NTSB Factual Report

HISTORY OF FLIGHT

On September 2, 2010, about 1151 Pacific daylight time, a Beechcraft Model 65 Queen Air, serial number LC-112, and registered as N832B, was substantially damaged when it impacted a salt-water lagoon shortly after takeoff from runway 30 at San Carlos Airport (SQL), San Carlos, California. The certificated airline transport pilot, the pilot-rated airplane owner, and the passenger received fatal injuries. The flight was operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was destined for South County Airport of Santa Clara County (E16), San Martin, California.

According to the local controller in the SQL air traffic control tower (ATCT) who was handling the flight, the pilot requested, and was approved, for the "Bay Meadows" departure. The departure consisted of a climb on runway heading to a point about 3 miles beyond the end of the runway, followed by a left turn, while remaining clear of the overlying Class B airspace for San Francisco International Airport (SFO). The controller reported that the airplane appeared to climb normally, and when it was about 1/2 mile beyond the runway, the controller observed the airplane make a "slight right rudder turn" and then correct back. About 3 to 4 seconds later, the local and ground controllers observed the airplane roll and turn to the right, and descend steeply out of sight. Many other witnesses reported a sequence of events similar to that observed by the controllers, but a few reported that the pitch excursion began before the roll excursion. All agreed that the airplane banked sharply to the right, followed closely by the nose pointing towards the ground. None reported a spin, and an ex-airline pilot was certain that the airplane did not spin.

No radio transmissions regarding the event were received from the airplane. Ground-based radar tracking data indicated that the airplane reached a maximum altitude of 500 feet, and that the airplane was airborne for about 40 seconds. Witnesses who saw the impact all reported that the airplane descended at a steep angle, in a nose-down attitude. The airplane struck the water in the shallow lagoon, and sank within a few minutes. First responders recovered the passenger shortly after the accident. The airplane was recovered from the lagoon about 30 hours after the accident.

PERSONNEL INFORMATION

Front Left Seat Occupant

According to FAA records, the individual in the front left seat held an airline transport pilot certificate, as well as flight and ground instructor certificates. He was 72 years old, and his most recent FAA second-class medical certificate was issued in April 2010. At the time of that application, he reported 18,000 total hours of civilian flight experience. A "Pilot History Form" for that individual, which contained hand-written entries and his signature, was recovered from the wreckage. That form was dated September 2009, and was part of an airplane insurance application/information package for the accident airplane and the registered owner. The form listed the individual's occupation as "aviator," and the date of his most recent flight review as January, 2008. He reported his total hours "Flying Hours as Pilot-in-Command" as "18k+," including "6k+" in the accident airplane make and model, and 150 hours in the 90 days prior to that application.

According to persons who either knew him or the airplane owner, the front left seat occupant was an aviation acquaintance of the owner. The owner's son stated that to his knowledge, that individual was the only person who flew the accident airplane in recent years.

This individual was in the left front seat when the airplane was recovered from the lagoon. The San Mateo County Coroner's Office autopsy report stated "multiple blunt injuries" as the cause of death. The Coroner's report on forensic toxicology examinations on specimens stated "No common acidic, neutral or basic drugs detected" and "No blood Ethyl Alcohol detected." The report stated that blood carboxyhemoglobin saturation was less than 3 percent. A subsequent separate communication from the Coroner's Office explicitly stated that "our normal toxicology screen does not test for THC." THC is the abbreviation for tetrahydrocannabinol.

The FAA Civil Aeromedical Institute (CAMI) also conducted forensic toxicology examinations on specimens from the individual in the front left seat. The carboxyhemoglobin test, which used a cutoff saturation limit of 10 percent, indicated that no carbon monoxide was detected in the blood. Tetrahydrocannabinol was detected in the lung, liver and chest cavity blood samples, and tetrahydrocannabinol carboxylic acid was detected in the lung, liver, chest cavity blood, and urine samples.

The son of the individual stated that he did not have any direct knowledge of his father's use of marijuana.

Front Right Seat Occupant

The individual in the front right seat was the registered owner of the airplane. He was 91 years old. According to FAA records, he held a commercial pilot certificate, with airplane single engine and multi-engine land ratings. On his April 2004 application for an FAA medical certificate, which was denied, he reported 12,004 total hours of civilian flight experience. No records of any subsequent FAA medical applications were discovered, and he did not hold a valid FAA medical certificate at the time of the accident. The San Mateo County Coroner's Office autopsy report stated "multiple blunt injuries" as the cause of death. The Coroner's report on forensic toxicology examinations on specimens stated "No common acidic, neutral or basic drugs detected" and "No blood Ethyl Alcohol detected." The report stated that blood carboxyhemoglobin saturation was less than 3 percent.

The FAA CAMI also conducted forensic toxicology examinations on specimens from the individual in the front right seat. The carboxyhemoglobin test, which used a cutoff saturation limit of 10 percent, indicated that no carbon monoxide was detected in the blood sample. Ethanol was detected in the brain and blood samples, methanol was detected in the muscle and blood samples, and N-Propanol was detected in the brain sample. Amlodipine, which is used alone or in combination with other medications to treat high blood pressure and chest pain (angina), was detected in the liver and blood samples.

Passenger

The female passenger was 47 years old, and did not hold any pilot certificates. She was recovered from the lagoon shortly after the accident, and the investigation was unable to determine where she was seated for the flight. The San Mateo County Coroner's Office autopsy report stated "multiple blunt injuries" as the cause of death. The Coroner's report on forensic toxicology examinations on specimens stated "No common acidic, neutral or basic drugs detected" and "No blood Ethyl Alcohol detected." The report stated that blood carboxyhemoglobin saturation was less than 3 percent. According to one of her sons, she was in a personal relationship with the front left seat occupant, and that she did not use marijuana.

AIRCRAFT INFORMATION

History and Background Information

According to FAA records, the airplane was manufactured in 1961, and was equipped with two Lycoming IGSO-480 piston engines. Each engine was equipped with a three-blade fully feathering Hartzell propeller, controlled by a lever in the cockpit. The airplane was equipped with tricycle-configuration retractable landing gear. The airplane was certificated to carry 9 persons, including 2 crewmembers, and had a maximum takeoff weight of 7,700 pounds. Entry and exit was via a cabin door aft of the left wing.

At the time of the accident, the airplane was registered to an individual who had purchased it in August 2008. Airport administrative records indicated that the airplane was hangared at SQL by that owner. The insurance application referenced in the "PERSONNEL INFORMATION, Front Left Seat Occupant" section stated that the airplane had not been flown in the year preceding September 2009.

Takeoff Weight and Balance Information

No weight and balance documentation for the accident flight was discovered. The most recent weight and balance information found for the airplane was dated August 2009. The estimated accident flight takeoff weight was 6,771 pounds, and the center of gravity location was estimated to be 156.27 inches aft of the datum, which was within the allowable envelope. Refer to the accident docket for substantiating information.

Maintenance Records and Maintenance Activity

Maintenance records were recovered in the wreckage and from the lagoon. Those records indicated that the most recent annual inspection was completed in September 2009. At that time, the airplane had a total time in service (TT) of about 4,722 hours. The left and right engines each had a TT of 1,725 hours, with service times of 260 hours since major overhaul (TSMOH). The left and right propellers each had a TT of about 4,722 hours; the left propeller had a TSMOH of 438 hours, while the right propeller had a TSMOH of 260 hours. At the time of the accident, the airplane hour meter registered slightly over 4726.6 hours, which indicated that the airplane had accumulated 4.2 hours in the year since the most recent annual inspection. No documentation regarding any maintenance subsequent to the most recent annual inspection was recovered.

A son of the rear-seat passenger reported that he had visited the hangar and the airplane with the left-seat occupant a few weeks before the accident. He reported that the left engine was observed to be decowled, and appeared to be in the midst of maintenance activity, although not actively at the time of his visit. No other persons were present or working on the engine at the time of his visit. The son was unable to provide any details regarding the nature or extent of the maintenance. He reported that the left-seat occupant had expressed frustration about the quality and duration of that maintenance. The investigation was unable to discover any further details about the alleged maintenance activity.

Fuel System

The airplane was equipped with a total of four fuel tanks. Each wing contained a 44-gallon capacity main tank, two 23-gallon auxiliary tanks, and one 25-gallon auxiliary tank, for a total airplane usable fuel capacity of 230 gallons. A review of fuel purchases at SQL for the airplane since 2007 revealed only three purchases. These were: December 2008, 157.8 gallons; July 2009, 56.0 gallons, and May 2010, 190.8 gallons.

The auxiliary fuel tanks in each wing were interconnected to one another, but independent of the main fuel tank. The main tank and the rear inboard auxiliary tanks each contained a boost pump which was electrically controlled from the cockpit. The airplane was also equipped with an "Idle Cut-Off (ICO)" switch and an "Enrichment" switch for each engine. The ICO switch controls a solenoid to permit (ICO switch ON) or prevent (ICO switch OFF) fuel pressure at the fuel nozzle, and it is primarily used for engine start and shutdown. In addition, the OM prescribed turning the ICO switch to "OFF" in the event of an engine failure after "it is positively known which engine has failed." The enrichment system was primarily intended for use during high power applications (such as climbs) at high altitudes.

Each of the two fuel selector valves (one per engine) had three positions; OFF, AUX and MAIN. The fuel selector valve controls were mounted in the cockpit, while the valves were mounted on the respective engine firewalls. The valve controls actuated the valves via cables. In addition, an electrically-controlled crossfeed valve could be used to feed either engine from the tanks on the opposite side wing.

The only entries in Section II ("Operating Check List") of the airplane manufacturer's OM "Pre-Starting Procedure" checklist that were related to the fuel system were steps 3, 4 and 7, which appeared as:

"Idle cut-off switches - DOWN"

"Enrichment switches - OFF"

"Fuel tank selectors - MAIN"

The only entries in the OM "Start Procedure" checklists that were related to the fuel system were steps 1, 2 and 6 for each engine, which respectively appeared as:

"Boost pump - on MAIN; check pressure"

"Idle cut-off switch - ON (up)"

"Boost pumps - OFF; check pressure."

The only entry in the OM "Before Take-off Check" that was related to the fuel system was step 3, which appeared as:

"Gas - fuel selector on MAIN. Check auxiliary position. Return to MAIN, actuate boost pumps, check crossfeed."

The "Normal Take-Off" portion in Section IV ("Flying Your BEECHCRAFT") of the OM stated that the pilot should "check to see that the fuel boost pumps are ON" as the airplane is being lined up on the runway.

METEOROLOGICAL INFORMATION

The 1200 recorded weather at SQL included winds of 7 knots from 350 degrees; clear skies; temperature of 29 degrees C; dew point 14 degrees C; and an altimeter setting of 29.85 inches of mercury.

COMMUNICATIONS

The operation of the SQL ATCT was contracted to, and conducted by, a company called Serco, Inc. Subsequent to the accident, Serco provided transcripts of the radio communications between SQL ATCT and the accident airplane. According to the transcripts, the flight's first radio transmission was made at 1142:40, when it called ground control for a radio check, followed by a request for taxi clearance. At 1142:54, the airplane was cleared to taxi to runway 30, and in response to the ground controller's question, the flight radioed that it was destined for E16 via the "ridgeline on the west side."

At 1148:43, the flight transmitted to the local controller that it was "number one on the east ready" for departure. Sixteen seconds later, the local controller cleared the airplane for takeoff, and 6 seconds after that, the flight transmitted that it was "moving." At 1149:59, which was 54 seconds after its "moving" call, the flight transmitted "and eight three two bravo ready to depart." This was followed 3 seconds later by the local controller's transmission "Queen Air three two bravo roger that runway three zero cleared for takeoff." At 1150:05, the flight transmitted "three two bravo going." No further transmissions from or to the airplane were recorded. At 1151:14, in response to the loss of the airplane, the local controller transmitted "all aircraft calling inbound to San Carlos tower stand by."

NTSB review of the recordings and the transcripts confirmed the accuracy of the transcripts, and also that there were few other aircraft on the respective communication frequencies during the period when the accident airplane was active on those frequencies. The son of the front left seat occupant confirmed that the voice on the radio was that of his father.

AIRPORT INFORMATION

According to FAA Airport/Facilities Directory information, SQL was equipped with a single runway, designated 12/30, which was paved, and measured 2,600 feet long. Airport elevation was 5 feet above mean sea level (msl). The airport was equipped with a non-federal ATCT, which was operating at the time of the flight.

WRECKAGE AND IMPACT INFORMATION

On-Site Examination

The impact site was located about 4,200 feet beyond the runway end, and offset about 1,300 feet to the right (northeast) of the extended runway centerline. Recovery divers reported that the lagoon had a depth of about 10 feet, and the bottom was silt and mud. The airplane was removed from the lagoon about 30 hours after the accident. Multiple documents, many of which were maintenance records for the airplane, were also recovered from the lagoon.

On-site examination of the airplane revealed crush damage, primarily in the up and aft direction, to the nose, cabin, wings, and engine nacelles. According to recovery divers, the engines remained attached to the airplane only by cables, and the divers cut the cables in order to extract the wreckage from the lagoon. All propeller blades remained in their respective propeller hubs, and each hub remained attached to its respective engine. All aerodynamic control surfaces remained att

NTSB Probable Cause

A loss of power in the right engine for undetermined reasons and the pilot’s subsequent failure to maintain adequate airspeed, which resulted in a loss of control. Contributing to the loss of control was the regulatory certification basis of the airplane that does not require airspeed indicator markings that are critical to maintaining airplane control with one engine inoperative.