San Bernardino International Airport
Aircraft Accident/Incident Report

San Bernardino, California 92408
Monday, February 7, 2011 11:47 PST

NTSB Narrative Summary Released at Completion of Accident

During the initial climb, the landing gear warning horn sounded. The pilot diagnosed the problem and determined that the landing gear had retracted successfully and that the indication system was in error. He continued the flight with the horn intermittently sounding. During the descent phase, the pilot was given an unexpected direct route to the airport, and, as a result, he rushed through the descent checklist items. The pilot decided to perform a low pass over the arrival runway to confirm that the landing gear had extended. The pilot said that during the low pass he started to have difficulty controlling the airplane. An onboard engine monitoring system recorded a total loss of engine power to the right engine at that time. The pilot did not recognize that his difficulty in maintaining altitude and airplane control was a result of a loss of engine power to one engine; he subsequently lost control of the airplane, which collided with a storage facility in a nose-down inverted attitude. Witness reports, photographic evidence, and a postaccident examination revealed that the pilot did not retract the landing gear and flaps after the loss of power, as instructed in the airplane's operating instructions for a go-around with one engine inoperative. The airplane's operating instructions recommend that the main fuel tanks be selected during descent and while landing. The pilot stated that he customarily uses the auxiliary fuel tanks during cruise flight and the main tanks while climbing and descending; however, both fuel selector valves were found in the auxiliary tank position at the accident site. The airplane's fuel tanks were serviced to capacity about 2.5 flight hours before the accident. Calculations of fuel consumption for the flights since the last fueling would have resulted in the use of a quantity of fuel that would have either been equal to or slightly exceeded the capacity of the auxiliary fuel tanks. Damage to the fuel system precluded an accurate assessment of the quantity and distribution of the remaining fuel onboard at the time of the accident. The engine monitoring system recorded a small rise in exhaust gas temperatures just before the loss of power; this rise is consistent with a lean fuel/air mixture, which would be present in a fuel starvation or exhaustion event. The postaccident examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. The pilot's increased workload, due to the unexpected routing and possible problem with the landing gear, during the abbreviated final approach clearance and subsequent low pass could have resulted in a task overload, which resulted in his mismanagement of the fuel system during the landing phase.

NTSB Probable Cause Narrative

The pilot did not recognize the loss of power in the right engine and did not execute the proper procedures for a go-around with one engine inoperative, likely due to increased workload. Contributing to the accident was the pilot's improper in-flight fuel management, which resulted in fuel starvation of the right engine.

Event Information

Type of Event Accident
Event Date 2/7/2011
Event Day of the Week Monday
Time of Event 1147
Event Time Zone Pacific Standard Time
Event City San Bernardino
Event State CALIFORNIA
Event Country --
Zipcode of the event site 92408
Event Date Year 2011
Event Date Month 2
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 340451n
Event Location Longitude 1171532w
Event Location Airport San Bernardino International
Event Location Nearest Airport ID SBD
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 1159
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1158 Pacific Standard Time
Direction of event from weather observation facility (degrees) 45
Weather Observation Facility ID SBD
Elevation of weather observation facility 1159
Distance of event from weather observation facility (units?) 1
Time Zone of the weather observation PST
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) 23
Dew Point at event time (in degress fahrenheit) 2
Wind Direction (degrees magnetic) 240
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 4
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.12
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report METAR KSBD 071958Z 24004KT 10SM SKC 23/02 A3012
Event Highest Injury Serious
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None --
Injury Total Serious 2
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 29488
NTSB Notification Source FAA ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jan 26 2012 8:38AM
User who most recently changed record broda
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N225DH
NTSB Number WPR11FA125
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name BEECH
Aircraft Model 95-B55 (T42A)
Aircraft Series Identifier --
Aircraft Serial Number TC-1271
Certified Max Gross Weight 5100
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 6
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Jun 23 2010 12:00AM
Airframe hours since last inspection 51
Airframe Hours 3981
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type C91-A
Aircraft Owner Name ROLLINS LONNY W
Aircraft Owner Street Address --
Aircraft Owner City SAN LUIS OBISPO
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 93401-6909
Operator is an individual? Yes
Operator Name ROLLINS LONNY W
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City --
Operator State --
Operator Country USA
Operator Zip code --
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 SBP
Departure City San Luis Obispo
Departure State CA
Departure Country USA
Departure Time 1033
Departure Time Zone PST
Destination Same as Local Flt crash at destination city
Destination Airport Code SBD
Destination City San Bernardino
Destination State CA
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Dec 16 2011 6:09PM
User who most recently changed record coos
Since inspection or accident Time of Accident
Event Location Runway Number and Location 24
Runway Length 10001
Runway Width 200
Sight Seeing flight No
Air Medical Flight No
Medical Flight --