Whites Creek, TN, USA
N412ES
BEECH 95-B55 (T4
During flight in instrument meteorological conditions, the left engine experienced a total loss of power due to the separation of the flexible fuel supply hose between the left engine firewall fitting and the engine-driven fuel pump inlet fitting due to an inadequately torqued B-nut. The pilot informed air traffic control of a discrepancy, although he was not specific in the nature of the problem. A momentary change in heading to the left occurred consistent with the pilot’s failure to maintain directional control of the airplane following the loss of left engine power. Radar data indicated that the airplane was allowed to decelerate, followed by a loss of lateral and directional control and a subsequent flat spin to the left. The stall warning horn was recorded during the pilot's comment to the controller that he was in a spin. The airplane descended uncontrolled and crashed into a wooded area behind a home and was destroyed by impact and a postcrash fire. No preimpact mechanical failure or malfunction of the airplane or of either engine was noted. Acoustic analysis of engine rpm signatures reflect a steadily decreasing rpm to 1,760, most likely from the left engine, which is below the normal operating range. The analysis indicated an rpm signature of 2,140, most likely from the right engine, which was in the normal operating range. The pilot neither feathered the left propeller nor secured the left engine following the total loss of power per the Pilot's Operating Handbook and Aircraft Flight Manual, and there were no mechanical discrepancies with the propeller or propeller governor that would have prevented him from doing so. Operational testing of the left engine with an exemplar flexible fuel hose that was finger-tight resulted in the separation of the line from the inlet fitting. The test runs determined that when finger-tight the B-nut loosened and tightened varying amounts with different power applications. Rebuilt engines were installed 9 months earlier and there was no entry indicating that the flexible fuel hoses were replaced at that time. There was no record that the left flexible fuel hose was ever replaced since the airplane was manufactured in 1978. Although the airplane manufacturer recommends that flexible fuel hoses be replaced when conditions warrant, at engine overhaul, or 5 years, whichever occurs first, there is no evidence to suggest that the age of the hose contributed to its separation from the engine-driven fuel pump inlet fitting.
HISTORY OF FLIGHT On November 24, 2008, about 1045 central standard time, a Beech 95-B55, N412ES, registered to and operated by a private individual, experienced an in-flight loss of control and crashed into a wooded area behind a house in Whites Creek, Tennessee. Instrument meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 business flight from Memorial Field Airport (HOT), Hot Springs, Arkansas, to Nashville International Airport (BNA), Nashville, Tennessee. The airplane was destroyed by impact and a postcrash fire and the certificated commercial pilot and 2 passengers were killed. The flight originated about 0909, from HOT. Before takeoff, the pilot contacted the Memphis Air Route Traffic Control Center and requested IFR clearance to the destination airport. The pilot was instructed that the flight was cleared as filed, to climb and maintain 5,000 feet, expect 7,000 feet ten minutes after departure, instructed as to the discrete transponder code (5524), and advised of the clearance void time. The pilot correctly read back the clearance, and at 0911, he established contact with the facility and advised the controller that the flight was climbing through 2,500 feet. The flight was radar identified and instructed to climb to 7,000 feet continuing towards the destination airport. Air traffic control (ATC) communications were transferred to several ATC facilities and at approximately 1024, while in contact with the Memphis Air Route Traffic Control Center, the pilot was instructed to descend and maintain 4,000 feet. At approximately 1032, ATC communications were transferred to the Nashville Air Traffic Control Tower, and at 1033:12 while in contact with that facility, the pilot advised the controller that the flight was at 4,000 feet. Radar data indicated that the pilot maintained approximately 4,000 feet from 1032:53 until 1044:12. The controller acknowledged the pilot contact and advised him that the automated terminal information service (ATIS) sierra was current and to expect vectors for an ILS approach to runway 20R at the destination airport. The pilot correctly read back the ILS runway designator and approximately 3 minutes later, at 1036:24, the pilot was instructed to fly heading 055 degrees for sequencing, which he also correctly read back. The radar data indicated that from 1037:21, to 1042:21, the airplane proceeded on the approximate heading instructed by the controller, but beginning at 1042:30, heading deviation left of the assigned course was noted. At 1042:58, the controller advised the pilot of the location of another airplane and the pilot responded at 1043:05, "yeah well I’m all screwed up up here so stick with me." The controller asked the pilot if he needed assistance and the pilot asked the controller how far he was from the localizer. The controller advised the pilot that the flight was 12 miles from the localizer and asked the pilot to make sure he wasn’t confusing the John Tune Airport localizer setting (110.3 MHz) with the BNA Airport runway 20R localizer setting of 111.3 MHz. While the transcription of communications indicates the pilot responded at 1043:43 with, "(unintelligible) again one eleven three", Safety Board review of the voice tape from the facility revealed the pilot replied with words to the effect that he had 111.3 selected. The controller then instructed the pilot to fly his present heading and to expect a base and final turn to the localizer; the pilot did not respond. The controller again advised the pilot to expect a base turn in 5 miles and a turn south onto the localizer. The transcription of communications indicates the pilot replied "gotcha." At 1044:24, the controller repeated the partial call sign of the airplane, and the pilot responded, "two echo sierra I’ve got you but I'm having trouble hold." A pause was noted and then grunting sounds were recorded on the frequency. The controller asked the pilot if he needed help and he responded, "I got it into a spin and I can’t stop it." Heavy breathing/grunting sounds for several seconds were heard on the frequency. At 1044:54, the controller advised the pilot to climb immediately to 3,000 feet. The pilot responded with "got no climb." At 1045:09, the controller again advised the pilot to climb immediately; there was no further response from the pilot. The controller broadcast on the frequency advising the pilot that the flight was 6 miles north of John Tune Airport, and that rescue vehicles had been dispatched. According to the controller who was communicating with the accident pilot, he noticed the pilot was not tracking his assigned heading, and then noticed a descent from the assigned altitude below the minimum vectoring altitude. He issued climb instructions and reported the accident airplane kept descending. He marked the aircraft's position and asked to be relieved from his position. Radar data correlated with the transcriptions of communications revealed that at 1042:30 which was approximately 35 seconds before the pilot first advised the controller of a discrepancy, the airplane's heading changed to the left without instruction from ATC to a maximum northerly heading of 023 degrees which occurred at 1043:03. The airplane then turned to 030 degrees and remained on that heading for 3 radar returns between 1043:08 and 1043:17. Between 1043:21 and 1043:31, the airplane turned to the right flying the approximate heading instructed previously by the controller (055 degrees), and between 1043:31 and 1044:12, heading changes to the left and right were noted as well as a decrease in groundspeed to 155 knots. Between 1044:12, and 1044:27 which was the approximate time the pilot advised the controller that he was "…having trouble hold", the radar data indicates that the airplane's heading changed from 051 degrees to 344 degrees, the altitude decreased from 4,000 to 3,700, and the groundspeed decreased from 155 to 145 knots. Further review of the radar data correlated with the transcription of communications revealed that between 1044:27, and 1044:40 which was the time the pilot advised the controller that the airplane was in a spin and couldn't stop it, the radar data reflected that the heading changed from 344 degrees to 035 degrees, altitude deviations between 3,700 and 3,500 were noted, and the groundspeed decreased from 139 to 107 knots. Between 1044:40 and 1045:03 (last correlated radar return), heading changes left and right were noted, the altitude decreased from 3,500 to 1,300 feet, and the groundspeed decreased from 107 to 51 knots. The last radar target was located at 036 degrees 17 minutes 22.01 seconds North latitude and 086 degrees 50 minutes 38.38 seconds West longitude, at an altitude of 1,300 feet. The accident site was located approximately 52 degrees and 0.04 nautical mile from the last radar return. A witness located near the crash site reported he was inside his house and heard an airplane that sounded abnormal; the witness and his son reported hearing a whirring sound. The witness looked outside his window and saw the airplane flying in a southwesterly direction. The abnormal sound faded momentarily, and then returned. The airplane began spinning in a counterclockwise direction and was flat while spinning. He estimated the airplane spun 4 times before losing sight. Each 360 degree rotation took approximately 1 second. He called 911 and ran to the scene. When he arrived there he noticed a fire at the front of the airplane which spread out. He estimated the fire department arrived in 5 minutes. The witness further reported the weather condition at the time consisted of low clouds with light drizzle. PERSONNEL INFORMATION The pilot, age 67, held a commercial pilot certificate with airplane single engine land, airplane multi-engine land, and instrument airplane issued June 28, 2002. His most recent special issuance third class medical certificate was issued November 21, 2008, with limitations to have available glasses for near vision. The pilot reportedly kept his pilot logbook inside the cockpit; the logbook was not located during the inspection of the wreckage. He listed 1,990 hours of total flight time on the application for his latest medical certificate. While no pilot logbook was located, correlation of the pilot's flight time based on maintenance record entries revealed the airplane had been operated approximately 20 hours between November 1, 2007, and May 26, 2008 which was the last entry in the engine logbooks. The pilot was paid on a monthly basis to fly the passengers on business trips when needed. During those trips, the pilot's fuel costs, lodging and meals were also paid for by the passenger's company. AIRCRAFT INFORMATION The airplane was manufactured in 1978, by Beech Aircraft Corporation, as model 95-B55, and was designated serial number TC-2198. It was powered by two Teledyne Continental Motors IO-520-E engines rated at 260 horsepower and 2,700 rpm for maximum continuous operation that were installed in accordance with (IAW) Supplemental Type Certificate (STC) SA432SO. The flight manual supplement (FMS) associated with the STC indicated the normal operating (green arc) range was 2,000 to 2,700 rpm. It was also equipped with two Hartzell HC-EHC-G3YF-2UF propellers, which are single-acting, hydraulically operated, constant speed with manual feathering capability. Review of the airframe maintenance records revealed the last entry pertaining to the transponder, altimeter, and pitot static system tests in accordance with 14 CFR Part 91.411, and 91.413 was logged as occurring on June 24, 2003. The work was performed by a Federal Aviation Administration (FAA) approved certified repair station. While there was no further entry in the airframe logbook indicating the transponder, altimeter, and pitot static systems were checked after that date, an individual who knew the pilot and the pilot's wife reported that the checks were performed on November 22, 2006. The individual who knew the pilot also reported that the facility that performed the work is no longer in business. The airplane was last inspected in accordance with an annual inspection on November 1, 2007; the airplane total time at that time was recorded to be 2,802.7 hours. The inspection entry indicates that IFR certification was overdue. The left and right engines were remanufactured at the Teledyne Continental Motors factory on February 3, 2008, and February 2, 2008, respectively. Both were shipped to a distributor (Aviall) on February 3, 2008. Further review of the maintenance records revealed that on February 29, 2008, both propellers and propeller governors were removed for overhaul, and both engines were removed and replaced with remanufactured engines. The airplane total time at that time was recorded to be 2,807.7 hours. The entry does not indicate that new flexible fuel hoses were installed. The mechanic who performed the installation of the engines stated that he pressure tested the fuel hoses and if they did not leak he re-used them. Entries in the left and right engine logbooks revealed that on May 26, 2008, at airplane total time 2,832.9 hours, the same mechanic who installed the engines changed the engine oil and cleaned the oil screens of both engines. The entry for the left engine indicates, "…Ground Run. No Leaks Noted At This Time." There was no further entry in the left engine logbook following the oil change indicating any further maintenance was performed. The airplane was modified by a FAA certified repair station on November 13, 2008, IAW STC SA09411AC-D. The STC removed the previously installed autopilot components and installed an S-Tec System 30 autopilot. Review of the FAA Approved Pilot's Operating Handbook and/or Airplane Flight Manual Supplement revealed that in the event of single engine operations during cruise flight, the procedures specify to retrim the airplane, and perform normal engine out procedures. The removal of the previous autopilot components and installation of the S-Tec autopilot system was not recorded in the permanent maintenance records; however, a logbook entry sticker documenting the work was later provided to Safety Board personnel. Review of the work order and logbook entry revealed no documentation of the airplane total time. METEOROLOGICAL INFORMATION The day before the accident, about 1917, the pilot called the Lockheed Martin Automated Flight Service Station and filed 2 IFR flight plans and was given standard preflight weather briefings. The first briefing and flight plan was for the intended flight from HOT to BNA, and the second briefing and flight plan was for another flight that same day from BNA to Asheville, North Carolina. According to the transcription of the weather briefing for the flight from HOT to BNA, the pilot was advised that a cold front was expected to move into the area of HOT about mid-morning, with the frontal boundary located just west of Nashville with rain showers or rain showers type activity ahead of the front. The terminal area forecast for the destination airport up until noon was for the visibility to be occasionally 2 miles with rain showers, ceiling 700 feet overcast clouds. The briefing specialist advised the pilot that the freezing level for the destination airport area was forecast to be at 9,000 feet, and provided him with the winds aloft. A special surface weather observation taken about 1036 at BNA on the day of the accident, or approximately 9 minutes before the accident, indicated the wind was from 210 degrees at 10 knots with gusts to 16 knots; the visibility was 3 miles with moderate rain and mist; scattered clouds existed at 1,600 feet, broken clouds (ceiling) existed at 2,200 feet, and overcast clouds existed at 4,500 feet. The temperature and dew point were 52 degrees and 48 degrees F respectively, and the altimeter setting was 29.98 inches of mercury (inHg). According to the transcription of communications with the Nashville Airport Air Traffic Control Tower, at 1038:39, during an air traffic control turnover briefing, local weather was briefed to the new controller who was informed there were no icing reports. The report of cloud bases at 1,200 feet exactly 1 hour earlier by an airplane at a nearby airport was also briefed. A surface weather observation taken about 1053 at BNA on the day of the accident, or approximately 8 minutes after the accident, indicated the wind was from 200 degrees at 9 knots with gusts to 16 knots; the visibility was 3 miles with light rain, and mist; broken clouds (ceiling) existed at 1,800 feet, and overcast clouds existed at 2,600 feet. The temperature and dew point were 52 and 48 degrees F; and the altimeter setting was 29.97 inHg. AIDS TO NAVIGATION Safety Board review of the BNA Daily Record of Facility Operation for the day of the accident revealed no navigational aid outages related to the ILS for runway 20R. COMMUNICATIONS No communication problems were reported. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed the airplane came to rest upright on a magnetic heading of 150 degrees in a wooded area behind a residential area. The accident site was located at 36 degrees 17.393 minutes North latitude and 086 degrees 50.597 minutes West longitude, at an elevation of 646 feet, and was also located approximately 13 nautical miles and 321 degrees from the center of BNA. Further examination of the accident site revealed the airplane impacted on a 10 to 15 degree downsloping terrain of a wooded area. Fire damage to a small area surrounding the wreckage was noted. The surrounding tree heights were approximately 60 feet and there was no evidence of a swath through the trees. Numerous trees surrounded the wreckage were noted. One approximately 60 foot tall tree was located immediately forward of the left wing outboard of the engine nacelle, and one 60 foot tall tree was located about midspan of the left flap. One approximately 45 foot tall tree was located at the right leading edge outboard of the engine nacelle, and one approximately 57 foot tall tree was located at the aft edge of the right flap near the outboard portion of the
The pilot's failure to feather the left propeller and secure the left engine following the total loss of left engine power, and his subsequent failure to maintain airspeed, lateral, and directional control of the airplane. Contributing to the accident was the failure of maintenance personnel to properly tighten the fuel supply hose at the engine-driven fuel pump.
Source: NTSB Aviation Accident Database
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