to Bryce Canyon Airport (BCE), Bryce Canyon, Utah. The airplane was refueled, and the pilot and his wife loaded their belongings into the airplane.

According to the communications recordings from the FLG air traffic control tower (ATCT), after startup and taxi out, the pilot requested and was granted a turnout to the northeast. The airplane took off from runway 21, and was observed to be climbing very slowly by a pilot in a Cessna 172, which departed shortly after the Beechcraft.

According to the Cessna pilot, once it was beyond the end of the runway, the Beechcraft followed a slightly meandering course initially to the south, and then turned further left towards the south-southeast. The Cessna pilot then witnessed the Beechcraft impact trees adjacent to a semi-rural neighborhood about 3 miles from FLG. The Cessna pilot reported the accident to the ATCT controller. The terrain between the airport and the accident site was forested, gently undulating, and generally lower than the airport.

Several residents of the accident neighborhood were outside, and witnessed the final portion of the flight. Most reported that the engine was making "popping" noises, and was not trailing any dark smoke. Some of those eyewitnesses were the first responders to the accident. They immediately began fire suppression efforts using portable fire extinguishers, shovels of dirt, and household/garden hoses. All those individuals reported that the fire was large and intense, but that their efforts were partially successful in suppressing or containing the fire.

PERSONNEL INFORMATION

Federal Aviation Administration (FAA) records indicated that the 59-year-old pilot held a private pilot certificate with an airplane single-engine land rating. That certificate was issued in May 2010. The pilot's most recent FAA third-class medical certificate was issued in September 2012. On the application for that medical certificate, the pilot indicated that he had a total flight experience of 540 hours.

FAA records indicated that the pilot purchased a turbo-charged Cessna 182 in December 2008; he retained that airplane, and purchased the non-turbocharged accident airplane (Beechcraft) in November 2011.

The pilot's fire-damaged flight logbook was recovered from the wreckage. Review of the logbook indicated that the pilot began flight training in 2008, and that at the time of the accident, had accumulated about 611 total hours of flight experience. The logbook indicated that the pilot completed a flight review in the Cessna in February 2013. Damage to the logbook precluded a determination of the pilot's total flight experience in each airplane.

The pilot's nephew stated that the Cessna was "not flown much" subsequent to the purchase of the Beechcraft. The nephew also reported that the pilot was familiar with high elevation airports, and noted that the pilot flew into Truckee California "regularly." Truckee-Tahoe airport (TRK) has an elevation of 5,901 feet above mean sea level (msl).

The pilot had flown the Beechcraft with at least two different certified flight instructors (CFI). The first CFI flew a total of about 33 hours in the airplane with the pilot; their first flight together was to transport the airplane from Colorado to California following the pilot's purchase of the airplane. Subsequent flights were conducted initially to satisfy insurance requirements, and then to increase the pilot's proficiency with the airplane. The second CFI began flying with the pilot in May 2012, when the pilot began training for an instrument rating. That CFI flew a total of about 3 hours with the pilot in the accident airplane.

MEDICAL AND PATHOLOGICAL INFORMATION

The Coconino County (Arizona) Office of the Medical Examiner autopsy report indicated that the cause of death was "thermal injuries." The FAA Civil Aeromedical Institute conducted forensic toxicology examinations on specimens from the pilot, and reported that no cyanide or ethanol was detected. The reported blood carbon monoxide level was 15 percent. Alpha-hydroxyalprazolam, a metabolite of alprazolam (trade name Xanax), was detected at a level of 0.009 micro-grams per milliliter in the urine, but was not detected in the blood. No other screened drugs were detected.

AIRCRAFT INFORMATION

FAA information indicated that the airplane was manufactured in 2001 as Beechcraft serial number E-3380, and was equipped with a Continental Motors IO-550 series engine. The airplane was purchased by, and first registered to, the pilot in late 2011.

The airplane was equipped with multiple factory- and post-delivery options. These included factory-installed cabin air conditioning, J.L. Osborne-brand wing tip tanks (20 gallons/side), Precise Flight-brand electric speedbrake system, a JPI-brand EDM-700 engine data monitor, AMSAFE- brand inflatable pilot and copilot dual shoulder harness restraint system, Garmin 430 and 530 nav-com units, and an Aerospace Systems & Technology-brand TKS de-icing system.

All those modifications had been accomplished prior to the pilot's purchase of the airplane. According to those records, the most recent annual inspection was completed on June 1, 2012, when the airplane had a total time (TT) in service of about 893 hours. The records indicated that a "top overhaul" of the engine was completed in April 2004, when the engine had a TT of about 243 hours.

In an interview with the NTSB, one of the pilot's CFIs indicated that the airplane was well-maintained, and that the CFI did not notice any problems or shortcomings with its climb capability, which he pays attention to when flying a new (to him) airplane. NTSB interviews with FLG ground personnel indicated that the airplane was not heavily loaded, and NTSB review of the specific information indicated that for the accident departure, the airplane was likely within its weight and balance envelope.

METEOROLOGICAL INFORMATION

On May 25, the day that the airplane arrived at FLG, the daily maximum recorded temperature of 22 degrees C was reached about noon, and lasted until about 1500 local time.

On May 28, the day of the accident, 1157 FLG automated weather observation included wind from 210 degrees at 17 knots, gusting to 26 knots, visibility 10 miles, clear skies, temperature 18 degrees C, dew point minus 4 degrees C, and an altimeter setting of 29.95 inches of mercury.

COMMUNICATIONS

Partial transcripts of the FLG ATCT ground and local communications surrounding the flight and accident were developed and provided by Serco, the company contracted by the FAA to staff and operate the ATCT.

At 1125:45, the pilot first radioed the ground controller, and advised that he was "ready to taxi," but did not specify any additional intentions. The controller cleared the airplane to runway 21 via the alpha and alpha one taxiways, which the pilot acknowledged. About 5 minutes later the pilot advised the ground controller that he did not realize that there was no run-up area near the runway 21 threshold, and asked for instructions to prevent a conflict with a twin-Cessna behind him. The controller and other pilot rectified the situation by routing the twin-Cessna via another taxiway. At 1136:21, the pilot of the Cessna 172 N3923Q who later witnessed the accident, contacted the controller for taxi clearance to runway 21.

At 1137:20, the Beechcraft pilot first radioed the local controller, and advised that he was "ready for takeoff headed to Tuba City." A few seconds later, the controller cleared the airplane for takeoff, to which the pilot responded "ready for takeoff taking runway two one can you tell me which way for a uh uh downwind departure?" The controller instructed the pilot to make a left downwind, and the pilot acknowledged that communication.

At 1139:24, Cessna 172 N3923Q radioed the local controller that he was ready for takeoff from runway 21, requested a left turnout, and was cleared for same a few seconds later. At 1141:44, the Cessna pilot stated that he was making his left turn, and asked the controller whether the Beechcraft was "okay, he is awful low." At 1141:51, the controller asked if the Beechcraft pilot needed any assistance, and the pilot responded "yah...I'm climbing very slowly and uh I'm climbing very slowly and staying close to the airport." At 1142:15, the Cessna pilot radioed that he did not "understand why he didn't stay over the interstate." At 1142:47, the Cessna pilot radioed that the Beechcraft had crashed and was on fire; the pilot circled the impact location for several minutes in an attempt to guide first responders to the site.

After the accident, the ground controller and the local controller each provided a written statement regarding the flight and accident. Neither statement explicitly cited whether its author actually witnessed the takeoff or climb-out. The local controller's statement reported that he was advised of the Beechcraft climb problem by the subsequently-departing Cessna.

AIRPORT INFORMATION

FAA information indicated that the pilot's home airport, MCC, was situated at an elevation of 77 feet above mean sea level.

FAA information indicated that FLG runway 3/21 measured 8,800 by 150 feet, and the airport elevation was listed as 7,140 feet above mean sea level. The runway was served by a single parallel taxiway ("alpha") with 9 access taxiways between the two. There was no dedicated runup area at either runway threshold. A dedicated runup area was situated on taxiway alpha about midway between the ramp and the runway 21 threshold, and the end of the taxiway could also be utilized for that purpose.

The airport was situated in a 2- to 3-mile wide valley that was oriented approximately north-south, with a gentle continuous descent to the south.

Calculations using the meteorological conditions at the time of the accident resulted in an airport pressure altitude of 6,983 feet, and a density altitude of 8,983 feet for FLG.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in the semi-rural neighborhood of Mountainaire, on moderate- to heavily-forested Coconino National Forest (CNF) property. The impact location was about 2.9 nautical miles (nm) from the departure end of FLG runway 21, on a true bearing of 170 degrees (158 magnetic) from that runway location. Impact site elevation was 6,815 feet. Review of topographic data revealed that virtually all of the terrain between the departure end of FLG runway 21 and the impact location was lower than the airport.

The impact site was situated about 1 nm to the east of the southern end of a straight section of a four-lane north-south highway that measured 1.15 nm in length, began about 1.17 nm from the threshold of runway 3, and was at an elevation of about 6,700 feet.

The airplane struck several tall pine trees before it struck the ground. The first tree impact was situated about 40 feet above ground level. The depression angle of the flight path through the trees was about 14 degrees. The distance from the first tree strike to the main wreckage, which primarily consisted of the fuselage from tail to propeller, was 135 feet, on a true heading of 180 degrees.

All major components were accounted for on scene. No evidence consistent with in-flight fire or in-flight structural failure was observed. Propeller and tree damage was consistent with the engine developing power at the time of impact.

The fuselage came to rest upright, on an approximate true heading of 322 degrees. Tree impacts had separated the right wing and the outboard section of the left wing from the airplane. The engine was separated from all four engine mounts, but remained adjacent to the firewall. The propeller remained attached to the engine. The fire consumed or severely damaged a significant portion of the fuselage, including the cockpit instruments and controls, and the cabin and its contents. Due to the fire damage, no useful information was able to be obtained from any cockpit instruments, switches, circuit breakers, or engine controls.

ADDITIONAL INFORMATION

Airframe Examination Details

About 8 feet of the left wing, and the entire right wing, were fracture-separated from the airplane. The left tip tank did not contain any fuel, and did not display any signatures of hydraulic deformation. The right tip tank was breached, did not contain any fuel, and did not reveal any hydraulic deformation. Significant portions of each wing, including both fuel tank bladders were significantly or completely consumed by fire.

Both ailerons remained attached to their respective wings at all mounting hinges, and sustained thermal damage. Aileron cable continuity was established from the right and left control column sprockets to the right and left aileron bellcranks. The aileron trim actuator remained intact and attached to the left wing. The aileron trim actuator extension equated to 2 degrees left tab trailing edge up.

The flaps and flap actuators were all found to be in the flaps-retracted position. Although significantly fire-damaged, the speed-brakes appeared to be in the retracted position at impact.

The horizontal stabilizers remained attached to the aft fuselage and displayed post-impact fire exposure. The left and right elevators, including their balance weights, remained attached to the horizontal stabilizers at the hinges. Elevator control cable continuity was established from the control column to the elevator bellcrank.

The left and right elevator trim surfaces remained attached to their respective elevators at their hinges. The elevator trim actuator extensions equated to approximately 6 degrees tab trailing edge down. Elevator trim cable continuity was confirmed from its cockpit control wheel to the actuators in the empennage.

The vertical stabilizer was fracture-separated from the aft fuselage at its spar roots. A portion of the rudder torque tube, the rudder bellcrank, and fragments of the rudder remained attached to the aft fuselage. The remainder of the fracture-separated rudder, including the rudder balance weight, was found near the aft fuselage. Continuity determination of the rudder control system was limited due to fire damage.

No pre-impact anomalies such as corrosion, wear, or misrouting, were observed on the primary or secondary flight control cables, but thermal and impact damage precluded a complete determination of the cables' pre-accident condition. All cable damage was attributed to impact overload and/or thermal exposure.

Both main landing gear assemblies were found in their retracted positions. The nose landing gear appeared to be in a near-retracted position.

Engine and Fuel System Examination Details

The engine came to rest upright, leaning towards its left side. The throttle, propeller, and mixture control cables remained attached to the throttle quadrant and their respective engine components.

The two magnetos were found properly secured to their mounting pads on the engine. Magneto-to-engine timing testing determined that both magnetos were timed to within 1 degree of the manufacturer's setting, and within 1 degree of each other. Due to the thermal damage the magnetos were shipped to Continental Motors. Examination of the magnetos did not reveal any pre-impact anomalies. After the thermally-damaged capacitor in each magneto was replaced, the right magneto functioned normally, but the left magneto only operated intermittently. That failure was attributed to additional internal thermal damage to the magneto.

The ignition leads remained attached to the magnetos and spark plugs, but sustained significant thermal damage. All spark plugs were removed, and displayed a "normal worn" condition. However, the top and bottom spark plugs from the number 5 cylinder bore very light soot, and the number 5 top plug also held a globule of solidified lead down in its barrel, at the base of the insulator. There was no evidence of lead fouling on any of the other spark plugs. Oil on the number 2 bottom, number 4 bottom, and number 6 top and bottom spark plug electrodes was attributed to the engine orientation after it came to rest. With the exception of the top spark plug from the number 6 cylinder, which had a cracked insulator, all spark plugs produced sparks during bench testing.

Once the spark plugs were removed, the crankshaft was rotated manually. Thumb compressions were obtained on all six cylinders, which confirmed crankshaft, camshaft, connecting rod, and rocker arm continuity. With the exception of cylinder number 5, examination did not note any anomalies with the cylinder barrels, pistons, valves, or valve seats. The cylinder number 5 exhaust valve bore signatures characteristic of excessively lean operation and a possible exhaust gas leak.

No anomalies with the engine lubrication system were noted.

The electric boost pump motor was recovered and was observed to be significantly fire damaged. The pump was not recovered, and presumed to have been consumed by fire.

The engine driven fuel pump (EDP) remained securely attached to the engine, with all fuel lines and fittings in place. The EDP drive coupling was intact. Manual rotation of the drive coupling while installed in the EDP drive shaft resulted in rotation of the shaft; however, there was some binding noted, likely due to internal coking from post accident thermal exposure. Disconnection of the flexible fuel lines resulted in charred material exiting from some of those lines. Removal of the fuel line fittings from the EDP revealed a significant amount of accumulated material in the vapor return outlet port and fitting; no other ports contained similar material. Some material was removed and sent to the NTSB Materials Laboratory for examination. Spectral analysis yielded a strong match for polyester, which is often used as a braided interlayer in flexible fuel lines.

Additional unidentified accreted deposits were found in the EDP swirl chamber. The NTSB Materials Laboratory reported that there was not enough material from the swirl chamber of the EDP to analyze. No non-thermal anomalies were noted with the EDP.

The throttle body was consumed by fire. The throttle plate remained attached to the throttle shaft and lever. The throttle and mixture control levers remained securely attached to their respective control shafts. The mixture control shaft could not be rotated in the fuel metering unit via manual manipulation of the mixture control lever. Examination of the mixture control shaft revealed charred debris adhering to the shaft and walls of the metering unit. The fuel inlet and return fittings remained attached to the fuel metering unit. The fuel inlet screen was found to be unobstructed.

The fuel manifold valve and the injector lines remained intact and securely attached. The manifold valve diaphragm was observed to be stuck to the cap and the housing of the manifold valve, and tore when the cap was removed. The diaphragm was brittle; this was attributed to its post impact fire exposure. The plunger was secured to the diaphragm and the screen was clear. No obstructions or other anomalies were noted.

The fuel nozzles were removed from their respective cylinders. The nozzle from the number 5 cylinder displayed some debris within its discharge orifice, partially obstructing the nozzle. None of the other nozzles displayed any orifice obstructions.

The fuel selector valve was found set to the left main tank. The port from the left main fuel tank was open to the port leading to the engine, and the passageway was confirmed to be unobstructed.

The engine monitor was recovered from the wreckage and sent to the NTSB Recorders Laboratory for possible data download. Thermal damage precluded the recovery of any data from the device.

Propeller Examination

The three-bladed Hartzell propeller remained attached to the crankshaft propeller flange. All three propeller blades remained attached to the propeller hub, but two of the blades were separated from their pitch change links. The tips of both of those blades had been fracture-separated from the blades, but both tips were recovered on site. One of those blades had deep leading edge gouges, and the other one had moderate leading edge gouges. The third blade was bent aft about 30 degrees at its mid-span point. Its tip was curled aft more than 180 degrees, and the blade displayed heavy leading edge gouging, primarily on the outboard span section. All damage was consistent with the propeller being driven under power at impact.

Detailed examination at the Hartzell facility confirmed that the propeller model was appropriate for the airplane, and did not reveal any pre-impact anomalies.

Cabin Air Conditioning System

The compressor of the refrigerative-type cabin air conditioning system was powered by a pulley-drive system on the engine accessory face. The system was operable on ground and in flight. The system was manually turned on or off by a dedicated toggle switch on an instrument panel subpanel, and delivered cooled air via the cabin ventilation "eyeball outlets."

An automatically-positioned three position air intake door was located on the fuselage belly. The door was closed when the system was off. When the system was operating, the door opened to an intermediate position in flight, and to its maximum limit when the airplane was on the ground. When the door was extended to its maximum position, an "AC DOOR EXTEND" annunciation light on the instrument panel would be illuminated.

The system was prohibited from use during takeoff, but could be turned on during climb by the pilot once obstacle clearance was assured. In the event of a go-around while the system was operating during a landing approach with the landing gear extended, when full throttle was applied, a throttle control limit switch would deactivate the compressor to terminate power extraction from the engine, and retract the intake door to reduce drag. Once the landing gear was retracted or the throttle was retarded, following a 20-second delay, the system would resume operation; the intake door would re-open, and the compressor would re-engage.

The only performance-related information in the Pilot's Operating Handbook (POH) was that cruise speed and range values were to be decremented by 5 percent with the air conditioning operating. The POH did not provide any information regarding the horsepower usage by the system, or system usage on climb performance.

FBO Fuel

As noted previously, the airplane was fueled with 40 gallons from the FBO on the morning of the accident. Several other airplanes were refueled from the same source prior to the accident airplane, and at least two (including the FBO owner's twin-engine airplane) were refueled after the accident airplane; all those airplanes were operated successfully and uneventfully after their respective refuelings. A fuel sample was obtained and tested in accordance with the fuel vendor's procedures; the FBO owner reported that no anomalies or problems with the fuel were detected.

Witness Information Regarding the Pilot

The CFI who helped the pilot fly the accident airplane to California after its purchase, and who conducted the pilot's February 2013 flight review in that airplane, stated that the pilot met the minimum standards for the flight review, and that there was nothing remarkable about the review. The CFI who was working with the pilot on his instrument rating stated that the pilot was "pretty cautious," and that his "basic stick and rudder skills" were "solid;" the CFI had "no doubt" about the pilot's flying abilities.

On the morning of the accident, the lodging proprietor asked the pilot if he was used to flying at high elevation airports; the pilot responded that he was "not familiar" or "used to" such operations. The pilot then stated that he was planning to fly to Bryce and Zion National Parks, in Utah, north-northwest of FLG. He also stated that FLG was 300 feet lower than that next destination, but that he was not particularly concerned about that trip segment.

According to the owner of the FBO, the pilot asked about a recommended route of flight to Bryce Canyon and Zion National Parks. The FBO owner provided that guidance, and showed the pilot the routing on a chart. The pilot was unfamiliar with the fact that the Grand Canyon, which was situated between FLG and the pilot's destination, had designated airspace constraints, and that there was a dedicated VFR chart for that airspace. The pilot was also unfamiliar with the procedures and constraints of Military Operations Areas. Because of the pilot's age, and the sophistication and complexity of the airplane that he was flying, the FBO owner was surprised by, and not favorably impressed with, the pilot's lack of knowledge and preparation.

Airplane loading and other pre-flight preparations appeared to be relatively normal, but the FBO owner noted that the pilot made several inexplicable trips between the airplane and the FBO, possibly as a result of "absentmindedness."

Cessna Pilot Witness Information

The pilot of the Cessna 172 that departed about 75 seconds behind the Beechcraft observed a portion of its flight and the accident. He did not observe the Beechcraft take off. The Cessna pilot observed the Beechcraft climbing "very slowly" on the runway heading. He reported that the Beechcraft maintained the runway heading until it was beyond the end of the runway, and then it turned slightly left, towards the south, and initially appeared to be following the nearby four-lane highway (Interstate 17). By the time the Cessna reached the end of the runway, it was higher than the altitude of the Beechcraft ahead. The Cessna pilot initially thought that perhaps the Beechcraft pilot was sightseeing. However, because the Beechcraft continued to remain extremely low, and appeared to be descending, the Cessna pilot queried the controller about the Beechcraft's situation. The Cessna pilot observed the Beechcraft making repeated small banks to the left and right, and watched the Beechcraft ground track become south-southeasterly, divergent from the interstate highway. The Cessna pilot then observed the Beechcraft continue to make repeated small banks as it descended, and then impact the trees and burst into flames. During his conversation with investigators, the Cessna pilot stated that he observed the Beechcraft turn towards rising terrain, and could not understand why its pilot did not either turn towards lower terrain (the descending valley to the south), or remain over the nearby four-lane interstate highway.

Air Traffic Control Radar Information

FAA air traffic control ground tracking radar data was examined to ascertain whether the accident flight was tracked by the radar system, and to derive a flight path if possible. The geographic locale is primarily served by two FAA radar antennae. One was situated about 73 miles west-northwest, and the other was situated about 80 miles south of FLG. Antenna site distances from the accident site, combined with mountainous topography, yielded a radar coverage floor estimated to be about 8,500 feet msl. The radar systems did not detect the airplane on its accident flight. The radar systems did intermittently detect the eyewitness Cessna 172; the minimum altitude detected was 8,700 feet msl.

Estimated Airplane Performance Capability

The investigation was unable to obtain any current or previous airplane empty weight or center of gravity (CG) information. Interviews with relatives and witnesses at FLG indicated that the pilot and passenger did not have a significant amount of luggage, and that the fuel tanks were not filled. FAA records did not indicate that the airplane maximum takeoff weight of 3,650 lbs had been increased via any supplemental type certificates (STCs).

Although the evidence suggested that the airplane was significantly below its maximum allowable takeoff weight, for conservatism, the investigation assumed that the airplane was at a weight of 3,600 lbs for the departure, and also assumed zero-wind conditions. Best angle of climb speed was 84 knots, and best rate of climb speed was 100 knots.

The POH provided performance data for takeoff using both zero flaps and "approach flaps" (12 degrees); the actual takeoff flap setting was not able to be determined. For zero flaps, the prescribed rotation speed was 72 knots, and the speed at 50 feet was 83 knots. For approach flaps, those speeds were 67 and 77 knots, respectively.

According to the manufacturer's performance data, for zero flaps, the takeoff ground roll would have been about 2,875 feet, and the total distance to 50 feet above ground level (agl) would have been about 5,270 feet. For a takeoff with approach flaps, the ground roll would have been about 2,336 feet, with a total distance to 50 feet agl of about 4,552 feet. The initial climb rate after flap retraction would have been about 512 feet per minute (fpm).

Factors Affecting Climb Performance

An airplane's climb capability is a function of its "excess power," which is defined as the difference between the power required to fly level at a given speed, and the power available at that same speed. When the power available exceeds the power required, the airplane will have a positive climb capability. Several factors can adversely affect airplane takeoff performance and climb capability, by either affecting the power required or the power available.

Power required is due to aerodynamic drag. Increased drag can be due to exit from ground effect, airplane condition or configuration (e.g. flap setting, or landing gear or air conditioning door extended), speedbrake deployment, incorrect climb speed, or increased weight.

Power available is a combination of engine power output, and the ability of the propeller to convert that power to thrust. In non-turbocharged piston engines, power output decreases with altitude. Propeller thrust typically decreases with speed; therefore, overall power available typically decreases directly as speed and altitude increase. Other factors that can decrease the power available include improper throttle or mixture setting, throttle or mixture malfunction; improper propeller blade pitch due to improper setting or malfunction; or air conditioning compressor operation.

The power output of a normally aspirated engine decreases with the decrease in air density that is due to increased altitude or increased density altitude. Turbocharging reduces or eliminates power losses due to increases in altitude or density altitude. On a comparative basis, at the high elevation, high density altitude departure airport, the takeoff and climb performance of the pilot's turbocharged Cessna would likely not have been adversely affected, whereas the takeoff and climb performance of his non-turbocharged Beechcraft was significantly reduced from its sea-level capability.

Ground Effect

The following paragraphs are synopsized from the Airplane Flying Handbook (AFH, FAA-8083-3).

Ground effect is a condition of improved performance encountered when the airplane is operating very close to the ground. The performance improvement is a result of a reduction in induced aerodynamic drag. Ground effect is most significant during takeoff when the airplane lifts off and accelerates to climb speed, and during the landing flare before touchdown.

The takeoff roll, lift-off, and beginning of the initial climb take place in the ground effect regime. As the airplane lifts off and climbs out of ground effect, the airplane will experience an increase in induced drag, and therefore thrust required, to maintain that speed or accelerate. The airplane will experience a pitch-up tendency, and will require less elevator deflection, due to the increase in downwash at the horizontal tail.

Due to the reduced drag in ground effect, the airplane may appear to be able to take off below the prescribed airspeed. However, as the airplane rises out of ground effect with an insufficient airspeed, initial climb performance may prove to be marginal, because of the increased drag. Under conditions of high-density altitude and/or maximum gross weight, the airplane may be able to become airborne at an insufficient airspeed, but unable to climb out of ground effect. Consequently, the airplane may not be able to clear obstructions.

Additional power is required to compensate for the increased drag that occurs as the airplane leaves ground effect. However, during an initial climb, because the engine controls have already been set to develop maximum (takeoff) power, the only alternative is to lower pitch attitude to gain airspeed, which will result in an altitude loss. Therefore, for takeoffs under marginal conditions, it is imperative that the airplane be operated at the prescribed airspeeds, in order to provide adequate initial climb performance.

Aerodynamic Drag Factors

The as-found condition of the airplane indicated that the landing gear, flaps, and speedbrakes were retracted, which was the proper minimum drag climb configuration. The investigation was unable to determine when the landing gear was retracted, or whether the speedbrakes had been extended for the takeoff and climb attempt. Post-accident position of the cabin air conditioning system intake door was not determined, but operational procedures and system design precluded a takeoff and initial climb with the intake door open, a configuration that would have increased drag. No preimpact anomalies that would have increased the basic aerodynamic drag of the airplane were observed.

Climb Speed

The power required versus speed curve is roughly "U" shaped, with the bottom of the "U" denoting the minimum drag speed. Normal operating climb speeds are typically set near the minimum drag speed of the airplane, with some additives for factors such as stall margin and engine cooling. Because there was no ground tracking radar or applicable onboard data available, the investigation was unable to determine whether the pilot adhered to the manufacturer-specified climb speed schedule. Deviations from the specified speed could reduce the airplane climb capability, and a speed much below the best angle of climb speed of 84 knots could significantly affect climb capability.

The power-off clean stall speed was about 69 knots; the manufacturer did not publish power-on stall speeds for the airplane. Power-on stall speeds are typically several knots lower than power-off stall speeds. The repetitive, small, left and right bank angles observed by the Cessna pilot were consistent with the behavior of an airplane approaching a stall, but those motions could have been caused by other factors, including pilot input and turbulence. There was no evidence to indicate that the airplane fully stalled during any portion of the flight.

Airplane Weight and Balance

As noted previously, all evidence was consistent with the airplane being within its certificated weight and balance envelope.

Engine Power

Engine power was directly affected by throttle and mixture settings. The POH specified that full throttle was to be used for takeoff and climb. There was insufficient evidence to enable a determination of whether the pilot set and maintained full throttle for the takeoff and climb attempt.

According to the POH, the takeoff mixture was to be set "as required by field elevation," by adjusting the full throttle fuel flow as a function of engine rpm, in accordance with a schedule in the POH. According to that schedule, based on the pressure altitude of 7,000 feet, the full-throttle fuel flow values should have been 23.2 gallons per hour (gph) at 2,700 rpm, or 21.2 gph at 2,500 rpm. The airplane was equipped with a fuel flow transducer and cockpit display to enable compliance with the schedule, and thus proper mixture setting. The investigation was unable to determine the pilot's familiarity with this procedure, or what mixture-setting procedures, if any, he conducted prior to the accident takeoff, or during the climb attempt.

Off-Schedule Fuel Mixture Effects

The pre-takeoff leaning schedule of the fuel mixture for high-elevation airport operations is designed to enable the engine to produce best power in the decreased-air-density environment. In contrast, engine leaning during cruise is accomplished to both adjust the mixture for the air density, as well as adjust the engine power for values below full power, and thereby, modulate the fuel economy.

In general, engines operated at off-schedule fuel mixtures will exhibit certain characteristic signatures which indicate whether the mixture was overly rich or overly lean. Engines that are operated on an overly rich fuel mixture will accrete unburned fuel in the form of dark carbon deposits in the cylinders and exhaust system, and can emit exhaust visible as dark smoke. In contrast, engines that are operated on an overly lean fuel mixture will be characterized by cylinders and exhaust systems with either a "clean" appearance, or fine whitish, tan, or light gray deposits. The investigation was unable to locate any detailed or substantiated data regarding the development or disappearance of these signatures as a function of time that an engine is operated at a particular off-schedule mixture.

As part of the engine certification process, CMI conducted engine power tests that measured power output as a function of fuel flow (and thus, mixture) for two different baseline, but less than full, power settings. Review of the test data indicated that power increased as a function of fuel flow (in pounds per hour, pph) to a certain point, then peaked or flattened out, and then decreased. Using either that peak, or the peak brake specific fuel consumption (BSFC, pounds of fuel per HP per hour) as the dividing line, the rate of power change per pph of fuel flow was greater on the lean sides of those lines than it was on the rich sides of the lines. Furthermore, when the peak BSFC line was used as the dividing point, the rate of power change per pph was significantly greater on the lean side than it was on the rich side.

The investigation did not obtain any similar mixture variation data for full power settings, and therefore was unable to determine the effects of off-schedule fuel mixtures on engine power for takeoff and initial climb.

Partially Obstructed Fuel Nozzle

A 1997 article in "Aviation Maintenance Technology" magazine stated that the most common form of fuel nozzle contamination happens as fuel evaporates in the nozzles after hot engine shut-downs. This evaporative process leaves deposits of varnish residue which buildup over time, and inhibits the free flow of metered fuel to the cylinders. If left unattended, nozzles begin to become blocked, but the contamination is not typically limited to a single nozzle.

The airplane was equipped with a turbine/rotary fuel flow transducer, as opposed to the pressure-type flow transducer. Because the rotary-type transducers measure the flow directly, they are not subject to the erroneous fuel flow indications of the pressure-type transducers when one or more fuel nozzles become partially or fully blocked.

The number 5 cylinder fuel injector nozzle was found to be partially blocked, which could result in lean operation and reduced power output of that cylinder, possibly accompanied by engine roughness and altered CHT and EGT values; the effect on each parameter would be proportional to the degree of blockage. The exhaust valve for that cylinder bore signatures characteristic of excessively lean operation. There was insufficient evidence to enable the investigation to determine the source of the blockage, quantify its effects, or its relation to the condition of the exhaust valve. There was also insufficient evidence to determine when the blockage occurred, including whether it was an artifact of the post-impact fire.

Engine-Driven Fuel Pump Debris

The investigation was unable to determine when the deposits were formed in the vapor return outlet or the swirl chamber of the engine-driven fuel pump, but their appearances were consistent with the results of a post impact fire. Partial or complete blockage of the vapor return line would result in an enrichment of the mixture, because that line is the primary flow path for the return of excess fuel from the pump output, which is utilized in a venturi setup to aid in vapor extraction. There was insufficient information to determine the engine power effects, if any, of that mixture change if the vent line was partially or completely blocked during the accident flight. The swirl chamber deposits did not occlude any orifices, or appreciably reduce the volume of the swirl chamber.

Backfiring and Detonation

Some of the signatures of backfiring and detonation were consistent with the available physical or witness report evidence.

According to the FAA Aviation Maintenance Technician Handbook, Powerplant (FAA-8083-32), "an extremely lean mixture either does not burn at all or burns so slowly that combustion is not complete at the end of the exhaust stroke. The flame lingers in the cylinder and then ignites the contents in the intake manifold or the induction system when the intake valve opens. This causes an explosion known as backfiring." The Handbook stated "A point worth stressing is that backfiring rarely involves the whole engine... In practically all cases, backfiring is limited to one or two cylinders. Usually, it is the result of ... defective fuel injector nozzles, or other conditions that cause these cylinders to operate leaner than the engine as a whole." Backfiring will result in a loss of power and characteristic "popping" sounds from the engine, which is congruent with the available evidence.

According to the Pilot's Handbook of Aeronautical Knowledge (PHAK, FAA-8083 25), detonation "is an uncontrolled, explosive ignition of the fuel/air mixture within the cylinder's combustion chamber" that can result in engine overheating, roughness, or loss of power. The PHAK cited one common cause of detonation as "operation of the engine at high power settings with an excessively lean mixture," and cited one preventative measure that pilots should "develop the habit of monitoring the engine instruments to verify proper operation according to procedures established by the manufacturer."

The FAA Aviation Maintenance Technician Handbook, Powerplant (FAA-8083-32) stated that "Unless detonation is heavy, there is no flight deck evidence of its presence," and the "effects of detonation are often not discovered until after teardown of the engine."

Although the No. 5 cylinder condition was consistent with excessively lean operation, none of the cylinder assemblies, including No. 5, displayed any evidence of detonation.

Propeller Blade Pitch Setting

The blade pitch angles for the installed model propeller were measured at the 30-inch blade station, with a certificated travel range of 13 to 36 degrees. Takeoff procedures specified that the propeller pitch cockpit control be set to full forward. According to information provided by Beechcraft, at takeoff power, at a speed of 90 knots for the given ambient conditions, the estimated propeller blade angle would have been 17.7 degrees. Impact witness marks indicated that the blade pitch setting was about 25 degrees. Evidence found at the accident site indicated that the propeller sliced through a number of trees and tree branches before contacting the rocky ground. Therefore, the investigation was unable to determine when the witness marks were made, and could not discount alteration of the blade pitch angles, without producing any witness marks, as the airplane descended through the relatively soft pine trees. Therefore the investigation was unable to determine whether the propeller blade pitch was set correctly for the takeoff and climb attempt.

Cabin Air Conditioning Operational Status

The recorded air temperature at FLG about the time of the accident was 18 degrees C (64 degrees F), which was not consistent with the use of cabin air conditioning. Even if the ambient temperature was conducive to the use of air conditioning, operational procedures and system design safeguards prevented the cabin air conditioning system compressor from extracting power from the engine during a takeoff and initial climb. The investigation was unable to determine the operational status of the air conditioning compressor during the takeoff and climb attempt.

NTSB Identification: WPR13FA244 
14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 28, 2013 in Mountainaire, AZ
Aircraft: RAYTHEON AIRCRAFT COMPANY A36, registration: N999PK
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On May 28, 2013, about 1143 mountain standard time, a Beechcraft A36, N999PK, was destroyed when it impacted trees and terrain in the Coconino National Forest adjacent to Mountainaire, Arizona, shortly after takeoff from Flagstaff Pulliam airport (FLG), Flagstaff, Arizona. A large post-impact fire ensued immediately. The owner/private pilot and the one passenger received fatal injuries. No persons on the ground were injured or killed. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight.

According to relatives of the pilot, he based the airplane at McClellan Airfield (MCC) Sacramento, California. The pilot and passenger departed MCC on the morning of May 25, 2013, and arrived at FLG that same day. According to personnel and information from Wiseman Aviation, a fixed base operator (FBO) at FLG, the couple rented a car that day, and returned the car to the FBO about 1100 on May 28. The pilot requested that 20 gallons of fuel be loaded into each of the main tanks, and then queried the FBO owner for about 15 minutes about flight route and other considerations for a flight to Bryce Canyon Airport (BCE). The airplane was refueled, and the pilot and his wife loaded the airplane.

According to information provided by representatives of the Federal Aviation Administration (FAA), after startup and taxi out, the pilot requested, and was granted, a turnout to the northeast by the FLG air traffic control tower (ATCT) controller. The airplane took off from runway 21, and was observed to be climbing very slowly by a pilot in a Cessna 172, which departed just after the Beechcraft. The Cessna pilot eventually queried the ATCT controller about the Beechcraft's intentions, and the Beechcraft pilot then radioed that he was climbing very slowly. The Cessna pilot watched the Beechcraft maneuver slightly. He subsequently watched the Beechcraft strike trees, and then explode; he reported this to the ATCT, and then orbited the accident site until ground help arrived.

FAA information indicated that FLG runway 21 measured 8,800 by 150 feet, and the airport elevation was listed as 7,140 feet above mean sea level. The 1157 FLG automated weather observation included wind from 210 degrees at 17 knots, gusting to 26 knots; visibility 10 miles; clear skies; temperature 18 degrees C; dew point minus 4 degrees C; and an altimeter setting of 29.95 inches of mercury.

 

Dr. Matthew Mezger and his wife Mary Patricia Hughes. 

Dr. Matthew Mezger, MD and wife Mary Patricia Hughes passed away together on May 28, 2013. Matt and Pat met at Carroll College in Helena, Montana and were married on May 28, 1983 in Duluth, MN. They lived briefly in San Diego during Matt's residency before moving to Sacramento where they resided for over 25 years and raised their three children Madeline, Thomas and John. 

Matt graduated from UCD Medical School and went on to practice medicine at Capitol Nephrology, co-owed and operated dialysis clinics in Woodland and Dixon and was very active in the Sacramento community. Pat was a licensed family therapist who spent her days caring for her children and creating a welcoming space for family and friends to gather and spend time together. Her generous spirit was rooted in her family, friends and community. 

Pat was preceeded in death by her parents, Chester and Jeanne Hughes. 

In addition to her children, Pat is survived by: sisters, Cathie (Steve) Trachsel, Duluth, MN, Lisa (Tim) Zellmer, Edina, MN, brothers, David (Carol) Hughes, Duluth, MN, John (Deb) Hughes, Jeff (Nada) Hughes, both of Richfield, MN, and Doug (Susan) Hughes, St. Louis Park, MN and 13 nieces and nephews. 

Matt was preceded in death by his father, Thomas Mezger. In addition to his children, Matt is survived by: his mother, Rosalie Mezger, 101 years, of Woodland, sisters Ann "Muvvie" (Steve) Marks, Woodland, Michelle (Brett) Wark, Sydney, Australia and brothers, Dan (Ellen) and Mark (Kerry) Mezger, Woodland and Tom, (MaryLynn), Parker, Colorado and 15 nieces and nephews. 

A Memorial Mass celebrating Matt and Pat's lives was celebrated on Tuesday, June 4th, 2013 at 11 a.m. in the Saint Ignatius Catholic Church, 3235 Arden Way, Sacramento, Ca. After Mass, a gathering to celebrate Matt and Pat will be held at the Saint Ignatius Parish Hall. Interment for Matt was held on Wednesday, June 5th, 2013, at 2 p.m. at the Mary's Chapel Cemetery, Yolo, California. Pat's ashes were be brought back to her home in Duluth. In lieu of flowers, the family requests donations to missionteachingfoundation.org, Jesuit High School, 1200 Jacob Lane, Carmichael, CA 95608 or Newman Center, www.sacnewman.org.

=======

Funeral services have been scheduled for well-known Woodland-area physician Dr. Matthew Mezger and his wife Mary Patricia Hughes who died in a private airplane crash on Tuesday in Mountainaire, Ariz., while celebrating their 30th anniversary.

A memorial mass is scheduled for 11 a.m., Tuesday, in the Saint Ignatius Catholic Church, 3235 Arden Way, Sacramento. Interment for Dr. Mezger will be held at 2 p.m., Wednesday, June 5, at Mary's Chapel Cemetery, 12020 County Road 98, Woodland. Hughes ashes will be returned to her hometown of Duluth, Minn.

The couple were killed last Tuesday morning during their take-off from an airport near Mountainaire in a Beechcraft 336 single-engine plane. They were the only people on board the small aircraft. Dr. Mezger was 59 years old. Hughes was 54 years old.

Federal Aviation Administration spokesman Ian Gregor said earlier that preliminary information indicates the plane left Flagstaff Pulliam Airport and had trouble gaining altitude before crashing about three miles southeast of the airport in Mountainaire.

Coconino County sheriff's officials reported the plane was headed to Bryce Canyon, Utah.

Dr. Mezger is a well-known Woodland physician. He was a 1980 UC Davis graduate, a longtime physician for Woodland Memorial Hospital as well as Sutter Health and other local medical facilities. Since 1987, he was in private practice at the Capital Nephrology Medical Group in Sacramento.

Mountainaire is located in Coconino County, and is south of Flagstaff.

An airplane which crashed in Mountainaire, Arizona, on Tuesday was registered to Dr. Matthew Mezger of Sacramento, a well-known Woodland physician.

However, whether Mezger was flying the airplane could not be determined, although the two occupants of the craft were both killed.

Dr. Mezger, a UC Davis graduate in 1980, was a longtime physician for Woodland Memorial Hospital as well as other local medical facilities. Since 1987, he also was in private practice at the Capital Nephrology Medical Group in Sacramento.

The plane itself was a fixed wing single-engine type manufacturer by Raytheon, built in 2001.

According to reporter Cyndy Cole of the Arizona Daily Sun, residents of the area heard the heard a small plane flying frighteningly close over their homes around noon Tuesday before it clipped several trees, striking the ground in a resident's back yard and exploding into flames.

"It was so low. It was so loud. And then: boom!" Siera Smyth, who immediately ran out to try to help the victims, told Cole. Both occupants of a small plane, which was registered out of Sacramento, died in the crash. Arizona law enforcement officers were working to find and notify family members.

Cole reported the pilot of the Beechcraft Bonanza bound for Tuba City, Arizonia, reported trouble gaining altitude, according to the Federal Aviation Administration.

"I heard it fly over the house really low," said resident Justin Adams. "... it didn't sound right. The motor was sputtering out."

The plane clipped and knocked down trees on what appeared to be a disc golf course, striking the ground about 50 feet from a home on Iroquois Drive, and landed facing back toward the airport.

Its engine and propeller were separated from the rest of the plane, and all were thoroughly charred.

Smyth and another person in her home, which is about two blocks away from the crash site, responded immediately.

"We both went running with shovels. All the neighborhood went running with shovels," to contain the fire, she said, which reached within a few yards of the nearest home.

Others tried to approach the plane, with two treated for smoke inhalation and released at the scene.

"Some guys ran over there with a fire extinguisher," Adams said.

Firefighters attempted to douse the fire from a distance, but they couldn't get very close to the plane right after the crash because it was engulfed in flames.

The magnesium components of the plane burned intensely, and firefighters later put a containment line around the wildfire it sparked, estimated at one-quarter acre, said Brian Katrales, spokesman for Highlands Fire District.

Katrales credited neighbors with acting quickly and calling for help immediately.

The National Transportation Safety Board and FAA will investigate, according to the FAA.  

===========

FLAGSTAFF, AZ - A single-engine plane crashed Tuesday morning near Flagstaff, killing two people on board.

Ian Gregor with the Federal Aviation Administration said a single-engine Beechcraft Bonanza had trouble gaining altitude after departing from Flagstaff Pulliam Airport.

The plane crashed about two to three miles southeast of the airport around 11:45 a.m.

"All I saw was a plane that came too low over our house and not even a minute later I heard this big boom and saw smoke just billowing," said Pat Policastro who witnessed the crash.  "The flame, I mean the flame only God knows how high it was, it was like watching TV."

Gregor said the plane was registered out of California and had been en route to Tuba City on the Navajo Nation.

According to the Coconino County Sheriff's Office, the crash happened within a hundred feet of residential buildings in the Mountainaire community.

"It was banking left as planes typically do when they head towards Sedona and the wing was pointed towards the ground and it went down," said Policastro.  "It was like a bomb going off, I mean the whole earth shook."

CCSO said several witnesses tried to extinguish the flames and help the occupants.

A fire was ignited by the crash which was eventually contained at about 1/4 acre. No structures were damaged.

"I never want to hear it again or see it again and the smell, I know what plane fuel smells like and that's what it was, it was burning fuel," said Policastro.

The FAA and National Transportation Safety Board are investigating this crash.

=========

FLAGSTAFF, Ariz. -- Two people died in a plane crash south of Flagstaff on Tuesday. 

 Coconino County Sheriff's Office spokesman Gerry Blair said the small plane struck the top of a couple of trees and crashed around noon. The plane exploded on impact and burned, starting a small forest fire.

Units from the Highland Volunteer Fire District responded and quickly contained the fire to a quarter of an acre.

The crash site is near the community of Mountainaire, 15 miles south of Flagstaff.

The single-engine privately owned aircraft is registered out of California. At this time, it is not clear where the plane was heading or who was on board.

The cause of the crash is not known at this time. The Federal Aviation Administration and the National Transportation Safety Board will investigate.

======

Two people are dead after a plane crashed into the back yard of a home in Mountainaire south of Flagstaff a little before 11:43 a.m. today.

The pilot of the Beechcraft Bonanza reported trouble gaining altitude after leaving the Flagstaff Pulliam Airport shortly before noon, according to the Federal Aviation Administration.

The plane crashed in a forested area about 50 feet from the nearest home and was engulfed in flames.

The identities of the victims have not been released.

Neighbors near the crash site on Iroquois Drive said the plane clipped several trees before crashing behind a house and touching off a small forest fire.

“I heard it fly over the house really low,” said resident Justin Adams. “… it didn’t sound right. The engine was sputtering out.”

Neighbors attempted to come to the aid of the occupants but were rebuffed by flames.

Two were treated at the scene for smoke inhalation.

Responding to the scene were Guardian Medical, Highlands Fire District, the Bear Jaw firefighting crew, and the Coconino County Sheriff's Office.

Firefighters credited residents with responding quickly and calling for help.

Eric True of the Highlands Fire District says crews have suppressed a quarter-acre fire resulting from the crash.

MOUNTAINAIRE, Ariz. -- Authorities say a Sacramento couple with family and professional ties to Woodland has been identified as having died in a small plane crash south of Flagstaff.

Coconino County Sheriff's officials announced Wednesday that 59-year-old Dr. Matthew Sullivan Mezger and his 54-year-old wife Mary Patricia Hughes were the only people aboard the plane that crashed just before noon Tuesday.

They say the couple was from Sacramento and Mezger was the owner and pilot of the Beechcraft 336 single-engine plane.

Federal Aviation Administration spokesman Ian Gregor says preliminary information indicates the plane left Flagstaff Pulliam Airport and had trouble gaining altitude before crashing about three miles southeast of the airport in Mountainaire.

Sheriff's officials say the plane was headed to Bryce Canyon, Utah.

Dr. Mezger is a well-known Woodland physician. He is a 1980 UC Davis graduate, was a longtime physician for Woodland Memorial Hospital as well as Sutter Health and other local medical facilities. Since 1987, he was in private practice at the Capital Nephrology Medical Group in Sacramento.

Mountainaire is located in Coconino County, and is south of Flagstaff.

A Sacramento physician and his wife have been identified as the couple who died Tuesday in the crash of single-engine aircraft in Arizona.

Matthew S. Mezger, 59, and his wife, Mary Patricia Hughes, 54, were the only occupants of the Beechcraft Bonanza that crashed and burned about three miles southeast of Pulliam Airport in Flagstaff about 11:45 a.m., according to a Coconino County Sheriff's Department news release.

Ian Gregor, a spokesman for the Federal Aviation Administration, said the plane, which was headed to Tuba City, Ariz., had trouble gaining altitude after departing the airport.

The Sheriff's Department reported receiving a call regarding an airplane crash near the community of Mountainaire from a resident of the area who witnessed the crash and fire. Before emergency personnel arrived, several citizens attempted to extinguish the flames and attend to the occupants, according to the news release.

The couple were pronounced dead at the scene.

According to the FAA, Matthew Mezger was the registered owner of the airplane.

Mezger is listed as a physician with the Capital Nephrology Medical Group in Sacramento. According to his resume on the medical group's website, he earned his medical degree from UC Davis and has been a staff physician at hospitals throughout the Sacramento area.

The Sheriff's Department reported that the couple left Sacramento on Saturday and spent the weekend in Flagstaff. Their intended destination after leaving Flagstaff was Bryce Canyon, Utah.

The crash is being investigated by the FAA and the National Transportation Safety Board.

 

  

 

 

 

 

 

NTSB Identification: WPR13FA244 
14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 28, 2013 in Mountainaire, AZ
Probable Cause Approval Date: 08/05/2015
Aircraft: RAYTHEON AIRCRAFT COMPANY A36, registration: N999PK
Injuries: 2 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The pilot had purchased the Beechcraft airplane about 18 months before the accident and based it at his home airport, which was located at an elevation of about 80 ft mean sea level (msl). The pilot flew the Beechcraft to an airport that was at an elevation of about 7,100 ft msl. A few days after his arrival, he returned to the airport for his planned departure and spent about 15 minutes asking the fixed base operator owner, who was also a pilot, multiple questions about the route to his next planned destination. According to the owner, he was surprised by the nature of the pilot’s questions, his lack of basic aeronautical information knowledge for area restrictions, and his lack of formal planning for his flight.

No witnesses reported anything unusual about the engine start or taxi. At the time the pilot was cleared by the air traffic control tower controller for takeoff, the airport density altitude was about 9,000 ft. No ground witnesses reported observing anything unusual with the takeoff, but a Cessna 172 pilot who was behind the Beechcraft reported that the Beechcraft’s climbout was slow. Shortly after his own takeoff, about 75 seconds after the Beechcraft, the Cessna pilot asked the tower controller about the Beechcraft’s situation and intentions because the Cessna was already well above the Beechcraft. This prompted the controller to ask the Beechcraft pilot if he needed assistance, and the pilot responded that he was climbing “very slowly” and would remain near the airport. Shortly after that, the Cessna pilot saw the Beechcraft impact trees. The accident site was about 3 miles southeast of the airport at an elevation about 300 ft below that of the departure airport. A postimpact fire obscured or destroyed a significant amount of evidence.

Review of the Beechcraft’s published performance data revealed that, for the given conditions, the airplane should have been able to successfully depart the airport and climb at a rate of about 500 feet per minute.
Most of the engine components and all of the propeller components that survived the accident, displayed no evidence of preimpact mechanical deficiencies. The engine cylinder conditions were indicative of a history of generally lean operation. In addition, the No. 5 cylinder exhaust valve’s appearance was consistent with excessively lean operation for an undetermined period of time, and the fuel injector nozzle for that cylinder was found to be partially occluded. Excessively lean operation will reduce engine power output, and will manifest itself as abnormally high exhaust and cylinder head temperatures and possible engine roughness. Further, if the No. 5 cylinder’s injector was occluded for the flight, it would have resulted in overly lean operation of and reduced power output from that cylinder, yielded higher exhaust and cylinder head temperatures, and likely manifested itself as engine roughness. (Some witnesses close to the impact site reported that the engine was making “popping” noises.) Although the airplane was equipped to monitor, display, and record temperatures for each cylinder, it could not be determined whether the pilot monitored that display, and fire damage prevented the recovery of that data from the engine monitor. Further, there was insufficient evidence to determine the source of the injector’s occlusion, quantify its effects on engine power output, determine its relation to the condition of the exhaust valve, or determine if it was present for the takeoff or an artifact of the postimpact fire.

Although the engine was developing power at impact, there was insufficient evidence to quantify the actual power output for the climb or at the time of impact. There was also insufficient evidence to determine whether the pilot ensured that the throttle and propeller controls were set to and remained in their appropriate positions for the departure or whether the pilot adjusted the mixture properly (not overly lean).

It is likely that the pilot lifted off prematurely at a speed lower than the prescribed value and was unable to accelerate or climb the airplane once it exited the ground effect regime. Because the surrounding terrain and the impact point were lower than the elevation of the airport, the pilot was able to continue to fly the airplane before crashing. This scenario is at least partially corroborated by the pilot’s reported lack of preparation for the flight, which could have included a lack of performance planning. This scenario is also partially corroborated by the observed repetitive minor banking of the airplane, which often occurs when an airplane is flying very slowly.

A premature liftoff or a climb attempt at a speed significantly below the prescribed value would place the airplane in a situation where the power required for level flight was very near to or exceeded the available power. A recovery would require the pilot to lower the nose in order to accelerate the airplane to obtain a positive rate of climb. Such an action is counterintuitive when low to the ground and requires accurate problem recognition, knowledge of the correct solution, and sufficient terrain clearance to accomplish.

During the departure, the pilot reduced his options by deciding to turn to the east instead of continuing straight ahead to the south. Review of topographic data revealed that a four-lane highway was located just beyond the south end of the runway, and was situated in a north-south valley that descended to the south. However, instead of tracking over that highway, which could have been used as an off-airport emergency landing site, and its descending valley, which provided increasing terrain clearance, the pilot opted to turn east, toward higher, wooded terrain. Although that turn was consistent with both a left traffic pattern (in order to remain close to the airport as the pilot reported to the air traffic controller), and toward the pilot’s on-course heading, by making that turn, the pilot reduced the likelihood of a partially or fully successful outcome to the flight.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

The pilot's inability to maintain a climb after departure in high-density altitude conditions, which resulted in a collision with trees and terrain. Contributing to the accident were the pilot's decision not to track the four-lane highway just beyond the departure runway, which he could have used as an alternate landing site; his premature rotation of the airplane; and degraded engine performance that affected the airplane's climb ability.

HISTORY OF FLIGHT

On May 28, 2013, about 1143 mountain standard time, a Beechcraft A36, N999PK, was destroyed when it impacted trees and terrain in the Coconino National Forest adjacent to Mountainaire, Arizona, shortly after takeoff from Flagstaff Pulliam airport (FLG), Flagstaff, Arizona. A large post-impact fire ensued immediately. The owner/private pilot and the one passenger received fatal injuries. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight.

According to relatives of the pilot, he based the airplane at McClellan Airfield (MCC) Sacramento, California. The pilot and his wife (the passenger) departed MCC on the morning of May 25, 2013, and arrived at FLG that same day. According to personnel and documentation from a fixed base operator (FBO) at FLG, the couple rented a car the day they arrived, and returned the car to the FBO about 1100 on the day of the accident. On their return, the pilot requested that 20 gallons of fuel be loaded into each of the main tanks, and then queried the FBO owner for about 15 minutes about route and other considerations for a flight to Bryce Canyon Airport (BCE), Bryce Canyon, Utah. The airplane was refueled, and the pilot and his wife loaded their belongings into the airplane.

According to the communications recordings from the FLG air traffic control tower (ATCT), after startup and taxi out, the pilot requested and was granted a turnout to the northeast. The airplane took off from runway 21, and was observed to be climbing very slowly by a pilot in a Cessna 172, which departed shortly after the Beechcraft.

According to the Cessna pilot, once it was beyond the end of the runway, the Beechcraft followed a slightly meandering course initially to the south, and then turned further left towards the south-southeast. The Cessna pilot then witnessed the Beechcraft impact trees adjacent to a semi-rural neighborhood about 3 miles from FLG. The Cessna pilot reported the accident to the ATCT controller. The terrain between the airport and the accident site was forested, gently undulating, and generally lower than the airport.

Several residents of the accident neighborhood were outside, and witnessed the final portion of the flight. Most reported that the engine was making "popping" noises, and was not trailing any dark smoke. Some of those eyewitnesses were the first responders to the accident. They immediately began fire suppression efforts using portable fire extinguishers, shovels of dirt, and household/garden hoses. All those individuals reported that the fire was large and intense, but that their efforts were partially successful in suppressing or containing the fire.


PERSONNEL INFORMATION

Federal Aviation Administration (FAA) records indicated that the 59-year-old pilot held a private pilot certificate with an airplane single-engine land rating. That certificate was issued in May 2010. The pilot's most recent FAA third-class medical certificate was issued in September 2012. On the application for that medical certificate, the pilot indicated that he had a total flight experience of 540 hours.

FAA records indicated that the pilot purchased a turbo-charged Cessna 182 in December 2008; he retained that airplane, and purchased the non-turbocharged accident airplane (Beechcraft) in November 2011.

The pilot's fire-damaged flight logbook was recovered from the wreckage. Review of the logbook indicated that the pilot began flight training in 2008, and that at the time of the accident, had accumulated about 611 total hours of flight experience. The logbook indicated that the pilot completed a flight review in the Cessna in February 2013. Damage to the logbook precluded a determination of the pilot's total flight experience in each airplane.

The pilot's nephew stated that the Cessna was "not flown much" subsequent to the purchase of the Beechcraft. The nephew also reported that the pilot was familiar with high elevation airports, and noted that the pilot flew into Truckee California "regularly." Truckee-Tahoe airport (TRK) has an elevation of 5,901 feet above mean sea level (msl).

The pilot had flown the Beechcraft with at least two different certified flight instructors (CFI). The first CFI flew a total of about 33 hours in the airplane with the pilot; their first flight together was to transport the airplane from Colorado to California following the pilot's purchase of the airplane. Subsequent flights were conducted initially to satisfy insurance requirements, and then to increase the pilot's proficiency with the airplane. The second CFI began flying with the pilot in May 2012, when the pilot began training for an instrument rating. That CFI flew a total of about 3 hours with the pilot in the accident airplane.

MEDICAL AND PATHOLOGICAL INFORMATION

The Coconino County (Arizona) Office of the Medical Examiner autopsy report indicated that the cause of death was "thermal injuries." The FAA Civil Aeromedical Institute conducted forensic toxicology examinations on specimens from the pilot, and reported that no cyanide or ethanol was detected. The reported blood carbon monoxide level was 15 percent. Alpha-hydroxyalprazolam, a metabolite of alprazolam (trade name Xanax), was detected at a level of 0.009 micro-grams per milliliter in the urine, but was not detected in the blood. No other screened drugs were detected.


AIRCRAFT INFORMATION

FAA information indicated that the airplane was manufactured in 2001 as Beechcraft serial number E-3380, and was equipped with a Continental Motors IO-550 series engine. The airplane was purchased by, and first registered to, the pilot in late 2011.

The airplane was equipped with multiple factory- and post-delivery options. These included factory-installed cabin air conditioning, J.L. Osborne-brand wing tip tanks (20 gallons/side), Precise Flight-brand electric speedbrake system, a JPI-brand EDM-700 engine data monitor, AMSAFE- brand inflatable pilot and copilot dual shoulder harness restraint system, Garmin 430 and 530 nav-com units, and an Aerospace Systems & Technology-brand TKS de-icing system.

All those modifications had been accomplished prior to the pilot's purchase of the airplane. According to those records, the most recent annual inspection was completed on June 1, 2012, when the airplane had a total time (TT) in service of about 893 hours. The records indicated that a "top overhaul" of the engine was completed in April 2004, when the engine had a TT of about 243 hours.

In an interview with the NTSB, one of the pilot's CFIs indicated that the airplane was well-maintained, and that the CFI did not notice any problems or shortcomings with its climb capability, which he pays attention to when flying a new (to him) airplane. NTSB interviews with FLG ground personnel indicated that the airplane was not heavily loaded, and NTSB review of the specific information indicated that for the accident departure, the airplane was likely within its weight and balance envelope.


METEOROLOGICAL INFORMATION

On May 25, the day that the airplane arrived at FLG, the daily maximum recorded temperature of 22 degrees C was reached about noon, and lasted until about 1500 local time.

On May 28, the day of the accident, 1157 FLG automated weather observation included wind from 210 degrees at 17 knots, gusting to 26 knots, visibility 10 miles, clear skies, temperature 18 degrees C, dew point minus 4 degrees C, and an altimeter setting of 29.95 inches of mercury.


COMMUNICATIONS

Partial transcripts of the FLG ATCT ground and local communications surrounding the flight and accident were developed and provided by Serco, the company contracted by the FAA to staff and operate the ATCT.

At 1125:45, the pilot first radioed the ground controller, and advised that he was "ready to taxi," but did not specify any additional intentions. The controller cleared the airplane to runway 21 via the alpha and alpha one taxiways, which the pilot acknowledged. About 5 minutes later the pilot advised the ground controller that he did not realize that there was no run-up area near the runway 21 threshold, and asked for instructions to prevent a conflict with a twin-Cessna behind him. The controller and other pilot rectified the situation by routing the twin-Cessna via another taxiway. At 1136:21, the pilot of the Cessna 172 N3923Q who later witnessed the accident, contacted the controller for taxi clearance to runway 21.

At 1137:20, the Beechcraft pilot first radioed the local controller, and advised that he was "ready for takeoff headed to Tuba City." A few seconds later, the controller cleared the airplane for takeoff, to which the pilot responded "ready for takeoff taking runway two one can you tell me which way for a uh uh downwind departure?" The controller instructed the pilot to make a left downwind, and the pilot acknowledged that communication.

At 1139:24, Cessna 172 N3923Q radioed the local controller that he was ready for takeoff from runway 21, requested a left turnout, and was cleared for same a few seconds later. At 1141:44, the Cessna pilot stated that he was making his left turn, and asked the controller whether the Beechcraft was "okay, he is awful low." At 1141:51, the controller asked if the Beechcraft pilot needed any assistance, and the pilot responded "yah...I'm climbing very slowly and uh I'm climbing very slowly and staying close to the airport." At 1142:15, the Cessna pilot radioed that he did not "understand why he didn't stay over the interstate." At 1142:47, the Cessna pilot radioed that the Beechcraft had crashed and was on fire; the pilot circled the impact location for several minutes in an attempt to guide first responders to the site.

After the accident, the ground controller and the local controller each provided a written statement regarding the flight and accident. Neither statement explicitly cited whether its author actually witnessed the takeoff or climbout. The local controller's statement reported that he was advised of the Beechcraft climb problem by the subsequently-departing Cessna.


AIRPORT INFORMATION

FAA information indicated that the pilot's home airport, MCC, was situated at an elevation of 77 feet above mean sea level.

FAA information indicated that FLG runway 3/21 measured 8,800 by 150 feet, and the airport elevation was listed as 7,140 feet above mean sea level. The runway was served by a single parallel taxiway ("alpha") with 9 access taxiways between the two. There was no dedicated runup area at either runway threshold. A dedicated runup area was situated on taxiway alpha about midway between the ramp and the runway 21 threshold, and the end of the taxiway could also be utilized for that purpose.

The airport was situated in a 2- to 3-mile wide valley that was oriented approximately north-south, with a gentle continuous descent to the south.

Calculations using the meteorological conditions at the time of the accident resulted in an airport pressure altitude of 6,983 feet, and a density altitude of 8,983 feet for FLG.


WRECKAGE AND IMPACT INFORMATION

The accident site was located in the semi-rural neighborhood of Mountainaire, on moderate- to heavily-forested Coconino National Forest (CNF) property. The impact location was about 2.9 nautical miles (nm) from the departure end of FLG runway 21, on a true bearing of 170 degrees (158 magnetic) from that runway location. Impact site elevation was 6,815 feet. Review of topographic data revealed that virtually all of the terrain between the departure end of FLG runway 21 and the impact location was lower than the airport.

The impact site was situated about 1 nm to the east of the southern end of a straight section of a four-lane north-south highway that measured 1.15 nm in length, began about 1.17 nm from the threshold of runway 3, and was at an elevation of about 6,700 feet.

The airplane struck several tall pine trees before it struck the ground. The first tree impact was situated about 40 feet above ground level. The depression angle of the flight path through the trees was about 14 degrees. The distance from the first tree strike to the main wreckage, which primarily consisted of the fuselage from tail to propeller, was 135 feet, on a true heading of 180 degrees.

All major components were accounted for on scene. No evidence consistent with in-flight fire or in-flight structural failure was observed. Propeller and tree damage was consistent with the engine developing power at the time of impact.

The fuselage came to rest upright, on an approximate true heading of 322 degrees. Tree impacts had separated the right wing and the outboard section of the left wing from the airplane. The engine was separated from all four engine mounts, but remained adjacent to the firewall. The propeller remained attached to the engine. The fire consumed or severely damaged a significant portion of the fuselage, including the cockpit instruments and controls, and the cabin and its contents. Due to the fire damage, no useful information was able to be obtained from any cockpit instruments, switches, circuit breakers, or engine controls.


ADDITIONAL INFORMATION

Airframe Examination Details

About 8 feet of the left wing, and the entire right wing, were fracture-separated from the airplane. The left tip tank did not contain any fuel, and did not display any signatures of hydraulic deformation. The right tip tank was breached, did not contain any fuel, and did not reveal any hydraulic deformation. Significant portions of each wing, including both fuel tank bladders were significantly or completely consumed by fire.

Both ailerons remained attached to their respective wings at all mounting hinges, and sustained thermal damage. Aileron cable continuity was established from the right and left control column sprockets to the right and left aileron bellcranks. The aileron trim actuator remained intact and attached to the left wing. The aileron trim actuator extension equated to 2 degrees left tab trailing edge up.

The flaps and flap actuators were all found to be in the flaps-retracted position. Although significantly fire-damaged, the speedbrakes appeared to be in the retracted position at impact.

The horizontal stabilizers remained attached to the aft fuselage and displayed post-impact fire exposure. The left and right elevators, including their balance weights, remained attached to the horizontal stabilizers at the hinges. Elevator control cable continuity was established from the control column to the elevator bellcrank.

The left and right elevator trim surfaces remained attached to their respective elevators at their hinges. The elevator trim actuator extensions equated to approximately 6 degrees tab trailing edge down. Elevator trim cable continuity was confirmed from its cockpit control wheel to the actuators in the empennage.

The vertical stabilizer was fracture-separated from the aft fuselage at its spar roots. A portion of the rudder torque tube, the rudder bellcrank, and fragments of the rudder remained attached to the aft fuselage. The remainder of the fracture-separated rudder, including the rudder balance weight, was found near the aft fuselage. Continuity determination of the rudder control system was limited due to fire damage.

No pre-impact anomalies such as corrosion, wear, or misrouting, were observed on the primary or secondary flight control cables, but thermal and impact damage precluded a complete determination of the cables' pre-accident condition. All cable damage was attributed to impact overload and/or thermal exposure.

Both main landing gear assemblies were found in their retracted positions. The nose landing gear appeared to be in a near-retracted position.


Engine and Fuel System Examination Details

The engine came to rest upright, leaning towards its left side. The throttle, propeller, and mixture control cables remained attached to the throttle quadrant and their respective engine components.

The two magnetos were found properly secured to their mounting pads on the engine. Magneto-to-engine timing testing determined that both magnetos were timed to within 1 degree of the manufacturer's setting, and within 1 degree of each other. Due to the thermal damage the magnetos were shipped to Continental Motors. Examination of the magnetos did not reveal any pre-impact anomalies. After the thermally-damaged capacitor in each magneto was replaced, the right magneto functioned normally, but the left magneto only operated intermittently. That failure was attributed to additional internal thermal damage to the magneto.

The ignition leads remained attached to the magnetos and spark plugs, but sustained significant thermal damage. All spark plugs were removed, and displayed a "normal worn" condition. However, the top and bottom spark plugs from the number 5 cylinder bore very light soot, and the number 5 top plug also held a globule of solidified lead down in its barrel, at the base of the insulator. There was no evidence of lead fouling on any of the other spark plugs. Oil on the number 2 bottom, number 4 bottom, and number 6 top and bottom spark plug electrodes was attributed to the engine orientation after it came to rest. With the exception of the top spark plug from the number 6 cylinder, which had a cracked insulator, all spark plugs produced sparks during bench testing.

Once the spark plugs were removed, the crankshaft was rotated manually. Thumb compressions were obtained on all six cylinders, which confirmed crankshaft, camshaft, connecting rod, and rocker arm continuity. With the exception of cylinder number 5, examination did not note any anomalies with the cylinder barrels, pistons, valves, or valve seats. The cylinder number 5 exhaust valve bore signatures characteristic of excessively lean operation and a possible exhaust gas leak.

No anomalies with the engine lubrication system were noted.

The electric boost pump motor was recovered and was observed to be significantly fire damaged. The pump was not recovered, and presumed to have been consumed by fire.

The engine driven fuel pump (EDP) remained securely attached to the engine, with all fuel lines and fittings in place. The EDP drive coupling was intact. Manual rotation of the drive coupling while installed in the EDP drive shaft resulted in rotation of the shaft; however, there was some binding noted, likely due to internal coking from post accident thermal exposure. Disconnection of the flexible fuel lines resulted in charred material exiting from some of those lines. Removal of the fuel line fittings from the EDP revealed a significant amount of accumulated material in the vapor return outlet port and fitting; no other ports contained similar material. Some material was removed and sent to the NTSB Materials Laboratory for examination. Spectral analysis yielded a strong match for polyester, which is often used as a braided interlayer in flexible fuel lines.

Additional unidentified accreted deposits were found in the EDP swirl chamber. The NTSB Materials Laboratory reported that there was not enough material from the swirl chamber of the EDP to analyze. No non-thermal anomalies were noted with the EDP.

The throttle body was consumed by fire. The throttle plate remained attached to the throttle shaft and lever. The throttle and mixture control levers remained securely attached to their respective control shafts. The mixture control shaft could not be rotated in the fuel metering unit via manual manipulation of the mixture control lever. Examination of the mixture control shaft revealed charred debris adhering to the shaft and walls of the metering unit. The fuel inlet and return fittings remained attached to the fuel metering unit. The fuel inlet screen was found to be unobstructed.

The fuel manifold valve and the injector lines remained intact and securely attached. The manifold valve diaphragm was observed to be stuck to the cap and the housing of the manifold valve, and tore when the cap was removed. The diaphragm was brittle; this was attributed to its post impact fire exposure. The plunger was secured to the diaphragm and the screen was clear. No obstructions or other anomalies were noted.

The fuel nozzles were removed from their respective cylinders. The nozzle from the number 5 cylinder displayed some debris within its discharge orifice, partially obstructing the nozzle. None of the other nozzles displayed any orifice obstructions.

The fuel selector valve was found set to the left main tank. The port from the left main fuel tank was open to the port leading to the engine, and the passageway was confirmed to be unobstructed.

The engine monitor was recovered from the wreckage and sent to the NTSB Recorders Laboratory for possible data download. Thermal damage precluded the recovery of any data from the device.


Propeller Examination

The three-bladed Hartzell propeller remained attached to the crankshaft propeller flange. All three propeller blades remained attached to the propeller hub, but two of the blades were separated from their pitch change links. The tips of both of those blades had been fracture-separated from the blades, but both tips were recovered on site. One of those blades had deep leading edge gouges, and the other one had moderate leading edge gouges. The third blade was bent aft about 30 degrees at its mid-span point. Its tip was curled aft more than 180 degrees, and the blade displayed heavy leading edge gouging, primarily on the outboard span section. All damage was consistent with the propeller being driven under power at impact.

Detailed examination at the Hartzell facility confirmed that the propeller model was appropriate for the airplane, and did not reveal any pre-impact anomalies.


Cabin Air Conditioning System

The compressor of the refrigerative-type cabin air conditioning system was powered by a pulley-drive system on the engine accessory face. The system was operable on ground and in flight. The system was manually turned on or off by a dedicated toggle switch on an instrument panel subpanel, and delivered cooled air via the cabin ventilation "eyeball outlets."

An automatically-positioned three position air intake door was located on the fuselage belly. The door was closed when the system was off. When the system was operating, the door opened to an intermediate position in flight, and to its maximum limit when the airplane was on the ground. When the door was extended to its maximum position, an "AC DOOR EXTEND" annunciation light on the instrument panel would be illuminated.

The system was prohibited from use during takeoff, but could be turned on during climb by the pilot once obstacle clearance was assured. In the event of a go-around while the system was operating during a landing approach with the landing gear extended, when full throttle was applied, a throttle control limit switch would deactivate the compressor to terminate power extraction from the engine, and retract the intake door to reduce drag. Once the landing gear was retracted or the throttle was retarded, following a 20-second delay, the system would resume operation; the intake door would re-open, and the compressor would re-engage.

The only performance-related information in the Pilot's Operating Handbook (POH) was that cruise speed and range values were to be decremented by 5 percent with the air conditioning operating. The POH did not provide any information regarding the horsepower usage by the system, or system usage on climb performance.


FBO Fuel

As noted previously, the airplane was fueled with 40 gallons from the FBO on the morning of the accident. Several other airplanes were refueled from the same source prior to the accident airplane, and at least two (including the FBO owner's twin-engine airplane) were refueled after the accident airplane; all those airplanes were operated successfully and uneventfully after their respective refuelings. A fuel sample was obtained and tested in accordance with the fuel vendor's procedures; the FBO owner reported that no anomalies or problems with the fuel were detected.


Witness Information Regarding the Pilot

The CFI who helped the pilot fly the accident airplane to California after its purchase, and who conducted the pilot's February 2013 flight review in that airplane, stated that the pilot met the minimum standards for the flight review, and that there was nothing remarkable about the review. The CFI who was working with the pilot on his instrument rating stated that the pilot was "pretty cautious," and that his "basic stick and rudder skills" were "solid;" the CFI had "no doubt" about the pilot's flying abilities.

On the morning of the accident, the lodging proprietor asked the pilot if he was used to flying at high elevation airports; the pilot responded that he was "not familiar" or "used to" such operations. The pilot then stated that he was planning to fly to Bryce and Zion National Parks, in Utah, north-northwest of FLG. He also stated that FLG was 300 feet lower than that next destination, but that he was not particularly concerned about that trip segment.

According to the owner of the FBO, the pilot asked about a recommended route of flight to Bryce Canyon and Zion National Parks. The FBO owner provided that guidance, and showed the pilot the routing on a chart. The pilot was unfamiliar with the fact that the Grand Canyon, which was situated between FLG and the pilot's destination, had designated airspace constraints, and that there was a dedicated VFR chart for that airspace. The pilot was also unfamiliar with the procedures and constraints of Military Operations Areas. Because of the pilot's age, and the sophistication and complexity of the airplane that he was flying, the FBO owner was surprised by, and not favorably impressed with, the pilot's lack of knowledge and preparation.

Airplane loading and other pre-flight preparations appeared to be relatively normal, but the FBO owner noted that the pilot made several inexplicable trips between the airplane and the FBO, possibly as a result of "absentmindedness."


Cessna Pilot Witness Information

The pilot of the Cessna 172 that departed about 75 seconds behind the Beechcraft observed a portion of its flight and the accident. He did not observe the Beechcraft take off. The Cessna pilot observed the Beechcraft climbing "very slowly" on the runway heading. He reported that the Beechcraft maintained the runway heading until it was beyond the end of the runway, and then it turned slightly left, towards the south, and initially appeared to be following the nearby four-lane highway (Interstate 17). By the time the Cessna reached the end of the runway, it was higher than the altitude of the Beechcraft ahead. The Cessna pilot initially thought that perhaps the Beechcraft pilot was sightseeing. However, because the Beechcraft continued to remain extremely low, and appeared to be descending, the Cessna pilot queried the controller about the Beechcraft's situation. The Cessna pilot observed the Beechcraft making repeated small banks to the left and right, and watched the Beechcraft ground track become south-southeasterly, divergent from the interstate highway. The Cessna pilot then observed the Beechcraft continue to make repeated small banks as it descended, and then impact the trees and burst into flames. During his conversation with investigators, the Cessna pilot stated that he observed the Beechcraft turn towards rising terrain, and could not understand why its pilot did not either turn towards lower terrain (the descending valley to the south), or remain over the nearby four-lane interstate highway.


Air Traffic Control Radar Information

FAA air traffic control ground tracking radar data was examined to ascertain whether the accident flight was tracked by the radar system, and to derive a flight path if possible. The geographic locale is primarily served by two FAA radar antennae. One was situated about 73 miles west-northwest, and the other was situated about 80 miles south of FLG. Antenna site distances from the accident site, combined with mountainous topography, yielded a radar coverage floor estimated to be about 8,500 feet msl. The radar systems did not detect the airplane on its accident flight. The radar systems did intermittently detect the eyewitness Cessna 172; the minimum altitude detected was 8,700 feet msl.


Estimated Airplane Performance Capability

The investigation was unable to obtain any current or previous airplane empty weight or center of gravity (CG) information. Interviews with relatives and witnesses at FLG indicated that the pilot and passenger did not have a significant amount of luggage, and that the fuel tanks were not filled. FAA records did not indicate that the airplane maximum takeoff weight of 3,650 lbs had been increased via any supplemental type certificates (STCs).

Although the evidence suggested that the airplane was significantly below its maximum allowable takeoff weight, for conservatism, the investigation assumed that the airplane was at a weight of 3,600 lbs for the departure, and also assumed zero-wind conditions. Best angle of climb speed was 84 knots, and best rate of climb speed was 100 knots.

The POH provided performance data for takeoff using both zero flaps and "approach flaps" (12 degrees); the actual takeoff flap setting was not able to be determined. For zero flaps, the prescribed rotation speed was 72 knots, and the speed at 50 feet was 83 knots. For approach flaps, those speeds were 67 and 77 knots, respectively.

According to the manufacturer's performance data, for zero flaps, the takeoff ground roll would have been about 2,875 feet, and the total distance to 50 feet above ground level (agl) would have been about 5,270 feet. For a takeoff with approach flaps, the ground roll would have been about 2,336 feet, with a total distance to 50 feet agl of about 4,552 feet. The initial climb rate after flap retraction would have been about 512 feet per minute (fpm).


Factors Affecting Climb Performance

An airplane's climb capability is a function of its "excess power," which is defined as the difference between the power required to fly level at a given speed, and the power available at that same speed. When the power available exceeds the power required, the airplane will have a positive climb capability. Several factors can adversely affect airplane takeoff performance and climb capability, by either affecting the power required or the power available.

Power required is due to aerodynamic drag. Increased drag can be due to exit from ground effect, airplane condition or configuration (e.g. flap setting, or landing gear or air conditioning door extended), speedbrake deployment, incorrect climb speed, or increased weight.

Power available is a combination of engine power output, and the ability of the propeller to convert that power to thrust. In non-turbocharged piston engines, power output decreases with altitude. Propeller thrust typically decreases with speed; therefore, overall power available typically decreases directly as speed and altitude increase. Other factors that can decrease the power available include improper throttle or mixture setting, throttle or mixture malfunction; improper propeller blade pitch due to improper setting or malfunction; or air conditioning compressor operation.

The power output of a normally aspirated engine decreases with the decrease in air density that is due to increased altitude or increased density altitude. Turbocharging reduces or eliminates power losses due to increases in altitude or density altitude. On a comparative basis, at the high elevation, high density altitude departure airport, the takeoff and climb performance of the pilot's turbocharged Cessna would likely not have been adversely affected, whereas the takeoff and climb performance of his non-turbocharged Beechcraft was significantly reduced from its sea-level capability.


Ground Effect

The following paragraphs are synopsized from the Airplane Flying Handbook (AFH, FAA-8083-3).

Ground effect is a condition of improved performance encountered when the airplane is operating very close to the ground. The performance improvement is a result of a reduction in induced aerodynamic drag. Ground effect is most significant during takeoff when the airplane lifts off and accelerates to climb speed, and during the landing flare before touchdown.

The takeoff roll, lift-off, and beginning of the initial climb take place in the ground effect regime. As the airplane lifts off and climbs out of ground effect, the airplane will experience an increase in induced drag, and therefore thrust required, to maintain that speed or accelerate. The airplane will experience a pitch-up tendency, and will require less elevator deflection, due to the increase in downwash at the horizontal tail.

Due to the reduced drag in ground effect, the airplane may appear to be able to take off below the prescribed airspeed. However, as the airplane rises out of ground effect with an insufficient airspeed, initial climb performance may prove to be marginal, because of the increased drag. Under conditions of high-density altitude and/or maximum gross weight, the airplane may be able to become airborne at an insufficient airspeed, but unable to climb out of ground effect. Consequently, the airplane may not be able to clear obstructions.

Additional power is required to compensate for the increased drag that occurs as the airplane leaves ground effect. However, during an initial climb, because the engine controls have already been set to develop maximum (takeoff) power, the only alternative is to lower pitch attitude to gain airspeed, which will result in an altitude loss. Therefore, for takeoffs under marginal conditions, it is imperative that the airplane be operated at the prescribed airspeeds, in order to provide adequate initial climb performance.


Aerodynamic Drag Factors

The as-found condition of the airplane indicated that the landing gear, flaps, and speedbrakes were retracted, which was the proper minimum drag climb configuration. The investigation was unable to determine when the landing gear was retracted, or whether the speedbrakes had been extended for the takeoff and climb attempt. Post-accident position of the cabin air conditioning system intake door was not determined, but operational procedures and system design precluded a takeoff and initial climb with the intake door open, a configuration that would have increased drag. No preimpact anomalies that would have increased the basic aerodynamic drag of the airplane were observed.


Climb Speed

The power required versus speed curve is roughly "U" shaped, with the bottom of the "U" denoting the minimum drag speed. Normal operating climb speeds are typically set near the minimum drag speed of the airplane, with some additives for factors such as stall margin and engine cooling. Because there was no ground tracking radar or applicable onboard data available, the investigation was unable to determine whether the pilot adhered to the manufacturer-specified climb speed schedule. Deviations from the specified speed could reduce the airplane climb capability, and a speed much below the best angle of climb speed of 84 knots could significantly affect climb capability.

The power-off clean stall speed was about 69 knots; the manufacturer did not publish power-on stall speeds for the airplane. Power-on stall speeds are typically several knots lower than power-off stall speeds. The repetitive, small, left and right bank angles observed by the Cessna pilot were consistent with the behavior of an airplane approaching a stall, but those motions could have been caused by other factors, including pilot input and turbulence. There was no evidence to indicate that the airplane fully stalled during any portion of the flight.


Airplane Weight and Balance

As noted previously, all evidence was consistent with the airplane being within its certificated weight and balance envelope.


Engine Power

Engine power was directly affected by throttle and mixture settings. The POH specified that full throttle was to be used for takeoff and climb. There was insufficient evidence to enable a determination of whether the pilot set and maintained full throttle for the takeoff and climb attempt.

According to the POH, the takeoff mixture was to be set "as required by field elevation," by adjusting the full throttle fuel flow as a function of engine rpm, in accordance with a schedule in the POH. According to that schedule, based on the pressure altitude of 7,000 feet, the full-throttle fuel flow values should have been 23.2 gallons per hour (gph) at 2,700 rpm, or 21.2 gph at 2,500 rpm. The airplane was equipped with a fuel flow transducer and cockpit display to enable compliance with the schedule, and thus proper mixture setting. The investigation was unable to determine the pilot's familiarity with this procedure, or what mixture-setting procedures, if any, he conducted prior to the accident takeoff, or during the climb attempt.


Off-Schedule Fuel Mixture Effects

The pre-takeoff leaning schedule of the fuel mixture for high-elevation airport operations is designed to enable the engine to produce best power in the decreased-air-density environment. In contrast, engine leaning during cruise is accomplished to both adjust the mixture for the air density, as well as adjust the engine power for values below full power, and thereby, modulate the fuel economy.

In general, engines operated at off-schedule fuel mixtures will exhibit certain characteristic signatures which indicate whether the mixture was overly rich or overly lean. Engines that are operated on an overly rich fuel mixture will accrete unburned fuel in the form of dark carbon deposits in the cylinders and exhaust system, and can emit exhaust visible as dark smoke. In contrast, engines that are operated on an overly lean fuel mixture will be characterized by cylinders and exhaust systems with either a "clean" appearance, or fine whitish, tan, or light gray deposits. The investigation was unable to locate any detailed or substantiated data regarding the development or disappearance of these signatures as a function of time that an engine is operated at a particular off-schedule mixture.

As part of the engine certification process, CMI conducted engine power tests that measured power output as a function of fuel flow (and thus, mixture) for two different baseline, but less than full, power settings. Review of the test data indicated that power increased as a function of fuel flow (in pounds per hour, pph) to a certain point, then peaked or flattened out, and then decreased. Using either that peak, or the peak brake specific fuel consumption (BSFC, pounds of fuel per HP per hour) as the dividing line, the rate of power change per pph of fuel flow was greater on the lean sides of those lines than it was on the rich sides of the lines. Furthermore, when the peak BSFC line was used as the dividing point, the rate of power change per pph was significantly greater on the lean side than it was on the rich side.

The investigation did not obtain any similar mixture variation data for full power settings, and therefore was unable to determine the effects of off-schedule fuel mixtures on engine power for takeoff and initial climb.


Partially Obstructed Fuel Nozzle

A 1997 article in "Aviation Maintenance Technology" magazine stated that the most common form of fuel nozzle contamination happens as fuel evaporates in the nozzles after hot engine shut-downs. This evaporative process leaves deposits of varnish residue which buildup over time, and inhibits the free flow of metered fuel to the cylinders. If left unattended, nozzles begin to become blocked, but the contamination is not typically limited to a single nozzle.

The airplane was equipped with a turbine/rotary fuel flow transducer, as opposed to the pressure-type flow transducer. Because the rotary-type transducers measure the flow directly, they are not subject to the erroneous fuel flow indications of the pressure-type transducers when one or more fuel nozzles become partially or fully blocked.

The number 5 cylinder fuel injector nozzle was found to be partially blocked, which could result in lean operation and reduced power output of that cylinder, possibly accompanied by engine roughness and altered CHT and EGT values; the effect on each parameter would be proportional to the degree of blockage. The exhaust valve for that cylinder bore signatures characteristic of excessively lean operation. There was insufficient evidence to enable the investigation to determine the source of the blockage, quantify its effects, or its relation to the condition of the exhaust valve. There was also insufficient evidence to determine when the blockage occurred, including whether it was an artifact of the post-impact fire.


Engine-Driven Fuel Pump Debris

The investigation was unable to determine when the deposits were formed in the vapor return outlet or the swirl chamber of the engine-driven fuel pump, but their appearances were consistent with the results of a post impact fire. Partial or complete blockage of the vapor return line would result in an enrichment of the mixture, because that line is the primary flow path for the return of excess fuel from the pump output, which is utilized in a venturi setup to aid in vapor extraction. There was insufficient information to determine the engine power effects, if any, of that mixture change if the vent line was partially or completely blocked during the accident flight. The swirl chamber deposits did not occlude any orifices, or appreciably reduce the volume of the swirl chamber.


Backfiring and Detonation

Some of the signatures of backfiring and detonation were consistent with the available physical or witness report evidence.

According to the FAA Aviation Maintenance Technician Handbook, Powerplant (FAA-8083-32), "an extremely lean mixture either does not burn at all or burns so slowly that combustion is not complete at the end of the exhaust stroke. The flame lingers in the cylinder and then ignites the contents in the intake manifold or the induction system when the intake valve opens. This causes an explosion known as backfiring." The Handbook stated "A point worth stressing is that backfiring rarely involves the whole engine... In practically all cases, backfiring is limited to one or two cylinders. Usually, it is the result of ... defective fuel injector nozzles, or other conditions that cause these cylinders to operate leaner than the engine as a whole." Backfiring will result in a loss of power and characteristic "popping" sounds from the engine, which is congruent with the available evidence.

According to the Pilot's Handbook of Aeronautical Knowledge (PHAK, FAA-8083 25), detonation "is an uncontrolled, explosive ignition of the fuel/air mixture within the cylinder's combustion chamber" that can result in engine overheating, roughness, or loss of power. The PHAK cited one common cause of detonation as "operation of the engine at high power settings with an excessively lean mixture," and cited one preventative measure that pilots should "develop the habit of monitoring the engine instruments to verify proper operation according to procedures established by the manufacturer."

The FAA Aviation Maintenance Technician Handbook, Powerplant (FAA-8083-32) stated that "Unless detonation is heavy, there is no flight deck evidence of its presence," and the "effects of detonation are often not discovered until after teardown of the engine."

Although the No. 5 cylinder condition was consistent with excessively lean operation, none of the cylinder assemblies, including No. 5, displayed any evidence of detonation.


Propeller Blade Pitch Setting

The blade pitch angles for the installed model propeller were measured at the 30-inch blade station, with a certificated travel range of 13 to 36 degrees. Takeoff procedures specified that the propeller pitch cockpit control be set to full forward. According to information provided by Beechcraft, at takeoff power, at a speed of 90 knots for the given ambient conditions, the estimated propeller blade angle would have been 17.7 degrees. Impact witness marks indicated that the blade pitch setting was about 25 degrees. Evidence found at the accident site indicated that the propeller sliced through a number of trees and tree branches before contacting the rocky ground. Therefore, the investigation was unable to determine when the witness marks were made, and could not discount alteration of the blade pitch angles, without producing any witness marks, as the airplane descended through the relatively soft pine trees. Therefore the investigation was unable to determine whether the propeller blade pitch was set correctly for the takeoff and climb attempt.


Cabin Air Conditioning Operational Status

The recorded air temperature at FLG about the time of the accident was 18 degrees C (64 degrees F), which was not consistent with the use of cabin air conditioning. Even if the ambient temperature was conducive to the use of air conditioning, operational procedures and system design safeguards prevented the cabin air conditioning system compressor from extracting power from the engine during a takeoff and initial climb. The investigation was unable to determine the operational status of the air conditioning compressor during the takeoff and climb attempt.

 NTSB Identification: WPR13FA244
14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 28, 2013 in Mountainaire, AZ
Aircraft: RAYTHEON AIRCRAFT COMPANY A36, registration: N999PK
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On May 28, 2013, about 1143 mountain standard time, a Beechcraft A36, N999PK, was destroyed when it impacted trees and terrain in the Coconino National Forest adjacent to Mountainaire, Arizona, shortly after takeoff from Flagstaff Pulliam airport (FLG), Flagstaff, Arizona. A large post-impact fire ensued immediately. The owner/private pilot and the one passenger received fatal injuries. No persons on the ground were injured or killed. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight.

According to relatives of the pilot, he based the airplane at McClellan Airfield (MCC) Sacramento, California. The pilot and passenger departed MCC on the morning of May 25, 2013, and arrived at FLG that same day. According to personnel and information from Wiseman Aviation, a fixed base operator (FBO) at FLG, the couple rented a car that day, and returned the car to the FBO about 1100 on May 28. The pilot requested that 20 gallons of fuel be loaded into each of the main tanks, and then queried the FBO owner for about 15 minutes about flight route and other considerations for a flight to Bryce Canyon Airport (BCE). The airplane was refueled, and the pilot and his wife loaded the airplane.

According to information provided by representatives of the Federal Aviation Administration (FAA), after startup and taxi out, the pilot requested, and was granted, a turnout to the northeast by the FLG air traffic control tower (ATCT) controller. The airplane took off from runway 21, and was observed to be climbing very slowly by a pilot in a Cessna 172, which departed just after the Beechcraft. The Cessna pilot eventually queried the ATCT controller about the Beechcraft's intentions, and the Beechcraft pilot then radioed that he was climbing very slowly. The Cessna pilot watched the Beechcraft maneuver slightly. He subsequently watched the Beechcraft strike trees, and then explode; he reported this to the ATCT, and then orbited the accident site until ground help arrived.

FAA information indicated that FLG runway 21 measured 8,800 by 150 feet, and the airport elevation was listed as 7,140 feet above mean sea level. The 1157 FLG automated weather observation included wind from 210 degrees at 17 knots, gusting to 26 knots; visibility 10 miles; clear skies; temperature 18 degrees C; dew point minus 4 degrees C; and an altimeter setting of 29.95 inches of mercury.


Sunday, June 02, 2013

To the editor:

I am a Flagstaff native and an airplane pilot with a little over 2,000 hours of logged time in several different airplanes. I learned to fly out of Flagstaff. The airport sits at 7,000 feet elevation and requires a different set of rules not familiar to many lowland pilots.

The crash this past week is not the first time that has happened. In the last 50-plus years I recall at least six or eight fatal airplane crashes caused by the same set of circumstances. They all involve pilots who have not taken any high-airport flying lessons and who do not have a clue about "density altitude" or gross flyable weight of their airplane.

Any lowland pilot who has plans to visit a high-altitude airport like Flagstaff or the Grand Canyon should be required to take some additional training on the minimum requirements for safe flight out of these high-elevation airports. Density altitude can rob an airplane of 50 percent of its takeoff power and it will not fly.

At least maybe the operators of the refueling facility could give visiting pilots a brochure on the necessary procedures for a safe takeoff.

ELMER HUBBARD JR.

Tucson

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