NTSB Factual Report

HISTORY OF THE FLIGHT

On January 5, 1994, about 1829 (all times eastern standard time), a Beech B90, N230TW, registered to Kimura International, Inc., collided with trees and then the ground near Okeechobee, Florida, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The aircraft was destroyed and the airline transport-rated pilot and nine passengers were fatally injured. The flight last departed from Kissimmee, Florida, on January 5, 1994, at 1801.

Representatives from Kimura International, Inc. stated the flight originally departed Opa Locka Airport, Opa Locka, Florida. The purpose of the flight was to go to Kissimmee, Florida, and pick up eight passengers, who were relatives of the pilot, and return to Opa-Locka. The pilot and pilot-rated right front seat passenger were the only persons onboard for the flight to Kissimmee. Federal Aviation Administration (FAA) communication transcripts from the Opa-Locka Tower indicated the flight departed Opa-Locka Airport at 1652.

A lineman at Marathon Flight School, Inc., at the Kissimmee Airport stated N230TW arrived on the morning of January 4, 1994, with 10 or 11 passengers, who deplaned and stayed in Kissimmee. On January 5, 1994, N230TW arrived on the ramp about 1750. The Japanese pilot remained in the left front seat and kept the engines running. The non-Japanese right front seat passenger went to the rear door and opened it. The eight Japanese passengers, who had been waiting about an hour, boarded the aircraft with only carry on luggage. After they boarded, the door was closed, and the non-Japanese passenger returned to the right front seat. The aircraft immediately began to taxi and went to the nearest intersection for runway 15. The flight then immediately performed an intersection departure on runway 15 and made a straight out departure at about 1800.

At 1818:38, a person with no Japanese accent made a radio call as King Air N230TW to Miami Radio, which was received at the FAA St. Petersburg Flight Service Station (FSS). St. Petersburg FSS did not reply and no further transmissions were received. Representatives of Kimura International, Inc. stated the pilot and eight passengers who boarded the aircraft at Kissimmee were Japanese, and spoke with a Japanese accent. The pilot-rated right front seat passenger was not Japanese and did not speak with a Japanese accent.

A pilot in another aircraft who was landing at the Okeechobee Airport heard on the unicom frequency, 123.0 mhz, a person with no Japanese accent, calling as King Air N230TW, just before 1830. The person stated the King Air had an indicator problem and they were going to make a precautionary landing at the Okeechobee Airport; however, they could not locate the airport. The person then talked to another pilot who was airborne and then stated they were changing to the emergency frequency 121.5 mhz. This pilot switched to 121.5 mhz and listened to the person on N230TW talk to the pilots of another aircraft, a Cessna Citation.

A flight instructor and student in another aircraft, in flight north of the Okeechobee Airport, heard on the unicom frequency, 123.0 mhz, the person on N230TW talking to the aircraft which was landing. The instructor then contacted the person on N230TW and gave him directions toward the Okeechobee Airport. He then flew over the airport with his landing light on to help the pilot of N230TW locate it. The person on N230TW reported that he had him in sight and that they were at 1,100 feet, loosing altitude and didn't know why, and were switching to 121.5 mhz. The instructor then switched to 121.5 mhz and heard the person on N230TW talking to the pilots of a Cessna Citation. The instructor and student then flew north and located the burning wreckage of N230TW.

The pilots of a Cessna Citation flying at 43,000 feet, about 80 nm east-northeast of Palm Beach, Florida, reported hearing a person with no Japanese accent transmitting on the emergency frequency 121.5 mhz, as King Air N230TW. The person reported that the flight was having engine trouble and that they were trying to land on a road. The person reported descending through 200 feet and that they were going into trees. The person then reported they were contacting trees. The pilots then heard the sounds of an emergency locator transmitter for about 3 seconds. The pilots reported the conversation to FAA Miami Center at 1828:46.

Witnesses on the ground near the crash site observed N230TW circle several times at low altitude to the west of Highway 441. The aircraft then appeared to approach a dirt road from west to east for landing, with the landing lights on. A car was going west on the road and the aircraft appeared to pull up and make a steep left turn. The aircraft was flying at a low speed and engine sounds were audible. As the aircraft flew to the north the right wing dipped down toward the ground. The aircraft then descended nose down, right wing down until ground impact. The aircraft exploded on impact.

Recorded radar data from the FAA Orlando Approach Control and the FAA Miami Air Route Traffic Control Center was reviewed after the accident. An aircraft was observed to depart the Kissimmee Airport at about 1801, and proceed south-southeast bound. This aircraft climbed to 7,000 feet, reaching this altitude at 1809:06. The aircraft immediately began a descent from this point. The aircraft continued in a descent and was lost from radar at 1825:06, at 1,100 feet, at a point 5 nm north of the crash site of N230TW.

For additional history of flight information see attachments to this report.

PERSONNEL INFORMATION

The pilot of N230TW reported to the FAA on April 30, 1988, on application for a flight instructor certificate renewal, that he had 4,220 total flight hours in airplanes and 6,160 total flight hours in helicopters. On March 1, 1991, on an application for an FAA medical certificate, the pilot reported he had 10,000 total flight hours and that he had flown 300 flight hours in the previous 6 months. On April 1, 1992, on an application for an FAA medical certificate, the pilot reported he had flown 20,000 total flight hours and that he had flown 600 flight hours in the previous 6 months.

On August 18, 1992, on an application for a rotorcraft airline-transport pilot certificate, the pilot reported he had 18,000 total flight hours. On June 23, 1993, the pilot reported on an FAA medical certificate application that he had 22,000 total flight hours and had flown 300 flight hours in the previous 6 months. The pilot's family could not locate a pilot logbook after the accident. The pilot's flight time could not be verified.

Representatives of Kimura International reported that the pilot had attended two ground schools on the King Air, as part of the certification process to place the aircraft on a 14 CFR Part 135 air taxi certificate. He did not complete either of the ground schools. The instructor for the last ground school the pilot attended stated they did not teach engine overspeed or propeller overspeed emergencies during the 15 hours he taught the school. The pilot was reported to have received 13 hours of dual flight instruction in the King Air. He also was reported to have flown 117 hours as pilot-in-command in the aircraft. Before this the only turbo-propeller powered aircraft experience the pilot was known to have received was 272 flight hours in turbo- propeller Aero Commanders.

FAA records indicated that on November 4, 1982, the pilot was involved in an aircraft accident at Doraville, Georgia, in a Cessna 152, when all fuel was exhausted and a forced landing was made. On March 26, 1984, the pilot was involved in an incident at Boulder City, Nevada, when he landed on a road following loss of electrical power at night in a Cessna 172. The pilot was involved in an incident on October 13, 1992, at Hialeah Gardens, Florida, when engine power was lost in a Cessna 152 due to a oil pump malfunction and a forced landing was made in a field.

Additional information on the pilot is contained in this report under Pilot Information and in attachments to this report. Information on the pilot-rated right front seat passenger is included in this report in Supplement E.

AIRCRAFT INFORMATION

Aircraft logbook records indicated the aircraft was last inspected on November 25, 1992, at aircraft total time 6,909 hours. The aircraft was on a Beech Aircraft Corporation progressive inspection program. The program requires that the aircraft be inspected each 150 flight hours. At the time of the accident the aircraft total time was 7,072 total flight hours or 163 flight hours since last inspection. The aircraft engines received a motoring compressor wash on December 28, 1993, at aircraft total time 7,066.

On April 21, 1993, Pratt and Whitney issued Service Information Letter 1052,applicable to all model PT6 engines. The letter recommended that operators of model PT6 engines remove the Bendix manufactured fuel controls on the engine at mid-life to fuel control overhaul, or 3,000 flight hours, and have the drive body inspected and the driveshaft bearings replaced in accordance with Bendix Service Information Bulletin No. 057. Logbook records for N230TW showed no indication that this bulletin had been complied with. The fuel control installed on the right engine had accumulated 3,610 flight hours since being installed on January 3, 1979, after overhaul. The fuel control installed on the left engine had accumulated 2,212 total flight hours since being installed on December 8, 1983, after overhaul. Postaccident examination of the fuel controls on N230TW indicated that the controls were installed on the opposite engines from which logbook entries indicated they were installed.

Representatives from Kimura International, Inc. stated after the accident that the aircraft had several open maintenance items at the time of the accident. The pressurization system would not maintain cabin altitude and therefore the aircraft was flown below 10,000 feet. The cabin heater was inoperative. Finally, the engine generators would not operate with even loads. The flight crew who flew the aircraft before the accident flight reported that they experienced no problems with the aircraft other than the open items listed above. They indicated engine performance was normal.

For additional aircraft information see Aircraft Information and attachments to this report.

WEIGHT AND BALANCE INFORMATION

Calculations indicate that at the time of the accident the aircraft weighed about 8,810 pounds and the center of gravity was at 158.26 inches aft of the datum. The maximum allowable gross weight for the aircraft is 9,650 pounds. The center of gravity limits at gross weight are between 153.2 inches and 160.0 inches aft of the datum. See attached weight and balance information.

METEOROLOGICAL INFORMATION

Visual meteorological conditions prevailed at the time of the accident. Sun and moon calculations contained in a computer- based program indicated that at the time and place of the accident the sun was at an altitude of -10.4 degrees on a bearing of 253.4 degrees. The moon was at an altitude of -74.0 degrees on a bearing of 333.8 degrees, with a 39 percent illumination. Sunset was at 1743 and end of twilight was at 1809. For additional meteorological data see weather data contained in this report and sun and moon data attached to this report.

WRECKAGE AND IMPACT INFORMATION

The aircraft crashed on U.S. Highway 441 at 354th Court in Fort Drum, Florida. Fort Drum is located in Okeechobee County and the mailing address for the area around the crash site is Okeechobee, Florida. The crash site is located 19 nautical miles north of the Okeechobee Airport.

Examination of the crash site indicated the aircraft struck a pine tree located on the west side of Highway 441. The aircraft was on a northeasterly heading and in an estimated 45-to 60- degree right bank angle during tree impact. Components from the aircraft's right wing outboard section were found at the base of this tree along with severed 3 to 5 inch tree limbs. The aircraft then crashed nose first, right wing low, on Highway 441, became inverted, and came to rest at the top of a ditch on the east side of Highway 441. A postcrash fire consumed the aircraft.

All components of the aircraft which are necessary for flight were found within 150 feet of the main wreckage. All separation points within the flight control system were typical of overstress separation. Actuators for the wing flaps and landing gear were found in the flap and gear retracted position. All instrumentation and switches were destroyed by fire.

Examination of the left engine indicated it separated from the aircraft during the crash sequence. The engine was found in two sections. The propeller exhibited extensive mechanical damage but remained attached to the propeller flange. Teardown examination of the engine revealed no evidence of precrash failure or malfunction of the engine rotating assembly or accessory components. Rotational signatures to the engine internal components indicated the engine was operating at high power at the time of ground impact.

Examination of the right engine indicated it separated from the aircraft during the crash sequence. The engine remained in one piece. The propeller separated from the engine at the propeller flange. The flange separation was typical of overstress. Teardown examination of the right engine revealed no evidence to indicate failure or malfunction of the engine rotating assembly. Rotational signatures to the engine internal components indicated the engine was operating at high power at the time of ground impact.

Examination of the right engine fuel control indicated the driveshaft and flyweight bearing assembly was missing the ball bearings and bearing debris was found in the unit. The ball bearing inner races were in place on the drive shaft. The bearing outer races remained with the fuel control unit body. The spacers and cage had damage consistent with the ball bearings wearing into the cage and spacers. The remainder of the right engine accessories indicated no evidence of precrash failure or malfunction.

Examination of the left propeller indicates blade twisting and chordwise scratches which are consistent with powered rotation at the time of ground impact. Crash damage precluded the determination of blade angle at the time of ground impact. No evidence to indicate precrash failure or malfunction was noted.

Examination of the right propeller indicates blade twisting and chordwise scratches which are consistent with powered rotation at the time of ground impact. Crash damage precluded the determination of blade angle at the time of ground impact. No evidence to indicate precrash failure or malfunction was noted.

For additional wreckage and impact information see attachments to this report.

MEDICAL AND PATHOLOGICAL INFORMATION

Post-mortem examinations of the pilot and nine passengers were conducted by Frederick P. Hobin, M.D., District Medical Examiner, Fort Pierce, Florida, and Charles A. Diggs, M.D., Associate Medical Examiner, Fort Pierce, Florida. The pilot and nine passengers died as a result of injuries sustained during the crash sequence or postcrash fire.

Toxicology testing on specimens obtained from the pilot was performed by the FAA Toxicology Laboratory, Oklahoma City, Oklahoma, and Wuesthoff Memorial Hospital Laboratory, Fort Pierce, Florida. Tests were negative for ethanol alcohol and drugs. The tests were positive for 1 percent carbon monoxide in blood, and caffeine.

Toxicology testing on specimens obtained from the pilot- rated right front seat passenger was performed by the FAA Toxicology Laboratory, Oklahoma City, Oklahoma, and Wuesthoff Memorial Hospital Laboratory. Toxicology testing on specimens obtained from the remaining eight passengers was performed by Wuesthoff Memorial Hospital Laboratory. For additional medical and pathological information see Supplements K and attachments to this report.

TESTS AND RESEARCH

NTSB Probable Cause

THE PILOT'S IMPROPER REMEDIAL ACTION CONCERNING A RIGHT ENGINE POWER ANOMALY, AND HIS FAILURE TO MAINTAIN ADEQUATE AIRSPEED DURING GO-AROUND FROM AN ABORTED PRECAUTIONARY LANDING, WHICH RESULTED IN A LOSS OF AIRCRAFT CONTROL AND AN UNCONTROLLED DESCENT. FACTORS RELATED TO THE ACCIDENT WERE: FAILURE OF THE OWNER/OPERATOR/PILOT TO ASSURE PROPER MAINTENANCE INSPECTION OF THE AIRCRAFT, FAILURE TO COMPLY WITH A SERVICE BULLETIN CONCERNING THE ENGINE FUEL CONTROLS, SUBSEQUENT BEARING FAILURE IN THE RIGHT ENGINE FUEL CONTROL, AND THE PILOT'S LACK OF FAMILIARITY WITH THIS MAKE AND MODEL OF AIRCRAFT.