Saturday, April 20, 2019

Ground Handling Event: Beechcraft B60 Duke, N65MY; fatal accident occurred April 18, 2019 at Fullerton Municipal Airport (KFUL), Orange County, California

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; Long Beach, California
Textron Aviation; Wichita, Kansas
Lycoming Engines; Williamsport, Pennsylvania

Investigation Docket - National Transportation Safety Board:

Location: Fullerton, California 
Accident Number: WPR19FA115
Date and Time: April 18, 2019, 19:51 Local 
Registration: N65MY
Aircraft: Beech 60
Aircraft Damage: Destroyed
Defining Event: Ground handling event 
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Personal


The pilot began the takeoff roll in visual meteorological conditions. The airplane was airborne about 1,300 ft down the runway, which was about 75% of the normal ground roll distance for the airplane’s weight and the takeoff environment. About 2 seconds after rotation, the airplane rolled left. Three seconds later, the airplane had reached an altitude of about 80 ft above ground level and was in a 90° left bank. The nose then dropped as the airplane rolled inverted and struck the ground in a right-wing-low, nose-down attitude. The airplane was destroyed.

Post-accident examination did not reveal any anomalies with the airframe or engines that would have precluded normal operation. The landing gear, flap, and trim positions were appropriate for takeoff and flight control continuity was confirmed. The symmetry of damage between both propeller assemblies indicated that both engines were producing equal and high amounts of power at impact.

The autopsy revealed no natural disease was present that could pose a significant hazard to flight safety.

Review of surveillance video footage from before the accident revealed that the elevator was in the almost full nose-up (or trailing edge up) position during the taxi and the beginning of the takeoff roll. Surveillance footage also showed that the pilot did not perform a preflight inspection of the airplane or control check before the accident flight.

According to the pilot’s friend who was also in the hangar, as the accident pilot was pushing the airplane back into his hangar on the night before the accident, he manipulated and locked the elevator in the trailing edge up position to clear an obstacle in the hangar. However, no evidence of an installed elevator control lock was found in the cabin after the accident.

The loss of control during takeoff was likely due to the pilot’s use of an unapproved elevator control lock device. Despite video evidence of the elevator locked in the trailing edge up position before the accident, an examination revealed no evidence of an installed control lock in the cabin. Therefore, during the night before the accident, the pilot likely placed an unapproved object between the elevator balance weight and the trailing edge of the horizontal stabilizer to lock the elevator in the trailing edge up position.

The loss of control was also due to the pilot’s failure to correctly position the elevator before takeoff. The pilot’s friend at the hangar also reported that the pilot was running about one hour late; the night before, he was trying to troubleshoot an electrical issue in the airplane that caused a circuit breaker to keep tripping, which may have become a distraction to the pilot. The pilot had the opportunity to detect his error in not freeing the elevator both before boarding the airplane and again while in the airplane, either via a control check or detecting an anomalous aft position of the yoke. The pilot directed his attention to the arrival of a motorbike in the hangar alley shortly after he pulled the airplane out of the hangar, which likely distracted the pilot and further delayed his departure. He did not conduct a preflight inspection of the airplane or control check before the accident flight, due either to distraction or time pressure.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s use of an unapproved elevator control lock device, and his failure to remove that device and correctly position the elevator before flight, which resulted in a loss of control during takeoff. Contributing to the accident was his failure to perform a preflight inspection and control check, likely in part because of distractions before boarding and his late departure time.


Aircraft Pitch control - Attain/maintain not possible
Aircraft Parking/storage - Incorrect use/operation
Personnel issues Attention - Pilot
Personnel issues Use of checklist - Pilot
Personnel issues Forgotten action/omission - Pilot
Personnel issues Preflight inspection - Pilot

Factual Information

History of Flight

Prior to flight Ground handling event (Defining event)
Takeoff Miscellaneous/other
Initial climb Loss of control in flight

On April 18, 2019, about 1951 Pacific daylight time, a Beech B60, N65MY, was destroyed when it was involved in an accident near Fullerton, California. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

According to the pilot’s relatives, he typically flew the accident airplane from Heber City, Utah, to Fullerton on Monday mornings and returned Thursday nights. If the weather was bad, he would take a commercial flight.

The accident sequence was captured by a series of video surveillance cameras located at multiple vantage points on the airport property. Review of the video data revealed that the pilot boarded the airplane at his hangar about 1928. He started the engines and taxied about 500 ft to the runup area at the east end of the airport, where the airplane remained for the next 11 1/2 minutes. During that time, the pilot was provided his instrument flight rules (IFR) clearance by the tower controller. The airplane then taxied to the hold short line on taxiway A at the approach end of runway 24.

After the pilot was given the takeoff clearance, the airplane began the takeoff roll. The airplane was airborne after traveling about 1,300 ft down the runway, and about 2 seconds after rotation, it began to roll to the left. Three seconds later, the airplane had reached an altitude of about 80 ft above ground level and was in a 90° left bank. The nose then dropped as the airplane rolled inverted and struck the southern side of taxiway E in a right-wing-low, nose-down attitude.

Pilot Information

Certificate: Private
Age: 48, Male
Airplane Rating(s): Multi-engine land Seat Occupied: Left 
Other Aircraft Rating(s): None
Restraint Used: Lap only
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None 
Toxicology Performed: Yes
Medical Certification: Class 3 With waivers/limitations 
Last FAA Medical Exam: February 21, 2019
Occupational Pilot: No 
Last Flight Review or Equivalent: March 30, 2019
Flight Time: 380.5 hours (Total, all aircraft), 87 hours (Total, this make and model), 38.3 hours (Last 90 days, all aircraft), 26.8 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

The pilot held a private pilot certificate issued in May 2011. He attained his instrument and multiengine ratings in January 2012 and January 2014 respectively. His logbooks indicated 35.6 hours of pilot-in-command night flight experience.

Before the pilot began flying the accident airplane in October 2017, he had 2 hours of flight experience in the airplane type. Of the 101 hours of flight time that he accrued between October 2017 and the accident, 87 hours were flown in the accident airplane.

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N65MY
Model/Series: 60 B 
Aircraft Category: Airplane
Year of Manufacture: 1974
Amateur Built:
Airworthiness Certificate: Normal
Serial Number: P-314
Landing Gear Type: Retractable - Tricycle 
Seats: 6
Date/Type of Last Inspection: December 26, 2018 Annual 
Certified Max Gross Wt.: 6965 lbs
Time Since Last Inspection: 49.5 Hrs
Engines: 2 Reciprocating
Airframe Total Time: 5419.3 Hrs as of last inspection
Engine Manufacturer: Lycoming
ELT: Installed, not activated 
Engine Model/Series: TIO-541-E1C4
Registered Owner: 
Rated Power: 380 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC) 
Condition of Light: Dusk
Observation Facility, Elevation: KFUL,96 ft msl 
Distance from Accident Site: 0.25 Nautical Miles
Observation Time: 19:53 Local 
Direction from Accident Site: 180°
Lowest Cloud Condition: Clear 
Visibility: 10 miles
Lowest Ceiling: None 
Visibility (RVR):
Wind Speed/Gusts: 6 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 30.1 inches Hg
Temperature/Dew Point: 19°C / 8°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Fullerton, CA (FUL)
Type of Flight Plan Filed: IFR
Destination: Heber, UT (HCR) 
Type of Clearance: IFR
Departure Time: 18:50 Local
Type of Airspace: Class D

On the day of the accident, sunset occurred in Fullerton at 1825, and clear skies with light wind conditions were forecast for Heber City throughout the evening.

Airport Information

Airport: Fullerton FUL 
Runway Surface Type: Asphalt
Airport Elevation: 96 ft msl 
Runway Surface Condition: Dry
Runway Used: 24
IFR Approach: None
Runway Length/Width: 3121 ft / 75 ft 
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries:
Aircraft Fire: On-ground
Ground Injuries:
Aircraft Explosion: On-ground
Total Injuries: 1 Fatal
Latitude, Longitude: 33.871387,-117.98139

An on-site examination showed that the first identified point of impact was located on taxiway E about 100 ft south of the runway 24 centerline. A set of four impact gouges were oriented diagonally across the centerline and spaced about 8 inches apart and matched the approximate dimension of the right propeller blades; a similar set of gouges were on the pavement about 18 ft to the southwest. Fragmented sections of the outboard right wing were distributed around the impact point and on the adjacent runway surface.

The main wreckage came to rest on taxiway A, about 100 ft beyond the second set of gouges. The main wreckage was comprised of the pressurized section of the cabin, both engines, the left wing, and the tail section, all of which sustained extensive thermal damage. The entire tail structure aft of the pressure bulkhead was thermally consumed, and only ash remnants of the vertical and horizontal stabilizer and flight control surfaces remained. The landing gear actuator was fully extended. Although the left flap actuator was partially consumed, the right flap actuator displayed an extension which corresponded with the flaps set to about 10°.

Examination of video footage also confirmed that the flaps were extended as the airplane taxied onto the runway and that the landing gear was in the down position at the time of impact.

The cockpit instruments and circuit breakers were all fire damaged, which precluded an accurate assessment of their readings and positions. The throttle and propeller engine controls were in the full forward position. The pilot seat, which was equipped with forward and aft seat stops, had detached but did not appear to be positioned close to the aft limits of the seat rails at impact.

There were no tools or foreign objects present in the footwell area enclosing the aileron pulleys and servo. Although the flight control systems sustained varying degrees of impact and thermal damage, control continuity was confirmed between the cabin controls and the respective control surfaces.

The elevator trim actuator was in a 5° tab down position, and the aileron trim actuator was in a 1° tab up position. Both fuel selector valves were fire damaged but appeared set to the “ON” position.

Most of the right wing’s structure was consumed, exposing the landing gear actuators, engine control cables, and fuel selector valve. The left wing remained attached to the fuselage; its main spar was intact along its full length, and the aft spar and trailing skins were mostly consumed by fire.

On-site examination showed that both propeller hub assemblies had separated from their respective engines at the crankshaft and were located on the grass adjacent to the impact point.

Post-accident examination of the propellers revealed that multiple blades of both propellers exhibited similar curl and twist damage opposite the direction of rotation as well as leading edge gouges and scoring. The symmetry of damage between both propeller assemblies was consistent with both engines producing equal amounts of power at impact.

Post-accident engine examination of both engines revealed varying degrees of thermal and impact damage but no evidence of catastrophic internal failure. Drive train continuity was confirmed, and both the fuel and oil filters were free of debris.

Medical and Pathological Information

According to the autopsy performed by the Orange County Sheriff-Coroner, the cause of death was multiple traumatic injuries with a finding of hypertrophic cardiomegaly (enlarged heart), but otherwise no natural disease was present.

Toxicology testing performed at the Federal Aviation Administration Forensic Sciences Laboratory did not identify the presence of any tested-for drugs, ingested alcohol, or carbon monoxide.

Tests and Research

Engine Monitor

The airplane was equipped with a G4 graphic engine monitor that was manufactured by Insight Avionics. It was configured to monitor and record cylinder head temperature (CHT), exhaust gas temperature (EGT), turbine inlet temperature (TIT), and fuel flow information for both engines.

Despite thermal damage to the engine monitor, the NTSB’s Vehicle Recorders Division extracted accident flight data from the device.

The data revealed that the EGT, CHT, and TIT values approximately matched between both engines from initial power-up through to the accident. The fuel flow for the right engine varied between about 5 and 15 gallons per hour (gph) for the first 20 minutes, which corresponded roughly from engine start to taxi. For the final 30 seconds of the accident flight, the fuel flow for the right engine increased to about 36 gph. The fuel flow for the left engine remained at 0 gph throughout the entire recording, which was inconsistent with video data and the other recorded engine parameters.

Elevator Positions

The airplane was stored in a hangar on the southeast side of the airport. A friend of the pilot who had an adjacent hangar said he was approached the evening before the accident by the pilot, who explained that one of the landing lights on the accident airplane had failed. They then worked together to replace the light bulb, and during those interactions, the pilot mentioned that one of the airplane’s circuit breakers kept tripping. The friend could not recall specifically what circuit breaker the pilot stated was tripping.

After completing the repair, they pulled the airplane out of the hangar, and the accident pilot taxied it to the fuel island. After adding fuel, they taxied to the runup area so the pilot could check the circuit breaker. He performed an engine runup, but it did not trip. The pilot’s friend was seated in the back and did not have a clear view of the instrument panel while the pilot was troubleshooting the circuit breaker issue.

As they later pushed the airplane back into the hangar, the accident pilot indicated that the elevator in the trailing edge down position typically would not clear the propeller blade of another airplane in the hangar, which the friend observed. The accident pilot then walked to the back of the airplane and appeared to move the elevator from the trailing edge down position to the trailing edge up position, where it remained, to clear the tip of the blade.

One of the surveillance cameras was positioned above the pilot’s hangar and captured the airplane as it was being moved inside that night. Review of the footage revealed that, as the airplane was first being maneuvered, the elevator was hanging at about the 15° trailing edge down position, consistent with the pilot’s friend’s observation. The following evening, as the pilot pulled the airplane back out of the hangar for the accident flight, the elevator was at about the 15° trailing edge up position such that the elevator balance weight hung below the lower skin of the horizontal stabilizer trailing edge.

The video footage also revealed that shortly after the pilot pulled the airplane out of the hangar, someone arrived at an adjacent hangar and the pilot assisted them with removing a motorbike from a trailer, talked to several individuals who had arrived, walked toward the restroom, and returned to the hangar, before immediately boarding the airplane. He did not perform a “walk
around” inspection at any time after he took the airplane out of the hangar.

Review of video footage throughout the airport revealed that the elevator remained in the same trailing edge up position throughout taxi, in the runup area, and at the runway hold short line.

The video footage on the day of the accident was compared with video footage of the last time the pilot flew the airplane on April 11, 2019. On that day, the elevator was in the trailing edge down position as the airplane was maneuvered out of the hangar and remained in that position while it taxied to the runup area. While in the runup area on April 11, the elevator moved up and down, consistent with the pilot performing a flight control check.

The friend with an adjacent hangar reported that the pilot stated that he was running late on the night of the accident. The accident pilot had initially filed an IFR flight plan for a 1900 departure for the accident flight, but because the weather was better than expected, he was considering flying under visual flight rules with flight following.

Control Lock

Beech B60 airplanes were initially equipped with a control surface lock and throttle assembly (control lock), which was designed to lock both the control yoke and rudder pedals from within the cabin and inhibit use of the engine throttle controls. According to multiple acquaintances of the pilot, the accident airplane did not appear to be equipped with this original control lock.

The airplane’s previous owner stated that the airplane was not equipped with the original control lock at the time of sale.

Post-accident examination did not reveal evidence of an approved control lock in the airplane, although an incompatible yoke and foot pedal lock assembly for another airplane type was found undamaged in the aft cabin. Examination of the foot pedals and control yoke did not reveal any evidence of the use of any kind of control locking device.

The elevator travel limits were 15° elevator down, and 17° elevator up. The design of the airplane was such that with no elevator control input, the elevators will drop to the full trailing edge down position. Review of historical photos of the accident airplane while sitting on the ramp confirmed this position.

Fairings were utilized on the aft fuselage and empennage of the airplane, such that access to the elevator bellcrank and control assembly was not readily available without disassembly.

Examination of a similarly equipped B60 airplane revealed that, with the control lock installed, the elevator was fixed to about the 5° trailing edge up position, and the leading edge of the elevator balance weight assembly was in line with the lower surface of the trailing edge of the horizontal stabilizer.

Airplane Performance

Wind was variable at 6 knots at the time of the accident, and as discussed, video footage revealed that the airplane became airborne after travelling about 1,300 ft down the runway.

Video from the previous flight on April 11 indicated that under similar wind conditions, it became airborne after travelling about 1,900 ft down the runway.

The airplane was equipped with a vortex generator system manufactured by Boundary Layer Research, Inc. The installation resulted in altered maximum gross weight and performance characteristics, which were documented in the airplane flight manual supplement. The normal takeoff chart in the supplement indicated that with an airplane gross weight of 6,250 lbs taking off from a paved sea-level runway with calm wind and a temperature of 20°C, the 50 ft obstacle clearance takeoff distance would be 2,200 ft with a ground roll distance of 1,738 ft.


Location: Fullerton, CA
Accident Number: WPR19FA115
Date & Time: 04/18/2019, 1953 PDT
Registration: N65MY
Aircraft: Beech 60
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On April 18, 2019, at 1953 Pacific daylight time a Beech B60, N65MY, collided with the ground after takeoff from Fullerton Municipal Airport (FUL), Fullerton, California. The private pilot sustained fatal injuries and the airplane was destroyed. The airplane was registered to KMA Technology Solutions LLC., and operated as a personal flight by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The flight had a planned destination of Heber City Municipal Airport - Russ McDonald Field (HCR), Heber, Utah. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan had been filed.

According to relatives of the pilot, he had moved with his family from Southern California to Utah at the end of 2018. He continued to maintain a business in California, and would work there during the week, and return to Utah at the weekends. His typical routine would be to depart Heber City for Fullerton on Monday morning and then return Thursday night. He would use the accident airplane to make the trip, unless weather was bad, in which case he would fly via commercial airline.

The accident sequence was captured by a series of surveillance video cameras located at multiple vantage points within the airport. Preliminary review of the video data revealed that the pilot boarded the airplane at his hangar at 1930. He started the engines, and taxied to the runway 24 runup were the airplane remained for the next 11 1/2 minutes. During that time, he was provided his IFR clearance by the tower controller. The airplane then taxied to the hold short line on taxiway A at the approach end of runway 24, and after the pilot was given the takeoff clearance, the airplane began the takeoff roll. The airplane was airborne after traveling about 1,300 ft down the runway, and about 2 seconds after rotation it began to roll to the left. Three seconds later, the airplane had reached an altitude of about 80 ft above ground level (agl), and was in a 90° left bank. The nose then dropped as the airplane rolled inverted, and struck taxiway E in a right-wing-low, nose down attitude. (See Figure 1).

The first identified point of impact was located on the centerline of taxiway E, about 100 ft south of the runway centerline. The impact was composed of a set of four gouges, oriented diagonally across the centerline, and spaced about 8 inches apart. The gouges matched the approximate dimension of the right propeller blades, and a similar set of gouges were present on the tarmac, about 18 ft to the southwest. Fragmented sections of the outboard right wing were distributed around the impact point and on the adjacent runway surface.

The main wreckage came to rest on taxiway A, about 100 ft beyond the second set of gouges. The main wreckage was composed of the pressurized section of the cabin, both engines, the left wing and tail section, all of which sustained extensive thermal damage. The entire tail structure aft of the pressure bulkhead was consumed, with only ash remnants of the vertical and horizontal stabilizer and flight control surfaces remaining. Examination of video footage indicated that the landing gear was in the extended position at the time of impact, and the flaps appeared to be partially extended as the airplane taxied onto the runway.

Airframe and engine logbooks indicated that the most recent maintenance was for an annual inspection, and was completed on December 26, 2018.

Figure 1 – Accident Sequence Viewed Midfield to the South 
(timestamp inaccurate)

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N65MY
Model/Series: 60 B
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dusk
Observation Facility, Elevation: KSLI, 36 ft msl
Observation Time: 0353 UTC
Distance from Accident Site: 6 Nautical Miles
Temperature/Dew Point: 20°C / 10°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: Calm / ,
Lowest Ceiling: None
Visibility:  10 Miles
Altimeter Setting: 30.01 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Fullerton, CA (FUL)
Destination: Heber, UT (HCR) 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 1 Fatal
Latitude, Longitude: 33.871389, -117.981389

Robert Kenner Ellis, 48, appears in an undated photo posted to his dentistry practice Luminous Family Dental’s website. 

The 48-year-old pilot killed in a fiery plane crash in Fullerton was a Southern California native and dentist who recently moved to Utah and commuted back and forth between the two states, his mother said Friday.

Robert Ellis was taking off at around 7:50 p.m. at the Fullerton Municipal Airport, at 4011 W. Commonwealth Ave., when his Beechcraft B60 Duke crashed near Runway 24 and burst into flames, according to Fullerton police.

He was pronounced dead at the scene, authorities said.

Ellis is survived by his wife of more than 25 years and their four sons — the oldest a 20-year-old and the youngest still in junior high, the victim’s mother, Sandra Ellis, said.

Sandra said the family is doing “OK,” largely because of their strong Mormon faith.

“We have a strong feeling about life and death in the Mormon church; it’s not as devastating as you think it might be,” she told KTLA. “I’ve always had the feeling that people never really are gone, they’re just always in another place. It’s not like you’ve lost them forever.”

The death will likely be hardest on Robert’s wife, his mother said, because he “never stopped dating her.” They loved going to concerts, Disneyland and the beach, where they roller-skated and rode bikes.

The family had only moved to Heber City, Utah, in January after living in Southern California their whole lives. Before that, they lived on Blue Jay Avenue in Orange in that house that Robert grew up in, which he bought from his parents in 2001, Sandra said.

Even after the move, Robert kept his dental practice in Tustin and flew between Utah and California about twice a week. He also flew from Orange County to Riverside about once a week, his mother said.

Loved ones said he was flying back home after work when he crashed.

Sandra described her son as an “energetic soul” who was smart, loving and talented man who showed an interest in mechanics from an early age. She said she wasn’t sure how he got into aviation, but “somehow or other, he thought he had to fly.”

“All I can say is, he died doing what he liked to do, and you can’t knock him for that,” Sandra said. “I told his little kids that this kind of thing can happen in a car, or falling down stairs. Life just has to go on.”

The small plane had just been fueled-up and was traveling about 15 feet above ground at about 80 mph when it suddenly veered to the left and plowed into the pavement, according to Fullerton fire officials.

"The aircraft rolled to the left and caught fire," Federal Aviation Administration spokesman Ian Gregor said.

It’s still unclear what led to the crash. The National Transportation Safety Board is investigating the incident.

Story and video ➤

The pilot who died when the Beechcraft B60 Duke he was in crashed and caught fire after barely taking off from Fullerton Municipal Airport has been identified as a 48-year-old Utah man.

Robert Kenner Ellis was pronounced dead shortly after the Beechcraft B60 Duke crashed at about 7:50 p.m. while departing from Runway 24 at the airport.

Federal Aviation Administration and National Transportation Safety Board officials were going to be at the airport Friday, April 19, to investigate the remnants of the charred plane and what could have led to the crash.

Ellis had set a flight plan from Fullerton to Heber City Municipal Airport in Heber, Utah, according to the FAA.

Kathy Schaefer, Fullerton Fire Department division chief, said on Friday that the pilot often flew from Orange County, where his parents live, back to Utah where he and his family recently moved.

The plane had been traveling 80 mph and was about 50 feet off of the ground when it veered left and crashed, Schaefer said. It soon was engulfed in flames on the taxiway.

Firefighters extinguished the blaze, which destroyed the back half of the aircraft.

Authorities said he had a full tank of gas when he took off, which led to the aircraft bursting into flames upon impact.

Original article can be found here ➤


  1. Details will be interesting on this one.


    1. I am thinking that if he wasn't working out in a gym and working his legs I can only imagine that as soon as the left engine failed then slammed the rudder all the way to the left, he just didn't have the strength to move that peddle or overcome those forces. I don't think many dentist do a lot of leg work to keep the muscles toned up.

    2. An engine failure at that point allows under three seconds for a pilot to respond. Once a wing is rising, rudder is of little help. The only solution is to yank back on the throttles -that is why multi-engine pilots are encouraged to keep a hand on the throttles during take-off. If you get lucky, they'll be time to ease power back in once the plane is under control, but usually speed has bled too low for successful flight.

  2. This person apparently has footage from security camera:

  3. "While the Duke shares the delightful handling of the Beech line, should pilots have the joy of single-engine operation, they will be up against the highest rudder-force of any piston twin – 150 pounds at Vmc – which happens to be the maximum the FAA allows. "

    Therein might be a good possibility.

  4. Piston twin take off procedure:

    Hands on the throttles. If a power loss occurs before 500', immediately pull the power back and land straight ahead. Plane will be totaled, but passengers may live.

    1. That's exactly what I did when the left engine on the Apache I was flying quit at 50'. Killed both throttles, lowered flaps and banked toward remaining runway. Fortunately I was able to land and get stopped on the remaining runway!

    2. Which shows why one shouldn't be in a hurry to pull up the gear.

  5. ^^^^ considering where the wreckage ended up he may have done just that ... Aborted. I agree that everyone might walk away ... If there is no fire.

    I attended both the factory pilot school and mechanic school in the 80s and then decided I didn't want to fly the plane.


    1. The aircraft would not have roll inverted if the power had been pulled to idle.

  6. ^^^ adding to my post above ... What I learned about the Duke is that it can be a handful ... And leg full ... With the loss of an engine. If the engine failure happened right after lift off you would be hard pressed to keep the plane on the center line during an abort ... Maybe in a perfect world wearing rose colored glasses.

    The nature of flying is such that a pilot can do every thing right and still die.

  7. That just sickens me. Prayers for his family and friends.

    Regarding the video, does anyone else think it looks hand shot through a office window? I guess it could be a security cam and just panned in on.

    I bet that Helicopter Pilot feels lucky as heck.

  8. The video shows a steep climb angle after liftoff then a hard roll ... speculation here but is it possible his seat slid back after rotation ? Not sure of the seat latch systems on the Beech but Cessna has their share of issues.

    1. The seat latch system is similar to Cessna. There’s three rails with the center one with the holes the pin sets in.

  9. Wow, that happened fast. Godspeed to the pilot and my condolences to his family. Piston-twins scare me.

  10. Piston twins are not any more dangerous than singles. You just have to stay above VMC. Most multi engine aircraft will takeoff and fly well below vmc. You just have to keep it on the ground until you reach VMC. I think this accident was due to takeoff below VMC and then the left engine failed at just the wrong time.
    The Mosquito has a takeoff speed of about 40 MPH below VMC. Of course only one is flying right now but the pilot has to keep the nose down and get to VMC which happens pretty quick according to Kermit Weeks.

    1. Yes and he was adding rudder too but they were not active due to speed

    2. Yes, get it wrong and Piston twins usually take you to the scene of the crash quicker than a single, like you said keep it on the ground till above VMC.

      Single pilot ops in complex aeroplanes can be a challenge at night. RIP

    3. Yes, and the aircraft seemed to be nose high. The whole situation is awful.

  11. Did his seat slide back perhaps? Prayers for his family.

    1. It happened at the Reno Air Races so that is a distinct possibility.

  12. At ~3100ft, the Fullerton runway is what I would consider short for a Duke. The steep climbout was probably because the pilot knew the runway was short and didn't want to keep it low to accelerate above blue line speed. With only the pilot onboard the plane was nowhere near its maximum weight. Nevertheless, it takes a few seconds to secure a dead engine and the advice above to chop and drop is probably the safer option. But with not much left of that 3100 ft, it's going to crossing a road into a construction lot.

  13. Good engine take you right to the scene of the accident

  14. Wow. No multi engine takeoff is ever routine. You have to be ready to chop and drop until gear are up. Some people suggest you say and think "stop ...stop...stop..." until the wheels are in the wells. Now I know why my instructor forced high sped takeoff aborts before we ever actually went airborne. Below VMC you are a dead man. RIP. I just hope we learn from peoples' misfortune.

  15. No more details needed. VMC roll. Dead man's grip on both throttles. So sad. RIP.

    PS. My DPE warned me that anyone can fly a twin on both engines.....

  16. Question here, could it have been caused by the heli vortex?? It seems to roll very fast for an engine loss..

  17. No ones mentioned the gear was fully retracted before he even started to roll so guessing he had just reached over to flip the gear switch and had an engine failure at approx. the same time.

    As someone mentioned the Duke has the highest rudder pressure of any twins to maintain straight flight with an engine out.

    With 380 HP on each side at full power suddenly losing an engine coupled with a relatively "short" distance from the engines to the rudder, while low and slow, combined with dusk lighting conditions, and the odds were stacked against a successful outcome.

    So sorry for him and his family.

  18. I was wondering about the helicopter as well. I have seen video of a Cirrus landing just after a large military chopper departed. Just as the Cirrus was about to flare, he was flipped over and landing inverted due to the wake turbulence from the large rotor on the chopper. Not sure if a smaller chopper like the one seen here could do that especially since he is still on the ground not producing lift. Interesting theory though.

  19. Watching the accident video, it happened so fast that I doubt that 99% of pilots in that exact scenario would have been able to "save" it. Worst possible time to lose an engine along with a short runway sealed his fate. It was just his time. RIP

  20. Take off a twin below VMC.
    Flip it upside down faster than you can say "ah".

  21. This is the second time that N65MY has had an incident in the past 12 months or so. About 8 months ago one of the cylinders on the left engine blew out and Robert had to make an emergency landing on runway 24. Trim Aire Aviation out of Texas had recently conducted engine overhauls on both right and left engines. Boyd 'Buddy' Miller is the owner of Trim Aire, and came down to conduct the left engine replacement. We speculate that during takeoff the left engine failed or lost power, causing the left wing to pull back which led to the aircraft rolling over and slamming into the ground. My personal experience with 65MY and Boyd Miller: I got the feeling that he was shady because he provided direction to conduct testing on the engine that would have resulted in further damage and liability to my company. As such we refused to work on the aircraft when the left engine failed the first time (approximately 8 months prior to the incident that resulted in Robert's death). On 4/19 I was leaving the airport around 7:40 PM. Saw 65MY in the run up area. About 10 minutes later I was notified of the crash and already knew who it was was before the aircraft's identity was made public. I revisited Trim Aire Aviation via google and identified that Buddy Miller was sued for selling a guy 6 engines that were not up to par. Not sure if the customer won that case or not but kinda goes to show that Buddy Miller has had opportunity with morals and ethics in the past. So, left engine fails twice in 8 months, pilot survives the first incident, but not the second. Same guy is responsible for the overhauled engine that failed, and the replacement engine that failed...

    1. NTSB final will include whatever is learned about who, what, when on the engine story from logbooks and maintenance records. Presume you made your shop records from that initial evaluation of the first incident available to NTSB.

      Posting anonymously about that lawsuit and saying "not sure if the customer won that case" is unethical, seeing as the case reference you Googled up made it clear in the 2003 rendered judgement that Mr. Miller was not found to be at fault in the original trial or in the claimant's appeal.

      The Googled up lawsuit reference describes that activity as involving brokering partially disassembled used turbine engines "as is" to a person who intended to part them out, not engines that were overhauled or otherwise represented as serviceable.

      Thorough reading of the rendered opinion does not suggest moral or ethics deficiencies by Trim Aire. Why use it to smear them if the courts dismissed the claims?

  22. Missed resetting the trim? Eager dirt sniffer?

    Not sure a good stunt pilot could get a Duke off the ground in 1300' ... Safely that is.

  23. Possibly split flaps, happened on the same type of aircraft a few years ago. Single pilot.

  24. I suspect he rotated early, immediately moved his hand from throttles to gear switch and retracted gear, and upon moving his hand back to throttles accidently pulled left throttle back with the heel of his hand.

  25. The surveillance photos show high angle of attack as soon as he lifted off at 1300 into the TO roll. The specs recite a TO roll of just over 2,000 at gross. He rotated at 1,300 but probably under gross. The NTSB initial recites ground speed of 80. Power off stall dirty is 67. Just eyeballing the TO roll photos, it appears his AOA is immediately high on rotation, maybe 25º. If true, then his stall speed is much higher than 67. Aircraft is just airborne when you can see that left wing begin to drop because it is stalled. Appears to be less than one second. Then he does the wing over spin. You can step through the video below. The pilot's seat and control positions should be recoverable so the theory of slippage, throttle positions, etc can be investigated as well as the engine out theories. I'm thinking it's more classic departure stall. The airplane was launched into a high AOA,and then fell. It was never really flying. Seems improbably that he would loose the seat, throttle, and/or the engine at the same time.

    Maybe some higher resolution photos or video will surface so we can see the control surface positions. I could not tell if he had rudder in or was trying to bank into the good engine if he had engine out. He had no time to react really. There is a video of a Queen Air that lost left engine and is trying to maneuver low and slow to return to the field following tower instructions to make a left turn (mistake). It stalls and spins in. Happens in an instant with that high wing loading.
    Unless you have several thousand feet of air to play with, it will be the end game.

    Condolences to the friends and family. Hopefully, he died on impact so no suffering in the fire.

  26. The photos seem to show that the aircraft traveled approximately 7 plane lengths from rotation to crash- about 250-300 feet. Just as the nose passes the striped pole, it's about 15% nose up. Then, less than 2 lengths more, it has pitched up to about 30%, right in front of the tower, which seems dramatic. Thinking here that it has stalled on TO and he's pulling the yoke back instead of pushing it forward. These aircraft do not have any recent history of seat problems I could find. Possibly another pilot was flying the same aircraft and it was not latched properly? Should be a pre-flight item. Anyway, at that point it stops flying, altitude does not increase past that AOA change point because it has entered a deep stall and spins over. Total forward travel after wing drop is about 3 lengths. His forward momentum has become circular momentum that is added to gravity and plane departs the flight path to the left. TO roll begin to crash is about 2,000 feet. Initial NTSB above indicates both engines creating power at impact as evidenced by two sets of prop witness marks about 15 feet from each other. The NTSB should be able to figure out the cause. RIP.

  27. that happens pretty fast....

  28. Looks like it stalled as soon as he left ground effect. He's pretty much at high AOA at lift-off in ground effect. Aircraft jumps off runway and he's thinking good to go and nudges the AOA even higher. AS soon as he loses the ground effect, it is totally stalled.

  29. Martin,

    I was rearly shocke when I saw that Crash video. I operated the Dukes since 1990 with more than 3.000 hours. In my opinion it looks like that the pilot seat was not correctly adjusted. I had this three times with the Duke P-581 and P-341 and in P-274. I am 1,80 m high, so that the seat in the full back position allows me to handle the Throttles. If the pilot is smaller and has both hands on the Control wheel instead of his right hand on the Throttle, he could be so shocked and keeps his hand convulsive on the Control wheel so pulled the plain into the stole.

    If you pull the Duke extra and conscious from the runway with only 69 knots, you could not believe how strong you have to pull the elevator. I cannot believe that this was done by the Pilot.

    It seems to be much more logical, that the pilot seat went into the full back position while the pilot had both hands on the control wheel.

    I am very sorry about that crash. The Duke flies always so well and safe.


  30. Looking at the one of the close-up security video, you could see that prior to the stall, the airplane yaws to the left and left wing slightly lowers; that is happening for some 3 long seconds.
    So it does not look as a stall, which happens very abruptly, when the airflow is ripped away from the top surface of the wing and does not give a reason for developing yaw effect. On the other hand, it is consistent with loss of left engine power and following vmc roll as discussed. The marks in the ground from a left engine mean the engine wasn't shut, but it doesn't mean it was producing sufficient power.

  31. I aggree with you. On the other hand I have this question: Why does he take of with only less than 70 knots? This ist total unnormal for a Beech Duke Takeoff?


    1. Martin, I'm not sure where the information about 70 kt (IAS?) comes from. The stall speed of the plane is 73 KIAS, so it wouldn't lift off the ground. Someone mentioned that NTSB noted it was lifting off at 80 kt (IAS?), but I didn't see any report yet. But just to be clear with terms, a stall itself is part of vmc roll, where unefectivness of control surfaces cause increasing correcting action, which causes higher drag, that turns into less effective control surfaces and it continues until stall of the wing with ineffective engine occurs. To recover developing vmc roll, one needs an energy to trade off for speed and that can be only achieved by lowering nose (mind how quickly it happens, pilots must train it, regardless single or multi engine). It can't be just corrected by rudder and airleons, it's part of the problem. But as people wrote here, that is why vmc is defined and why multi engine aircraft should not take off before achieving it.

  32. Dear unknown person,

    in the Information are 1.300 ft =396 m with full fuel of Groundroll and a speed of 80 mph = 69,5 knots described. This is the Information I was looking at, and I came to a not correct adjusted pilots chair.

    If you are airborn with 70 knots in a Duke, you need full ruder to the right to hold the aircraft strait. If you lose control, it would roll immediately to the left, as it shows in the (crash) video.

    with best regards


  33. Video angle at 1:19 to 1:23 in this clip shows a clockwise pirouette underway just before going out of sight behind the hangar. That motion at 1:21 to 1:22 suggests strong pull effect and torque from the starboard engine was in control. If that interpretation is correct, the port engine was not performing properly.

  34. Unrelated to the accident but I believe Bob Hoover said it best and demonstrated an airplane doesn't care how many engines you have or don't have, all it cares about is airspeed.

    1. Saw Bob Hoover's Rockwell Shrike Commander engine-out aerobatic show at Kissimmee in early 1970s where he did loops and 8 point rolls in glider mode. He showed how to trade airspeed for height, height for airspeed as energy management with engines feathered. Can still remember the ripping air sound of the gliding Shrike at the bottom of the loop as he began to pull up.

      Many people are unaware of the danger from light twin engine loss on takeoff, thinking only of whether an airplane can maintain flight level on one. The default belief is that two engines provide redundancy, but on takeoff having two wing mounted piston engines just doubles the likelihood of calamity at rotation and initial climb. Simple statistics math.

  35. how is skymaster on take off if say the front engine fails?

    1. Hard to see from the vid which is aimed at the RH side of the plane: I don't see any RH rudder. (Stopped vid several times)

  36. The airplane did NOT stall. The crash was a VMC roll event.

    1. Wrong! It had nothing to do with a VMC roll. Both engines were operating normally. The pilot forgot to remove an unauthorized control lock which kept the elevator full nose up during takeoff, causing the aircraft to stall on takeoff.

  37. Anonymous on May22 2019 said it was an unapproved control lock. He was dead right according to the NTSB.

  38. This report about this accident should be updated as to the cause as found by the NTSB. The readers of Kathryns Report need to know that the cause of this widely known accident was an unapproved control lock.