NTSB Factual Report

HISTORY OF FLIGHT

On December 25, 2003, at 1322 Pacific standard time, a Beech A36TC, N364JR, collided with terrain during takeoff from runway 12 at the North Las Vegas, Nevada, airport (VGT). The pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The airline transport pilot and five passengers sustained fatal injuries; the airplane was destroyed. The personal cross-country flight was en route to Bullhead City, Arizona. Visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 36 degrees 12.104 minutes north latitude and 115 degrees 11.395 minutes west longitude, and was near the airport perimeter fence.

Reports from the Federal Aviation Administration (FAA) indicated that air traffic control tower (ATCT) personnel cleared the airplane for takeoff on runway 12. After liftoff, the pilot declared an emergency and attempted to return to the field.

The National Transportation Safety Board investigator-in-charge (IIC) interviewed a certified flight instructor who was a ground witness. The CFI observed the airplane lift off about 1,000 feet down the runway. The airplane's nose went up quickly to an "extremely nose high" attitude. The airplane began to "mush," and then leveled off. The landing gear went up about midfield. The airplane was flying and stopped mushing, but it was not gaining much altitude. At the end of the runway, the airplane began turning to the right. During the turn, the nose of the airplane went back up, and the airplane began to mush again. About 90 degrees through the turn, the airplane was about 250 feet above ground level (agl) and 75 feet above power lines. About the same time, the left wing went up until the airplane approached 90 degrees angle of bank. The nose went down and the airplane went straight into the ground. During the entire sequence, the CFI did not observe any smoke, fluids, or parts coming from the airplane.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held an airline transport pilot certificate with a rating for airplane multiengine land. The pilot held a commercial pilot certificate with a rating for airplane single engine land and instrument airplane. The pilot held a certified flight instructor (CFI) certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. He held a ground instructor certificate with advanced and instrument ratings.

The pilot held a second-class medical certificate issued on September 4, 2002. It had the limitations that the pilot must wear corrective lenses.

AIRCRAFT INFORMATION

The airplane was a Beech A-36TC, serial number EA-135. The engine was a Teledyne Continental Motors TSIO-520-UB engine, serial number 248928-R. No maintenance records were located for the airframe or engine.

COMMUNICATIONS

The airplane was in contact with VGT airport traffic control tower. Tower personnel reported that they cleared the airplane for takeoff at 1321.

AIRPORT INFORMATION

The Airport/ Facility Directory, Southwest U. S., indicated that VGT runway 12 was 5,000 feet long and 75 feet wide. The runway surface was asphalt.

WRECKAGE AND IMPACT INFORMATION

Investigators from the Safety Board, the FAA, Raytheon Beech, and Teledyne Continental Motors (TCM) examined the wreckage at the accident scene.

The first identified point of contact (FIPC) was a ground scar in a concrete drainage canal with tan and green markings. The airplane had tan and green accents. The canal had 45-degree sloping sides, and a flat bottom that was about 10 feet wide. The ground scars were along a magnetic bearing of 210 degrees on the north downslope side of the canal, and veered to 235 degrees on the upslope side. The flat bottom contained slash marks that were 17 inches apart, and were perpendicular to the debris path.

The propeller separated from the engine, and was between the FIPC and the engine. It was at the juncture of the flat bottom and the south upslope side of the canal.

In the bottom of the canal was a portion of the top right wing. Near this piece was an intact green lens. A road, which ran parallel to the west side of the canal, was about 10 feet from the canal's edge. Red lens fragments were on this road about 50 feet from the FIPC. The red rotating beacon on top of the rudder was intact.

The main wreckage came to rest about 95 feet from the FIPC. The left wing and engine were at the bottom of the upslope side of the canal, and the forward cabin area pointed down into the canal. The orientation of the fuselage, which was on sloped dirt at the top of the canal, was 052 degrees.

The instrument panel, firewall, and engine were hanging by wires; hoses and cables on the slope of the ditch. These components sustained severe thermal damage.

Fire consumed the cabin, left wing, and engine compartment. The debris path extended about 275 from the FIPC. The most distant pieces were cylinder head parts and the alternator.

MEDICAL AND PATHOLOGICAL INFORMATION

The Clark County Coroner completed an autopsy. The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the pilot. The results of analysis of the specimens contained no findings for carbon monoxide, cyanide, or volatiles.

The report contained the following results: ephedrine detected in urine, and pseudoephedrine detected in blood and urine.

TESTS AND RESEARCH

The FAA, Beech, and TCM were parties to the investigation.

Investigators examined the wreckage at Lone Mountain Aviation at VGT on December 27, 2003.

The empennage remained attached to the fuselage. The elevator and rudder flight control cables were attached to their respective flight control surfaces. Investigators manipulated the elevator and rudder flight control cables forward of the center carry-through section, and both flight control surfaces moved accordingly. The left and right stabilizers exhibited little or no damage. The rudder remained attached to the vertical stabilizer, and exhibited little or no damage.

The left aileron flight control cables were lying in resolidified melted metal. Post-impact fire consumed the aileron bell crank. The right aileron remained attached to the right wing by the outboard aileron hinge.

The right flap measured approximately 1.73 inches, or 0 degrees flap extended. Fire destroyed the left flap actuator.

The fuel selector valve was in the right main position.

The airframe manufacturer's investigator determined that the landing gear was in the retracted position. The representative estimated that the elevator trim tab was 2 degrees tab down, which corresponded to a neutral position.

Investigators removed the engine. They slung it from a hoist, and removed the spark plugs. All spark plugs except the top plug for cylinder No. 5, which sustained mechanical damage, were circular and clean with no mechanical deformation. The spark plug electrodes were gray. The bottom plug for cylinder No. 6 was oily.

The engine sustained mechanical damage and would not rotate. The propeller separated from the crankshaft along a plane that was angular to the longitudinal axis. The front right portions of the engine sustained the most mechanical damage. The front of the crankshaft separated, and remained attached to the propeller hub. The crankcase fractured in several directions around cylinder No. 6, and sections of the right front portion of the crankcase separated exposing the No. 5 main journal and bearings.

The head for cylinder No. 5 separated. Cylinder No. 3 sustained the next most mechanical damage; its intake valve was displaced. The piston head on cylinder No. 3 exhibited a semicircular witness mark on the intake side. Fire partially consumed the valve covers for cylinders No. 2 and 6.

Investigators dismantled the engine. All piston heads exhibited similar, light deposits. All rings moved freely except those on the piston for cylinder No. 5; there was mechanical damage on a portion of that piston. The connecting rods were intact; the rods and counterweights moved freely. The camshaft lobes were smooth and shiny with no pitting. None of the cam lobes were circular. The lifter faces were smooth and shiny, and not deformed or pitted. The main bearings were not scored, and investigators observed no fretting on the case.

Investigators manually rotated the magnetos. One magneto generated spark on four of six leads; two leads sustained mechanical and thermal damage. The second magneto produced spark on five out of six leads.

The vacuum pump drive gear melted.

The oil sump screen was clean and open. The governor screen was clean. The main oil pump gears were intact; investigators observed no scoring on the chamber walls. The scavenge pump gears were intact; they observed no scoring on the chamber walls.

The fuel pump drive gear was undamaged, and the pump rotated freely. The fuel manifold valve had a drop of water on top of the diaphragm, which was not torn. The manifold valve screen was clean, and the fuel nozzles were open.

The throttlebody sustained mechanical impact damage and burned. The butterfly valve was fully open.

The turbocharger sustained mechanical damage, and separated into several pieces. The compressor housing separated from the assembly, and partially melted. The blades on the compressor section of the turbocharger sustained mechanical damage, and bent opposite the direction of rotation. There was rotational scoring on one side of the housing throat. The faceplate melted into the impeller, and the impeller would not rotate. Only part of the turbine wheel could be seen. The turbine blades did not appear to be damaged; a white powder covered the blades.

The spinner exhibited aft crushing and rotational scoring.

One propeller blade bent forward about 10 degrees near the 3/4-blade point. It then bent aft, and twisted toward the low pitch (high rpm) position.

The second blade bent aft at midblade, and twisted over 90 degrees toward the low pitch position.

The third blade was loose in the hub, and had extensive leading edge damage at midblade. The outboard half of the blade from leading edge to midchord curled aft. The blade had a 1/2-inch hole through it near the trailing edge at 2/3-span.

NTSB Probable Cause

An in-flight collision with terrain for an undetermined reason while the pilot was maneuvering to return for a landing during an unknown emergency.