NTSB Factual Report

HISTORY OF FLIGHT

On April 19, 1995, about 0700 central daylight time, a Cessna T337G, N4KP, operated by Kansas Paint & Color Company, Wichita, Kansas, crashed on takeoff from the Coffeyville Municipal Airport, Coffeyville, Kansas. The airplane was destroyed. The airline transport certificated pilot and the two passengers aboard the airplane were fatally injured. The flight was an "Angel Flight", to transport a cancer patient to Houston, Texas for treatment. His wife was accompanying him. The flight was conducted under 14 CFR Part 91. An IFR flight plan was filed, and visual meteorological conditions prevailed at the time.

One witness to the accident, in a personal interview, reported that the pilot landed and spent about five minutes on the ground onloading the two passengers. He noted that the pilot had a difficult time starting the number one engine. The witness believed the engine was flooded. He observed the number two engine start and reported that it started immediately. He reported that he could not tell if the pilot ran up both engines.

He observed the airplane during the takeoff roll and indicated that the airplane was still on the ground at a speed similar to a "fast taxi" as it passed the 3,000 foot point on the runway. The wings rocked during the initial climb and the airplane barely cleared the first row of trees. He reported that he believed both engines were running. He did not see a stopped propeller and could not discern the flap position. He thought the airplane was going to impact the second row of trees and the pilot initiated a turn to the left. During the turn the airplane descended and the left wing impacted the terrain.

Two other witnesses to the accident reported that the airplane sounded "as if it were laboring" during the takeoff and took off much further down the runway than other airplanes they had observed in the past. They said the airplane became airborne at the 4,000 foot point of the runway. They heard no "missing or backfiring." The airplane "did not climb normally" and cleared the trees at the end of the runway by 20 to 30 feet. It climbed to an altitude of approximately 100 feet, the left wing dropped, "as if starting to turn," the nose dropped, and the airplane impacted the terrain. A postcrash fire ensued almost immediately.

WRECKAGE AND IMPACT INFORMATION

The NTSB on-scene investigation began on April 19, 1995, about 1730 central daylight time. The wreckage was located .25 miles north of the Coffeyville Airport, approximately 1/2 mile east of highway 169 and north of county road 2800. The wreckage path was located a heading of 310 degrees. The first item in the path was an impact mark which contained fragments of the left wing tip. Next were several lateral slashes spaced 15 to 16 inches apart, followed by a fragment of the left wing tip light, the left lift strut, the left main landing gear strut, and the nose landing gear strut. The main wreckage was located 240 feet from the first impact mark on a heading of 165 degrees.

The cabin area, forward fuselage, and left wing were thermally destroyed. The right wing and empennage were relatively intact. The lower portion of the right vertical stabilizer was crushed in the upward direction. Both blades of the number one propeller were bent aft. One blade was loose in the hub. Minor leading edge damage and chordwise scratching were evident. The number two propeller was in a horizontal position. No impact damage was noted on either blade.

The flap actuator was extended 5.7 inches. The right flap was extended 25 degrees. The left flap position was destroyed by fire. Examination of flight control and engine control continuity revealed no evidence of preimpact malfunction. All three wheels rotated freely when turned.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsy of the pilot was conducted by Jill Gould, MD, 533 S. W. Danbury Lane, Topeka, Kansas 66606. The results of FAA toxicological testing were negative for all tests conducted except 38 percent carboxyhemoglobin and 1.650 ug/ml cyanide detected in the blood specimen.

TESTS AND RESEARCH

The engines were examined at Teledyne Continental Motors (TCM), in Mobile, Alabama on June 16, 1995. The number one engine exhibited severe thermal and impact damage. Laboratory disassembly and examination of the engine, wastegate, and variable absolute controller revealed no evidence of mechanical malfunction. The turbocharger turbine wheel exhibited evidence of minor foreign object damage.

On June 22, 1995, the number two engine was tested in a TCM production test cell with both the flight propeller and a test club. The engine started immediately and operated normally in both configurations.

Single engine performance calculations, provided by Cessna Aircraft Corporation, for the model P337 at 4,700 pounds with the flaps extended 25 degrees, indicates a takeoff ground run of 3,636 feet.

The pilot operating handbook for the Cessna T337G specifies that flaps should be set "up to 1/3 down" for a normal takeoff and "1/3 down" for a maximum performance takeoff. A note in the normal takeoff section specifies "lead with rear engine to verify rear engine operation..."

ADDITIONAL DATA/INFORMATION

Parties to the investigation were the Federal Aviation Administration Flight Standards District Office, Wichita, Kansas, Teledyne Continental Motors, the Cessna Aircraft Company, Allied Signal Aerospace, and the Kansas Paint & Color Company.

Additional Persons - Steve Macon, P. O. Box 29003, Phoenix, Arizona 85038-9003.

NTSB Probable Cause

the pilot's failure to abort the takeoff during an excessive takeoff roll. Factors were the loss of power on the number two engine which occurred for an undetermined reason, the pilot's disregard of the takeoff checklist, and the 25 degree flap setting.