N6004E

Destroyed
Fatal

BEECH 76 S/N: ME-127

Accident Details

Date
Tuesday, June 28, 1994
NTSB Number
BFO94FA120
Location
ELIZABETH, PA
Event ID
20001206X01450
Coordinates
40.600833, -78.760261
Aircraft Damage
Destroyed
Highest Injury
Fatal
Fatalities
2
Serious Injuries
1
Minor Injuries
0
Uninjured
0
Total Aboard
3

Probable Cause and Findings

1) THE FAILURE OF THE PILOT-IN-COMMAND (CFI) TO PROVIDE ADEQUATE SUPERVISION OF THE DUAL STUDENT DURING A SIMULATED SINGLE-ENGINE APPROACH, AND 2) HIS FAILURE TO PERFORM REMEDIAL ACTION. THIS LED TO A LOSS OF AIRCRAFT CONTROL IN CLOSE PROXIMITY TO THE GROUND. CONTRIBUTING TO THE ACCIDENT WAS THE DUAL STUDENT'S FAILURE TO MAINTAIN MINIMUM CONTROLLABLE AIRSPEED AND A PROPER GLIDEPATH TO THE RUNWAY DURING THE APPROACH.

Aircraft Information

Registration
N6004E
Make
BEECH
Serial Number
ME-127
Engine Type
Reciprocating
Model / ICAO
76 BE76
Aircraft Type
Fixed Wing Multi Engine
No. of Engines
2

Registered Owner (Historical)

Name
MARSHALL AIR SERVICE INC
Address
2619 WYNCOTE RD
Status
Deregistered
City
BETHEL PARK
State / Zip Code
PA 15102
Country
United States

Analysis

HISTORY OF FLIGHT

On June 28, 1994, about 1357 hours eastern daylight time, N6004E, a Beech BE-76, operated by O.T. Aviation, Inc., West Mifflin, Pennsylvania, impacted terrain in Elizabeth, Pennsylvania, and was destroyed during approach to runway 25 at the Rostraver Airport. The certified flight instructor (CFI) was seriously injured, the private pilot who was receiving instruction was fatally injured, and the rear seat passenger was fatally injured. Visual meteorological conditions prevailed and a flight plan was not filed. The instructional flight departed from the Allegheny County Airport, West Mifflin, at 1342 and was conducted under 14 CFR 91.

According to the assistant manager of O.T. Aviation, who was present in the lounge/office area of O.T. Aviation on the day of the accident, the private pilot had called earlier in the day to schedule a flight simulator session for that afternoon. The assistant manager later learned after the accident that the person who received the call mistakenly scheduled the simulator under another name. This statement was corroborated by an examination of the operator's daily flight schedule.

Another witness, a single-engine airplane flight instructor at O.T. Aviation, was also present in the lounge/office area on the day of the accident. He stated that when the private pilot arrived, he saw that someone else's name had been entered on the schedule. The private pilot said "I've got to fly today," and checked to see if there were any airplanes available to fly in lieu of the simulator. The flight instructor stated that the accident airplane, N6004E, a Beech "Duchess," was probably the only airplane available at the time, because it was "pretty busy" that day at the airport. The Duchess was parked in front of the office at the time the private pilot arrived because it had been prepared for flight by someone who had previously cancelled the flight; this was corroborated by the operator's flight schedule.

Seeing that N6004E was available, the private pilot asked the flight instructor if he wanted to fly with him. The flight instructor stated that he could not because he wanted to wait for the person who had been mistakenly entered on the simulator schedule.

The flight instructor then observed the private pilot ask another flight instructor, who had multiengine flight instructor privledges, if he would fly with him, but the multiengine flight instructor could not because he had another student scheduled.

According to the multiengine flight instructor, the private pilot clearly asked him for "single engine work," and stated that the private pilot desired flight instruction involving practice approaches under simulated single-engine emergency procedures. After the multiengine flight instructor declined, he observed the private pilot ask the accident CFI if he "would like to go up and do some single engine work." The CFI said "yes."

The multiengine flight instructor also stated that he heard the private pilot and CFI discuss what they would do during the flight. The discussion involved "upper air work" and "single engine work at Rostraver." The multiengine flight instructor stated that he was certain that "the whole purpose" of the flight was for instructional purposes, and he overheard the accident CFI tell the private pilot "I'm going to show you something you've never seen before."

The multiengine flight instructor also stated that the passenger (seated in the left rear seat of the accident airplane) was in the lounge at the time of these conversations and decided to fly on the accident flight to observe.

The accident CFI was interviewed in the hospital on August 19, 1994, after he had partially recovered from his serious injuries, and again on February 1, 1994, via telephone conversation. He stated that his memory of the accident flight ends at the time the airplane was about to taxi for takeoff at Allegheny County Airport. However, he did remember the events that led up to that time.

According to the CFI, he arrived at the airport about noon on the day of the accident. He stopped in at the O.T. Aviation lounge to check if he was on the schedule for flight instruction.

He saw the private pilot in the lounge area and the private pilot told him someone else was written into the schedule for the simulator during the time that he had previously requested. The CFI also recalled that he was going to monitor the private pilot during the simulator session, because the private pilot wanted to perform low approaches coming out of a 100-foot ceiling.

An examination of the O.T. Aviation aircraft and flight instructor schedule (copy attached) for the day of the accident revealed that the CFI did not have any students scheduled. The examination also indicated that the private pilot was scheduled to fly a Piper PA-28 airplane at 1530; it was determined that the airplane was placed out of service and into maintenance prior to the scheduled time. Also, a name was entered for the flight simulator at 1300.

The CFI stated that because someone else's name was written in the simulator schedule, the private pilot suggested that he and the CFI fly to Rostraver Airport in N6004E and have lunch there, figuring that when they returned, the simulator would be available. The CFI stated that he agreed, and that it was understood the flight would not be instructional and that he would be "just a passenger" on the flight.

The CFI stated that he and the passenger stayed in the lounge and watched the first pilot perform a "thorough" pre-flight inspection that lasted about 20 minutes. The CFI observed the private pilot check the oil in both engines. No problems with the airplane were reported to the CFI by the first pilot.

According to the CFI, the three occupants boarded the airplane and "... strapped in with the seat belts and shoulder harnesses." The private pilot went through the start-up checklist "... by the numbers..." and started both engines. The CFI stated that he did not perform any crewmember duties and was a "passenger" during this time. He stated that he remembered the private pilot contacting ground control and receiving clearance to taxi. The CFI stated that "...everything was operating normally..." at that point. After receiving the clearance, the private pilot said: "OK boys and girls, we're ready to taxi," or something similar. That is when the CFI's recollections of the accident flight end.

According to the FAA Air Traffic Control (ATC) transcripts, the airplane received clearance to takeoff from runway 28 at the Allegheny County Airport at 1342 hours. No other pertinent radio communications were recorded by any FAA facility following the acknowledgement of the clearance. According to ATC personnel at the Pittsburgh International Airport, recorded radar data was not available at the time of the accident due to equipment and software modifications in progress.

One witness, a pilot, was sitting on the rear deck of his home when he saw "... a twin engine, high tail, Duchess aircraft..." flying overhead about 1345. The witness's home is located about 2.5 miles southeast of the Rostraver Airport. The witness stated:

My attention was directed to the east/southeast and the sound of an aircraft with a wooshing air sound (such as when an [aircraft] is losing altitude quickly). A ... Duchess ... was observed in a steep descent from what appeared to be about [3,500 to 4,000 feet above the ground] on a heading of approximately 290 degrees to 300 degrees. The [aircraft] appeared to level out, with landing gear extended, above normal pattern altitude for Rostraver [airport]. As it leveled, an engine could be heard backfiring, but I could not detect if one engine was feathered or off. The [aircraft] then powered up, and began turning to the right as if to be entering a wide left down wind for Rostraver - Runway 25. The [aircraft] proceeded toward [the airport], and went out of sight. No other unusual noise could be detected.

According to flight instructors at O.T. Aviation, the area located to the east/southeast of Rostraver Airport is part of a practice area utilized for flight instruction.

According to another witness located about 1/2 mile from the Rostraver airport:

I was in my house [when the] plane went over the house, too low to hit the airport. [The plane] tried to turn around the hill (right in front of runway). He would have smashed into the hill the way he was going, so he turned to the right [about 30 degrees of bank as shown with model airplane], then disappeared into trees. I heard the crash about a second later. There was no fire or smoke coming from the airplane. I did not hear anything unusual before the crash - no popping or sputtering.

According to a resident who lives about 100 yards from the accident site: "I did not see the airplane, but I heard it roar loudly for a couple of seconds. It sounded like the engines were revving up. Then I heard a loud crash - then a dead silence."

The accident occurred during the hours of daylight at 40 degrees 12.85 minutes North, and 79 degrees 49.38 minutes West.

PERSONNEL INFORMATION

The CFI, age 57, was a commercial pilot and certified flight instructor with ratings for single and multiengine instrument airplanes. He was employed as the chief flight instructor at O.T. Aviation at the time of the accident. According to FAA records, he was issued an FAA Second Class Medical Certificate on May 7, 1994, with the limitation that he "must wear lenses for distant - possess glasses for near vision." An examination of the CFI's logbook revealed that he had a total of 5,533 hours of flight time, including 302 hours in type. The CFI also had 1,008 h...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# BFO94FA120