SANTA MONICA, CA, USA
N1898W
BEECH 95-B55
THE CFI AND STUDENT HAD DEPARTED SANTA MONICA AT 1356 ON A CROSS-COUNTRY CHECKOUT WITH FULL FUEL TANKS. TAKEOFFS, LANDINGS, AND/OR INSTRUMENT APPROACHES WERE MADE AT 6 DIFFERENT LOCATIONS THROUGHOUT THE FLIGHT. THE CFI KNEW THE AIRCRAFT HAD INACCURATE FUEL GAUGES. AFTER FLYING FOR 5.3 HOBBS-METER-HOURS, WHILE USING FUEL FROM A COMBINATION OF AUX AND MAIN TANKS, THEY RETURNED TO SANTA MONICA. BOTH PILOTS REPORTED THAT THE MAIN TANKS' FUEL GAUGES INDICATED AT OR ABOVE THE 'YELLOW ARC.' THE CFI AUTHORIZED ONE FINAL TRAFFIC PATTERN CIRCUIT. WHILE CLIMBING TO 1,000 FT, ONE OF THE ENGINES STARTED RUNNING ROUGH THEN QUIT. SECONDS LATER, POWER WAS ALSO LOST ON THE SECOND ENGINE. THE CFI TOOK CONTROL, REVERSED COURSE, AND GLIDED TO THE RUNWAY WITH THE LANDING GEAR INTENTIONALLY RETRACTED TO INCREASE THE LIKLIHOOD OF REACHING THE AIRPORT. THE AIRCRAFT WAS DESTROYED BY THE POSTCRASH FIRE.
HISTORY OF FLIGHT On November 22, 1994, at 2012 Pacific standard time, a Beech 95-B55, N1898W, operated by Cloverfield Aviation, Inc., made a forced landing at the Santa Monica Municipal Airport, Santa Monica, California. The airplane was substantially damaged during the landing, and thereafter it was destroyed by fire. Neither the certificated commercial pilot, who was receiving a checkout in the airplane, nor the airline transport certificated flight instructor (CFI) was injured. In part, the checkout (instructional flight) consisted of airplane familiarization including single-engine and multiengine flying procedures, and instrument flying. Visual meteorological conditions prevailed. The flight originated from Santa Monica at 1356. On November 23, 1994, the National Transportation Safety Board interviewed both pilots via telephone. According to the pilots, prior to commencing the flight all of the airplane's fuel tanks were completely full of fuel. The pilots reported that the airplane held 136 usable gallons of fuel. The CFI subsequently reported that after takeoff, a series of practice approaches and/or landings were performed at Bakersfield, Shafter, and Porterville. While at Porterville, the engines were shut down and he and his student exited the airplane and had lunch. No fuel was added to the airplane. After returning to the airplane, the instructional lesson was continued. Additional approaches and/or landings were made at Visalia, Fresno-Chandler, Madera, and Santa Monica. The CFI further reported that the landing at Santa Monica was uneventful. Runway 21 was used. In the CFI's completed "Aircraft Accident Report, NTSB Form 6120.1/2," he made the following statement regarding the events which then occurred: "I wanted the student to have two more night landings before we shut down, so we taxied to runway 3 (the active at the time), reorganized the cockpit, and requested closed traffic. Tower cleared us for right closed traffic, we took off and completed one pattern with a full stop landing. We taxied back once again to runway 3, held short, requesting one more closed pattern. At this time the Hobbs read 5.3 hours of total elapsed time and the fuel gauges were several needle widths above yellow arcs on the main tank quantity gauges, indicating that there was approximately 30 gallons of total usable fuel remaining. This would be adequate for one pattern and still have our 45-minute night reserve upon landing. When cleared for takeoff, we departed runway 3 as before for a right pattern. At approximately 1000 feet, while beginning a right turn, we experienced an engine failure. . . . I had not failed an engine on him, and I immediately took over on the controls and rolled out on crosswind. As I was beginning to verify full power and all drag retracted, the other engine failed." The CFI additionally reported that he was in command of the flight, and he made an immediate decision to reverse course and attempt to land on runway 21. The CFI stated he informed the control tower that power was lost. In order to increase the likelihood of reaching the runway, the landing gear and flaps were kept retracted. Within a few seconds of the airplane having slid to a stop on the runway, a fire was observed near the belly of the airplane. FUEL MANAGEMENT AND AIRCRAFT INFORMATION According to the CFI, no mechanical problems were experienced with the engines. In the CFI's completed "Aircraft Accident Report," he also wrote the following statement regarding fuel management: "Fuel was burned enroute out of the aux. tanks as much as possible as a standard operating practice to ensure that usable fuel at the end of the flight would all be in the same place - the mains. The 'Cruise' checklist which we perform at every enroute level off, prompt us to consider fuel selectors at which point we switch to aux. tanks if we have not already done so in the climb. While it is common in this procedure to actually run aux. tanks dry enroute, this did not occur on our flight. We fully expected to run them dry on the leg from Madera to Santa Monica, and by Burbank Aux Tank gauges read 'empty', but it was necessary at that point to configure for the approach and complete the 'Before Landing' checklist, so we switched to the Mains for the remainder of the flight. . . . It is my conclusion that the nature of the accident, insofar as the engine failures is concerned, is a function of the available fuel (30 gallons) not reaching the engines. . . ." Regarding the accuracy of the airplane's fuel gauges, the CFI reported the following: "When the airplane was checked out at dispatch we were also aware of a discrepancy regarding the accuracy of the fuel gauges. This discrepancy was on the dispatch book ever since the airplane had come on line with us and was repeatedly deferred at every 100-hour inspection. Those of us who flew the airplane regularly had operational experience with the gauges, and it was understood that the gauges were inaccurate and unreliable in the upper end (half) of their travel; then, at about mid tanks, the floats seemed to stabilize allowing the needles to come down normally and evenly for the rest of their travel. . . ." SECOND PILOT (STUDENT) STATEMENT The Safety Board requested and received a statement from the pilot who was receiving instruction during the accident flight. In pertinent part, the student reported the following events occurred during the last takeoff: ". . .[The CFI] told me to taxi for another take-off from Rwy 3. We reached the hold-sort line, and I conducted the pre-takeoff check as before. The fuel gauges indicated at the top of the yellow arc. We received take off clearance at 8:10 pm, and I began the take-off roll, accelerated to 95 mph and rotated. I selected gear up quickly, and controlled pitch attitude to maintain 123 mph. My left hand was on the yoke and my right hand was on the throttles. I noticed the [CFI's] hand move down to the fuel selector panel, and began to mentally prepare for a simulated engine-out emergency. I counted off in my head, waiting for one engine or the other to sputter. Exactly when I expected it, one of the engines began to run rough and the plane yawed slightly. I countered with rudder, and moved my right hand to the mixtures, beginning the simulated emergency response. We were at about 1000 ft AGL, and I was in a right bank entering right crosswind, and it was not obvious which engine was failing. Almost right away, however, the sound of sputtering became 'stereo,' and the yaw force neutralized. I realized that we had a problem with both engines, and simultaneously the [CFI] called that he 'had the airplane'." The second pilot also reported to the Safety Board that, at the direction of the CFI, he immediately took his hands off the airplane's controls. The CFI proceeded to land the airplane. A fire was observed within seconds after coming to a stop on the runway. The fire was initially small, but after a few minutes it spread. By the time the fire department arrived it had engulfed the cockpit. FLIGHT TIME INFORMATION Following the accident the Federal Aviation Administration (FAA) coordinator examined the airplane and records associated with its operation. The FAA coordinator reported to the Safety Board that the airplane's Hobbs hour recording meter indicated the total time the airplane had been operated since originally departing Santa Monica for the instructional lesson was approximately 5.4 hours. The student reported that he observed the Hobbs hour meter after the crash. According to the student, the total elapsed Hobbs meter time from engine start to crash was actually 5.5 hours. COMMUNICATION In pertinent part, the following transmissions were recorded by the FAA Santa Monica Air Traffic Control Tower during communications between control tower personnel (SMO); (1) the accident airplane (N1898W); and (2) a Mooney (N01H) which was in the SMO traffic pattern. Time Facility Statement 2010:04 N1898W Santa Monica tower Baron one eight niner eight whiskey ready for take off runway three closed pattern 2010:13 SMO Baron one eight niner eight whiskey Santa Monica tower runway three cleared for take off 2010:16 N1898W Cleared for take off runway three niner eight whiskey 2011:59 N1898W Niner eight whiskey we've had an engine failure 2012:06 SMO Mooney zero one hotel start a and climb and go around 2012:17 N01H Go around for the Mooney 2012:19 SMO Mooney zero one hotel (unintelligible) thats affirmative start a climb and go around 2012:21 N01H Okay The FAA reported that immediately upon the conclusion of this transmission, SMO personnel used the "red phone" in the tower cab to notify the Santa Monica Fire Department (SMFD) of the mishap. The SMFD provided the Safety Board with a tape re-recording of its telephone communications between the SMFD dispatch center and SMO, and recorded radio transmissions between the SMFD dispatch center and various fire department equipment (Units) which responded to the accident. The Safety Board extracted pertinent communications from SMFD's re-recording. All references to non-key event communication times is approximate. SMFD reported that key events were listed by its "logging recorder", which used a time clock believed synchronized with a WWV time signal. Regarding the accuracy of communication times listed in the FAA's transcript, the FAA reported that when it compared its time signal marker against a WWV time signal, the transcript times were found slow by approximately 7 seconds. In the following portion of the abbreviated transcript, personnel associated with the SMFD communications (dispatch) center are listed as "SMFD." Personnel associated with responding emergency vehicles are listed as "Rescue, Battalion, Engine," and/or "Units." Time Facility Statement 2012:34 SMFD to SMO Fire department dispatch 2012:35 SMO to SMFD This is tower weve had uh a Barron land on runway two one the engine failed and it made a gear up just in front of Gunnell on the runway 2012:41 SMFD to SMO Ah so ah you do have a crash on the runway is there a fire with it 2012:44 SMO to SMFD Ah there doesnt seem to be a (unintelligible) a few sparks with the engine right now hes ah stopped ah come to a full stop right in front of Gunnell 2012:51 SMFD to SMO Okay we'll get right on on it thanks 2012:52 SMO to SMFD Okay thanks a lot 2012:56 SMFD to Units The engine failed and it landed gear up (background tone) okay stand by one second 2012:57 SMO to AIRPORT SECURITY Security theres an aircraft landed gear up hes in front of Gunnell right now its a Baron there appears to be a little bit of a fire 2013.18 SMFD to ENGINE FIVE Engine five we just had a call from the tower there is a fire down confirmed down in front of Gunnell on the runway the fire appears to be on the ground right now fuel spill 2014:05 SMFD DISPATCHES FIRE DEPARTMENT UNITS 2014:58 RESCUE FIVE to SMO Engine five to uh Santa Monica ground 2015:01 SMO to RESCUE FIVE Rescue five Santa Monica ground you can proceed onto the runway the aircrafts in front of Supermarine 2015:06 RESCUE FIVE to SMO Uh ten four are we gonna need more than uh just uh rescue five we're coming in from another run so we're just pulling up to the station now 2015:14 SMO to RESCUE FIVE That's possible you might need more (unintelligible) uh I can't tell if the aircraft is on fire now engine air correction fuel spilled on the runway and the um uh fuel on the runway is on fire 2015:28 RESCUE FIVE to SMO Uh engine five ah copy 2015:47 ENGINE FIVE to SMFD Engine five roll a full assignment on this I talked to the tower they said theres they said theres fuel on the runway uh thats on fire 2017:21 UNIT to SMFD Seventy four are we going to need ambulances on this ah crashed plane 2017:28 SMFD to UNIT Ah we're not on scene yet stand by 2017:35 (ringing sound) 2017:45 SMO to SMFD Yeh tower 2017:49 SMFD to SMO Yeh this is Santa Monica fire do we know are there people still on the plane or they out or where are we workn on this 2017:55 SMO to SMFD I believe they got out but I ah saw somebody get out I couldn't tell though if they ah got out or not SMFD to SMO So we don't know then 2018:00 SMO to SMFD No I didn't 2019:09 RESCUE FIVE to SMFD Ah Rescue five to ah ah were confirmed we have a little fire on the runway here were not quite there yet Ill get right back to you 2020 FIRST FIRE DEPARTMENT UNIT ARRIVES AT THE ACCIDENT SITE 2024:44 UNIT Ah Battalion one ah we appear to have a knock down on this its a little stubborn kept reignighting on us (unintelligible) were gonna probably continue to cool it here for a few minutes were going to hold everybody here for a little bit . . . 2039:04 RESCUE FIVE to SMO Let me give you an update on this plane where were at right now weve got the magnetos off weve got the battery pulled ah weve got a pretty good fuel leak it punctured the left wing tank ah were diking it ah part way away from the plane out on the runway and then well see where its going to go after that. . . . ADDITIONAL INFORMATION --- AIR TRAFFIC PROCEDURES Effective January 14, 1992, the FAA Air Traffic Control Tower (ATCT) Manager at SMO, the Santa Monica airport director, and the City of Santa Monica fire chief, initiated a Letter of Agreement (LoA). The stated purpose of the LoA was: "To establish procedures for alerting the City of Santa Monica Fire Department emergency equipment when emergency situations exist. . . ." In part, the Lo
fuel starvation to both engines due to the CFI's inadequate fuel consumption calculations during the flight, and his failure to ensure that adequate fuel existed in the main tanks to complete the traffic pattern circuit.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
