San Carlos Airport
Aircraft Accident/Incident Report

Redwood City, California 94065
Thursday, September 2, 2010 11:51 PDT

NTSB Narrative Summary Released at Completion of Accident

Shortly after takeoff for a repositioning flight for the airplane’s upcoming annual inspection, numerous witnesses, including the two air traffic controllers, reported observing the airplane climbing out normally until it was about 1/2 mile beyond the runway. The witnesses stated that the airplane then underwent a short series of attitude excursions, rolled right, and descended steeply into a lagoon. All radio communications between the airplane and the air traffic controllers were normal. Ground-based radar tracking data indicated that the airplane's climb to about 500 feet was normal and that it was airborne for about 40 seconds. Postaccident examination of the airframe, systems, and engines did not reveal any mechanical failures that would have precluded continued normal operation. Damage to both engines’ propeller blades suggested low or moderate power at the time of impact; however, the right propeller blades exhibited less damage than the left. The propeller damage, witness-observed airplane dynamics, and the airplane’s trajectory were consistent with a loss of power in the right engine and a subsequent loss of control due to airspeed decay below the minimum control speed (referred to as VMC). Although required by the Federal Aviation Administration (FAA)-approved Airplane Flight Manual, no evidence of a cockpit placard to designate the single engine operating speeds, including VMC, was found in the wreckage. The underlying reason for the loss of power in the right engine could not be determined. The airplane's certification basis (Civil Air Regulation [CAR] 3) did not require either a red radial line denoting VMC or a blue radial line denoting the single engine climb speed (VYSE) on the airspeed indicators; no such markings were observed on the airspeed indicators in the wreckage. Those markings were only mandated for airplanes certificated under Federal Aviation Regulation Part 23, which became effective about 3 years after the accident airplane was manufactured. Neither the Federal Aviation Administration (FAA) nor the airplane manufacturer mandated or recommended such VMC or VYSE markings on the airspeed indicators of the accident airplane make and model. In addition, a cursory search did not reveal any such retroactive guidance for any twin-engine airplane models certificated under CAR 3. Follow-up communication from the FAA Small Airplane Directorate stated that the FAA has "not discussed this as a possible retroactive action... Our take from the accident studies is that because of the accident record with light/reciprocating engine twins, the insurance industry has restricted them to a select group of pilot/owners…" Toxicology testing revealed evidence consistent with previous use of marijuana by the pilot; however, it was not possible to determine when that usage occurred or whether the pilot might have been impaired by its use during the accident flight.

NTSB Probable Cause Narrative

A loss of power in the right engine for undetermined reasons and the pilot’s subsequent failure to maintain adequate airspeed, which resulted in a loss of control. Contributing to the loss of control was the regulatory certification basis of the airplane that does not require airspeed indicator markings that are critical to maintaining airplane control with one engine inoperative.

Event Information

Type of Event Accident
Event Date 9/2/2010
Event Day of the Week Thursday
Time of Event 1151
Event Time Zone Pacific Daylight Time
Event City Redwood City
Event State CALIFORNIA
Event Country --
Zipcode of the event site 94065
Event Date Year 2010
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 373043N
Event Location Longitude 1221502W
Event Location Airport San Carlos
Event Location Nearest Airport ID SQL
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 1
Degrees magnetic from airport --
Airport Elevation 25
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1200 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 120
Weather Observation Facility ID SQL
Elevation of weather observation facility 25
Distance of event from weather observation facility (units?) 1
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 29
Dew Point at event time (in degress fahrenheit) 14
Wind Direction (degrees magnetic) 350
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 7
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.85
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 3
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 29999
NTSB Notification Source FAA Western Pacific ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jun 7 2012 5:40PM
User who most recently changed record coos
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N832B
NTSB Number WPR10FA448
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name BEECH
Aircraft Model 65
Aircraft Series Identifier --
Aircraft Serial Number LC-112
Certified Max Gross Weight 7700
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 8
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Sep 15 2009 12:00AM
Airframe hours since last inspection --
Airframe Hours --
ELT Installed Yes
ELT Activated Unknown
ELT Aided Location of Event Site No
ELT Type C91-A
Aircraft Owner Name Robert Borrmann
Aircraft Owner Street Address --
Aircraft Owner City Belmont
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 94002
Operator is an individual? Yes
Operator Name Robert Borrmann
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City Belmont
Operator State CA
Operator Country USA
Operator Zip code 94002
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
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) Personal
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code SQL
Departure City San Carlos
Departure State CA
Departure Country USA
Departure Time 1158
Departure Time Zone PDT
Destination Same as Local Flt --
Destination Airport Code E16
Destination City Santa Clara
Destination State CA
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jun 7 2012 5:40PM
User who most recently changed record coos
Since inspection or accident --
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --