YV2466P – Beechcraft (Textron Aviation) C90 – 2001-06-14 NTSB Accident Report

HISTORY OF FLIGHT

On June 13, 2001, about 2122 eastern daylight time, a Beech C90, YV2466P, Venezuelan registered to a private individual, operating as a Title 14 CFR Part 91 personal flight, crashed while on final approach to Fort Lauderdale-Hollywood International Airport, (FLL) Florida. Night visual meteorological conditions prevailed and an international instrument flight plan had been filed. The aircraft was destroyed, a Venezuelan single engine private pilot-rated passenger in the right pilot's seat was fatally injured, and the left seated Venezuelan BE-90 rated captain was seriously injured, as was a passenger in the cabin. The flight originated from Caracas, Venezuela's Oscar Machado Zuloaga International Airport, (SVCS) at 1516 eastern daylight time.

According to the FLL tower controller who was directing the aircraft for landing, the flight was routinely handed off to his position from Miami Approach Control radar for a visual landing. When YV2466P made his initial radio call to FLL tower at 2117, he was given the following instructions, " YV2466P, you are number one for [runway] 9R, winds are 140 at 7, cross the shoreline at one thousand", [feet-altitude, msl]. At 2120, the tower controller transmitted, "2466P cleared to land." At 2121, the pilot of YV2366P transmitted, "I need the field, I have difficulties here...small problem with engine." The controller transmitted, "wind check, 140 at 8, no need to acknowledge", and estimated YV2466P was 500 feet agl, and 3/4 mile from the threshold to runway 9R with landing lights illuminated, when he momentarily directed his attention to an air carrier jet rolling out on the north runway. When he redirected his attention to runway 9R, he could no longer see YV2466P's lights.

PERSONNEL INFORMATION

The pilot held a private pilot certificate issued by the Republic of Venezuela on April 10, 1979. Endorsements on the license include the Beechcraft Bonanza 33A, Baron 55 and 58 with instrument, and BE-90 Captain. The pilot stated he owned VY2466P exclusively for 6 years, and that he was in the process of selling 6/7 ownership to a friend in Venezuela. Personal log books were not produced, but the pilot stated that he had accrued 3,203 flight hours total, with about 1,800 of those hours in the King Air aircraft. He stated his most recent proficiency check ride was on March 1, 1994. The pilot possesses a valid medical, (No. 7837) for private pilot that expires on November 30, 2001.

The pilot stated he was a principal and attorney for a business in Barcelona, Venezuela, known as Soltuca, a steel pipe factory. The flight was for the purpose of continuing on to Charleston, South Carolina, the following day for business meetings. The two passengers aboard were connected to the business, as well. The right seat occupant was the pilot's nephew and held a Venezuelan private pilot's license, with single engine rating.

AIRCRAFT INFORMATION

According to the type certification data sheets, the 1973 Beech King Air C90, Serial No. LJ-591, was manufactured with Pratt and Whitney PT6A-20 turbo-propeller engines developing 550 shp. YV-2466P's engine data plates revealed installation of PT6A-20A engines. The factory confirmed that the original PT6A-20's had been fitted with PT6A-27 propeller reversing and exhaust cases which effectively converts the -20 to a -20A engine. Both engines, Serial Nos. 24022 and 24032, had been overhauled by Pratt and Whitney Engine Services, West Virginia, on February 21, 1996. The aircraft underwent Beechcraft model 90 series phase inspections one through four on June 26, 2000, by Raytheon Aircraft Services, Inc., of Fort Lauderdale, Florida at an aircraft total time of 8052.3 hours. The latest entry in the log pages, dated December 13, 2000, showed accomplishment of phase one inspection at 1,258.5 hours since overhaul for both engines, 116.4 hours since overhaul for both propellers, and 8,168.7 hours on the airframe. The pilot reported the aircraft had flown 207 hours since last inspection. The hour-meter read 1904.35 at the accident site.

The aircraft was modified in accordance with STC SA00257AT; replacement of the original air-cooled nickel-cadmium battery with a Concorde RG-380E sealed lead-acid battery on June 26, 2000, by a Raytheon service dealer in Fort Lauderdale, Florida.

Prior to departure from Caracas, on the day of the accident, the aircraft underwent removal and replacement of the two left engine igniter plugs because of engine start problems. This information was not entered in the maintenance log pages, but was reported by the pilot.

Reference to the aircraft trip log sheets reveal that aircraft onboard fuel is adequate for non-stop flight between Caracas and Fort Lauderdale. Between November, 1998 and August, 1999, the aircraft flew the trip 15 times. Of those 15 trips, eight were flown with a fuel stop, (Port-Au-Prince or Nassau) and seven made the trip non-stop.

METEOROLOGICAL INFORMATION

The 2053 terminal weather observation for the FLL airport was, scattered clouds at 3,200 feet agl, scattered clouds at 14,000 feet agl, broken cloud layers at 25,000 feet agl, winds from 140 degrees at 5 knots, visibility 10 statute miles, a temperature of 84 degrees F, and an altimeter setting of 30.00 inches Hg.

According to radiosonde data for eastern North America and the Caribbean, a plot of contoured winds aloft at flight level 220, along the route of flight at about 2000 eastern daylight time, shows light cross winds from the east northeast during the first half of the flight, and light crosswinds from the southwest during the latter half of the flight. Analysis of the aloft wind's direction and speed with respect to the magnetic course of Amber 315 appeared to have contributed very little to the aircraft's ground speed.

WRECKAGE AND IMPACT INFORMATION

The aircraft's first impact with the terrain was onto road pavement near the centerline of an off-ramp two lane road that runs parallel to north-south oriented Interstate 95 (I-95), on its west side, or about 1,700 feet from the threshold of runway 9R, and about 700 feet south of centerline of the runway. The wreckage path was perpendicular to I-95 , was 33 feet in length, and terminated at a 15-foot vertical concrete wall that elevates I-95. Scars on the road and wreckage examination revealed first impact was the landing gear on the road hard enough to collapse all three gear struts, as well as bending the empennage and both wing outer panels downward before impacting the wall. The aircraft was in a slight left bank and very near longitudinally level when the three landing gear struck the road top. The concrete wall bore distinct imprints of the nose and both propeller spinners, as well as a tire mark from the separated left main wheel. The nose structure had been uniformly accordioned and the crushing extended to the base of the windscreen. The radome was missing, and pieces lay scattered at the base of the wall. The weather radar's antenna had been flattened and its mounting assembly was fractured. Both engines had broken loose from their respective engine mounts, and the extent of the under cowl crushing was difficult to determine because the cowlings, themselves, were so heavily accordioned and unmovable. Neither propeller was feathered. Both propeller spinners exhibited heavy crushing and were uniformly accordioned, front to rear. Behind the propeller spinners, both propeller domes had impacted the concrete wall and were cracked. No evidence of spinner rotation at wall impact was evident. Both propellers exhibited rearward bending of all three blades. Two blades of the left propeller exhibited rearward curled tips. Chord wise scarring at the tips from road surface impact revealed the propellers were turning in a low energy condition when the tips collided with the road pavement. Additionally, some propeller span wise burnishing was revealed due to the slide through the roadside grass and sand.

Examination of the fuel system revealed no fuel observed through any of the four overwing fuel filler openings which represent the left and right nacelle tanks and leading edge tanks. The four fuel filler caps fit tightly to the filler neck flanges, and no stains of in-flight fuel leakage were noted anywhere on the wings or nacelles. Both nacelle fuel tanks were subsequently found breached from impingement with accessory gear box and accessories during the crash sequence. Fuel found in the fuel lines and fuel filter housings of both engines totaled less than a pint. The wreckage salvager who moved the wreckage from the site to a hangar on the FLL airport stated about 3 gallons of fluid smelling like jet fuel leaked from the vicinity of the lower midsection during transit. The wreckage had been hosed down with a foam mixture from FLL airport crash/fire rescue personnel. The flaps were found in the "up" position, although the cockpit selector was in the "approach flap" position. Both outboard cockpit walls had been cut open by rescue personnel to facilitate pilot extrication. The front seat occupant shoulder harnesses had not been cut, and appeared to be unused during the accident. Both cockpit flight control columns were broken, but flight control continuity in all three axes was confirmed from the control surface to a point under the floorboards of the cockpit. The flight control trim tabs were all found near neutral positions, both by cockpit indicators and measurement of actuator control rods. Lenses were removed from the warning/caution lights on the glare shield annunciator panel for the purpose of examining the individual light filaments. The following lights had stretched or broken filaments: (1) "Fault Warning"- two light bulbs, both filaments stretched, (2) "RH Fuel Press"- two light bulbs, both filaments stretched, (3) "LH Fuel Press"- two light bulbs, both filaments stretched, (4) "LH Bleed Air Line Failure", filaments stretched, (5) "RH Bleed Air Line Failure", filaments stretched, (6) "RH Gen Out", filaments stretched, (7) "LH Gen Out", filaments stretched, (8) "RH Secondary Low Pitch Stop"-two light bulbs, both filaments broken. No other light bulbs in the annunciator panel revealed stretched or broken filaments.

Aboard the wreckage was found two sets of customs/immigration general declarations forms for the flight. The first set of forms was filled out for the Caracas to Nassau leg and exhibited the official Venezuelan immigration stamp. The second set was filled out for the Nassau to Fort Lauderdale leg with no stamp. No other forms were found aboard the wreckage.

MEDICAL AND PATHOLOGICAL

The pilot was extricated from the aircraft and transported to Memorial Regional Hospital, Hollywood, Florida, by emergency medical personnel. Hospital records listed his primary injuries as, left upper and forearm fractures, fractures of bones in the right hand, pelvis, and rib, pulmonary contusions, and forehead lacerations. Toxicological testing upon admittance revealed no ethanol detected in the blood.

Postmortem examination of the right cockpit seat occupant was conducted by Dr. Linda Rush, M.D. on June 14, 2001, of the Broward County Medical Examiner's office, District 17, Broward County, Florida. The right seat occupant's cause of death was listed as, multiple blunt trauma injuries secondary to an airplane crash. Toxicological tests were conducted at the Federal Aviation Administration Research Laboratory, Oklahoma City, Oklahoma. The urinalysis tests were negative for ethanol, basic, acidic, and neutral drugs.

According to hospital records, the third occupant, sitting in the cabin, facing backwards behind the pilot's seat, was admitted to Memorial Regional Hospital with leg injuries and released on June 16, 2001.

TESTS AND RESEARCH

On June 18, 2001, the pilot was interviewed in his hospital room at Hollywood Memorial Regional Hospital by NTSB personnel, accompanied by a Raytheon safety investigator. Prior to interviewing the pilot, the pilot's daughter stated that her father had flown to the U.S. about three times a month for the last few years, and that she believed that he always stopped at Nassau for fuel before continuing on to Fort Lauderdale. She did not know why he made no fuel stop this particular time. The pilot stated that he was an attorney and businessman in Venezuela, with a residence in South Florida, and that he and his passengers had planned to continue travel to a business meeting in Charleston, South Carolina the next day. He owned the aircraft for 6 years, and had flown about 1,700 hours total in the King Air type aircraft. The pilot's nephew was occupying the right seat, but was not rated on the King Air aircraft or any multiengine aircraft, and was not acting as copilot. He stated he thought neither front seat occupant was wearing the shoulder harness. As to the events leading up to the accident, the pilot mentioned his route of flight from Caracas to FLL was: SVCS direct to Maiquetia, ( MIQ), Amber Route-315 to Bimini, (ZBV), Bahama Route 57V to FLL, at flight level 220, with 7 hours 15 minutes of fuel aboard. At a position abeam and west of Nassau while still navigating on A-315 and with the fuel cross feed system on "AUTOMATIC", the " RH NO FUEL TRANSFER" light on the warning/caution annunciator panel illuminated, followed shortly by the "LH NO FUEL TRANSFER". When the pilot routinely shut off the fuel transfer pumps, the "FUEL CROSSFEED" light illuminated. This condition confused the pilot, and he stated that reference to the flight manual advised that if the fuel gages indicated that fuel aboard was at least 200 lbs. on each side or a total of 500 lbs. were aboard, it would be safe to continue to destination. Just prior to the accident, he stated that as he turned base leg for runway 9R at FLL, he started to lose the left engine. He stated that he observed no lights illuminated on the annunciator panel as he started to lose power on the left engine. At that point he, "got disturbed" and "lost control at 500 [feet, agl]". He stated he had no further memory of the actual crash or of any trouble with the right engine.

Numerous attempts through family members and pilot associates to deliver an NTSB form 6120 1/2 to the accident pilot in Venezuela resulted in no submission of a completed form, however, a Venezuelan DGAC accident form was eventually submitted. The pilot's written statement reflects the events as stated during his hospital interview, except he does not mention the illumination of the "FUEL CROSSFEED" light. His written narrative in the Venezuelan accident form states that after about 5:00 hours of flight, the "NO FUEL TRANSFER" lights illuminated, first the "RH", and then the "LH". This was a normal condition and occurred at the expected time. This would mean that the wing tank fuel was exhausted and that 60 gallons in the left and 60 gallons in the right nacelle tank remained. Once he was in the landing pattern for runway 9R at FLL, the motors failed, they shut down, and the accident resulted.

According to the pilot's operating handbook, fuel transfer operates in the following manner: Automatic fuel transfer from the wing tanks to the nacelle tanks [thence to the engine] begins when the "transfer pump" switches are turned on, unless the nacelle tanks are full. The nacelle tank will continue to fill until the fuel reaches the upper transfer limit and a float switch turns the pump off. As the engine burns fuel from the nacelle tank, fuel from the wing tanks transfers automatically. When all of the 132 gallons [each wing] are used from the wing tanks, a pressure switch reacts to a pressure drop in the fuel transfer line, at which time the transfer pump shuts off and the annunciator panel illuminates a "LH (or) RH NO FUEL TRANSFER". The "NO FUEL TRANSFER" light will also illuminate if the transfer pump fails, at which time gravity feed from the wing to the nacelle tank occurs.

The fuel crossfeed system operates in the following manner: The crossfeed system is controlled by a three position switch placarded: "OPEN", "CLOSED", OR " AUTO". Under normal conditions it is left in the "AUTO" position. In this position, fuel pressure switches are connected into the crossfeed control circuit. These switches open the crossfeed valve automatically if a drop in line pressure is sensed, either by a failed boost pump or a lack of fuel in a wing tank. This allows the remaining boost pump/fuel tank to supply both engines with fuel under pressure during emergency operations. When the "FUEL CROSSFEED" light illuminates, the crossfeed valve is open.

The Hartzell propellers, part no. HC-B3TN-3B, serial Nos. BUA 23361 and BUA 23411, were examined, post crash, at a fixed base operator on the Fort Lauderdale Executive Airport on July 13, 2001. No precrash anomalies with the propellers or their respective components were noted.

The PT6A-20A engines, serial numbers 24022 (LH) and 24032 (RH) were shipped to the Pratt and Whitney Canada Engine Service Center, Atlanta, Georgia, for post crash examination by Pratt and Whitney Canada, Raytheon, and NTSB air safety investigators. Both engines revealed identical impact damage. The compressor turbine disc and the power turbine disc of each engine had compressed against each other. The scrape signatures on each respective disc were indicative of low or no rotation at ground and wall impact. According to the Pratt and Whitney Canada Accident Report No. TL-1694, dated 29 October 2001, "The left hand engine displayed minor impact damage and no fire damage. Very light circumferential rubbing was displayed by the compressor turbine, the power turbine guide vane ring and interstage baffle, and the power turbine due to their making axial contact with their adjacent components under impact loads and external housing deformation. The power turbine shroud displayed very light rotational scoring due to radial contact with the power turbine blade tips. The right hand engine displayed minor impact damage and no fire damage. Very light circumferential rubbing was displayed by the compressor turbine, the power turbine guide vane ring and interstage baffle, and the power turbine due to their making axial contact with their adjacent components under impact loads and external housing deformation. The power turbine shroud displayed very light rotational scoring due to radial contact with the power turbine blade tips. Both the left and right hand engines displayed light rotational contact signatures to their internal components characteristic of the engine being unpowered, and rotating under air loads, at the time of impact. None of the engine components displayed any indications of pre-impact anomalies that would have precluded normal engine operation prior to impact." The engine factory disassembly examination report is an attachment to this report.

According to a fuel receipt from BP Oil Venezuela Limited, Caracas Airport, on June 13, 2001, at 1210 Atlantic daylight time, the pilot of YV-2466P purchased 144 liters, (38 gallons) of jet A fuel for an international flight to Nassau. It could not be confirmed if the fueling represented a "top off", but the pilot stated that he, personally, determined that the fuel tanks were full as the aircraft sat on the Venezuelan customs ramp prior to departure. The fueler forwarded a fuel contamination check report dated June 18, 2001, indicating the fuel was clear and uncontaminated. Type certification data sheets for the C90 state that the unusable fuel aboard is 24 lbs., (3.6 gallons of Jet-A fuel). The "Fuel System" subsection of the pilot's operating handbook states, "To assure that the system is properly filled, service the nacelle tank first, then the wing tanks."

According to a copy of the pilot's filed flight plan, the filed TAS was 350 knots at 22,000 feet msl, which may have been an error in filing since the FAA air traffic control, (ATC) "strip" showed the filed TAS as 250 kts. Reference to the performance and planning section of the pilot operating handbook, borrowed from the wreckage, for a cruise altitude of 22,000 feet msl, at a takeoff gross weight of 9,612 lbs., (basic operating aircraft weight of 6,535 lbs. with full fuel tanks and three persons on board) gives a TAS range of 186 kts. to 223 kts., depending on temperature and choice of either maximum range cruise or maximum recommended power cruise. In actuality, the ATC radar tracking data recorded his ground speed as 243 kts. Manually calculating the aircraft cruise speed using known ATC tracking data yielded about a 220 kt. ground speed. A copy of the flight plan as well as ATC tracking data are attachments to this report.

ADDITIONAL INFORMATION

The wreckage, less those items listed on the NTSB Wreckage Release form 6120.15, were released to a representative of the operator and signed on June 16, 2001. All items retained by the NTSB and listed on the form 6120.15 were returned to a representative of the operator on August 15, 2001. The engines were returned to a representative of the operator on September 13, 2001, and signed for on March 20, 2002.