Aviation Accident Summaries

Aviation Accident Summary LAX92FA161

PARADISE, CA, USA

Aircraft #1

N9367Y

BEECH A33

Analysis

THE 60 HOUR STUDENT PILOT HAD A TOTAL OF 25 HOURS IN TYPE, ALL OF WHICH WERE DUAL. WITH HIS CURRENT FLIGHT INSTRUCTOR THE STUDENT RETURNED TO THEIR HOME BASE AIRPORT TO PERFORM A PREARRANGED GO-AROUND TO FINALIZE THEIR DUAL PERIOD FOR THE EVENING. AFTER THE APPROACH TO THE RUNWAY, THE INSTRUCTOR CALLED FOR THE GO-AROUND. AFTER THE CLIMB WAS ESTABLISHED AT ABOUT 500 FEET AGL HE CALLED FOR THE COWL FLAPS TO BE OPENED, AND MOMENTS LATER THE ENGINE SUDDENLY AND WITHOUT WARNING QUIT. THE INSTRUCTOR SAID THAT AFTER THE ENGINE QUIT THE STUDENT PULLED THE CONTROL YOKE ALL THE WAY BACK AND THE AIRCRAFT ENTERED A DEEP STALL. THE AIRPLANE HAD BEEN MODIFIED TO ACCOMMODATE AN ENGINE WITH MORE HORSE POWER WHICH REQUIRED THE INSTALLATION OF COWL FLAPS. THE FAA APPROVED STC MODIFICATION DRAWINGS REQUIRED THE PUSH-PULL CONTROL FOR THE COWL FLAPS TO BE LOCATED TO THE LEFT OF THE THROTTLE CONSOLE ON A SEPARATE SWITCH PANEL. THE ACTUAL LOCATION OF THAT CONTROL IN THE ACCIDENT AIRPLANE WAS FOUND TO THE RIGHT OF THE THROTTLE BELOW THE PROPELLER CONTROL AND NEXT TO

Probable Cause and Findings

THE STUDENT PILOT'S INADVERTENT USE OF THE MIXTURE CONTROL INSTEAD OF THE COWL FLAPS AT A CRITICAL PHASE OF FLIGHT, HIS MISUSE OF THE FLIGHT CONTROLS AFTER THE ENGINE FAILURE AND THE INSTRUCTOR'S INADEQUATE SUPERVISION OF THE STUDENT. CONTRIBUTING FACTORS IN THE ACCIDENT WERE: THE NON STANDARD LOCATION OF THE COWL FLAP PUSH PULL CONTROL, DUE TO AN IMPROPER AIRCRAFT MODIFICATION, THE DARK NIGHT LIGHT CONDITIONS WHICH IMPAIRED THE FLIGHT INSTRUCTORS ABILITY TO MONITOR THE STUDENT COCKPIT CONTROL MANIPULATIONS.

 

Source: NTSB Aviation Accident Database

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