Wednesday, August 7, 2019

Loss of Control in Flight: Beech G58 Baron, N669CS; accident occurred June 12, 2015 near Taylorville Municipal Airport (KTAZ), Christian County, Illinois

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Springfield, Illinois
Textron Aviation; Wichita, Kansas
Continental Motors; Mobile, Alabama

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 


http://registry.faa.gov/N669CS


Location: Taylorville, IL 
 Accident Number: CEN15LA280
Date & Time: 06/12/2015, 1350 CDT
Registration: N669CS
Aircraft: BEECH G58
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Instructional

HISTORY OF FLIGHT

On June 12, 2015, about 1350 central daylight time, a Beechcraft G58 airplane, N669CS, experienced a loss of left engine power during a go-around and subsequent impact with terrain near Taylorville Municipal Airport (TAZ), Taylorville, Illinois. The airplane sustained substantial damage to the firewall and aft bulkhead. The student pilot, who was the registered owner, and instructor pilot were not injured. Visual meteorological conditions prevailed for the flight, which was being operated in accordance with Title 14 Code of Federal Regulations Part 91, without a flight plan. The flight departed from Decatur Airport (DEC), Decatur, Illinois, at 1211 and was destined to TAZ.

The pilot receiving instruction (student pilot) stated he hired the instructor pilot for 4 days of flight instruction to help prepare him for the multi-engine practical exam. The accident occurred on the last landing of the last day of the 4-day training period. After lunch, they took off from Decatur, Illinois and headed to Champaign, Illinois where they completed about one hour of instrument training "under the hood." When completed with the instrument training, they decided to return to TAZ. They were coming from the northeast, about 8 to 9 miles from TAZ, when the instructor "pulled power to the left engine." They were about 7,500 ft above ground-level (agl). The student said he identified, verified, and feathered the left engine propeller. The instructor said he wanted to practice a simulated dual engine out emergency and pulled the right engine to idle about 7,000 feet agl. About 3 miles out of TAZ the instructor advised he was going to restart the feathered left engine, and the left propeller started turning which indicated to him that the engine was running. The pilot receiving instruction made the call for 2-mile final for runway 8 over the radio. The instructor advised him to conduct a straight-in approach and target 1,000 feet down the runway because they had no power. His airspeed was about 100kts targeting 95 kts for landing. He was on short final, with full flaps and gear down for landing, when the instructor noticed he was lined up for the taxiway. The instructor pushed the throttles forward and announced to "get the wheels up for a go-around." The airplane made a severe left turn. The student stated he could not control the airplane as it continued in the left turn. The airplane "barely cleared a hangar," flew across the highway, went under some power wires, and landed in a corn field. There was no formal transfer of controls, the instructor just took the throttles and control yoke.

PERSONNEL INFORMATION

The pilot receiving instruction held a private pilot certificate with a rating for airplane single-engine land. He reported 276 hours of total flight experience, with about 19 hours in multi-engine airplanes in the prior 30 days. All the student pilot's multi-engine time was completed in the accident airplane. The student held an FAA third-class medical certificate, dated July 12, 2013, without any limitation or waivers.

The student flew a Cessna 206 prior and was new to multi-engine airplanes, with no prior multi-engine flight time. According to the student pilot, he felt the instructor was a "bit intimidating with his resume" and "take charge kind of guy." The instructor owned a Beechcraft Bonanza of his own with many hours logged, the student said did not question the instructor's actions because he was a low time pilot in comparison.

The instructor pilot held an airline transport pilot certificate; with ratings in single- and multi- engine land, single-engine sea, instrument airplanes and a flight instructor certificate with ratings for airplane single- and multi- engine land. The instructor reported 18,645 hours of total flight experience, with about 1,400 hours in multi-engine airplanes and 25 multi-engine hours in the last 30 days. The instructor held an FAA second-class medical certificate, dated May 15, 2015, with the limitation: must wear lenses for distance, have glasses for near vision.

His flight instructor certificate was renewed in July 2014. His flight review was completed on March 22, 2015. He had flown Beech airplanes for 26 years and about 1,300 hours of instruction in the Beech Barron 55 and 58 airplanes. He had a total of about 13,600 hours as pilot-in-command for single and multi-engine airplanes, including 5,000 hours of military time in F-100 and F-16 airplanes. He remarked that he has owned a Beech Bonanza F33A for 34 years and has about 7,500 hours flying that airplane.

The instructor pilot stated he had been instructing through the Bonanza Proficient Pilot Program (BPPP) since 1988. To be accepted into the program an instructor must pass a review of his flight records and a flight check. The program typically looks for pilots with substantial training. In addition, semi-annual ground training and a flight check were required to remain a BPPP qualified instructor. He had a private contract between himself and the accident student pilot.

WRECKAGE AND IMPACT INFORMATION

The airplane was moved to a hangar at Taylorville Municipal Airport, in Taylorville, IL where the National Transportation Safety Board (NTSB) Investigator-in-Charge (IIC), along with FAA and airplane manufactures, conducted a wreckage examination and engine test runs.

It was noted the FAA had removed two access panels on the lower fuselage aft of the nose landing gear to visually inspect for damage to the firewall bulkhead during their initial on-scene response to the accident. The lower section of the firewall bulkhead was buckled.

The aircraft hobbs meter displayed 24.7 hours. Both throttle levers were at idle, both propellers were at high RPM, both mixture levers were at idle cutoff, both fuel selectors were in the 'off' position. The flap handle was up and visually indicated the flaps were up. The landing gear handle was down. The cowl flaps were in the 'closed' position. The pitch trim displayed 5 units nose up. The rudder and aileron were in the 'neutral' position. Both the left and right fuel gauges indicated 47 gallons, a total of 94 gallons of fuel onboard.

Engine continuity was confirmed by turning the crankshaft and audibly observing the 'clicking' magnetos. Engine control continuity of the throttle, mixture and propeller to the left engine was verified.

The upper and chin cowling were removed to access the engine. The engine was visually inspected, no apparent damage was noted. The engine crankshaft propeller flange was visually inspected, no damage was noted.

The SD card was removed from the Garmin 1000 and downloaded by the NTSB IIC. The data showed the fuel flow to the left engine (engine 1) began to decrease about 13:43:13. A minute later, at 13:44:13 fuel flow to the left engine went to 0. A 0 RPM indicates the engine was showdown and feathered by a pilot/operator. Engine RPMs for the left engine began decreasing at 13:44:12 and slowed to a completed stop at 13:44:21. The left engine fuel flow and RPMs remained at 0 until 13:48:18. A second later, both fuel flow and RPMs began to increase. The RPMs remained about 2,000 RPM for about a minute when it began decreasing, coinciding with the decreasing airspeed toward the end of the flight. However, the fuel flow only briefly increased above minimum fuel levels before decreasing below minimums again at 13:48:26 for the remainder of the recording at 13:49:42.

TESTS AND RESEARCH

Engine Test Run

Before removing the propeller, each blade on the damaged Hartzel (Model-PHC-J3YF-2UF, SN-ED6360B) accident propeller was twisted using hand pressure, two of the blades exhibited excessive movement similar to pitch change mechanism damage. After removing the accident propeller, a two-bladed McCauley (Model-2A34C201, SN-173880) non-counter-weighted propeller was installed. The deice slip ring was removed from the left engine to allow for the replacement propeller to be installed. The air conditioning compressor was removed and secured to the aft air conditioner mount. The belt tensioner was removed. Relocation of the air conditioning compressor and removal of the belt tensioner was to ensure the propeller could spin free for testing.

The airplane was moved out of the hangar and placed on a clear area on the ramp in front of the hangar. The left and right battery switches were placed in the 'on" position, and the master switch was placed in the 'on' position. The Garmin G1000 primary flight display unit powered on an indicated there were 24 volts coming from the left and right battery. The left fuel selector was place in the 'on' position. The left mixture lever was places at full rich and left throttle lever moved to almost full open. The left airframe electric boost pump was placed in the 'on' position and was secured when fuel flow peaked.

The engine was started and was running at approximately 900 RPM. When oil temperature indicated in the 'green' on the G1000, the throttle lever was reduced to idle. It was noted that with the throttle at idle, RPM was between 600-620 and the fuel flow was 1.9 GPH. The manifold pressure was noted to be 4.7 inches. The throttle lever was repeatedly manipulated idle to mid-range, the engine was responsive to the throttle commands. The mixture was reduced slowly, the RPM did not change until reaching 1.2 GPH fuel flow. Engine temperature was noted at 433 and reducing as the fuel flow decreased. At 1.2 GPH fuel flow, the engine stopped running. While at approximately 1350 RPM, the mixture was leaned to establish a 'lean of peak value' using the cylinder number 1 engine temperature (approximately 720). Once the 'lean of peak' was established, the left throttle lever was placed at idle. The engine continued to run, and fuel flow was noted at 1.2 GPH. With slight movements of the left mixture lever toward idle cutoff, the engine stopped running. A magneto check was conducted; a drop of between 20-30 RPM was noted.

Fuel Samples

The airplane had a 200-gallon fuel capacity stored in various wing tanks in the left and right wings that fed to a single output for each wing. A light blue tint colored fuel (resembling 100 low-lead) was found in the fuel strainer, fuel selector valve and main tank. Fuel collected from the left main tank was tested using water detecting paste. No water was detected. After the accident, the FAA collected fuel samples from the wing tanks and reported all samples taken were absent of water and debris.

ADDITIONAL INFORMATION

The Beechcraft 58 Pilot Operating Handbook, Section 3 – Emergency Procedures, states:

SYSTEMS EMERGENCIES

ONE-ENGINE-INOPERATIVE OPERATION ON CROSSFEED

NOTE

The fuel crossfeed system is to be used only during emergency conditions in level flight only.

Left Engine Inoperative:

1. Right Fuel Boost Pump . . . . . . . . . . . . . . . . . . . . . . LOW

2. Left Fuel Selector . . . . . . . . . . . . . . . . . . . . . . . . . . OFF

3. Right Fuel Selector . . . . . . . . . . . . . . . . . . CROSSFEED

(feel for detent; confirm visually)

4. Right Fuel Boost Pump . . . . . LOW or OFF (as required)

The Beechcraft 58 Pilot Operating Handbook, Section 4 – Normal Procedures, states:

SIMULATING ONE-ENGINE-INOPERATIVE (ZERO THRUST)

Use the following power setting (only on one engine at a time) to establish zero thrust. Use of this power setting avoids the difficulties of restarting an engine and preserves the availability of power to counter potential hazards.

The following procedure should be accomplished by alternating small reductions of propeller and then throttle, until the desired setting has been reached.

1. Propeller Lever . . . . . RETARD TO FEATHER DETENT

2. Throttle . . . . . . .SET 12 in. Hg MANIFOLD PRESSURE

NOTE

This setting will approximate Zero Thrust using the recommended

One-Engine-Inoperative Climb speed.

FAA Order 8900.1, Flight Standards Information System, Volume 5: Airmen Certification, restricted simulated engine failures "at altitudes lower than 3,000 feet above the surface must be performed by adjusting the throttle to simulate zero thrust" during practical testing.

Further, the FAA General Aviation Joint Steering Committee (GAJSC) published a Safety Enhancement Topic bulletin entitled "Emergency Procedures Training." The GAJSC identified the mismanagement of light, twin-engine airplanes in single-engine operations was of concern in aviation accidents following a powerplant failure. The GAJSC believes that scenario-based training in emergency procedures would be effective in reducing these kinds of mishaps. However, the bulletin noted "Losing an engine en route or on approach is less critical because you'll likely have more airspeed and possibly more altitude to deal with; but what if you have to go around? Single-engine go-arounds in light twins often don't go well and they should be avoided if possible."

Student Pilot Information

Certificate: Private
Age: 66, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 07/12/2013
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  257.7 hours (Total, all aircraft), 19.2 hours (Total, this make and model), 74.5 hours (Pilot In Command, all aircraft)

Flight Instructor Information

Certificate: Airline Transport; Flight Instructor; Commercial
Age: 78, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land; Single-engine Sea
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 05/15/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent: 03/22/2015
Flight Time:  18645 hours (Total, all aircraft), 1343 hours (Total, this make and model), 18645 hours (Pilot In Command, all aircraft), 131 hours (Last 90 days, all aircraft), 63 hours (Last 30 days, all aircraft), 4 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N669CS
Model/Series: G58
Aircraft Category: Airplane
Year of Manufacture: 2015
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: TH2440
Landing Gear Type: Tricycle
Seats: 6
Date/Type of Last Inspection: 05/29/2015, Unknown
Certified Max Gross Wt.: 5500 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time: 23 Hours as of last inspection
Engine Manufacturer: Continental Motors
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: IO550C72B
Registered Owner: Michel Agricultural Service Inc
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KTAZ, 622 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1835 UTC
Direction from Accident Site: 268°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 14 knots / 23 knots
Turbulence Type Forecast/Actual:
Wind Direction: 220°
Turbulence Severity Forecast/Actual: 
Altimeter Setting: 29.83 inches Hg
Temperature/Dew Point: 30°C / 23°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: DECATUR, IL (DEC)
Type of Flight Plan Filed: None
Destination: Taylorville, IL (TAZ)
Type of Clearance: VFR
Departure Time: 1205 CDT
Type of Airspace: Class E

Airport Information

Airport: TAYLORVILLE MUNI (TAZ)
Runway Surface Type: Asphalt
Airport Elevation: 622 ft
Runway Surface Condition: Dry
Runway Used: 18
IFR Approach: None
Runway Length/Width: 4001 ft / 75 ft
VFR Approach/Landing: Straight-in

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 39.533611, -89.323611 (est)

6 comments:

goldwing said...

The instructor pilot was Henry D Canterbury, a retired USAF Major General. He was a Thunderbird slot pilot for 230 air shows, had 386 combat missions in F-100 and F-4E, and was a member of the initial cadre of F-16 pilots.

Anonymous said...

Wow... you can't make this stuff up!

Anonymous said...

Story about Maj. Gen. Canterbury's son who also followed in his father's footsteps:

https://www.emeraldcoastmagazine.com/the-father-son-legacy-of-two-passionate-ambitious-fighter-pilots/

I'm glad they both walked away, but I think it's time for the good Major General to hang up his instructor business at age 78. That was some bad judgement and the student pilot feeling intimidated never makes for good cockpit chemistry in teamwork and communication. Many crashes, including major airline crashes over many decades, have proved that.

goldwing said...

Regarding intimidation. In the early 1970s I earned my Commercial Rating at Marathon Flight School, Kissimmee, FL. The owner and check pilot was Ernest Pretch. He had recently retired as the most senior TWA pilot. He knew both Amilia Earheart and Charles Lindberg personally in the mid-1930s. I still remember my check flight with Pretch. I passed, and that is now a pleasant memory, but yes, I was intimidated.

Anonymous said...

GA is altogether a thing of its own.

Anonymous said...

To goldwing: yep, I learned how to fly out of Eglin AFB's Aero Club mentioned in the article I linked to above. And while there were no legend instructors there, there were both active duty and retired military pilots of all genres (TAC/SAC/MAC at the time) teaching there along with the greenhorn Embry-Riddle instructor grads there.

One former F-105 driver and combat veteran in Vietnam however had the intimidation factor to 11 though. Miss the exact landing point on the runway he wanted past the emergency arresting cable* at the threshold, even as a 20-something hour student solo, and he made sure you knew about it in debrief.

*That's right for those out there who do not know, USAF bases have emergency arresting cables at the end of the runways and fighters have emergency arresting hooks (look up "BAK-14").