N28MRZenith Aircraft ZODIAC 601 XL · 2015

On August 7, 2010, about 0920 eastern daylight time, a Beech 58, N28MR, descended into a house near Saltsburg, Pennsylvania. The certificated commercial pilot and certified flight instructor (CFI) were killed. The airplane sustained substantial damage and the occupied house was destroyed, while an occupant of the house was not injured. The airplane was registered to Sataire LLC, and operated by the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as an instructional flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The flight originated from Arnold Palmer Regional Airport (LBE), about 0908.

According to a transcription of communications with the LBE Air Traffic Control Tower, and a certified copy of the voice tape, an occupant of the airplane contacted ground control which was combined with the local control position and requested taxi clearance from the east ramp to runway 23, with a departure to the northwest for "…some airwork." The flight was cleared to taxi to runway 23, and review of the voice tape revealed the same occupant contacted local control and advised the controller that the flight was ready to depart. The local controller cleared the flight for takeoff from runway 23 with a right turn approved. That transmission was acknowledged by the occupant; there was no further recorded communications from the accident flight.

One witness who was outside reported hearing sputtering sounds from an engine, then observed the airplane flying in level flight in a westerly direction. She then noted that the wings were teeter-tottering followed by seeing the nose pitch down. She then saw the airplane in a spin descending in a nose-low attitude. Another witness who was also outside reported hearing spitting and sputtering sounds from the engine and looked up seeing the airplane flying in level flight in a northwesterly direction with little white puffs of smoke coming out of both engines. The witness attributed the smoke to be coming from the sputtering engines, but once the engines restarted 3 or 4 seconds later, the smoke stopped, but the spitting and sputtering started again followed by the puffs of smoke. The witness reported the engines stopped operating and to him it appeared that the airplane slowed, followed by the airplane drifting to the left side and left wing dipped down. The airplane started a 45 degree nose and left wing low descent spinning to the left. The witness described seeing pencil streams of smoke trailing both engines during the descent with the streams twisting behind the airplane like licorice candy.

Several witnesses reported hearing abnormal engine sounds, followed by seeing the airplane in a left spin, or spiraling down which continued to the ground. One witness heard the engine quit and restart several times, then rev up loudly after the third restart. Several witnesses reported to the Federal Aviation Administration (FAA) inspector-in-charge seeing smoke or vapor trailing both wings. One witness reported seeing the airplane in a slow left spin, which continued until the airplane went down below the tree line. The witness then heard the impact and saw rising smoke.

The occupant of the house who was in the basement reported he was asleep on a couch and was awakened by a violent noise. House debris was blown into the basement, and he immediately got up, got his dog, and went outside where he called 911 to report his house was on fire, which burned incredibly fast. While outside he noticed a portion of a wing beyond the edge of the roof, and could also distinguish a "chrome propeller."

Uncorrelated radar data for airplanes transmitting VFR transponder code (1200) at the departure airport and surrounding area for the approximate takeoff and accident times was provided by the FAA. Review of the supplied data revealed at 0909, or approximately 1 minute after the flight was cleared for takeoff, a target at 2,000 feet mean sea level (msl) was noted approximately 240 degrees and 0.6 nautical mile from the departure end of runway 23. The target proceeded in a north-northwesterly direction and climbed to approximately 3,600 feet msl. At approximately 0914, the radar data indicates the target turned 360 degrees to the left while maintaining approximately 3,600 feet msl; the turn took slightly less than 2 minutes. The radar data indicates the target briefly resumed the north-northwesterly heading, before turning 360 degrees to the left again, while maintaining approximately 3,600 feet msl. The second turn took less than 1 minute and at the completion of the turn, the target briefly continued north-northwesterly before turning 360 degrees to the right while maintaining approximately 3,600 feet msl. The right turn took approximately 1 minute to complete, then the target was noted proceeding on the north-northwesterly heading. While continuing on that heading the target climbed to a maximum altitude of 4,200 feet msl which occurred at 0919:31, and the groundspeed slowed to 137 knots. The target remained at that altitude until 0919:44, during which time the groundspeed was recorded to be 127 knots. The next radar target with altitude and groundspeed at 0919:45, indicates the altitude was 3,900 feet, the heading was 292 degrees, and the groundspeed was 113 knots. The radar data indicates that between 0919:45, and 0919:53, the altitude remained constant at 3,900 feet, the groundspeed decreased from 111 to 81 knots, and the heading changed from 290 to 194 degrees. The next and last radar target at 0919:57, indicates the airplane was at 3,900 feet, the groundspeed was 70 knots, and the heading was 323 degrees. The last radar target was located at 40 degrees 28 minutes 55.59 seconds North latitude and 079 degrees 30 minutes 58.47 seconds West longitude, or approximately 137 degrees and 900 feet from the accident site location.

The pilot, age 65, held a commercial pilot certificate with rating(s) airplane single and multi-engine land, instrument airplane. On August 3, 2007, a notice of disapproval of application was prepared indicating that during a practical test in a level D simulator for a Cessna 510 airplane, the pilot failed several areas including powerplant failure during takeoff. He received 6.0 hours of additional training and on August 14, 2007, he obtained a type rating in a Cessna 510 airplane with a limitation that a second-in-command was required because he did not meet the single pilot proficiency requirement. There were no other records of failures for any pilot certificate or additional rating(s). He held a second class medical certificate with no medical restrictions or limitations issued November 23, 2009. On the application for his last medical certificate he listed 3,200 hours as his total flight time. There were no records of enforcement action or previous accidents or incidents in the FAA database.

Three pilot logbooks were presented documenting his flight time from May 16, 1967, to the last entry in logbook No. 3 dated November 5, 1999. Although a current pilot logbook was not located, copies of pilot logbook pages, and spreadsheet pages were provided to NTSB documenting his flight time from July 15, 2006, to January 3, 2010. Review of the logbooks, copies of pilot logbooks pages, and spreadsheet pages reflect flights in multi-engine airplanes consisting of Hawker Beechcraft 58 and B60, Cessna 340 and 510 (N75ES), and Piper PA-60. He logged a total multi-engine flight time of approximately 1,516 hours, of which approximately 560 hours were accrued in the accident make and model airplane between July 21, 1983, and March 21, 1990.

The CFI, age 66, was a FAA designated pilot examiner (DPE), and held an airline transport pilot certificate with airplane multi-engine land and instrument airplane ratings. He also held commercial and certified flight instructor (CFI) certificates. The commercial pilot certificate was endorsed with airplane single engine land rating, and the CFI certificate was endorsed with airplane single and multi-engine, instrument airplane ratings. At the airline transport pilot certificate level he was type rated in a Hawker Siddeley HS-125, Lockheed L-1329 (Jetstar), and Learjet LR-60 airplanes. He held a first class medical certificate issued June 14, 2010, with a restriction to wear corrective lenses. On the application for his last medical certificate he listed 23,250 hours as his total flight time. There were no records of enforcement action or previous accidents or incidents in the FAA database. On March 25, 2008, a notice of disapproval of application was prepared indicating that during a flight test in a level D simulator for a Learjet 60 airplane, the pilot failed the powerplant failure during takeoff procedure. There were no other records of failures for any pilot certificate or additional rating(s).

The airplane was manufactured in 1982 by Beech Aircraft Corporation as model 58, and was designated serial number TH-1328. At the time of the accident, it was powered by two 300 horsepower Teledyne Continental IO-550-C engines and equipped with 2 four-bladed Hartzell HC-C4YF-2E constant speed full manual feathering propellers. It was also equipped with vortex generators and a throw-over control yoke.

Review of the maintenance records revealed the airplane was last inspected in accordance with an annual inspection on March 8, 2010. The airplane total time at that time was 1,809.8 hours. The destruction of the airplane precluded determination of the airplane total time at the time of the accident.

A surface observation weather report taken at the departure airport at 0950, or approximately 30 minutes after the accident indicates the wind was from 230 degrees at 5 knots, the visibility was 9 miles, and clear skies existed. The temperature and dew point were 21 and 17 degrees Celsius respectively, and the altimeter setting was 30.02 inches of Mercury. The accident site was located approximately 14 nautical miles and 338 degrees from LBE.

Examination of the accident site revealed the house was destroyed by fire. Tall trees surrounding three sides of the house did not exhibit any evidence of contact by the airplane; however, the foliage exhibited heat damage. Further examination of the accident site revealed one cargo door and the outer 11 feet of the left wing were located outside of the house, but were in very close proximity to the basement walls.

The majority of the recovered wreckage was found in the garage or in close proximity to the garage. The entire airplane was nearly consumed by the postcrash fire. The left propeller was separated from the engine but found inside the garage, while the right propeller remained attached to the engine which was also found inside the garage. Both engines and propellers were retained for further examination. The right engine crankshaft was rotated approximately 180 degrees to facilitate removal of the propeller.

Excavation of the house debris was performed in an effort to locate parts or components of the airplane. Recovered components of the airplane consisted of both engines, both propellers, components of the landing gear system, seat components, avionics, several flight and engine instruments, fuel system components consisting of the fuel selector panel and a fuel selector valve, flap system components consisting of the flap actuators, and a portion of the control column. All recovered components with the exception of the components found away from the interior of the house exhibited extensive heat damage.

A portion of the control column with attached single duplex chain sprocket and chain was recovered from the garage. Based on the position of the filet inside the sprocket end on the lower hemisphere of the control column, the throw-over control yoke was positioned to the left side. The left aileron trim actuator was located and found to be extended 1 22/32 inches, which equates to 4.75 degrees trailing edge tab down. Both flap actuators and the recovered fuel selector valve were extensively heat damaged which precluded determination of their positions. Flight instruments, engine instruments, and avionics were recovered and found to exhibit extensive heat damage.

Examination of the left engine revealed extensive heat damage which precluded a formal disassembly. Using mechanical means, the engine crankcase was cut in several areas to view the crankshaft which was not fractured. The camshaft was able to be viewed because the engine oil sump was burned away; the camshaft was not fractured. A detailed examination report with accompanying pictures is contained in the public docket for this accident.

Examination of the right engine revealed extensive heat damage which precluded an engine run. Disassembly inspection of the engine revealed crankshaft, camshaft, and valve train continuity. No lubrication distress was noted on any of the lubricating system components. Inspection of the fuel pump revealed it exhibited thermal damage and could not be rotated by hand. Removal of the fuel pump from the engine revealed the drive coupling was fractured. Disassembly of the fuel pump revealed the vanes did not exhibit any abnormal wear. Disassembly of the fuel manifold valve revealed thermal damage; the diaphragm was thermally destroyed. The plunger assembly was secure. Inspection of the fuel nozzles revealed all were unrestricted and exhibited thermal discoloration. The ignition harness and left magneto which could not be rotated by hand exhibited extensive thermal damage. The right magneto was able to be rotated by hand; however, disassembly revealed extensive thermal damage. The top and bottom spark plugs exhibited normal wear signatures when checked with the Champion Aviation check-a-plug comparison chart. The engine-driven fuel pump was retained for further examination. A detailed examination report with accompanying pictures is contained in the public docket for this accident.

Examination of the left and right propellers indicated both propellers exhibited extensive postaccident thermal damage. The examination of the left propeller revealed all blades were melted outboard of the blade counterweights; the outboard portions of the blades were missing. All four propeller blades and the piston were at a low pitch position. The preload plates on the butt end of each blade could not be examined in an effort to determine witness marks because the propeller hub could not be split apart. The low pitch stop, feather stop, and start locks were missing. The examination of the right propeller revealed all four propeller blades were at a low pitch position. Discoloration of the pitch change rod indicated it was at a low pitch position during the postaccident fire. The preload plates did not have impact marks that could be used to calculate blade angle; however, rust discoloration from the rusted fork indicated the fork was at a low pitch position. The blade marked “R1” was straight but the outer half of the blade was melted/missing, while the blade marked “R2” was bent aft approximately 90 degrees but was not twisted. The blades marked “R3” and “R4” were melted/missing outboard of the blade counterweights. All four propeller blade pitch change knobs were not fractured and all four propeller blade counterweights were “intact.” The low pitch stop exhibited an impact mark, the feather stop was unremarkable, and the start lock was undamaged except for thermal damage to the springs. A detailed examination report with accompanying pictures is contained in the public docket for this accident.

Postmortem examinations of the pilot and CFI were performed by the Cyril H. Wecht and Pathology Associates, Inc., Pittsburgh, Pennsylvania. The cause of death for both were listed as blunt force trauma of chest with a descending list or additional injuries.

Forensic toxicology was performed on specimens of the pilot and CFI by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, and also NMS Labs, Willow Grove, Pennsylvania. The toxicology report for the pilot by FAA stated the results were negative for carbon monoxide, cyanide, and volatiles. An unquantified amount of naproxen and quinine were detected in the urine specimen. The toxicology report for the pilot by NMS Labs was positive in the blood (10 percent) carbon monoxide.

The FAA toxicology report for the CFI indicated the results were negative for carbon monoxide, cyanide, volatiles, and drugs of abuse, while the result of analysis by the NMS Labs was negative.

On the day of the accident, a total of 119 gallons of 100 low lead (100LL) fuel were added to the airplane. The individual who performed the fueling stated that he filled only the inboard fuel tanks as requested by the pilot. There were no reported discrepancies related to other airplanes fueled from the same source.

At the time the airplane was manufactured, it was equipped in part with two Teledyne Continental IO-520-CB engines each rated at 285 horsepower at 2,700 rpm. The Pilot’s Operating Handbook and FAA Approved Airplane Flight Manual (POH/AFM) specified that the air velocity minimum single engine control speed was 81 knots indicated.

As previously reported, the airplane was equipped with vortex generators (VG’s) on the wings and vertical stabilizer, which according to the maintenance records were installed in accordance with (IAW) supplemental type certificate (STC) SA4016M on August 22, 1989. The maintenance record entry also indicates that a new airspeed indicator was installed. Documents associated with the STC indicate the air velocity minimum single engine control speed was marked on the airspeed indicator as being 74 knots.

The maintenance records also reflect that on January 12, 1999, the airplane was modified by installation of different engines and propellers, modification of the engine nose cowlings, and installation of winglets. The work was performed IAW STC SA1762SO, and although the FAA 337 Form associated with the STC was not in the FAA records located in Oklahoma City, Oklahoma, it was located with the original records that were inspected by NTSB and FAA several days after the accident. The 337 Form was signed off by the STC holder. The newly installed engines were each 15 horsepower greater than the horsepower for each engine installed when the airplane was manufactured. The “Limitation and Conditions” section of the STC indicated that, “This approval should not be extended to other aircraft of this model on which other previously approved modifications are incorporated, unless it is determined by the installer that the interrelationship between this change and any other previously approved modifications will not produce adverse effect upon the airworthiness of that airplane….” The Pilot’s Operating Handbook and FAA Approved Airplane Flight Manual (POH/AFM) supplement associated with the STC indicates the air velocity minimum single engine control speed was 87 or 88 knots indicated. The installation instructions specified that the airspeed indicator was required to be marked as specified in the flight manual supplement.

According to the current STC holder pertaining to the engines and propellers, no flight testing was performed to determine the interrelationship between their STC and the STC pertaining to the vortex generator installation. Further, the FAA does not provide any guidance to an installer in an effort to determine STC compatibility.

The previous airplane owner provided several pictures of the instrument panel which were reportedly taken in July 2007. Review of the makings of the airspeed indicator revealed the air velocity minimum single engine control speed remained marked on the faceplate at 74 knots indicated.

The previous owner of the airplane flew it 5 days before the accident date, which was 1 day before the accident pilot purchased it. He reported performing a simulated engine failure on takeoff at 80 knots, no discrepancies were reported. The flight departed and he operated the autopilot with no discrepancies noted. The flight returned for an uneventful landing approximately 10 to 15 minutes after takeoff. There were no reported discrepancies pertaining to the airplane. He did not recall the hour meter reading at the end of the flight. He also reported that with respect to the throw-over control yoke, he tried to reposition it to the other side during a previous flight with a certified flight instructor on-board, and reported it was difficult.

As previously reported, the pilot-in-command had flown a Cessna 510 airplane but was required to have a second-in-command on-board because he did not meet the single pilot proficiency requirements. Interview of a pilot who had flown with the pilot for about 50 percent of the approximately 124 hours flown in the Cessna 510 airplane revealed he was not aware that he had flown a reciprocating engine airplane between the time the accident pilot’s corporation owned the Cessna 510 airplane (August 22. 2007, to March 8, 2010), and his purchase of the accident airplane. It was later learned that the accident pilot flew the accident airplane on August 5, 2010, and three full stop landings were performed. Following the first landing the pilot reported to the controller that the “landing was a little hot.” The individual who flew with him in the Cessna 510 airplane also stated that he most of the operational issues were related to approaches or speed control, but in his opinion, the pilot knew his procedures.

The accident pilot purchased the airplane on August 3, 2010; however, FAA records indicated he previously owned it from July 1, 1985, to November 3, 1988. The insurance company did not require a check out in the accident airplane, but a broker with the insurance company “suggested” he get a multi-engine instrument proficiency check ride as a result of his purchase in 2010.

Review of the POH/AFM revealed the systems description section indicates that the optional dual control column is required for flight instruction. The POH/AFM also indicates that FAA regulations do not, “require spin demonstration of airplanes of this weight; therefore, no spin tests have been conducted. The recovery technique is based on the best available information.”

Examination of the right engine-driven fuel pump and fractured coupling was performed at the Safety Board’s Materials Laboratory located in Washington, DC. The results of the examination revealed the coupling was fractured at the reduced diameter portion. The fracture surface was flat and perpendicular relative to the length of the axis and exhibited a circular texture consistent with ductile overstress separation in torsion mode. No evidence of pre-existing fracture was found on the fracture faces of the coupling or other areas of the pump.

Title 14 CFR Part 91.109(a) states that no person may operate a civil aircraft that is being used for flight instruction unless that aircraft has fully functioning dual controls. As previously reported, the airplane was equipped with a throw-over control yoke.

There was no record with the FAA that the CFI/DPE had an exemption to conduct flight instruction in an airplane equipped with a throw-over control yoke.