NTSB Factual Report

HISTORY OF FLIGHT

On June 7, 2004, approximately 1650 mountain daylight time, a Raytheon Aircraft Company A36, N6162E, piloted by a private pilot, was destroyed when it impacted terrain approximately 2 miles south of Gilcrest, Colorado. Visual metrological conditions prevailed at the time of the accident. No flight plan had been filed for the local personal flight being conducted under the provisions of Title 14 CFR Part 91. The private pilot and the student pilot passenger in the front seat were fatally injured. The rear passenger received serious injuries. The flight departed Vance Brand Airport (2V2), Longmont, Colorado, approximately 1630.

Witnesses driving north on U.S Highway 85 observed the airplane flying low above the ground in a northerly direction. According to one witness, the airplane's wings rocked from side to side and then the airplane pitched up. The airplane's nose dropped and the airplane impacted the terrain in a right wing low attitude. The airplane came to rest in a sod field approximately 1/4 mile east of the highway. One witness exited his vehicle to help those on board the airplane. While approaching the wreckage, he noted a strong odor of fuel.

The owner of Airwest Flight Center in Longmont, Colorado, said he heard a mayday call at the approximate time of the accident. He said he heard, "Mayday, Mayday, Beechcraft N (witness could not recall the N number} east of Longmont, going down, 3 souls on board."

In a hospital interview and subsequent telephone interviews to clarify the submitted written statement, the surviving passenger stated that the flight had departed from Longmont approximately 20 to 30 minutes prior to the accident. They had flown over the pilot's home and were en route to Greeley when the accident occurred. The passenger stated that the front seat passenger, the pilot's daughter, expressed a wish to fly the airplane. She remembered she was "typing in the autopilot," and she recalled the pilot correcting her, "GXY, not GYX," or words to that effect (GXY is the 3-letter designator for the Greeley-Weld County Airport, located about 18 miles north of the accident site). As soon as she disengaged the autopilot, the "airplane shuttered [sic], and a lot of the alarms on the plane started going off." The passenger estimated that they were approximately 500 feet agl and had been attempting to climb. According to the passenger, the pilot "could [not] reach the switch for the gas tanks" so the front seat passenger switched it. The passenger was not sure if they tried to start the engine. She heard the front seat passenger make a mayday call and could not recall anything after the impact.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with an airplane single engine land rating, which was issued April 27, 2004. The pilot held a third class medical certificate, dated January 9, 2004, with the limitation "must wear corrective lenses." According to the pilot's logbook, he received endorsements for complex and high performance airplane operations on April 1, 2001. The pilot had logged approximately 139 hours total time, 75 of which was in the accident airplane.

The front seat passenger held a student pilot certificate, which was issued on January 9, 2004. This third class medical certificate contained the limitation "must wear corrective lenses." According to her flight instructor, she had logged approximately 40 hours in a Cessna 172S and had soloed on May 14, 2004. He said he had never flown with her in the A36 and to the best of his knowledge, she had never flown in the airplane.

AIRCRAFT INFORMATION

The airplane, a Raytheon A36 "Bonanza" (s/n E-3492), was certified in the utility category on March 5, 2003. The airplane was equipped with an IO-550-B, 300 horsepower Teledyne Continental Motors, Inc. engine (s/n 695995). The engine was driven by a 3-bladed, constant speed Hartzell propeller. In addition, the airplane was equipped with retractable landing gear and flaps. The pilot purchased the airplane in January 2004 from Stevens Aviation in Broomfield, Colorado. Stevens Aviation also maintained the airplane. Although the aircraft maintenance logbooks were never located, Stevens Aviation records indicate an annual inspection was accomplished on April 6, 2004. At that time, the airframe and engine had accrued 95.2 hours total time.

METEOROLOGICAL INFORMATION

According to the Fort Collins-Loveland routine aviation weather report (METAR), 15 miles northwest of the accident site, the weather at the time of the accident was: Wind, 120 degrees at 7 knots; visibility, 10 statute miles (or better); sky condition, clear; temperature, 93 degrees F.; dew point, 30 degrees F.; altimeter, 29.64 inches of mercury. Density altitude was calculated to be between 8,244 and 8,631 feet at ground level.

WRECKAGE AND IMPACT INFORMATION

The National Transportation Safety Board's (NTSB) on scene investigation began on June 7, 2004.

The accident site was located on level terrain in a turf farm, approximately 0.25 miles east of U.S. Highway 85, at 40 degrees, 15.434 minutes north latitude, and 104 degrees, 48.151 minutes west longitude. The accident site elevation was at 5,740 feet msl.

The initial impact point was located approximately 160 feet south of the main wreckage. This point was defined by a series of small ground scars that extended for 20 feet. Within the first ground scar were right wing tip lens fragments. The impact heading was approximately 010 degrees.

Approximately 25 feet from the initial impact point was a 10 foot long ground scar and several adjacent ground scars, consistent with propeller blade strikes. The debris field extended from the initial impact point north for approximately 160 feet. Within the debris field were the propeller assembly, the right front seat headrest, windscreen Plexiglas and fiberglass fragments, and the glare shield. The main wreckage was oriented on a heading of 118 degrees. The main wreckage consisted of the empennage, fuselage, both wings, and the engine. Between the initial impact point and the main wreckage, the sod was discolored to a shade of brown.

The left wing tip and aileron were unremarkable. The inboard leading edge of the wing was wrinkled. The trailing edge of the wing acted in the manner of a scoop and was covered in sod. The left fuel bladder had not been compromised and approximately 1 gallon of fuel was recovered. The left main landing gear had collapsed towards the fuselage. The left main landing gear door was found closed, underneath the collapsed left gear. The landing gear turnbuckle was extended and the flap jackscrew was retracted. According to the Raytheon Aircraft investigator, these would indicate that the landing gear was down and the flaps were up.

The engine cowling was torn off and the engine was separated from its mounts. The entire propeller assembly was located approximately 80 feet south east of the main wreckage. The propeller was sheared off at its attachment bolts.

The right wing was bent and crushed from the wing tip to the attachment point at the fuselage. Both the right aileron and flap were bent. The right main landing gear door was found closed and the right main landing gear had been bent out towards the wing tip. The right wing fuel bladder was compromised and no fuel was recovered.

The cabin door was torn open. The windscreen was fragmented and the instrument panel was crushed in towards the cabin.

The airplane's flight instruments showed the following indications:

Turn Coordinator: Right wing low/full left ball

Air Speed Indicator: Zero

Attitude Indicator: 50 degrees right bank/40 degrees nose down

Vertical Speed Indicator: 600 feet descent

Altimeter: 5,740 feet msl.

Kollsman window: 29.65 inches

The airplane's engine instruments showed the following indications:

Vacuum gauge: Zero

Tachometer: Zero

Fuel flow: Zero

Oil temperature: Zero

Oil pressure: Zero

Left fuel gauge: Empty

Right fuel gauge: Empty

Hobbs: 0095.2 hours

The airplane's cockpit controls were found in the following positions:

Flaps: Up

Landing gear: Down

The airplane's engine controls were found in the following positions:

Mixture: Idle cut off

Propeller: Full forward

Throttle: Full forward

Fuel selector valve: Off

Magnetos: Off

Auxiliary fuel pump: Off

Police, fire, and rescue personnel were asked if they had moved the position of the fuel selector valve. They said they had not.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed on the pilot and front seat passenger for the Weld County Coroner's Office on June 8, 2004. There was no evidence of physical incapacitation or impairment of either pilot that would have been causal to the accident. The autopsy report stated that the pilot was 73 inches tall and weighed 310 pounds.

Toxicological screens were performed by FAA's Civil Aeromedical Institute (CAMI #200400127001 and 200400127002). Drug, chemical, and alcohol screens were negative for both pilots.

TESTS AND RESEARCH

The airplane wreckage was taken to Greeley, Colorado, on June 8, 2004, for further examination. Control continuity was established to all flight control surfaces. An examination of the engine and engine components showed no anomalies. The manifold was wet with fuel, but nothing that could be measured. The top spark plug bank was uniform in dark discoloration. According to a representative from Teledyne Continental Motors, this is characteristic of a lean mixture or fuel exhaustion or starvation.

The fuel selector valve was removed for further examination. The valve was in the off position. There was circular scoring on the faceplate of the fuel selector valve, leading to the "off" position. According to the Raytheon Aircraft representative, the selector would have to have been forced to create the circular scoring. The valve assembly contained residual fuel in the lines leading to the fuel tanks. In addition, the electric boost pump contained fuel in the lines.

The autopilot servos were retained for further examination. On July 7, 2004, they were examined in Olathe, Kansas, under the auspices of the NTSB. No anomalies were noted.

ADDITIONAL INFORMATION

Several flight instructors reported the pilot had mentioned to them his inability to reach the fuel selector valve. One instructor said the pilot told him he had difficulty feeling the detent position on the fuel selector valve. The pilot was scheduled to have a specially-designed seat installed in his airplane during the week of June 14-18 that would accommodate his girth.

According to the Raytheon Pilot Operating Handbook, each fuel bladder contains 40 gallons; 37 of which is useable fuel. No documents were located that would indicate when the airplane was last refueled, or how long the airplane had flown since it was last refueled.

Parties to the investigation included the FAA, Honeywell, Raytheon Aircraft Company, and Teledyne Continental Motors, Inc.

The wreckage was released to a representative of the insurance company on July 26, 2004.

NTSB Probable Cause

the pilot's inadequate in-flight planning/decision by his failure to switch fuel tank selector position which resulted in fuel starvation. Also causal was the pilot's failure to maintain airspeed which resulted in a stall.