NTSB Factual Report

HISTORY OF FLIGHT

On August 23, 1996, at 1903 Pacific daylight time, a Beech D-50 Twin Bonanza, N567SF, operated by and registered to the pilot as a 14 CFR Part 91 personal flight, experienced a loss of engine power and collided with a light pole and subsequently the terrain near the parking garage at the Seattle-Tacoma International Airport, Seattle, Washington. Visual meteorological conditions prevailed at the time and no flight plan was filed. The airplane was substantially damaged and the private pilot was seriously injured. The passenger was fatally injured. The flight had departed from Coeur d'Alene, Idaho, approximately two hours prior to the accident.

The pilot reported during an interview approximately two weeks after the accident, that he did not recall any of the events leading up to the accident, except for a vague memory of the first contact with Seattle approach control near Paine Field, Everett, Washington. The pilot reported that the purpose of the flight was to attend a Seattle ball game.

The pilot reported that prior to departing to Seattle, he flew the airplane earlier in the day to practice touch-and-go landings at Coeur d'Alene. The mechanic who worked on the airplane reported that he was in his hangar while the pilot was practicing the touch-and-go-landings. He stated that he had the local Coeur d'Alene airport radio frequency turned on and overheard a transmission from a flight instructor, who was holding short of the runway, state "N567SF you're landing with the gear-up." The mechanic then went outside and observed the airplane going around at about 30 feet with the landing gear retracted. When the pilot landed, the mechanic stated that the pilot came into the fixed base operation and bought a Seattle sectional chart. The mechanic told the pilot that maybe he should get some dual instruction as the pilot made a comment about not being able to find "things on the panel," and not being sure what "goes on and what goes off." When the pilot declined the suggestion, the mechanic then suggested that the pilot should sit in the airplane for a while and familiarize himself with the location of the items in the airplane. The pilot stated to the mechanic that he would have a good hour in flight to Seattle to do that. The mechanic then asked the pilot if everything was working okay in the airplane. The pilot responded that everything was working fine.

Witnesses near the accident site, who provided written statements, reported that the airplane was observed flying low and approaching the Seattle-Tacoma airport. Two pilots who were in an automobile by the traffic signal to the entrance to the airport, reported that they heard the reciprocating engine(s) of a low flying airplane. The pilots looked up and saw the Twin Bonanza directly over the intersection at approximately 150 feet above ground level. The pilots felt that the heading of the airplane at this point was about 300 degrees, and traveling "extremely slow" in a shallow 10 degree bank turn to the right. The landing gear was down and "very little flaps if any" were down. The pilots had a good view of the right engine and reported that it appeared to be operating normally and was not feathered. The pilots did not see any smoke or fire coming from the airplane. They could not see the left engine due to the bank angle of the airplane. Shortly after the pilots first sighted the airplane, the airplane appeared to "stall" with the right wing down. The bank angle increased to approximately 40 to 45 degrees and the nose pitched down to 15 to 20 degrees. The airplane was lost from sight at this point. One of the pilots reported that from the time he first saw the airplane until he lost sight of it, he did not hear any change in the engine sound, which appeared to be just above idle. The pilot also stated that the engines definitely were not at maximum power. There was no sound that either engine was "cutting out."

Other witnesses located further away from the accident site reported that they heard the airplane and looked to see that it was flying low at about 100 feet and traveling to the south. The airplane was in a straight and level attitude, moving fast, with the engines sounding normal. The landing gear and flaps were up. As the airplane continued to the south and at about mid-field to the Seattle-Tacoma runways, a witness reported that the engines suddenly went silent. The airplane started a shallow turn to the right (west). Just before the witness lost sight of the airplane, he stated that "one or both engines fired-up, but made an unusual sound." The sound lasted for about two seconds before the witness lost sight of the airplane.

PERSONNEL INFORMATION

At the time of the accident, the pilot held a private pilot certificate, and was rated in single-engine land, multi-engine land and single-engine sea aircraft. The pilot's flight logbook indicates that he had accumulated a total flight time, in all aircraft, of 138 hours, with 76 hours as pilot-in-command. The pilot had accumulated a total flight time of 25 hours in multi-engine land airplanes, with 16 hours as pilot-in-command.

The flight logbook indicates that the pilot's first flight in a multi-engine land aircraft was on April 28, 1995, in a Cessna 310. Six dual instructional flights were logged from April 28, 1995, to May 21, 1995, that originated from Paine Field, Everett, Washington. Instructional maneuvers were logged in the book and practice landings were made to Bremerton, Washington, and Renton, Washington. On August 26, 1995 through September 16, 1995, seven dual instructional flights were logged originating from Felts Field, Spokane, Washington. Instructional maneuvers were logged in the Spokane area with practice landings made to Deer Park, Washington, and Coeur d'Alene, Idaho.

On September 19, 1995, the pilot did not satisfactorily pass the multi-engine flight test. On September 21, 1995, the pilot logged a dual instructional flight from Felts Field to Deer Park and returning to Felts Field. The maneuvers logged for this flight indicated "engine failure on takeoff and approach, touch-and-go, and go-around." On September 22, 1995, the logbook indicates that the pilot satisfactorily passed the multi-engine flight test in the Cessna 310.

From September 23, 1995 to November 26, 1995, the pilot logged eight flights in a Taylorcraft seaplane. There are no multi-engine flights logged since September 22, 1995, and no further flights logged in any make/model aircraft after November 26, 1995. During an interview with the pilot, he stated that he did have one other flight in the Taylorcraft that wasn't logged, but did not recall the date of this flight.

On the day of the accident, the pilot reported that he flew the Beech D-50, for the first time as pilot-in-command, and performed touch-and-go landings at Coeur d'Alene before departing for Seattle.

AIRCRAFT INFORMATION

The maintenance logbooks indicate the last annual inspection, prior to the pilot purchasing the airplane on February 17, 1995, was performed on October 3, 1994. At this time, the engine logbooks indicate that for the right engine, the crankshaft, connecting rod bearings, the crankshaft bearings, and lifters were replaced. The camshaft was ground, the ignition harness was replaced, and the starter was rebuilt. The engine was reassembled and signed-off as airworthy. The left engine was inspected and signed-off as airworthy, with no major discrepancies noted.

The logbooks indicate that the oil was changed in both engines on January 24, 1995. This was the last logbook entry prior to the pilot purchasing the airplane.

After the pilot purchased the airplane, it was flown to Coeur d'Alene where it was to be based. During this flight, the pilot stated that the pilot-in-command of this flight had to feather the left propeller prior to landing, because "the governor disconnected and there was no propeller control."

On December 30, 1995, two hours and 36 minutes after the oil change, the engine logbook for the left engine indicates that the engine was removed "due to large chunks of metal in the engine oil." The oil sump was removed and the mechanic determined that the metal was from the magneto drive cushion housing. The entry indicates that the engine required an inspection and reassembly by an Inspection Authorized mechanic. The right magneto coil was also replaced in accordance with the applicable Airworthiness Directive. This entry was signed off by an airframe and powerplant mechanic.

The mechanic who eventually annualled the airplane reported that he recalls when the airplane was flown into Coeur d'Alene and witnessed the airplane landing with the left propeller feathered. The airplane sat on the ramp for several months before someone took the left engine off the airplane. The airplane sat all winter on the ramp until April when the airplane was towed to the mechanic's hangar. The left engine was in pieces in the back of a pick-up truck. The mechanic stated that the crankcase was not split and the cylinders were still on. All of the accessories had been removed.

On July 5, 1996, the engine logbooks indicate that the engines were signed-off for an "annual" inspection. The entry for the left engine indicates that a compression check was performed with the lowest compression of 62/80 and 65/80 psi in cylinders #2 and #6. The engine was "flushed due to metal contamination." The accessory section gears and accessories, new generator drive shaft, new oil pump gears, new teflon oil/fuel hose and propeller with new bolts and o-rings, and new points and distributor block assembly in the magneto were installed. The vacuum pump was overhauled, and the spark plugs were cleaned and adjusted. The engine was re-installed on the airframe with new engine mounts. The engine was test run and signed-off as airworthy by an Inspection Authorized mechanic.

The right engine was inspected and signed-off as airworthy with no significant items noted.

At the time of the accident, approximately two hours and 36 minutes had been accumulated on the airplane since the annual.

COMMUNICATIONS

At 1617, on August 23, 1996, the pilot contacted the Boise, Idaho, Flight Service Station and requested a standard weather briefing, from Coeur d'Alene, Idaho, to Boeing Field, Seattle, Washington. The pilot reported that he intended to takeoff about 1630 hours and fly visual flight rules (VFR) direct to Boeing Field. The time en route was reported to be one hour and forty minutes. The specialist reported excellent VFR conditions and no weather advisories along the route of flight. The specialist reported the current weather conditions at Coeur d'Alene and at Seattle, and continued by reporting the winds aloft. The specialist asked the pilot if he wanted to file a flight plan and the pilot responded that he did not. The conversation was concluded at 1621.

At 1822, the pilot made contact with Seattle approach control and reported that he was forty miles to the east and that his destination was Boeing Field. The controller instructed the pilot to squawk a transponder code and inquired as to the pilot's location and altitude. The pilot responded that his altitude was 12,000 feet. The controller responded that he was not receiving the aircraft's transponder code and asked if the pilot was navigating off of the Seattle VOR. The pilot responded that he was not and stated "visual flight only." The controller instructed the pilot to remain VFR and outside of the Seattle bravo airspace until the pilot thought that he was 30 miles east of Seattle, then he would give the pilot flight following.

At 1835, the pilot contacted Seattle approach and stated that "believe we are thirty miles to the east." The controller responded that he was still not receiving the transponder code and asked the pilot what his current altitude was. The pilot responded that his altitude was 11,700 feet. The controller informed the pilot that if he did not pick the aircraft up on radar, he would be unable to provide flight following. The pilot was to remain VFR outside of the Seattle bravo airspace. The pilot responded that he would be descending and that "I'll need vectors towards Boeing Field." The controller responded that he would be unable to give the pilot vectors if he did not pick the airplane up on the radar.

At 1843, the controller informed the pilot that he was still not receiving the aircraft's transponder code and asked the pilot if he knew what his position was. The pilot responded "approaching the sound and I see a lot of islands, but I can't verify my position." The controller instructed the pilot to "ident" and the pilot responded that he was "identing" his transponder. The controller then asked the pilot if his heading was 270 degrees or maybe 280 degrees. The pilot responded that his heading was 270 degrees. The controller then informed the pilot that he had the aircraft radar identified 16 miles northeast of Paine Field, Everett, Washington. The controller then asked the pilot to verify that his destination was Boeing. The pilot responded "roger." (see Radar Plot #1)

At 1844, the controller suggested that the pilot turn to a heading of 170 degrees and confirmed that the airplane's altitude was 8,700 feet. The controller then informed the pilot that he would point Boeing Field out to the pilot when he got closer.

The controller continued to give the pilot heading changes, information on his location relative to Boeing Field and traffic advisories. The controller continued to instruct the pilot to continue his descent and to remain in VFR conditions.

At 1854, the controller instructed the pilot to fly a heading of 130 degrees as the radar indicated that it looked like he was still flying 170 to 180 degrees. The pilot responded by saying 130. The controller then informed the pilot of traffic and the pilot responded by saying "seven sierra fox." (see Radar Plot #17)

At 1856, the controller notified the pilot that the Boeing airport was at the pilot's one o'clock position and six miles. The pilot responded that he had the airport in sight. The controller instructed the pilot to continue the VFR descent. The pilot responded that he was continuing to descend. (see Radar Plot #21)

At 1857, the approach controller contacted the local controller at Boeing tower and informed the Boeing controller that the Twin Bonanza was at the north end of Mercer and that "five six sierra foxtrot is lost, doesn't know what he's doing, he says he sees the airport." The controller at Boeing tower acknowledged this.

At 1857, the approach controller instructed the pilot to contact Boeing tower on 118.3. The pilot acknowledged 118.3.

At 1857, the pilot contacted Boeing tower and was instructed to make a right traffic to runway 31 left, and to report turning downwind. The pilot responded "(unintelligible) unfamiliar airport (unintelligible)." The controller instructed the pilot to turn right 30 degrees and asked the pilot if he saw the airport to his right. The pilot responded "roger." (see Radar Plot #23)

At 1858, the controller instructed the pilot to turn direct to the airport for right traffic and to expedite his descent "now" to 1,000 feet. The pilot responded, "expediting descent." The controller then reported to the pilot that he would be number two behind a Bonanza that was approaching a one-and-a-half mile final. The controller asked if the pilot had the traffic in sight. The pilot responded that he would extend the downwind and that he did not have the traffic in sight. The controller then instructed the pilot to turn left 20 degrees. The pilot responded "20 degrees left turn."

At 1859, the controller instructed the pilot to turn left 30 degrees "now." The pilot responded to the thirty degree left turn. The controller then instructed the pilot that he now had a Gulfstream ahead and to his left that was approaching a three mile final. The controller asked the pilot if he had the traffic in sight and that he was going to be following the Gulfstream. The pilot stated that he would advise when he had the traffic in sight. (see Radar Plot #27)

NTSB Probable Cause

failure of the pilot to follow proper emergency procedures (properly configure the airplane and feather the appropriate propeller) after loosing power in one engine, which resulted in his inability to maintain altitude until reaching an airport. Factors relating to the accident were: the loss of engine power in one engine for undetermined reason(s), the pilot's lack of experience in the make and model of airplane, his lack of recent flying experience, and his lack of familiarity with the geographic area.