Aircraft Accident/Incident Report

Tulare, California 93274
Wednesday, January 20, 1993 18:05 PST

NTSB Narrative Summary Released at Completion of Accident

THE CFI IN THE RIGHT SEAT WAS GIVING DUAL TO THE LEFT SEAT CFI, WHO HAD NO EXPERIENCE IN TYPE. DURING THE INITIAL CLIMB, AT ABOUT 400-500 FT AGL, WITNESSES HEARD THE ENGINE LOSE POWER OR SURGE. THE AIRPLANE WAS SEEN TO ROLL TO ONE SIDE AND DESCEND STEEPLY TO IMPACT. THE AIRPLANE HAD BEEN EXTENSIVELY MODIFIED WITH AN UNAPPROVED WING TIP FUEL TANK SYSTEM ADDITION. THE FUEL SELECTOR VALVE FOR THE TIP TANKS DID NOT HAVE ANY PLACARDS SHOWING POSITION OR OPERATION. BOTH CFI'S HAD BEEN GIVEN INCORRECT INSTRUCTIONS ON HOW TO POSITION THE FUEL SYSTEM SELECTOR VALVES BY THE OWNER AND A MECHANIC WHO SIGNED OFF THE ANNUAL INSPECTION. POST-CRASH EXAMINATION REVEALED THAT THE STANDARD FACTORY FUEL SELECTOR WAS IN THE AUX POSITION, AND THE TIP TANKS FUEL SELECTOR VALVE WAS IN A HALF-ON/HALF-OFF POSITION. THE AIRPLANE ALSO HAD A POWERPLANT MODIFICATION FOR INCREASED HORSEPOWER AND OTHER AIRFRAME MODIFICATIONS, NOT ALL OF WHICH WERE DOCUMENTED OR APPROVED. THIS WAS THE FIRST FLIGHT SINCE THE ANNUAL INSPECTION.

NTSB Probable Cause Narrative

THE INSTALLATION OF AN UNAPPROVED WING TIP FUEL TANK SYSTEM; AN INADEQUATE ANNUAL INSPECTION WHICH DID NOT NOTE, OR CORRECT, THE UNAPPROVED FUEL SYSTEM ADDITION; A WING TANK FUEL SELECTOR VALVE INSTALLATION WITHOUT ADEQUATE PLACARDS TO SHOW POSITION OR OPERATION; AND INCORRECT INSTRUCTIONS TO THE PILOTS BY THE OWNER AND MECHANIC ON POSITIONING FUEL SELECTOR VALVES WHICH LED TO INADVERTENT MISPOSITIONING BY THE PILOTS AND SUBSEQUENT FUEL STARVATION. IN ADDITION, THE PILOT AT THE CONTROLS FAILED TO MAINTAIN ADEQUATE AIRSPEED FOLLOWING THE POWER LOSS WHICH RESULTED IN AN INADVERTENT STALL/SPIN. A FACTOR WHICH CONTRIBUTED TO THE LOSS OF CONTROL WAS THE DARK NIGHT LIGHT CONDITION.

Event Information

Type of Event Accident
Event Date 1/20/1993
Event Day of the Week Wednesday
Time of Event 1805
Event Time Zone Pacific Standard Time
Event City TULARE
Event State CALIFORNIA
Event Country --
Zipcode of the event site 93274
Event Date Year 1993
Event Date Month 1
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 0
Degrees magnetic from airport 0
Airport Elevation --
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 1755 Pacific Standard Time
Direction of event from weather observation facility (degrees) 325
Weather Observation Facility ID VIS
Elevation of weather observation facility 292
Distance of event from weather observation facility (units?) 11
Time Zone of the weather observation PST
Lighting Conditions Night/Dark
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 14
Dew Point at event time (in degress fahrenheit) 9
Wind Direction (degrees magnetic) 0
Variable Wind Indicator Unknown
Wind Speed (knots) 0
Wind Velocity Indicator Calm
Wind Gust Indicator Unknown
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 30
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal 2
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 214
NTSB Notification Source --
NTSB Notification Date Jan 20 1993 12:00AM
NTSB Notification Time 1950
Fiche Number and/or location -used to find docket information 52260
Date of most recent change to record Dec 11 2000 1:07PM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N595B
NTSB Number LAX93FA097
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? --
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name BEECH
Aircraft Model A35
Aircraft Series Identifier A35
Aircraft Serial Number D-1616
Certified Max Gross Weight 2650
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 4
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Dec 29 1992 12:00AM
Airframe hours since last inspection 1
Airframe Hours 4950
ELT Installed Unknown
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name RENT AND LEASE PROGRAMS
Aircraft Owner Street Address 10984 AVENUE 352
Aircraft Owner City VISALIA
Aircraft Owner State CA
Aircraft Owner Country
Aircraft Owner Zipcode 93291
Operator is an individual? --
Operator Name RENT AND LEASE PROGRAMS
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address 10984 AVENUE 352
Operator City VISALIA
Operator State CA
Operator Country
Operator Zip code 93291
Operator Code
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Instructional
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code
Departure City
Departure State
Departure Country
Departure Time 1804
Departure Time Zone PST
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code
Destination City
Destination State
Destination Country
Specific Phase of Flight Takeoff
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:30AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --