NTSB LAX95FA297 — 1995-08-17 · KINGSBURG, California, United States

Aircraft involved

N4884J Beech D55 Fatal

Probable cause & findings

the failure of the pilot to maintain sufficient airspeed during a simulated engine failure to avoid an inadvertent stall/spin, and inadequate supervision by the designated pilot examiner. A factor in the accident was the decision of the examiner to use an airplane without dual flight controls during a multiengine airplane flight test.

Factual narrative

HISTORY OF FLIGHT

On August 17, 1995, at 1314 hours Pacific daylight time, a Beech D55, N4884J, collided with level terrain near Kingsburg, California, after an in-flight loss of control. The airplane was operated by the pilot/owner and was engaged in a multiengine add-on class rating practical flight test when the accident occurred. The airplane was destroyed by impact. The certificated private pilot and designated pilot examiner (DPE) were fatally injured. The flight originated in Visalia, California, at 1308 hours. Visual meteorological conditions prevailed at the time. The day before the accident the pilot/owner had failed the practical flight test for a multiengine class rating. The purpose of the accident flight was to retest the pilot on the failed portion of the previous flight test. According to the accident pilot's instructor, the pilot failed to maintain altitude during a simulated engine failure while flying a practice instrument approach under simulated instrument conditions. The flight instructor administered 1.5 hours of remedial flight instruction on the day of the initial failure and endorsed the pilot's logbook indicating he was competent to pass the practical flight test. The flight instructor further indicated to the Safety Board that the DPE intended for the pilot to demonstrate the Visalia VOR runway 12 approach under simulated single-engine failure conditions. Witnesses reported seeing the accident airplane descend uncontrolled in a flat spin. The airplane came to rest in a harvested alfalfa field northwest of the Visalia VOR and north of the outbound/inbound course of the instrument approach procedure (IAP) to runway 12. Radar data extracted from the Lemoore Naval Air Station Air Traffic Control facility displayed an aircraft track from the Visalia airport to about 0.5 mile of the accident site at the time of the accident. The radar track paralleled the north side of the outbound course of the VOR runway 12 IAP. The procedure turn altitude shown on the IAP is 2,000 feet msl. The radar data also recorded an altitude profile showing an aircraft climbed to 2,200 feet above mean sea level (msl). Then, the altitude decreased to 2,000 feet msl, and increased to 2,200 feet msl for about 3 minutes. This was followed by a descent until radar contact was lost at 1,100 feet msl. CREW INFORMATION Designated Pilot Examiner The DPE received examiner designation from the Federal Aviation Administration (FAA) on April 19, 1978. The DPE's most recent renewal was on January 11, 1995. According to FAA records, the DPE administered 120 flight examinations since October 1, 1994, of which nine were in multiengine airplanes. A review of FAA records revealed eight examinations were in Beech airplanes; five were in the Beech 55. Two of the multiengine airplane flight checks were disapproved by the DPE as a result of the applicant's failures of flight tests. The most recent second-class medical certificate was issued to the DPE on March 16, 1995, and contained the limitation that correcting lenses be worn. Applicant Pilot The applicant held a private pilot certificate which was issued on February 9, 1995, with a single-engine and an instrument rating. The pilot had applied for an airplane multiengine class rating with instrument privileges. A review of the applicant's FAA airman records revealed the pilot was previously tested by the accident DPE when he applied for an airplane instrument rating. The most recent third-class medical certificate was issued to the pilot on March 11, 1994, and contained the limitation that correcting lenses be worn. The aeronautical experience listed in this report was obtained from a review of the pilot's application for the multiengine class ratings, and the pilot's logbooks. According to the records, the pilot's total aeronautical experience consisted of about 521 flight hours; 36.8 hours were accrued in multiengine airplanes. The pilot had accrued about 34 hours in the accident airplane.

AIRCRAFT INFORMATION

The airplane, a Beech D55, was equipped with a throw over type control column for elevator and aileron control. The single control can be placed in front of either front seat by pulling a "T-handle" latch located at the back of the control arm. An optional dual control column is manufactured for the airplane. The manufacturer states in the pilot operating handbook that the dual control column is required for flight instruction.

METEOROLOGICAL INFORMATION

The closest official weather observation station is the U.S. Naval Air Station Lemoore, which is located 19.7 nautical miles southwest of the accident site. The elevation of the weather observation station is 234 feet msl. At 1255 hours, a record surface observation was reporting in part: sky condition and ceiling 500 foot scattered; visibility 10 statute miles; winds 320 degrees at 3 knots; altimeter 29.97" Hg.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located 6 miles southwest of the city of Kingsburg, at latitude 36 degrees 27 minutes north, and longitude 119 degrees 34 minutes 22.5 seconds west in a cut alfalfa field. The airplane came to rest with the longitudinal axis heading 015 degrees magnetic. A ground scar about the size of the propeller spinner was found about 3 feet in front of the left propeller. The soil displaced from the scar was pushed forward in relation to the orientation of the nose of the airplane. The soil was also plowed from the ground scar back to the left propeller. Control continuity was established for all flight, engine, and propeller controls. The propeller controls, throttle controls, and right mixture control were found in mid-range position. The left mixture control was found in the full rich position. The throw over control wheel was found positioned in front of the left pilot seat. The flaps and landing gear were found in the up position. The upper hinge of the rudder was found broken. The rudder was found bent in half with the crease in the bend parallel to the ground. The upper half of the rudder was displaced to the right over the right elevator. The right elevator counterweight was separated and was found lying on the ground under the right elevator. The elevator trim tab measured 1.6 inches which corresponds to 12 degrees nose-up trim. The rudder trim actuator was extended 3 7/8 inches which corresponds to 2 degrees nose right trim. The aileron trim tab actuator was found extended 1 5/16 inches which corresponds to a right wing down trim setting of 4.5 degrees. Both propellers were found attached to their respective engines. The three propeller blades from each propeller assembly were found tight in the hubs. The blade angle of each propeller was noted and none of the blades were found in the feathered position. The right engine's propeller blades exhibited chordwise scoring and were found twisted and bent around the engine cowling. The left engine's propellers did not exhibit chordwise scoring or twisting. Two blades were found bent aft under the left engine cowling. One blade was found undamaged pointed straight up from the propeller hub. Cut alfalfa was found in both engine cowlings next to the exhaust system. The alfalfa in the right engine cowling was burnt where it was touching the exhaust system. Alfalfa found in the left engine cowling was not burnt.

MEDICAL AND PATHOLOGICAL INFORMATION

Post mortem examinations were conducted by the King County Coroner's Office on August 18, 1995, with specimens retained for toxicological examination. The specimens were sent to the FAA Civil Aeromedical Institute (CAMI) for analysis. The results of the toxicological analysis were negative for the applicant pilot for routine drug and alcohol screens. The results of the toxicological analysis for the DPE were positive for ethanol. According to CAMI, the positive ethanol was attributed to post mortem ethanol production.

TESTS AND RESEARCH

14 CFR Part 61.45 The Federal Aviation Regulations leave the decision to use an airplane without dual flight controls at the discretion of the examiner. The regulations state in part: "An aircraft furnished for any flight test must have engine power controls and flight controls easily reached and operable in a normal manner by both pilots, unless after considering all the factors, the examiner determines that the flight test can be conducted safely without them."

ADDITIONAL INFORMATION

Engine and Propeller Examination The airplane's engines and propellers were disassembled and examined on August 29, 1995. There was no evidence of mechanical failure or malfunction. Wreckage Release The wreckage was released to the representative of the pilot/owner on August 29, 1995. In addition, the pilot's logbook, airman certificates, and aircraft records found in the wreckage were also released to the representative of the pilot/owner on the same date. The purpose of the flight was for the designated pilot examiner to reexamine the private pilot for a multiengine class rating flight test. During the previous flight test, the applicant pilot failed to maintain altitude during a simulated engine failure while flying a practice instrument approach under simulated instrument conditions. Thereafter, the pilot received 1.5 hours of remedial flight instruction from his flight instructor. During the accident flight test, radar data showed the airplane paralleling the outbound course of the VOR instrument approach at the procedure turn altitude. Witnesses observed the airplane descending in a flat spin and crash into an open field. Examination of the wreckage revealed the right engine's propeller blades had damage to all three blades consistent with rotation. The left engine's propeller blades had one blade undamaged and two blades bent aft. No evidence was found indicating that any of the blades had been feathered; and no evidence was found of any mechanical malfunctions. The airplane was equipped with a throw over type of control column for elevator and aileron control and was located in front of the applicant. The decision to use an airplane without dual flight controls is at the discretion of the examiner. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12

Verbatim from NTSB's published report. Source file NTSB_1995_LAX95FA297.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

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