NTSB Factual Report

HISTORY OF FLIGHT

On June 22, 2005, about 1800 mountain standard time, a Beech BE76, N5274M, impacted level terrain during an attempted go-around at Glendale Municipal Airport (GEU), Glendale, Arizona. Makarion Institute of Aeronautics (MIA) was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI), the commercial pilot undergoing instruction (PUI), and one passenger sustained minor injuries; the airplane was destroyed during the post impact fire. The local instructional flight departed Glendale about 1700. Visual meteorological conditions prevailed, and no flight plan had been filed. The approximate global positioning system (GPS) coordinates of the primary wreckage were 31 degrees 32.05 minutes north latitude and 112 degrees 17.25 minutes west longitude.

The National Transportation Safety Board investigator-in-charge (IIC) interviewed the CFI who related that the training flight was to indoctrinate the PUI with the Beech BE76 (Duchess). After demonstrating a couple of single engine maneuvers with the left engine shutdown, they attempted to restart the engine but were unsuccessful. During the subsequent attempts to start the engine they could smell burning insulation and saw a trace of smoke coming from behind the right side of the instrument panel. The CFI said he performed the emergency procedures for an electrical fire in flight as specified in the Federal Aviation Administration (FAA) approved flight manual. During the checklist, he found the number 2 electrical bus circuit breaker had popped. With a loss of all of the aircraft radios and instruments except for the number 1 radio/GPS and the fuel gauges, he decided to return to GEU.

While flying back to GEU they transitioned past Phoenix Goodyear Airport (GYR), Goodyear, Arizona. The CFI contacted GYR tower, and requested and received clearance to transition Goodyear's airspace.

When the CFI contacted GEU tower he requested a straight in approach to runway 01 due to single engine operations. The CFI reported that he did not declare an emergency or request priority handling due to the electrical problems and inability to restart the left engine. On final, the CFI attempted to extend the landing gear by use of the manual extension procedures. He observed that the nose gear down indicator failed to illuminate. The CFI contacted GEU tower and asked them if the nose gear was down. The controller told him that the nose wheel did not appear to be down and directed the CFI to go around. The CFI aborted the landing and tried to circle around to land on runway 19. The CFI said he was finally able to extend the landing gear, and declared an emergency because the airplane was not able to maintain altitude. The airplane landed about 1/4-mile north of runway 19 in an open dirt field. After the CFI, PUI, and the passenger exited the airplane the grass caught fire and the post impact fire consumed the airplane.

PERSONNEL INFORMATION

Certified Flight Instructor (CFI)

A review of FAA airman records revealed that the CFI held an airline transport pilot certificate with ratings for airplane single and multiengine land; and a certified flight instructor (CFI) certificate with ratings for airplane single and multiengine land, and instrument airplane. He also held a private pilot (foreign based) certificate with ratings for airplane single engine land and instrument airplane.

The CFI held a first-class medical certificate issued on June 28, 2004, with the limitation that he must wear corrective lenses.

The pilot reported a total flight time of 2,100 hours. He logged 108 hours in the last 90 days, and 19 hours in the last 30 days. He had an estimated 200 hours in the accident make and model, and had completed a biennial flight review on March 14, 2005.

Pilot Under Instruction (PUI)

A review of FAA airman records revealed that the PUI held a commercial pilot certificate with ratings for airplane single and multiengine land, and airplane single engine sea, and instrument airplane. He also held a flight instructor certificate with ratings for airplane single engine land and instrument airplane.

According to FAA records, the PUI held a first-class medical certificate issued in December 2004, with the limitation that he must wear corrective lenses.

The PUI reported he had a total flight time of 908 hours. He logged 120 hours in the last 90 days, and 60 in the last 30 days. He had no prior flight time in the accident make and model. He completed a biennial flight review on February 22, 2004.

AIRCRAFT INFORMATION

The airplane was a Beech BE76 (Duchess), serial number ME-24. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 5,658.9 hours at the last 100-hour inspection, dated May 19, 2005. The tachometer read 509.9 at the last inspection, and the Hobbs hour meter read 2,112.1. On June 16, 2005, a repair was performed replacing the ball joints on the nose gear doors, and replacement of a bolt and a nut on the right main landing gear torque links. Some fiberglass repairs were also performed. At that time, the tachometer read 565.4; the Hobbs meter read 2,175.6. On June 22, 2005, the number 2 Navigation-indicator was repaired. At that time, the tachometer read 584.5; the Hobbs hour meter read 2,197.7. The operator reported a total airframe time of 5,748 at the time of the accident.

The left engine was a Lycoming, O-360-A1G6D, serial number L-24652-36A. Total time recorded on the engine at the last 100-hour inspection was 5,671.8 hours; time since major overhaul was 1,556.6 hours. The operator reported a total time of 5,798 hours at the time of the accident, with 1,633.4 hours since the last major overhaul.

The right engine was a Lycoming, O-360-A1G6D, serial number L-124-71A. Total time recorded on the engine at the last 100-hour inspection was 5,670.2 hours; time since major overhaul was 1,611.1 hours. The operator reported a total time of 5,747 hours at the time of the accident, with 1,687.9 hours since the last major overhaul.

Both the left and right propellers were inspected during the 100-hour inspection.

Examination of the maintenance records did not reveal any unresolved maintenance discrepancies against the airplane prior to departure.

METEOROLOGICAL CONDITIONS

The airport weather observation station issued an aviation routine weather report (METAR) for Glendale at the time of the accident. It stated: winds variable at 4 knots; visibility 20 statute miles; skies were reported as few clouds at 15,000 feet and a scattered cloud layer at 20,000 feet; temperature 43 degrees Celsius; and altimeter 29.67 inHg.

AIRPORT INFORMATION

The Airport Facilities Directory (A/FD) indicated that runway 01 and runway 19 were both 7,150 feet long and 100 feet wide. The runway surfaces were asphalt. Runway 01 had a displace threshold of 700 feet. Runway 19 had a displace threshold of 1,000 feet. The A/FD reported a right-hand traffic pattern for runway 01, and a left-hand traffic pattern for runway 19. Additional remarks indicated that there were high-tension power lines 1/4 mile west and parallel to the runway.

TESTS AND RESEARCH

The Safety Board IIC examined the wreckage at Air Transport, Phoenix, Arizona, on June 23, 2005. Raytheon was a party to the investigation.

Investigators manually rotated the left engine's crankshaft via the propeller. The crankshaft rotated freely, and the valves moved approximately the same amount of lift in firing order. The gears in the accessory case turned freely, and thumb compression was obtained on all cylinders in firing order.

Investigators manually rotated the left engine's magnetos, and both magnetos produced spark at all posts for each cylinder. Investigators visually observed that the starter for the left engine was still in engaged.

The Raytheon representative determined that the left propeller was in the feathered position. He measured the unfeathering accumulator pressure at approximately 5 pounds per square inch (psi) on the left engine and zero psi on the right engine.

The airframe manufacturer's representative determined that the left main landing gear appeared to be in the down position. He measured the flaps' jackscrew assembly at 6 inches, and determined that the left torque tube was in the retraced position, which corresponded to the full UP position. The representative visually determined that the elevator trim tab was in the 7-degree nose up position. The rudder was visually observed to be deflected 15 degrees to the left, which the airframe representative indicated was consistent with an inoperative left engine.

The cockpit area, right engine, and right wing were destroyed as a result of the post impact fire.

The Pilots Operating Handbook and FAA Approved Airplane Flight Manual (POH) for the Beechcraft Duchess 76 provided the following emergency procedures for an air start. The procedures included a note that airspeed should be maintained at or above 100 indicated airspeed (KIAS) to ensure the engine will windmill. With unfeathering accumulators, the following procedure was identified:

1. Fuel Selector - ON

2. Throttle - Set approximately ¼ travel

3. Aux Fuel Pump - ON

4. Magneto/Start Switch - BOTH

5. Propeller Control - MOVE FULL FORWARD UNTIL ENGINE WINDMILLS, AND THEN BACK TO MIDRANGE. USE STARTER MOMENTARILY UNTIL AIRSPEED IS BELOW 100 KTS.

Prior to the next step, the procedures instruct that "if the propeller does not unfeather or the engine does not turn, proceed to the WITHOUT UNFEATHERING ACCUMULATORS procedure."

The continued procedures were as follows:

6. Mixture - FULL RICH

7. If engine fails to run, clear engine by allowing it to windmill with mixture in the full lean position. When engine fires, advance mixture to full rich.

8. When engine starts - adjust throttle, propeller and mixture controls.

9. Aux Fuel Pump - OFF (when reliable power has been regained)

10. Alternator Switch - ON

11. Oil pressure and oil temperature - CHECK

12. Warm up engine (approximately 2,000 rpm and 15 in. HG)

13. Set power as required and trim.

The emergency procedures without unfeathering accumulators per the POH are as follows:

1. Fuel selector - ON

2. Throttle - Set approximately 1/4 travel

3. Aux fuel pump - ON

4. Magneto/Start Switch - BOTH

5. Mixture - FULL RICH

6. Propeller control - MOVE FORWARD OF FEATHERING DETENT TO MIDRANGE

7. Magneto/start switch - START and PUSH TO PRIME (hold on START until windmilling begins and continue to prime as required)

Prior to the next step, the procedures note that if an air start is unsuccessful, return the propeller control to the feather position and secure the engine. Steps 8 through 13 then continue the same as noted above.

The POH provided the following emergency procedures for electrical smoke or fire, with consideration for the existing conditions and equipment installed:

1) Battery and alternator switches - off (the instructions warn that electrically driven instruments and stall warning horn will become inoperative);

2) All electrical switches - off;

3) Battery and alternator switches - on; and essential electrical equipment - on (isolate defective equipment).

The POH contains a note to ensure that the fire is out and will not be aggravated by drafts. It instructs the pilot to turn off the cabin heat switch and push in the cabin air control. Also in the emergency procedures under the section titled simulated one-engine inoperative, referred to as a zero thrust (simulated feather), the POH indicated:

Use the following power setting (only on one engine at a time) to establish zero thrust. Use of this power setting avoids the difficulties of restarting an engine and preserves the availability of power to counter potential hazards.

1. Throttle Lever - Set 8.0 in. Hg Manifold Pressure

2. Propeller Lever - Retard to Feather Detent

Note: This setting will approximate Zero Thrust using recommended one-engine-inoperative climb speeds.

ADDITIONAL INFORMATION

The IIC released the wreckage to the owner's representative on June 30, 2005.

NTSB Probable Cause

the flight instructor's decision to attempt a single engine go-around with multiple aircraft system failures, and his improper in-flight decision to pass up one airport for landing and continue the flight to the home base airport with known mechanical deficiencies.