NTSB Factual Report

HISTORY OF FLIGHT

On October 19, 2003, about 1625 Pacific daylight time, a Beech 35-C33, N9438S, collided with terrain about 100 yards from the airport boundary fence at the approach end of runway 19 at Mesquite, Nevada. VTB Fliers LLC was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) pilot and the private pilot undergoing instruction (PUI) sustained fatal injuries; the airplane was destroyed. The cross-country instructional flight departed Henderson Executive Airport (HND), Las Vegas, Nevada, about 1500. Visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 36 degrees 50.617 minutes north latitude by 114 degrees 2.942 minutes west longitude.

The National Transportation Safety Board investigator-in-charge (IIC) interviewed a sheriff's deputy. The deputy said that he was driving on a nearby freeway and saw smoke near the airport. He went to investigate and discovered the burning wreckage. Two off-duty firemen were trying to extinguish the blaze with handheld extinguishers, however, they were unsuccessful.

PERSONNEL INFORMATION

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

The CFI held a first-class medical certificate issued on July 29, 2002. It had no limitations or waivers.

The IIC was unable to locate personal flight records for the CFI, and obtained the aeronautical experience listed in this report from a review of the airman FAA records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated a total time of 1,890 hours.

A review of FAA airman records revealed that the PUI held a private pilot certificate with a rating for airplane single engine land. He held a third-class medical certificate issued on August 9, 2002. It had no limitations or waivers. His charred logbook was in the wreckage and the last page filled in indicated that he had about 255 hours of airplane single engine land time. He indicated to the airplane's owners that he had 288 hours total time. He had 1 hour in this make and model, which he accrued in the accident airplane the previous day.

AIRCRAFT INFORMATION

The airplane was a Beech 35-C33, serial number CD-1004. A review of the airplane's logbooks revealed an estimated total airframe time of 8,615 hours. The logbook included an entry for an annual inspection dated October 23, 2002, at a tachometer time of 8,511.8 hours.

The engine was a Teledyne Continental Motors IO-470-N (17), serial number 096734-R. Total time on the engine at the last inspection was 1,160 hours.

One of the airplane's owners completed a 1.4-hour flight with the CFI in the accident airplane immediately prior to the accident flight. They started with 30 gallons in each main tank and 6 gallons in each tip tank. He said that they burned fuel out of the left main tank during the flight at an approximate rate of 13 gallons per hour. He left the fuel selector valve on the left tank.

After the owner's flight with the CFI, he observed the PUI and the CFI do a walk around inspection of the airplane. After a ground briefing, they taxied to runway 35 where they did a 15- to 20-minute run up before taking off. He did not see them refuel.

METEOROLOGICAL INFORMATION

The closest official weather observation station was St. George, Utah (SGU), which was located 27 nautical miles (nm) northeast of the accident site. The elevation of the weather observation station was 2,941 feet mean sea level (msl). An aviation routine weather report (METAR) for SGU was issued at 1635. It stated: winds from 210 degrees at 4 knots; visibility 10 miles; skies clear; temperature 31/87 degrees Celsius/Fahrenheit; dew point 0/32 degrees Celsius/Fahrenheit; altimeter 30.10 inHg.

AIRPORT INFORMATION

The Airport/ Facility Directory, Southwest U. S., indicated that Mesquite runway 19 was 5,100 feet long and 75 feet wide. The runway surface was asphalt.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest in soft sand near the bottom of a valley that crossed diagonally across the approach end of runway 19. The terrain was rough and uneven and sloped up toward the runway. Investigators from the Safety Board, the FAA, and Beech examined the wreckage at the accident scene.

The first identified point of contact (FIPC) was a series of three parallel ground scars. The left ground scar was 9 feet 6 inches from the center scar. The right ground scar was 11 feet 6 inches from the center scar. The center of the cabin came to rest 25 feet from the center scar, and on a magnetic bearing of 200 degrees. The fuselage came to rest on a magnetic bearing of 240 degrees with the engine displaced to 245 degrees.

The nose wheel separated and was midway between the center scar and the main wreckage. The rest of the airplane was together. However, the post crash fire consumed the inboard edge of the left wing, the cabin, the engine compartment, and the right wing. The empennage was not damaged.

About 4 gallons of a clear light blue fluid that smelled like aviation fuel remained in the left tip tank. The manufacturer's representative determined that the fuel selector valve was on the left main fuel tank. The left main tank had been compromised in the impact sequence.

One propeller blade bent aft under the right side of the engine. The cambered side of this blade was polished. The leading edge had dents and nicks.

The second propeller blade pointed toward the 11 o'clock position and did not exhibit any marks or gouges. This blade was charred.

Investigators established control continuity from the control surfaces to the burned and crushed control column and rudder pedals. The airplane had a single control yoke. The manufacturer's representative determined that the yoke was to the left side.

MEDICAL AND PATHOLOGICAL INFORMATION

The Mohave County Coroner, Kingman, Arizona, completed an autopsy. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilots.

Analysis of the specimens for the CFI contained no findings of carbon monoxide or cyanide detected in blood, no ethanol detected in vitreous, and no tested drugs in urine.

Analysis of the specimens for the PUI contained a finding of 15 percent carbon monoxide detected in blood, no cyanide detected in blood, no ethanol detected in urine, and no tested drugs in urine.

TESTS AND RESEARCH

Investigators examined the engine in a hangar at North Las Vegas on October 22, 2003.

The post crash fire consumed about 1/2 of the oil sump. The engine sustained thermal and mechanical damage. The right side sustained more damage than the left side.

The engine had been removed during recovery. Investigators placed it on a stand. Oil leaked out following removal of the rocker covers on cylinders 4 and 6. Investigators rotated the engine on the stand. The engine rotated freely, and the gears in the accessory case turned freely. The push rod tubes for cylinder no. 1 were consumed by fire, and the hydraulic lifters had fallen from the cylinder. The lifters were stuck in cylinder no. 3. The valves on cylinders no. 2, 4, 5, and 6 moved approximately the same amount of lift. Investigators obtained thumb compression on cylinders no. 2, 4, 5, and 6.

Both magnetos were charred. Investigators manually rotated the magnetos, but neither magneto produced spark. Investigators disassembled the magnetos. The right magneto's internal components had melted. The left magneto was less damaged than the right; however, solder near the coil had melted. The ignition harness sustained mechanical and thermal damage.

None of the spark plug electrodes sustained mechanical damage. All electrodes were oval. Most of the spark plug electrodes were gray in color. The top plugs in cylinders no. 3 and 5 were sooty, and the bottom plug in cylinder no. 5 was oily. The top plugs in cylinders 2 and 4 and bottom plugs in cylinders 1 and 6 contained deposits.

The oil sump screen was clean and open. The governor screen was clean. The oil screen was clean.

The fuel pump would not turn. The drive was unbroken, but the pump was full of debris. The diaphragm in the fuel distribution valve was undamaged and the screen was clean. The fuel injectors were open.

The throttle quadrant sustained thermal damage. The throttle and propeller controls appeared to be full forward. The mixture was out about 3/4 inch and bent.

The airframe manufacturer's representative determined that the landing gear was down. The representative measured the flap actuator at 4 3/4 inches, which corresponded to the full down position. The representative estimated the elevator trim was about 2 degrees tab down.

Mesquite was about 75 nm from Henderson. The Pilot's Operating Handbook and Airplane Flight Manual included cruise performance charts. The charts indicated cruise speeds between 138 and 158 knots for 55 to 75 percent power settings at altitudes from 4,000 to 10,000 feet.

ADDITIONAL INFORMATION

The IIC released the wreckage to the owner's representative.

NTSB Probable Cause

fuel starvation due to the pilot's inadequate in-flight planning and fuel system management, and failure to select a fuel tank containing fuel. Also causal was the certified flight instructor's inadequate supervision.