NTSB Factual Report

HISTORY OF FLIGHT

On June 27, 1994, at 1933 central daylight time, a Beech A-35 V-tail Bonanza, N3042V, owned and operated by Paul D. Johnson of New Prague, Minnesota, impacted level terrain at the departure end of runway 29 during takeoff from Airlake Airport, Lakeville, Minnesota. The airline transport certificated pilot and two passengers sustained fatal injuries. Visual meteorological conditions existed at the time of the accident and no flight plan was filed. The flight operated under 14 CFR Part 91 as a personal flight to Two Harbors Municipal Airport, Two Harbors, Minnesota, for a fishing trip.

Witnesses reported that the airplane became airborne, pitched nose down, rolled left, impacted at a steep angle, and was consumed by fire. One witness reported that the airplane became airborne and "adopted an unusually nose high attitude. The aircraft climbed to approximately 200 feet...with the pitch attitude remaining high...the nose pitched higher, and the aircraft rolled sharply to the left with the nose pitching rapidly down...The aircraft hit the ground after +/- 180 degrees turn and the nose pitched almost vertically down (+/- 80 degrees)." A second witness described a 5-10 degree nose up attitude, a stall, a 75-80 degree left bank, a 200 degree left yaw, and an 80 degree nose down impact. A third witness stated "The plane appeared to be nose high, slow, mushing through the air on the verge of a stall...the planes' nose suddenly pitched down and the plan spun to the left."

PERSONNEL INFORMATION

The pilot held an airline transport pilot certificate with priveledges for multi and single engine airplanes. He also held flight engineer certificate (turbojet) number 2215721. He was employed as a DC-9 captain for a major airline, and had approximately 16,766 hours of total flight time. His total flight time in the accident airplane is unknown. He had flown it 46 hours between March 2, 1990 and July 7, 1993. Only 2 flights, of approximately 2 hours total could be determined since July 7, 1993. The pilots' wife stated she did not believe he flew any other single engine airplanes.

The pilot held a current Class 1 medical certificate, with the limitation of "must wear corrective lenses."

The estimated weight of the pilot was 195 pounds, and 190 pounds for each passenger.

AIRCRAFT INFORMATION

The airplane was a Beechcraft Model 35 V-Tail Bonanza, serial number D-451. The airplane had 3768.2 total hours at the last annual inspection on July 7, 1993. The engine was a Continental model E-185, with a total time unknown, and 1186 hours since the last overhaul on July 7, 1993. The airplane was equipped with a "Federal F-200" autopilot, installed per STC SA1-55. The date of installation is unknown. The front seats were fixed, not on movable tracks, and unable to slide aft with forward acceleration.

The amount of flight time between the last annual inspection and the accident could not be determined. The last record of the aircraft having flown was from October 30, 1993. Two fuel slips were on file at Flyteline Services, Inc., at Airlake Airport which shows the airplane receiving 14.1 gallons of 100LL fuel, and then 7.3 gallons of 100LL fuel, both on October 30, 1993. The pilots' wife stated she believed his last flight in the accident airplane was around September or October, 1993.

The line person who fueled the airplane on June 27, 1994, while the airplane was being loaded prior to the accident flight, stated that the pilot did not know that the fuel truck had been inoperative for over a year and "I assumed this meant he hadn't flown, or at least bought gas from us in awhile." He also stated "The plane had a lot of dust on it and the bugs were hard to get off...like they had been there for a long time." 15.6 gallons of 100LL gasoline was placed in the airplane.

It was reported that the pilot had pulled the airplane out of its hangar approximately 1 week prior to the accident and operated the engine on the ground, but did not taxi or fly the airplane. It was described as being returned to the hangar after the ground run.

A review of the airplane maintenance logs revealed no outstanding Airworthiness Directives (AD), nor any recent maintenance. No specific maintenance activity could be identified which took place within the empennage or in the vicinity of the elevator control cables or the autopilot package. The last recorded activity regarding the empennage was on July 7, 1993, at tachometer time 776.2, airframe total time 3768.2. The hours flown since the annual inspection are unknown. At this time AD number 57-18-01 (Aft Fuselage Bulkhead inspection) was complied with. During this same annual inspection, 100 hour inspections for AD numbers 76-05-04 (Stabilizer Attach Fittings inspection), and 89-05-02 (Ruddervator Control Arms inspection) were also accomplished.

The maintenance logs indicated that between March 2, 1990, and August, 1991, the airplane was flown 35 hours. Between August 1991, and July 7, 1993, the airplane was flown 11.2 hours.

METEOROLOGICAL

The weather was clear, with winds from 260 degrees magnetic at 5 knots. The pilot had received three weather briefs from the Princeton Flight Service Station (PNM AFSS) throughout the day, which indicated thunderstorms along his route of flight and at his destination. His original departure was scheduled for earlier in the day, but his discussions with PNM AFSS indicated he had delayed to allowed the weather to improve.

AERODROME INFORMATION

The airplane departed runway 29 which measured 4,098 feet long and 75 feet wide.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest upright, with its nose pointed 070 degrees magnetic (opposite the direction of takeoff). The terrain was a flat, planted corn field. A ground scar existed which was 24 feet 8 inches long, with red glass and blue paint chips at the end pointed 035 degrees and a gouge at the end pointed 215 degrees where a piece of the spinner and 1 prop blade were embedded. The red glass was 214 feet on a bearing of 190 degrees magnetic from the south edge of runway 29, directly abeam the departure end.

The engine remained attached to the airplane, and was located 15 feet on a heading of 260 degrees from the ground scar containing the separated prop blade. No other ground scars were visible.

The front spar remained intact. The right wing was canted ahead of its normal position and the left wing aft of its normal position with respect to the fuselage by approximately 15 edgrees. Both wing leading edges exhibited chordwise crushing. The left wing exhibited damage along its entire length, and the outboard half was deformed aft almost 90 degrees. The inboard 1/3 of the right wing exhibited heat discoloration, but was not completely burned. The inboard 1/3 of the left wing, and left wing fuel tank were consumed by fire. There was molten, puddled aluminum below the left tank area. The left fuel tank outlet screen could not be located. Both wing tanks were ruptured and open to the environment. Fluid was found inside the tank cavities, which did not smell like gasoline.

The empennage was intact, and exhibited very little thermal damage or paint blistering aft of the wing trailing edges. The ruddervators and stabilizers displayed no impact damage. The empennage exhibited a crease which extended from the mid-waterline on both sides across the top of the fuselage, located at the midpoint between frame 444 and 448, just forward of the cross-member which provides support for the ruddervator assembly. The frames at 444 and 448 were deformed toward the right.

The center section of the airplane, and entire cabin was consumed by fire. An automotive battery and 2 license plates were located in the left rear seat position.

Both propeller blades exhibited bending toward the cambered side from midspan outboard, and chordwise scratching. The blade hub from which the separated blade departed exhibited torsional deformation.

All controls located within the cockpit were burned away. The fuel pump shaft was found intact and was able to be rotated by hand. The fuel selector valve housing was disassembled and the ports found to be in the left tank position. The carburetor inlet screen was clean. The pressure carburetor was broken at its base but remained attached to the engine. The engine oil screens exhibited no metal debris. Residual oil was present inside the engine. The spark plugs were all dry, clean, and dull gray. The propeller pitch electric actuator gear was in the low pitch, high rpm position. Both magnetos were fire damaged, could be rotated, but would not spark. The engine was able to be rotated by hand, and all 6 cylinders produced compression.

The landing gear and flaps were in the retracted position. The ruddervator trim tab actuator was at 1 inch. This equals 0 degrees (neutral) deflection.

Flight control cable continuity was confirmed from the cockpit flight controls to all control surfaces. The control lock was located behind the right front seat. There was no elongation of the control column lock pin hole.

The autopilot servo package remained attached to its mounts on the bottom of the forward tailcone. The actuating cables remained intact and connected from the pitch servo gears to their terminus at the ruddervator mixing unit. The right side control cable which connected the autopilot pitch servo to the ruddervators was observed to be on the outboard side of the cable guide bracket at frame 444, and hooked under the guide center bolt. The normal routing for this cable is inboard and between the two cable guides located at frame 444. The insulation on this cable displayed the same burning as the left cable, except in the vicinity of the cable guide. The insulation at this location displayed several distinct, parallel marks which appeared to be the same spacing as the threads on the pulley bolt. The cable insulation also exhibited a single slice which was the same distance forward of the thread marks as the edge of the pulley bracket. This section of cable was removed and examined by the Safety Board's metallurgical lab.

The outboard edge of the cable guide bracket exhibited soot deposits except for an area approximately the same diameter as the servo pitch cable directly below the bolt threads. The inboard edge of the same bracket appeared to have uniform sooting with no clean areas.

After documentation of cable positions and continuity, the ruddervators were checked for freedom of movement. When moved in roll, yaw or a combination of these, all movement was free and unobstructed. When the ruddervators were moved in only the pitch direction, movement was unobstructed in the trailing up (nose up) direction.

When moved in the trailing edge down (nose down) direction, the ruddervators would lock at the trailing edge level position. The normal range of travel for the elevators is 20 +/- 1 degrees up, and 20 +/- 1 degrees down. At this location, the sliced insulation spot on the control cable from the autopilot pitch servo would snag on the cable guide bracket. This slice was oriented so that if the cable was pulled in the forward direction (nose down), the metal edge would be driven deeper into the insulation. When the cable was released from the cable guide bracket edge, full ruddervator (nose down) input was possible. This snag did not occur when mixed control inputs were applied, but only when the input was pure nose down. Once the snag did occur, the cable could not be freed unless manually removed from the metal bracket, or the input was reversed.

There was no indication of cargo in the empennage. The pilots' wife indicated that fishing poles and equipment were located at the destination.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was requested by the Minnesota Regional Coroner's Office and conducted at the Regina Medical Center, Hastings, Minnesota, on June 28, 1994. Toxicological testing revealed no anomalies.

FIRE

Witnesses stated that immediately upon impact the aircraft caught fire. No witnesses described seeing any fire prior to impact. The entire cabin area was consumed. The empennage, aft of the wing trailing edge, indicated sooting but little paint peeling or direct fire damage. The insulation which covered the autopilot control cables to the ruddervator mixing unit displayed bubbling and dark discoloration at the forward ends, and progressively less heat damage aft. Soot was deposited over all interior surfaces of the empennage.

SURVIVAL ASPECTS

The two passengers remained in the wreckage. The pilot was found partially in the wreckage, and removed by the first responder to the scene prior to the airplane becoming completely engulfed by the post-crash fire. This responder stated that "it was apparent that this person had obviously not survived." The airplane was not equipped with shoulder harnesses. The medical examiner's report indicated multiple trauma and internal injury. No soot appeared in the trachea.

TESTS AND RESEARCH

The stall warning switch was removed and electrical continuity was confirmed.

ADDITIONAL INFORMATION

The airplane was released to the owners insurance company on June 29, 1994. The items retained at that time were returned on September 28, 1994.

NTSB Probable Cause

THE JAMMING OF THE ELEVATOR CONTROL WHICH RESULTED IN THE PILOT'S INABILITY TO CONTROL THE PITCH ATTITUDE OF THE AIRPLANE. THE AIRPLANE ENCOUNTERED A STALL-SPIN AND IMPACTED LEVEL TERRAIN IN AN UNCONTROLLED DESCENT.