NTSB CAROL · Event
Event MIA07FA011
Aircraft involved
Probable cause & findings
The flight instructor's inadequate preflight planning which resulted in fuel exhaustion.
Factual narrative
HISTORY OF FLIGHT
On November 1, 2006, about 1118 eastern standard time, a Beech BE-76 Duchess, N6017U, registered to Christiansen Aviation Inc., and operated by Aussie Air Inc., as a Title 14 Code of Federal Regulations Part 91 instructional flight, crashed in Port Orange, Florida. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The student and commercial-rated flight instructor received fatal injuries, and the airplane was destroyed. The flight originated in Daytona Beach, Florida, the same day, about 0945. The student and instructor were engaged in instrument training aboard N6017U, and had been in radio communications contact with the Federal Aviation Administration (FAA) Daytona Beach Approach Control Arrival Radar North controller. They had performed approaches to include the very high frequency omni-directional range (VOR) runway 17 approach, at Ormond Beach, and thereafter the instructor had requested the "hold," followed by the non-directional beacon (NDB) runway 29 approach at New Smyrna Beach. After the approach at New Smyrna Beach, the instructor initiated contact with the Daytona Beach Approach Control Arrival Radar South controller, and was being vectored for the instrument landing system (ILS) runway 7L approach, to a full stop, at Daytona Beach. As the training flight progressed, the instructor and student were given a vector, and at 1110:55 were told to contact the Daytona Beach Tower Controller. According to the FAA Daytona Beach Airport Traffic Control Tower transcript of communications, at 1112:24, a crewmember on N6017U declared an emergency, stating, "we've had an engine failure." At 1112:28 the controller responded stating "... roger the closest airport is spruce creek off your right side or do you want to come to daytona." At 1112:33, the crewmember responded saying that they can come straight to Daytona, and can still maintain altitude. At 1112:37, the controller said, "okay you say you lost an engine", and at 1112:38, the crewmember responded, "that's affirmative." At 1112:40, the controller stated, "souls on board amount of fuel fly heading three six zero." At 1112:42, the crewmember responded saying, "okay we're close to a actual minimum fuel right now, i'm only on my right tank, so we looks like we lost our a right engine." After the crewmember provided information to the air traffic control (ATC) controller pertaining to souls onboard, the controller acknowledged, and informed the flight that Spruce Creek was two and a half miles behind, and that Daytona was about eight and a half miles. At 1113:18, the crewmember stated, "we're able to maintain altitude right now, and I think we should be okay." At 1113:32, the crewmember stated, "we're going to spruce creek we're about to lose our second engine." At 1113:37 the controller responded, "roger, spruce creek's right behind you four miles altimeter three zero zero five wind zero two zero at one zero gusting one four." The controller continued to provide information to the flight, and at 1114:05, the crewmember said that he saw Spruce Creek ahead and that they were headed there right now. At 1114:50, the crewmember said, "roger that we're heading over there we're about we're almost losing our second engine yet." As the flight progressed, the controller continued to provide the flight with information, and at 1116:34, the crewmember said, "roger I have spruce creek but I don't have the runway in sight." The controller provided assistance to the flight, and at 1117:25, the crewmember said "I can't see the runway six zero one seven uniform too low", which was the last communications transmission received from the crew aboard N6017U. A witness stated that about 1100, while he and his wife were in the front room of their house, he heard an airplane close, and it sounded like it was "right on top of them." He further stated that "the motor shut off, popped, and started again." He said they looked out the front window and saw the airplane "hit the ground pointing in a different direction..." A second witness stated that he was working outside and he heard an airplane's engine "backfire, start again, and then heard it crash across the road." He further stated that "some neighbors and I ran to the site, and the plane was burning, I cut the man's seatbelt with a knife I got from a guy who helped me drag him away from the plane."
PERSONNEL INFORMATION
Records obtained from the FAA showed that the student held an FAA private pilot certificate, with ratings for both single engine land and instrument airplane, issued on August 25, 2006. He also held an FAA first-class medical certificate, issued on June 9, 2005, with no stated limitations. According to the owner of the flight school, Aussie Air Inc., the student was enrolled in the flight school, and was attempting to obtain multiengine and instrument ratings. The student's logbook was found in the wreckage, and was mostly destroyed by fire, however a few pages were readable. The pages showed that he had accumulated about 230 hours of flight experience, of which about 30 hours were in the accident airplane. FAA records showed that the fight instructor/pilot in command (PIC) for the flight, held an FAA commercial pilot certificate, with ratings for airplane single and multiengine land, and instrument airplane, issued on September 13, 2005. He also held a flight instructor certificate, with rating for airplane single and multiengine land, and instrument airplane. Records also showed that he held an FAA first-class medical certificate, issued on August 6, 2004, with the stated limitation that he must wear corrective lenses. The flight instructor/PIC's logbook was not available to the National Transportation Safety Board, however copies of logbook pages and flight records were obtained from the owner/operator of the aircraft/ flight school, Aussie Air Inc., where he was employed. The company's records showed that the flight instructor had accumulated about 470 hours of total flight time, of which 353 hours were listed as flight experience while acting as pilot in command, 58 hours of instrument flight experience, 97 hours of multiengine experience, 43 hours of dual flight training given, and 21 hours in the same make and model as the accident airplane.
AIRCRAFT INFORMATION
N6017U was a 1979 Beechcraft BE-76 Duchess, serial number ME-159. The airplane was equipped with two 180-horsepower four-cylinder O-360 Lycoming engines, mounted on each wing. Information obtained from the airplane's maintenance records showed that it had received an annual inspection on June 15, 2006, at which time it had an accumulated tachometer time of 8,763.1 total flight hours. According to information in the airplane's maintenance records, the airplane was 25.52 hours past due for the next 100-hour inspection at the time of the accident. Maintenance records showed that the left engine, serial number L-25451-36A, had been installed on October 19, 2000. At the time of the accident, the engine had accumulated about 8888.62 flight hours. The right engine, serial number RL-529-71A, had been installed on September 14, 2000. N6017U was also equipped with two two-bladed constant speed Hartzell propellers. The hub serial number of the propeller mounted on the left was FB1109A and the number on the right was FB1113A. METEOROLOGICAL INFORMATION Visual meteorological conditions prevailed at the time of the accident. The Daytona Beach International Airport, 1053, surface weather observation was, wind from 360 degrees at 11 knots, visibility 10 statute miles, few clouds at 2,600 feet, a broken layer at 6,500 feet, and an overcast layer at 6,500 feet, temperature 26 degrees Celsius (C), dew point temperature 19 degrees C, altimeter setting 30.05 inches of mercury (Hg), with remarks saying showers in the vicinity to the south-southeast.
WRECKAGE AND IMPACT INFORMATION
N6017U crashed in between two residences about 1.13 nautical miles northwest of the Spruce Creek Airport. According to witnesses, when the airplane impacted the ground, a fire ensued, and examination of the wreckage revealed evidence consistent with a postimpact fire having occurred. The fire had consumed significant sections of the airplane, and the burnt wreckage of the airplane was found oriented along a heading of 009 degrees magnetic. The airplane had come to rest on the fence line/boundary between two properties, straddling a bush and fence, after having impacted and cut a utility wire located above the fence along the property line. Utility wires were on the ground under the airplane. In the vicinity of the wreckage there was ground scarring/gashes in the grass, and the left propeller was found pushed into the dirt. The right propeller was lying on the ground. The debris path was 45 feet long and stretched along a heading of 155 degrees magnetic. The cabin doors had separated from the fuselage and the utility door had been destroyed by fire. The airplane's left wing had remained attached to the fuselage but had incurred impact damage and was largely destroyed by fire. On the left wing the aileron and aileron bell crank had incurred fire damage. The aileron cables had separated from the bell crank but had remained connected to the control in the cockpit. The left flap was also destroyed by fire, however the torque tube's position was consistent with the flap having been retracted. The left engine remained attached to its respective wing, but had incurred fire damage. The right wing separated from the fuselage at the attach fittings, and it exhibited leading edge crushing which began at the wing tip and had extended inboard to the engine nacelle. The right engine was positioned under the wing and remained attached to the wing only by the control cables. About 64 inches of the right flap had remained attached to the wing, and the flap with its torque tube position was consistent with the flap having been in the retracted position. The aileron separated from the wing but remained attached to the aileron pushrod. When the aileron flight control cables were manipulated in the cockpit, continuity to the aileron was noted. The empennage remained intact and attached to the fuselage. In addition, the rudder had remained attached to the vertical stabilizer, and when moved, control continuity was confirmed to the cockpit. The rudder trim tab was also found to be intact, and its actuator measured 1.2 inches, consistent with a 0-degree deflection. The cabin and cockpit had incurred extensive damage due to the impact and fire, however cockpit instrument readings were noted as follows: The airspeed indicator read 0, the altimeter read 1,400 feet, and its associated "Kollsman" window 30.05. The directional gyro indicated 280 degrees, the horizontal situation indicator showed 070 degrees, and the heading bug was set to 327 degrees. The attitude indicator showed a left bank of about 67 degrees, and the vertical speed indicator showed a 700-foot-per-minute descent. The left fuel selector handle was "On," the fuel selector valve port was open, and the right fuel selector handle was "On." The left cowl flap was "Closed," and the right cowl flap was "Open." The left magneto switch was set to the right position, and the right magneto switch was on both. The left manifold pressure read 31 inches Hg, and the right manifold pressure was not readable. The left rpm indicator read 0, and the tachometer read 8888.62 hours. The right rpm indicator had a reading lower than 400 rpm and the tachometer read 8861.70 hours. Both throttles, both propeller controls, and both mixture controls were full forward, and the landing gear lever was up. The ammeter was at 50 percent and the needle for the right meter was missing. The left cylinder temperature gage read 250 degrees and the right gage indicated less than 200 degrees. The left fuel gauge needle was on the top of the yellow arc, and the right fuel gauge needle was on "E." "COMM 1"was indicating a frequency of 122.97, and was positioned on, consistent with it being the radio in use. "NAV1" was set to 109.70. The flap lever was on the "Up" position, and the flap indicator showed "Up." The left control column had separated at the instrument panel, and the right control column had separated six inches above the instrument panel. Circuit breakers that had been activated included the circuit breakers designated "AUX pump," gear warning, lights, "NAV," and "COMM." Of the two pilot side rudder pedals, the left pedal had separated, and the right was bent toward the left. The co-pilot's rudder pedals had its left pedal against the floor, and the right one was full aft. All seats had been destroyed by impact fire. Initial examination of the propellers revealed that the left propeller had separated from the engine aft of the crankshaft flange, and was noted not to be feathered. Both blades pertaining to the left propeller remained in the hub and exhibited polishing on the cambered surface. Both were twisted toward low pitch and 2 inches of one blade tip was found curled outward, and the other blade exhibited evidence of gouging and chord wise striations. The propeller governor had incurred both impact and fire damage, and its control position was deemed unreliable. When examined the gasket screen was clean and the coupling was noted to be intact. The right propeller separated from the right engine aft of the crankshaft flange, and as found, the propeller was noted to not have been feathered. One blade had not incurred damage, and the other had remained in the hub, but was bent slightly aft 27 inches from the blade tip and had an area of about 14 inches that was polished on the cambered side. The propeller governor was found intact and secure to the right engine, however the control cable was stretched in tension, and its position unreliable. When examined the gasket screen was clean and the drive coupling intact. Under Safety Board supervision, a technician with Hartzell Propeller Inc., performed a detailed examination of both propellers. The examination revealed that impact damage to both propellers was similar, and no discrepancies were found that would have precluded normal operation. Both propellers had incurred a fractured engine crankshaft and harsh frontal impact damage on the spinner domes. The crushing of the spinner domes captured a blade counterweight position, and the blades of both propellers were noted to be at a low pitch position when the spinners were crushed. There were impact marks on both low pitch stops and counterweight damage to the cylinders indicating that the blades were driven toward lower pitch at impact. The left propeller had an impact mark on a preload plate that occurred with the blade at a low pitch position. The blades of the left propeller also were noted to have bends, twisting and scoring, consistent with rotation and low power at impact, and was noted not to have been feathered. The right propeller blades displayed very little damage. One blade had some rotational scoring in the paint, and a slight bend but no twisting, and the other blade displayed no damage. The right propeller was noted to have not been feathered, and had evidence of very little rotational energy upon impact. Examination of the left engine revealed no evidence of any preimpact anomalies, which would have precluded the left engine from developing power. The left engine had remained attached to the to the left wing nacelle and had incurred impact and fire damage. The firewall was attached and the mounts had fractured. In addition, the induction filter and air box were destroyed by impact and fire. The exhaust system was also crushed as a result of the impact. The crankcase was noted to have impact damage to the sump and accessory mounting area. The left engine subsystems/accessories, to include the lubrication system, induction system, carburetor, and ignition system (magneto, ignition harness, spark plugs) revealed no evidence of any preimpact anomalies. The crankshaft was rotated by hand and there was continuity of the crankshaft and camshaft and valve train, through to the accessory drives, with compression being noted on all four cylinders. In addition, a lighted borescope was used to examine top end engine components, and no anomalies were noted. All spark plugs on the left engine were removed and examined and they exhibited brown color combustion deposits, except for No. 4 bottom spark plug which was soaked with oil. The spark plug electrodes exhibited moderate wear when compared to the Champion spark plug reference chart, and their settings were normal. The ignition harness had incurred fire damage, which precluded testing. The dual magneto unit had remained attached and secure to the engine case, and it had incurred fire damage, which precluded testing, however its impulse coupling and gears had remained intact. The starter and alternator had incurred impact damage and no anomalies were noted. On the lubrication system, the oil cooler and hoses had incurred fire damage and the oil had been consumed in the fire. The oil filter element had partially burned and when examined no metal contamination was found. The vacuum pump had incurred fire damage and its drive coupling had burned, however no anomalies were noted. On the left engine fuel system the airplane main fuel strainer was clean, and no evidence of fuel was found. In addition, the carburetor and fuel pump for the left engine was partially destroyed by fire. When examined, the right engine revealed no evidence of any preimpact anomalies, which would have precluded the right engine from developing power. There was no evidence of fire damage, however the right engine and firewall had separated from the wing structure and was displaced from the nacelle consistent with heavy frontal impact forces. The induction air filter and air box had remained intact, but the exhaust system was partially crushed. The right engine subsystems/accessories, to include the lubrication system, induction system, carburetor, and ignition system (magneto, ignition harness, and spark plugs) revealed no evidence of any preimpact anomalies. A lighted borescope was used to examine top end engine components, and no anomalies were noted. All spark plugs on the right engine were removed and examined and the exhibited a light gray colored combustion deposits, and the electrodes had moderate wear with their gap settings being normal. Only the No. 1 bottom spark plug had incurred impact damage. The dual magneto unit had remained attached and secure to the case, and when removed and tested, produced a spark on all towers. The ignition harness had incurred impact damage that precluded it from being tested. During examination of the fuel system on the right engine, there was no residual fuel found in the supply lines, and there was no evidence of fuel in the flow divider. The mixture was found to be full rich, and the carburetor heat was off. The carburetor controls had been damaged in the impact and the throttle was found in the idle position. The carburetor and fuel pump remained intact on the engine and were removed. When examined, all the fuel lines were noted to be tight and when fuel system components were opened, they were found to be devoid of fuel. The carburetor screws were tight and secure and there were no signs of fuel leakage. The interior of the carburetor was clean and devoid of fuel, with all internal passages being clear an unobstructed. The metal float needle valve and seat functioned manually, and did not exhibit any abnormalities. The fuel pump screws were tight and secure with no signs of leakage and the pump drive mechanism was intact. The interior of the pump was clean and devoid of fuel, and all internal valves and diaphragms were intact. The right engine starter's drive gear was extended and the alternator had incurred impact damage, however no anomalies were noted to either unit. The right engine's lubrication system's suction screen and oil filter were clean and the oil cooler and associated hoses were tightly affixed, with no leaks being noted. In addition, there was a normal quantity of oil and no anomalies were noted with the system. The vacuum pump had incurred impact damage and when removed and examined, its drive coupling was noted to be intact.
TESTS AND RESEARCH
Refueling records showed that on October 30, 2008, the accident airplane had been topped off with 82.7 gallons of low lead aviation fuel. The student's logbook recovered from the wreckage showed that on October 31, 2006, he had completed instructional flight training of 1.8 hours duration in the accident airplane. In addition, the operator's dispatch report showed the student was billed for 1.8 hours on October 31, 2006; however, it did not specify an airplane. The operator's flight records and transaction list for the student did not show any record of the 1.8-hour flight. The operator's records did not reflect that any other flights occurred until the accident flight, and that flight began about 0945 and ended about 1118. According to the Beech BE-76 flight manual, the BE-76 is equipped with two wing tanks, each with 51.5 gallons fuel capacity (i.e. 103 gallons total capacity), of which 3 gallons is unusable. The Lycoming Engine Operator's Manual for the O-360-Series Engines, Part Number 60297-12, Section 3, pages 3 to 12, indicate that two O-360-A series engines, operating at 75 percent power, in performance cruise, would burn 21 gallons of fuel per hour.
MEDICAL AND PATHOLOGICAL INFORMATION
Postmortem examinations of both the flight instructor and student were performed by the pathologists with the Office of the Medical Examiner for Districts 7 and 24, Volusia and Seminole Counties, Daytona Beach, Florida. The causes of death in both cases were attributed to blunt force trauma. No findings which could be considered causal were reported. The FAA Toxicology Laboratory, Oklahoma City, Oklahoma, conducted toxicology studies on specimens from the flight instructor. The samples were tested for carbon monoxide cyanide, volatiles and drugs, and none were found to be present. The American Institute of Toxicology (AIT) Laboratories conducted toxicology studies on specimens from the flight instructor. The samples were tested for carbon monoxide, amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine/metabolites, fentanyl, methadone, opiates, oxycodone/metabolite, phencyclidine, propoxyphene, salicylates, tricyclic antidepressants, alcohols, stimulants, narcotics, sedatives/hypnotics, antidepressants, analgesics, anesthetics, cardiovascular agents, antihistamines, anticonvulsants, and antipsychotics. Only caffeine was found to be present. The FAA Toxicology Laboratory, Oklahoma City, Oklahoma, conducted toxicology studies on specimens from the student. The samples were tested for carbon monoxide cyanide, volatiles and drugs. Lidocaine and atropine were found present in blood, and lidocaine was present in urine. The American Institute of Toxicology (AIT) Laboratories conducted toxicology studies on specimens from the student. The samples were tested for carbon monoxide, amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine/metabolites, fentanyl, methadone, opiates, oxycodone/metabolite, phencyclidine, propoxyphene, salicylates, tricyclic antidepressants, alcohols, stimulants, narcotics, sedatives/hypnotics, antidepressants, analgesics, anesthetics, cardiovascular agents, antihistamines, anticonvulsants, antipsychotics. Only caffeine was found to be present. During an instructional flight in a Beech BE-76, the flight instructor and student noted a total loss of power in the right engine. They declared an emergency to air traffic control (ATC), and initially flew toward their home airport, about 8 nautical miles away. The flight instructor and student pilot subsequently reported minimum fuel to ATC, and then diverted to a closer airport, as they believed that the airplane was about to lose power in the left engine. The airplane impacted a residential area about 1 nautical mile from the alternate airport. Examination of fueling records, operator records, and the student's pilot logbook revealed that the airplane flew about 3.3 hours since it was completely fueled; however, the operator records were incomplete, and any additional flights in the accident airplane during that time could not be verified. The airplane's fuel capacity was 103 total gallons, of which 3 gallons were unusable fuel. Review of engine manufacturer information revealed that each engine consumed about 10.5 gallons-per-hour at 75 percent power. Examination of the wreckage did not reveal any preimpact mechanical malfunctions, and no fuel was present throughout the fuel system. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2006_MIA07FA011.txt.
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