NTSB Factual Report

HISTORY OF FLIGHT

On June 28, 1994, about 1357 hours eastern daylight time, N6004E, a Beech BE-76, operated by O.T. Aviation, Inc., West Mifflin, Pennsylvania, impacted terrain in Elizabeth, Pennsylvania, and was destroyed during approach to runway 25 at the Rostraver Airport. The certified flight instructor (CFI) was seriously injured, the private pilot who was receiving instruction was fatally injured, and the rear seat passenger was fatally injured. Visual meteorological conditions prevailed and a flight plan was not filed. The instructional flight departed from the Allegheny County Airport, West Mifflin, at 1342 and was conducted under 14 CFR 91.

According to the assistant manager of O.T. Aviation, who was present in the lounge/office area of O.T. Aviation on the day of the accident, the private pilot had called earlier in the day to schedule a flight simulator session for that afternoon. The assistant manager later learned after the accident that the person who received the call mistakenly scheduled the simulator under another name. This statement was corroborated by an examination of the operator's daily flight schedule.

Another witness, a single-engine airplane flight instructor at O.T. Aviation, was also present in the lounge/office area on the day of the accident. He stated that when the private pilot arrived, he saw that someone else's name had been entered on the schedule. The private pilot said "I've got to fly today," and checked to see if there were any airplanes available to fly in lieu of the simulator. The flight instructor stated that the accident airplane, N6004E, a Beech "Duchess," was probably the only airplane available at the time, because it was "pretty busy" that day at the airport. The Duchess was parked in front of the office at the time the private pilot arrived because it had been prepared for flight by someone who had previously cancelled the flight; this was corroborated by the operator's flight schedule.

Seeing that N6004E was available, the private pilot asked the flight instructor if he wanted to fly with him. The flight instructor stated that he could not because he wanted to wait for the person who had been mistakenly entered on the simulator schedule.

The flight instructor then observed the private pilot ask another flight instructor, who had multiengine flight instructor privledges, if he would fly with him, but the multiengine flight instructor could not because he had another student scheduled.

According to the multiengine flight instructor, the private pilot clearly asked him for "single engine work," and stated that the private pilot desired flight instruction involving practice approaches under simulated single-engine emergency procedures. After the multiengine flight instructor declined, he observed the private pilot ask the accident CFI if he "would like to go up and do some single engine work." The CFI said "yes."

The multiengine flight instructor also stated that he heard the private pilot and CFI discuss what they would do during the flight. The discussion involved "upper air work" and "single engine work at Rostraver." The multiengine flight instructor stated that he was certain that "the whole purpose" of the flight was for instructional purposes, and he overheard the accident CFI tell the private pilot "I'm going to show you something you've never seen before."

The multiengine flight instructor also stated that the passenger (seated in the left rear seat of the accident airplane) was in the lounge at the time of these conversations and decided to fly on the accident flight to observe.

The accident CFI was interviewed in the hospital on August 19, 1994, after he had partially recovered from his serious injuries, and again on February 1, 1994, via telephone conversation. He stated that his memory of the accident flight ends at the time the airplane was about to taxi for takeoff at Allegheny County Airport. However, he did remember the events that led up to that time.

According to the CFI, he arrived at the airport about noon on the day of the accident. He stopped in at the O.T. Aviation lounge to check if he was on the schedule for flight instruction.

He saw the private pilot in the lounge area and the private pilot told him someone else was written into the schedule for the simulator during the time that he had previously requested. The CFI also recalled that he was going to monitor the private pilot during the simulator session, because the private pilot wanted to perform low approaches coming out of a 100-foot ceiling.

An examination of the O.T. Aviation aircraft and flight instructor schedule (copy attached) for the day of the accident revealed that the CFI did not have any students scheduled. The examination also indicated that the private pilot was scheduled to fly a Piper PA-28 airplane at 1530; it was determined that the airplane was placed out of service and into maintenance prior to the scheduled time. Also, a name was entered for the flight simulator at 1300.

The CFI stated that because someone else's name was written in the simulator schedule, the private pilot suggested that he and the CFI fly to Rostraver Airport in N6004E and have lunch there, figuring that when they returned, the simulator would be available. The CFI stated that he agreed, and that it was understood the flight would not be instructional and that he would be "just a passenger" on the flight.

The CFI stated that he and the passenger stayed in the lounge and watched the first pilot perform a "thorough" pre-flight inspection that lasted about 20 minutes. The CFI observed the private pilot check the oil in both engines. No problems with the airplane were reported to the CFI by the first pilot.

According to the CFI, the three occupants boarded the airplane and "... strapped in with the seat belts and shoulder harnesses." The private pilot went through the start-up checklist "... by the numbers..." and started both engines. The CFI stated that he did not perform any crewmember duties and was a "passenger" during this time. He stated that he remembered the private pilot contacting ground control and receiving clearance to taxi. The CFI stated that "...everything was operating normally..." at that point. After receiving the clearance, the private pilot said: "OK boys and girls, we're ready to taxi," or something similar. That is when the CFI's recollections of the accident flight end.

According to the FAA Air Traffic Control (ATC) transcripts, the airplane received clearance to takeoff from runway 28 at the Allegheny County Airport at 1342 hours. No other pertinent radio communications were recorded by any FAA facility following the acknowledgement of the clearance. According to ATC personnel at the Pittsburgh International Airport, recorded radar data was not available at the time of the accident due to equipment and software modifications in progress.

One witness, a pilot, was sitting on the rear deck of his home when he saw "... a twin engine, high tail, Duchess aircraft..." flying overhead about 1345. The witness's home is located about 2.5 miles southeast of the Rostraver Airport. The witness stated:

My attention was directed to the east/southeast and the sound of an aircraft with a wooshing air sound (such as when an [aircraft] is losing altitude quickly). A ... Duchess ... was observed in a steep descent from what appeared to be about [3,500 to 4,000 feet above the ground] on a heading of approximately 290 degrees to 300 degrees. The [aircraft] appeared to level out, with landing gear extended, above normal pattern altitude for Rostraver [airport]. As it leveled, an engine could be heard backfiring, but I could not detect if one engine was feathered or off. The [aircraft] then powered up, and began turning to the right as if to be entering a wide left down wind for Rostraver - Runway 25. The [aircraft] proceeded toward [the airport], and went out of sight. No other unusual noise could be detected.

According to flight instructors at O.T. Aviation, the area located to the east/southeast of Rostraver Airport is part of a practice area utilized for flight instruction.

According to another witness located about 1/2 mile from the Rostraver airport:

I was in my house [when the] plane went over the house, too low to hit the airport. [The plane] tried to turn around the hill (right in front of runway). He would have smashed into the hill the way he was going, so he turned to the right [about 30 degrees of bank as shown with model airplane], then disappeared into trees. I heard the crash about a second later. There was no fire or smoke coming from the airplane. I did not hear anything unusual before the crash - no popping or sputtering.

According to a resident who lives about 100 yards from the accident site: "I did not see the airplane, but I heard it roar loudly for a couple of seconds. It sounded like the engines were revving up. Then I heard a loud crash - then a dead silence."

The accident occurred during the hours of daylight at 40 degrees 12.85 minutes North, and 79 degrees 49.38 minutes West.

PERSONNEL INFORMATION

The CFI, age 57, was a commercial pilot and certified flight instructor with ratings for single and multiengine instrument airplanes. He was employed as the chief flight instructor at O.T. Aviation at the time of the accident. According to FAA records, he was issued an FAA Second Class Medical Certificate on May 7, 1994, with the limitation that he "must wear lenses for distant - possess glasses for near vision." An examination of the CFI's logbook revealed that he had a total of 5,533 hours of flight time, including 302 hours in type. The CFI also had 1,008 hours of flight instruction given, including 292 hours of instruction in type.

The private pilot, age 41, was a certificated private pilot with ratings for single and multiengine land airplanes. According to FAA records, the private pilot was issued an FAA Third Class Medical Certificate on October 12, 1993, with the limitation that he "must wear corrective lenses." An examination of the private pilot's personal logbook revealed that he had a total of 270 hours, including 3 hours of pilot-in-command time in type. The private pilot satisfied the flight currency requirements as per FAA regulations. The logbook also indicated that the private pilot had flown a total of three flights as pilot-in-command since the time that he successfully completed the FAA Practical Test for the Multiengine Rating on November 16, 1993.

AIRCRAFT INFORMATION

The accident airplane was a 1978 Beech BE-76 "Duchess." It had four seats and was powered by two 180-horsepower counter- rotating engines. The airplane was registered to the Marshall Air Service, Inc., Bethel Park, Pennsylvania, and was operated by O.T. Aviation.

An examination of the airplane's engine, airframe, and propeller logbooks did not reveal any unresolved discrepancies prior to departure the day of the accident.

An examination of fuel and servicing records indicated that the accident airplane had been fueled with 44 gallons of 100 octane low lead aviation gasoline on the day of the accident. No evidence of fuel contamination was found. Five days prior to the accident, a quart of oil was placed into the right engine and 3/4-quarts of oil was placed into the left engine. According to the person who performed the oil servicing, a total of eight quarts was seen on the dipstick for each engine at that time.

WRECKAGE AND IMPACT INFORMATION

The aircraft wreckage was examined at the accident site on the evening of the accident, June 28, 1994, and again on June 29. An additional examination occurred on June 30, 1993, at the Rostraver Airport after the wreckage had been moved. Subsequent examinations of the engines and propellers occurred on July 7, 1994, and September 13, 1994, respectively.

The airplane came to rest about 1/4-mile north of the approach threshold of runway 25 in down-sloping, wooded terrain. There was no evidence of fire or in-flight separation. The wreckage distribution path was aligned along a magnetic bearing of 360 degrees. The initial tree strike (85 feet above the ground) was found 125 feet from the main wreckage. Plexiglas pieces and portions of the right wing tip were found in the area of the initial tree strike. An area of widespread defoilage about 30 feet in diameter was found about half-way from the initial tree strike to the main wreckage.

The airplane came to rest upright within the confines of its pre-impact dimensions and its longitudinal axis was aligned along a magnetic bearing of about 165 degrees.

All primary and secondary flight control surfaces were accounted for at the accident site. Flight control cable continuity was verified for all controls and no evidence was found to indicate a flight control deficiency. The flaps were found in the fully retracted position. The landing gear were all found in the extended position. The left and right elevator trim tabs were found in the 12-degree tab down (trim nose up) position. The rudder trim tab was found in the 2-degree tab right (trim nose left) position.

Both wings remained partially attached to the airframe. The right engine and nacelle, including the right propeller, was attached to the right wing; its underside was crushed. The leading edge of the outboard portion of the right wing was crushed aft. The left wing sustained greater damage than the right wing. The left engine was separated from the wing and was found lying on its side in front of the wing. The entire leading edge of the left wing was crushed rearward and splayed open. The inboard portion of the left wing exhibited "accordion" crush damage and had dirt and tree bark embedded inside.

All tail flight control surfaces remained attached to the tailcone; the tailcone was partially separated from the rest of the airframe. The cabin was deformed and exhibited downward crush damage. The left side of the cabin sustained greater damage than the right side. An examination of the cockpit controls and instrument panel revealed the following data:

LEFT ENGINE RIGHT ENGINE

Cylinder Temperature Gage 350 F 0 F Oil Temperature Gage 130 F 0 F Oil Pressure Gage 100 psi 5 psi Auxiliary Fuel Pump Switch ON OFF Carburetor Heat Control ON OFF Magneto Switch BOTH LEFT Throttle Control Full Forward 1 inch < Full Propeller Pitch Control Full Forward 1/2 inch < Full

Both main fuel tanks, including their associated fuel lines and attaching hardware, were compromised in the accident. The right wing fuel selector valve cockpit control was found in the ON position and its control cable continuity from the cockpit to the valve was verified. The left engine fuel selector valve control was found in the OFF position; it was damaged and separated from its associated control linkage.

After a cursory examination of the engines at the accident site, a detailed disassembly and inspection of both engines occurred under Safety Board supervision on July 7, 1994, at the Allegheny County Airport.

An examination of the right engine, a Lycoming LO-360-A1G6D, revealed the presence of about 8 ounces of engine oil from the oil sump. The sump drain plug was examined and was found jammed upward in the open position. The engine was free to rotate by hand; continuity and compression for all cylinders were confirmed during the rotation. The No.3 cylinder, piston and connecting rod were removed from the engine; evidence of lubrication throughout the interior was found. The carburetor was disassembled and inspected; the inspection revealed the presence of fuel in the float bowl. No pre-impact mechanic

NTSB Probable Cause

1) THE FAILURE OF THE PILOT-IN-COMMAND (CFI) TO PROVIDE ADEQUATE SUPERVISION OF THE DUAL STUDENT DURING A SIMULATED SINGLE-ENGINE APPROACH, AND 2) HIS FAILURE TO PERFORM REMEDIAL ACTION. THIS LED TO A LOSS OF AIRCRAFT CONTROL IN CLOSE PROXIMITY TO THE GROUND. CONTRIBUTING TO THE ACCIDENT WAS THE DUAL STUDENT'S FAILURE TO MAINTAIN MINIMUM CONTROLLABLE AIRSPEED AND A PROPER GLIDEPATH TO THE RUNWAY DURING THE APPROACH.