NTSB Factual Report

HISTORY OF FLIGHT

On September 27, 1995, about 2303 eastern daylight time, a Beech 58, N4095A, registered to VCA, Inc., crashed during takeoff from the Greenville-Spartanburg Airport, Greer, South Carolina. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed for the 14 CFR Part 135 nonscheduled domestic cargo flight. The airplane was destroyed and the commercial-rated pilot, the sole occupant, was fatally injured. The flight was originating at the time of the accident.

After landing from the previous flight, the pilot was unable to shut down the right engine using the mixture control. He used the fuel selector to do so and later stated to an acquaintance that he thought the mixture cable was broken and there was no resistance when he moved the mixture control in the cockpit. After cargo was loaded into the airplane the pilot was unable to start the right engine.

The pilot then called a company pilot and advised him of the malfunction and stated that he was unable to contact any individual in the maintenance department. The company pilot was also unable to contact company maintenance personnel and offered to fly another airplane there to complete the flight. The pilot was then advised by another company pilot to have the airplane inspected by a mechanic and if the problem was not corrected when he called back in 15 minutes, the first company pilot contacted would fly another airplane there to complete the flight.

A mechanic employed by the FBO where the airplane was parked stated he inspected the right engine and advised the pilot that the right engine mixture control cable was failed about 3-4 inches aft of the rod end bearing which attaches to the mixture control arm. The mechanic reportedly also advised the pilot that it would take about 8 hours to replace the failed control cable. The pilot inquired if the mixture control was spring loaded to the full rich position to which the mechanic stated, "I don't know about this one." The pilot then closed the engine cowling and after several attempts, the right engine was started followed by the left. While the airplane was taxiing to the runway, the company pilot who told the pilot to have the airplane inspected called the FBO and spoke with the mechanic who inspected the airplane. The mechanic was asked if the airplane was still on the ramp to which the mechanic responded that the airplane was taxiing. The company pilot stated that he believed the mixture control was fixed. The mechanic stated that the company pilot thanked him for fixing the broken cable to which the mechanic stated that he did not.

The flight was cleared for takeoff with a right turn on course and the tower controller observed the airplane turn to the right immediately after rotation. At about the midpoint and to the right of the runway about 104 feet above the ground, the airplane was observed to roll inverted and crash. Witnesses located at the FBO where the airplane was parked observed the airplane rotate about 1,500 feet down the runway. The airplane was then observed during the climb in a steep pitch attitude about 40 degrees and surging of one of the engines was heard. The airplane was then observed to roll inverted.

PERSONNEL INFORMATION

The day before the accident the pilot was given an instrument proficiency check flight by an FAA operations inspector in the accident airplane. The FAA inspector stated that he twice simulated an engine failure to the right engine and on both occasions the pilot performed satisfactorily. Review of the pilot's training file revealed that 2 days before the accident he had completed 4.7 hours of flight training in the make and model airplane which included in part emergency procedures and one engine inoperative procedures. The results were recorded as satisfactorily. Further information pertaining to the pilot is contained on page 3 of this report under the section titled First Pilot Information.

AIRCRAFT INFORMATION

Review of the engine logbook revealed that on September 18, 1995, a rebuilt/zero time engine was installed on the right side of the airplane. Review of the airframe logbooks revealed no entry which indicates that the right engine mixture control cable was ever replaced. Further information pertaining to the airplane is contained on page 2 of this report under section titled Aircraft Information and in Supplements A and B.

METEOROLOGICAL INFORMATION

Visual meteorological conditions prevailed at the time. Additional information pertaining to the weather is contained on pages 3 and 4 of this report under the section titled Weather Information.

WRECKAGE AND IMPACT INFORMATION

Examination of the crash site revealed the airplane came to rest inverted on a magnetic heading of about 105 degrees on the grass to the right of runway 3 about 118 feet from the initial impact point on a taxiway. The airplane first impacted while inverted on taxiway A about 642 feet to the right of the centerline and about 3,544 feet from the approach end of runway 3. Ground scars from the nose section, both engines, and the vertical stabilizer were observed on the taxiway. Located adjacent to the right engine ground scar were two perpendicular ground scars 3 feet 3 1/2 inches apart. A single ground scar oriented perpendicular to the left engine was also observed on the taxiway. The ground scars which were magnetically oriented about 090 degrees continued to the edge of the taxiway. Continuing along the wreckage path were one propeller blade from each engine propeller assembly, both of which exhibited evidence of chordwise scratches on the cambered side of the blades and also torsional twisting. Also located along the wreckage path was one of the magnetos from each engine.

Examination of the right engine compartment revealed that the right engine mixture control shaft was failed where it secures to the rod which threads into the rod end bearing. The failed rod was removed for metallurgical examination (see tests and research section). Examination of the airframe revealed that the landing gear and flaps retracted. Slight fire damage to both engine compartment areas was noted and both wing tips were deformed down as was the cockpit roof and nose section. The top portion of the vertical stabilizer and rudder was deformed to the right. All components necessary to sustain flight were attached to the airframe and examination of the flight controls revealed no evidence of preimpact failure or malfunction. Fuel leakage was noted from the left wing fuel tank. Cursory examination of the engines and propellers revealed no evidence of preimpact failure or malfunction.

MEDICAL AND PATHOLOGICAL

A post-mortem examination of the pilot was performed by J. David Wren, M.D., Ph.D., Pathologist, Spartanburg Regional Medical Center. The cause of death was listed in part as multiple body trauma. Toxicological testing of specimens was performed by the FAA Toxicology and Accident Research Laboratory and the South Carolina Law Enforcement Division, Forensic Services Laboratory Report. The results of both analyses were negative for volatiles, carbonmonoxide, and tested drugs.

TESTS AND RESEARCH

Metallurgical examination of the failed mixture control rod revealed that it failed due to reverse bending fatigue. Also, the rod end bearing was observed to be difficult to move by hand.

ADDITIONAL DATA/INFORMATION

FAA personnel interviewed an individual at the previous departure airport who indicated that the pilot did not mention any problem pertaining to the right engine mixture control.

The wreckage minus the retained right engine mixture control cable was released to Mr. Gary Ramsy, of Atlanta Air Salvage on September 30, 1995. The retained failed mixture control was released to Mr. Curtis H. Blackwell, DOM VCA, Inc., on December 15, 1995.

NTSB Probable Cause

operation of the aircraft by the pilot with a known deficiency (failed mixture control linkage in the right engine), which resulted in loss of power in the right engine; and his failure to maintain control of the airplane during the initial climb after takeoff.