NTSB Factual Report

History of Flight

On July 20, 1997, at 1630 central daylight time (All times CDT), a Beech B-60, N3359P, was destroyed when it impacted terrain two miles northeast of the Springfield/Branson Regional Airport, Springfield, Missouri. The pilot reported that he was having engine problems and he attempted to return to the airport. The airline transport pilot, a pilot rated passenger, and two passengers received fatal injuries. The 14 CFR Part 91 flight departed the Springfield/Branson Regional Airport en route to the Spirit of St. Louis Airport, Chesterfield, Missouri. Visual meteorological conditions prevailed and a VFR flight plan had been filed.

The airplane had departed the Spirit of St. Louis Airport about 0930 and landed at the Springfield/Branson Regional Airport about 1020. The pilot did not request aircraft servicing or fuel. Later that day the pilot and passengers returned and prepared for departure.

An aircraft service lineman at the Springfield/Branson Airport reported that the pilot in the left seat "could have been heavy set" and was wearing a dark tee shirt. The autopsy indicated that the pilot was wearing a knit navy blue and green shirt and weighed over 250 pounds.

At 1610, the pilot called the ground controller and obtained taxi instructions for a VFR flight back to the Spirit of St. Louis Airport. The pilot received taxi instructions for a runway 22 takeoff.

At 1615, the airplane departed and turned on course to the Spirit of St. Louis Airport.

Radar data indicated that the airplane departed to the northeast after takeoff. The first radar "hit" was at 1619:58 and the airplane was about 3.5 nm to the southeast of the field at 2,800 feet mean sea level (msl) and climbing at a rate of 750 fpm.

At 1621, the airplane was about 5 nm east of the airport at 4,300 feet msl. The airplane was about 3,033 feet above ground level (agl).

Witnesses reported that they heard a twin engine airplane with engine problems at about 1615. The location of the witnesses when they observed the airplane was about three miles east of the Springfield Regional Airport. The witnesses reported hearing the airplane's engine/s sputtering, cutting out, or backfiring. They reported seeing the airplane flying, wings level, to the northeast.

At 1621:34, the radar data indicated that the airplane had started a descent on a northeasterly heading. The average rate of descent was about 402 fpm.

At 1624:59, the airplane's altitude was 2,800 feet msl and about 12 nm to the northeast of the airport, about 7 nm further to the northeast from the initial descent point.

At 1624:59, the airplane started a left hand descending turn. The radar data indicated that the airplane made a 180 degree turn and was heading to the southwest.

At 1626.35, the last radar hit on the airplane indicated that it was at 2,200 feet msl and about 10 miles to the northeast of the airport. The airplane was about 933 feet agl.

At 1626:38, the pilot contacted the Springfield local air traffic controller. At 2126:41 the pilot reported, "Yes, sir, we need to return to the airport."

At 2126:54, the controller directed the pilot to fly a 210 degree heading and informed the pilot that he would sequence the airplane in for landing behind a Beech 1900 that was fifteen miles out from the airport.

At 2127:13, the pilot responded, "Okay, ah, we may, ah, not be able to do that. We're going to let you know here in just a minute."

At 2127:18, the controller asked, "Are you experiencing any difficulties?" The pilot responded, "Yes, sir."

At 2127:21, the controller asked, "Can you give me any, ah, information right now?"

At 2127:23, the pilot responded, "Ah, negative. Stand by a minute."

At 2148:49, the pilot informed the controller that, "...ah, we've got a partial engine failure on the left side. We're going to have to limp it on in."

At 2128:54, the controller told the pilot, "Okay, go straight in to runway two zero, sir." The pilot acknowledged landing runway 20.

At 2129:22, the controller asked, "Duke, ah five niner poppa, you want the equipment?"

At 2129:25, the pilot responded, "Ah, not at this point. We're gonna see if we can't make the airport here."

At 2129:36, the controller cleared the airplane to land on runway 22.

At 2129:39, the pilot responded, "Okay, we don't have the airport."

At 2129:41, the controller asked, "Okay, what's your heading?"

At 2129.42, the pilot said, "Isn't going to work. We're gonna have to put it down."

At 2129:44, the controller asked, "Your landing at your present position?"

At 2129:46, the pilot responded, "Ah yeah. We're looking for a field down here."

At 2129:49, the controller responded, "All right, sir. Thank you very much."

There were no further communications from the pilot.

Witnesses reported seeing a twin engine airplane flying to the southwest at a low altitude at about 1630. The location of the witnesses was about .5 to 1.5 miles to the northeast of the accident site. The witnesses reported that they did not hear any backfiring or sputtering noises from the airplane's engines. They reported that both propellers were turning.

A witness reported that he saw the airplane flying through a valley about 1/8 mile to the east of his farmstead. He reported that the airplane was flying north to south "straight down the road." He reported that the airplane was flying 50 to 100 feet below the tree line but above the telephone poles. He reported that the airplane was level, the props were turning, the flaps and gear were up, and the noise sounded like full power. He reported that the engines were not sputtering. He reported that the airplane climbed 50 to 100 feet in order to clear the trees at the south end of the valley where the terrain was higher. The airplane went out of his field of view.

He reported that his wife saw the airplane momentarily. He reported that she saw the airplane get over the trees. She did not see any abrupt maneuvers.

A third witness reported he saw the airplane climb over the trees. He reported that the airplane missed the powerlines but was, "struggling to get over the powerlines." He reported that everything went up in flames. He reported that a little wind was blowing to the northeast. He reported that the local firefighters put out the grass fire, and that the airport firefighters put out the aircraft fire.

Personnel Information

The pilot was an airline transport rated pilot with single and multi-engine land ratings. He held a First Class medical certificate. He had a total of about 10,734 hours of flight time. 7,643 hours were in multi-engine aircraft. In the last 12 months he had logged 46 hours in the accident aircraft. The aircraft operator reported that the pilot initially began flying a B-60 in 1980, but logbooks covering that time period were not obtained.

The pilot was an employed pilot of the aircraft operator. The operator reported that the pilot was meticulous and conscientious in his approach to flying. He reported that the pilot had checked-out the four company pilots in the B-60.

The pilot rated passenger in the right seat of the airplane was an airline transport rated pilot with single and multi-engine land ratings. He held a First Class medical certificate. He had over 20,500 total flight hours.

The operator reported that the pilot rated passenger was a friend of the pilot. He reported that the pilot and pilot rated passenger were planning a fishing trip to Canada for the following week. He reported that the purpose of the flight to Springfield, Missouri, was a pleasure flight in order to purchase fishing equipment. The operator reported that the flight to Springfield was not an instructional flight or an indoctrination flight.

Aircraft Information

The airplane was a twin engine Beech B-60, Duke, serial number P400. The airplane seated six and had a gross weight of 6,775 pounds. The engines were 380 horsepower Lycoming TIO-541-E1C4 engines. The last annual inspection was conducted on September 6, 1996. The airplane had flown 40 hours since the last inspection and had a total time of 3,358 hours.

The engine logbooks indicated that both engines were overhauled on September 30, 1988. The time since overhaul was about 887 hours. The engine teardown revealed that Superior Air Parts pistons (p\n SL 10545) were installed on both engines during the overhaul. The engine teardown revealed that the #3 and #5 pistons in the left engine had SL 10545 Revision AF pistons installed. SL 10545 Revision AF pistons were not produced until February 1990. There were no logbook entries indicating when they had been installed. The #1, #2, and #5 pistons in the right engine had been replaced since overhaul. Logbook entries indicated the dates they had been installed.

The operator of the aircraft reported that they had purchased the airplane in 1996. The operator reported that they did not replace any pistons in the left engine. A logbook entry indicated the operator had replaced the #1 and #5 cylinders on the right engine with chrome reconditioned cylinders on April 1, 1996.

The left engine turbocharger had been replaced on June 30, 1997. Time since replacement was about 3 hours.

The aircraft logbook indicated that maintenance had been performed on the right wing fuel tank on July 10, 1997. The logbook entry read, "Repair fuel seepage right wing by tightening leading edge fuel cell interconnect nipple. Fuel right wing and confirm repair." The aircraft operator reported that fuel had started seeping out of the right wing. To locate the leak, fuel was transferred manually from the right tank to the left tank. The mechanics determined that the fuel was leaking at the interconnect nipple. After the leak was fixed, the fuel in the left tank was pumped back into the right tank utilizing the aircraft's fuel pump and a hose. The operator reported that all the fuel from the left tank was pumped into the right tank, and that only residual fuel remained in the left tank. He reported that the left fuel gauge read zero fuel. He reported that the right fuel tank had about 50 to 60 gallons.

The operator reported that the airplane was not fueled or flown between July 11 and July 20, 1997. The operator reported that on July 20, 1997, the pilot ordered 50 gallons of fuel and had 25 gallons put in each wing. A fuel receipt indicated that 50 gallons of fuel were put on the airplane on July 20, 1997.

The operator reported that the left fuel tank had about 25 to 35 gallons of fuel and the right tank had about 75 to 80 gallons of fuel when it departed for Springfield, Missouri, on July 20, 1998. The operator reported that the fuel gauges worked and were accurate. A Hoskins fuel totalizer was installed on the airplane. The operator reported the totalizer indicated the total fuel on board but it did not indicate how much fuel was in each tank.

The operator reported that each engine's fuel consumption was normally about 30 gallons per hour for the first hour, and 25 gallons per hour after the first hour. The flight from the Spirit of St. Louis Airport to the Springfield Regional Airport required about 50 to 60 minutes of flight time.

The airplane departed Springfield Regional Airport at 1615. At 1621:22, about 5.4 minutes after takeoff, the airplane started descending from 4,300 feet msl. At 2128:49, 11.8 minutes after takeoff, the pilot reported to the controller that he had a "...partial engine failure on the left side... ."

Meteorological Conditions

At 1630, weather conditions reported at Springfield/Branson International Airport were VFR. The sky was clear with 10 miles visibility. The temperature was 89 degrees Fahrenheit and the winds were 270 at 3 knots.

Wreckage and Impact Information

The airplane wreckage was located about 2 nautical miles to the northeast of the Springfield Regional Airport. The approximate heading to the airport was 220 degrees.

The airplane impacted in a hard gravel and clay ravine that was within a pasture. The pasture's terrain was characterized by rolling hills with some open flat areas. The pasture contained some tree clusters, but was mostly covered with grass. The terrain surrounding the pasture contained rolling hills covered with woods and small pastures or clearings.

The airplane impacted in the ravine on about a 210 degree heading. The wreckage path indicated that the airplane hit the ground inverted and was at or near a nose down, vertical flight path. The left and right propellers, hubs, and spinners separated from the engines and remained imbedded in the ravine at the point of impact. The left propeller was located on the right side of the wreckage path, and the right propeller was located on the left side of the wreckage path. Fragments of the left wingtip position light were located about 16 feet to the right of the left propeller.

The wreckage path indicated the airplane continued on a 210 degree heading before coming to rest on the edge of a grassy slope next to the ravine, right side up, and about 60 feet from the initial point of impact. Both wings remained attached to the fuselage. The nose of the wreckage was headed 330 degrees.

The left wingtip (with a wingtip fuel tank installation) and the nose landing gear separated and landed about 85 feet and 90 feet from the initial point of impact, respectively. The left wingtip exhibited no fire damage. The left wing tip leading edge exhibited diagonal and chordwise crushing.

The majority of the fuselage and empennage were consumed by fire. The left horizontal stabilizer, vertical stabilizer, and about one half the right horizontal stabilizer were consumed by fire.

The majority of the right wing was consumed by fire from the wing root out to about four feet from the wingtip. The right engine remained partially attached to the right nacelle and exhibited extensive fire damage. The fire consumed part of the engine's aft accessory section.

The left wing area between the wing root and left engine nacelle exhibited extensive fire damage and melting. The rest of the left wing, left engine, and nacelle were not destroyed by the fire.

The left engine and nacelle separated from the wing.

The leading edge of the left wing outboard of the engine nacelle exhibited leading edge crushing and upward bending.

The flight control system exhibited continuity from the flight controls to the cockpit area.

The left wing flap actuator exhibited a fully retracted (flap up) position. The right wing flap actuator extension was not obtained due to extensive fire consumption. The left aileron trim tab actuator extension indicated a three degrees up trim tab deflection (left wing up trim). The rudder trim tab actuator indicated a left trim tab deflection (nose trim right). The left elevator trim tab actuator was beyond the normal limit of actuator travel. The right elevator trim tab actuator extension was not obtained due to extensive fire consumption.

The cables from the power quadrant to the engines had severed and the power quadrant was destroyed by fire.

The remains of the landing gear actuator and the landing gear indicated that the landing gear was in the down position at impact.

The remains of the left and right fuel selectors indicated that the left fuel selector was in the OFF position, and the right fuel selector was in the ON position.

The left and right fuel boost pump switches were destroyed by fire.

Medical and Pathological Information

Autopsies were performed on the pilot and pilot rated passenger at Tri-Lakes Pathology, Branson, Missouri.

Forensic Toxicology Fatal Accident Reports were prepared by the FAA Civil Aeromedical Institute. The report concerning the pilot indicated the following results:

No Carboxyhemoglobin detected in blood.

No Cyanide detected in blood.

No Ethanol detected in vitreous fluid.

Atenolol was detected in blood and kidney fluid.

Pseudoephedrine was detected in blood and kidney fluid.

Ephedrine was detected in blood and kidney fluid.

Phenylpropanolamine was detected in blood and kid

NTSB Probable Cause

The pilot's fuel mismanagement and his failure to maintain adequate airspeed which resulted in fuel exhaustion followed by the loss of power in one engine and the loss of aircraft control. Contributing was the pilot's failure to refuel the aircraft, the pilot's failure to feather the propeller of the non-operating engine, and his extension of the landing gear.