NTSB Factual Report

HISTORY OF FLIGHT:

On October 27, 1995, at 2003 central daylight time, a Beech 95-B95, N9943R, collided with trees beyond the departure end of runway 36L at Tulsa International Airport, Tulsa, Oklahoma. The instrument rated/commercial pilot/owner sustained fatal injuries and the airplane was destroyed by fire. The airplane was being operated by a private owner on a personal flight under Title 14 CFR Part 91 when the accident occurred. Visual meteorological conditions prevailed for the planned cross country flight operating on an IFR clearance.

During interviews, conducted by the investigator-in-charge and a FAA inspector, witnesses and local authorities reported the information in this paragraph. The airplane arrived at the airport and parked on the ramp area at Tulsair; however, no services were performed at Tulsair. The pilot later requested and was cleared for takeoff on runway 36L from intersection Mike 2. Within seconds, the airplane passed within 5 feet of a vehicle (traveling on a west to east road), impacted trees, terrain and a railroad track before coming to rest in a park. Passengers in the vehicle reported observing an in-flight fire on the right side of the airplane. The driver of the vehicle stated the navigation lights were on; however, she did not see any fire prior to impact.

During a personal interview, conducted by the investigator-in-charge, the pilot's father stated that the pilot delivered an airplane from Arlington, Texas, to Houston, Texas, on October 26, 1995, and arrived back at home about 2230 that night. The pilot went to bed approximately midnight and awoke the following morning to arrive at Northwest Regional Airport, Roanoke, Texas, at about 0715 for the flight to Oklahoma. The planned round trip flight route included stops at Bartlesville and Tulsa. Following the purchase of a vehicle in Bartlesville, the pilot flew the airplane to Tulsa and the father drove the vehicle. Later that evening, after purchasing some components for the vehicle, they returned to the Tulsa International Airport. The father stated that the pilot was "tired" and he insisted that the pilot file an IFR flight plan. The pilot checked the weather for the return flight to Roanoke, Texas, filed the flight plan, and taxied for departure.

PERSONNEL INFORMATION:

The pilot's logbook indicated that the pilot began flight training in October 1991, obtained the private pilot single engine land rating in June 1992, and subsequently began training in N9943R. The pilot obtained the multiengine rating in July 1992, and in August 1993, added an instrument rating. The pilot upgraded the multiengine rating to the commercial level in April 1994, and in July 1995, he added the multiengine instructor rating. Accumulated flight time by October 1995, was 1188.9 hours of which 506.9 hours was multiengine flight time. All multiengine flight time except 5.6 hours was in N9943R.

AIRCRAFT INFORMATION:

A review of the airplane and maintenance records revealed that, at the time of the inspection, the airframe total time was 6155.6 hours. Engine total time since overhauled was 1704.2 hours for the left engine and 1516.7 hours for the right engine. The before takeoff manufacturer procedures (checklist enclosed) include a check of all flight controls for free and correct movement.

COMMUNICATIONS:

A review of air traffic control data (enclosed) revealed the following summary information. All times are converted to central standard time unless otherwise indicated.

At 1930 the pilot obtained a preflight weather briefing for a flight from Tulsa, Oklahoma, to Northwest Regional Airport, Roanoke, Texas. At 1942 the pilot filed an IFR flight plan for the route.

Clearance delivery was contacted at 1955:12 by the pilot and the flight was given a final expected altitude of 6,000 feet MSL with an assigned transponder code of 2177. Ground control was contacted at 1952:42 for taxi instructions which were issued at 1956:51 to runway 36L. At 2002:01, the pilot contacted the tower for takeoff from intersection "Mike two." The flight was cleared for the intersection takeoff at 2002:07.

During a personal interview on October 28, 1995, at the Tulsa Air Traffic Control Tower, the controller stated that he had worked at the Tulsa Tower since 1989, and on the date of the accident, his duty shift was from 1245 through 2045. The controller recalled that N9943R had requested taxi clearance from Tulsair and was cleared to taxi to runway 36L. Other traffic being worked by the controller was a Southwest flight cleared to land on runway 36R and a helicopter departing between the parallel runways. The controller then noticed N9943R was still on the runway, "rolling," and "passing taxiway kilo." The airplane "went off the end he never got airborne." The controller further stated that the airplane "was picking up speed all the way down, but he never got off," there was "no lift at all," there were "no flames" and there was "nothing until he disappeared, and then the explosion."

AERODROME INFORMATION:

Tulsa International Airport, Tulsa, Oklahoma, runway 36L is a hard surface (asphalt) runway with a total length of 6,101 feet and a width or 150 feet. Runway slope to the South is 0.8% up. The total runway 36L length from intersection Mike two is 5,450 feet. The last 900 feet of the departure end of runway 36L was closed and unlit during the construction of a taxiway.

WRECKAGE AND IMPACT INFORMATION:

Three ground scar marks, 52 feet 3 inches to the right of the runway 36L centerline, were found in the grass beyond the departure end of the runway. The distances between the ground scars approximated the distances between the airplane landing gear. Broken tree branches, containing paint chips, were found 428 feet through 470 feet beyond the departure end of runway 36L. One tree branch was slashed. Ground scars and burn areas were found in the area of the tree branches. A portion of the right wing inboard leading edge from the area of the main fuel tank was found in the area of the ground scars. The left propeller separated from the engine and came to rest on the railroad tracks. The airplane came to rest on a measured magnetic heading of 150 degrees, 586 feet north of the departure end of runway 36L. See the enclosed diagram for additional details.

The landing gear actuator was in the gear down position and the flaps were in the retracted position. Fuel tank selectors were on the main tanks. Cockpit and cabin area was destroyed by fire. The wings, ailerons, and flaps remained attached to the fuselage with a portion of the left aileron destroyed by the fire. The outboard leading edge of the right wing had a 15 inch diameter crushed area with pieces of wood imbedded in the torn metal. Portions of the inboard sections of each wing were destroyed. Flight control continuity was confirmed to the fuselage. Fuel sump filters were clear of debris. Fuel tank (right main, left main, left auxillary) integrity was compromised. Visual examination of fuel samples from the right auxillary tank did not reveal any contamination.

The propellers, which were found separated from the engines, exhibited striations, nicks, gouges, twisting and bending. The propellers were forwarded to Hartzell Propeller, Inc., for teardown.

Fire damage was found on both engines. The left engine (O-360-A1A, S/N L-7582-36) separated from the firewall with the oil and fuel hoses on the ground between the firewall and the engine. The oil cooler was separated from the mount; however, the hoses were attached to the oil cooler and the aft sump. The bottom portion of the fuel pump was destroyed by the fire. The carburetor separated from the engine with the throttle linkage remaining attached. Mixture and carburetor heat linkages were separated from the carburetor. The starter and generator were separated from the engine. Engine intake tubes were in place; however, the #1 and #2 exhaust stacks were partially separated from the cylinders and all exhaust stacks were partially crushed. The propeller governor oil line was intact. No evidence of an inflight fire was noted.

The right engine (O-360-A1A, S/N L-7581-36) was found partially attached to the engine mounts and the firewall. The lower portion of the fuel pump was destroyed by the fire. The carburetor was found attached to the intake air box, carburetor heat linkage and the throttle linkage. Mixture linkage was separated from the carburetor. Engine intake tubes were attached to the cylinders; however, the #2 exhaust stack was partially separated from the cylinder. The propeller governor oil line was in place. No evidence was found of a pre-impact fire. Exhaust system components were forwarded to the NTSB Materials Laboratory for examination and both engines were forwarded to Textron Lycoming, Inc., for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION:

The Office of the Chief Medical Examiner at Tulsa, Oklahoma, performed the autopsy. Toxicological findings were negative.

TESTS AND RESEARCH:

Cockpit control column components were examined in January 1995, at Lancaster, Texas. The control column inner tube (P/N 95-324006-5) and the outer tube (P/N 95-324006-49) contained a control lock rod that prevented movement of the control tubes designed to interconnect for aileron and elevator flight control movement respectively. The control column tubes exhibited deformation of the rod insert holes. The rod measured 4 1/8 inches in length and did not contain a slot. The manufacturer representative stated that the control lock was "not representative of the part depicted in the engineering drawing." Manufacturer specifications for the rod include a slot at the outer end and a total length of 3 5/8 inches for the control lock rod.

Examination of the propellers (enclosed report) found the blade butt end markings, on one of the right propeller blades, matched to corresponding hub arm markings placed the blade angle at about 22 degrees and 8 degrees respectively at the 30 inch reference. Right propeller piston position was in a low blade angle range. No blade butt end markings were noted that could be converted to blade angles for the left propeller.

Continuity of both engines was verified through rotation at the vacuum pump drive pads. The left magneto (left engine)impulse coupling rotated; however, fire damage precluded rotation of the right magneto (left engine) impulse coupling. The propeller governor drive adapter (left engine) rotated. Both right engine magnetos rotated 360 degrees. Oil pressure line for the propeller governor (right engine) was checked at 350 lbs. There were no anomalies found that would preclude engine(s) operation.

Right engine exhaust system components examined by the NTSB Metallurgists (report enclosed) contained fractures "typical of overstress separations." The components showed "no evidence of leakage of exhaust gas through flanges or pipe joints."

ADDITIONAL INFORMATION:

The airplane was released to the owner's representative.

NTSB Probable Cause

Inadequate preflight by the pilot by failing to remove the flight control lock and failing to check the flight controls before takeoff, and the pilot's failure to abort the takeoff.