WPR11FA125

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.

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.

HISTORY OF FLIGHT On February 7, 2011, at 1147 Pacific standard time, a Beech 95-B55 (T42A), N225DH, impacted the grounds of a recreational vehicle (RV) storage facility after performing a precautionary low pass at San Bernardino International Airport, San Bernardino, California. The pilot operated the airplane under the provisions of Title 14 Code of Federal Regulations Part 91. The private pilot and private pilot licensed passenger sustained serious injuries. The airplane sustained substantial damage. The personal cross-country flight departed San Luis Obispo, California, at 1033, with a planned destination of San Bernardino. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The pilot and passenger were interviewed by the NTSB investigator-in-charge (IIC) on numerous occasions subsequent to the accident. They both reported that due to their injuries, recollection of the accident, in particular the final stages, was somewhat unclear. Both the pilot and pilot rated passenger reported that prior to departure from San Luis Obispo, they performed an uneventful preflight inspection. The passenger reported that the main fuel tanks were full, and that the auxiliary tanks were filled to about 1/2 of their capacity. The pilot filed an IFR flight plan, and shortly thereafter, they departed. While on the upwind leg, he heard the landing gear warning horn sound. He asked the control tower personnel to confirm that the landing gear was retracted. The controller confirmed that it was, and the pilot sent a text message to his mechanic describing the circumstances. He subsequently deduced that there was a fault with the landing gear indication system, rather than the landing gear. He therefore elected to continue the flight, with the horn intermittently sounding, with the intention of performing a precautionary low-approach at the destination airport. The pilot continued with the climb, and began his departure checklist, which included switching from the main wing fuel tanks to the auxiliary tanks. The pilot stated that he customarily utilized the auxiliary fuel tanks during cruise, and the main tanks during climb and descent. The flight continued uneventfully; however, prior to reaching his final planned waypoint, air traffic control gave a clearance direct to San Bernardino. The clearance caught him by surprise, and he reported that as such, he performed his descent checklist in a rushed manner. He recalled switching to the main fuel tanks, but rather than waiting a customary 10 seconds between tanks, he switched both at the same time. Upon arrival, the pilot extended the landing gear, confirming its deployment visually with the gear mirror, and by observing the illumination of the green landing gear light. He reported his intention to the tower, and continued with the low pass. The tower personnel confirmed that the landing gear appeared extended. The pilot stated that as soon as he received the tower's confirmation, he felt that something was not right with the airplane. His recollection from this point onward was somewhat unclear, but he reported that the airplane was not climbing as expected, and both engines seemed to be "cycling." The flight progressed with no change in altitude, and he recounted that he was struggling to maintain control of the airplane. He could not recall if any one engine had lost power, but felt that he was losing power in both engines. He could not specifically recall the steps he took to troubleshoot the problem, however, he did ask the passenger to look for any erroneous indications on the engine and flight instruments. The pilot stated that he began to turn the airplane around, as he looked for a landing area. At an altitude of about 20-30 feet above ground level (agl), he observed what appeared to be an RV park. He was concerned that if he attempted to land there, he could cause injuries to anyone on the ground, so he made the decision to stall the airplane, minimizing the accident footprint. He reported that he then switched the fuel selector valves to the off position, and pulled the mixture lever for both engines to idle cut-off. He could not recall if he turned off the magnetos during this time. He then pulled back on the elevators in an attempt to stall the airplane. A Federal Aviation Administration (FAA) and Boeing flight test crew was situated on the flight deck of a Boeing 747-8, located along the north taxiway, adjacent to the departure end of runway 24 at San Bernardino International Airport. The crew recounted similar observations of the airplane flying level about 150 feet agl over the runway, with its landing gear and flaps extended. It then began a turn to the left while simultaneously descending. A few seconds later, the nose of the airplane appeared to pitch up, followed by a subsequent roll to the right and an inverted nose down descent. They reported that throughout the sequence, the landing gear and flaps remained extended, and the airplane did not appear to be emitting smoke or vapors. The airplane was equipped with a Garmin GPSMap 496 global positioning systems receiver. Historical flight data from the unit was extracted, revealing the entire flight sequence. The airplane departed San Luis Obispo on a heading of 100 degrees true, while climbing to a maximum altitude of about 9,400 feet mean sea level (msl). Twenty-six minutes later, the airplane turned 15 degrees left over Santa Barbara towards the Los Angeles area. After an additional 15 minutes, the airplane began a gradual descent to 5,000 feet msl over Corona. At 1138, the airplane turned 90 degrees left towards San Bernardino airport. At 1143, the airplane joined the left downwind for runway 24, while at an altitude of about 2,400 feet msl (1,241 ft agl). The airplane continued to descend during the downwind phase, while its GPS groundspeed decreased to 135 mph. The airplane began a sweeping left turn through the base leg, turning onto final at an elevation of about 1,287 msl (128 feet agl). For the next 40 seconds the airplane maintained runway heading, reducing speed to 108 mph while descending to about 20 feet agl. The airplane then began a right turn, climbing to 163 feet agl as its speed decreased to 88 mph. For the remaining 66 seconds, the airplane began a descending 180 degrees left turn, while maintaining an average speed of 84 miles per hour. Recorded radio transmissions made over the airport's common traffic advisory frequency revealed that while on the left downwind for runway 24, the pilot reported problems with the airplane's landing gear. He made a request for a low approach, and to overfly the runway so that tower personnel could check the gear. Tower personnel cleared the request, the pilot overflew the runway, and the tower personnel reported that the gear appeared to be down. The pilot was subsequently approved for a left turn, and given a clearance to land on runway 24. A few seconds later the pilot reported, "I've got another problem now, just standby, I'm going to head straight for a while." Tower personnel then canceled the landing clearance, and advised the pilot that runway 6 was available for landing. The pilot then made his final radio transmission, reporting that he was going to attempt to circle back to runway 6. The tower subsequently cleared him to land on that runway. Tower personnel reported light and variable winds with the clearance. The airplane came to rest in the parking lot of the RV storage facility, about 4,700 feet southwest of the departure end of runway 24. The airplane was located upright, on a heading of about 310 degrees magnetic, adjacent to a collapsed steel awning. Fragments of roofing material and awning cross members were comingled with the airplane wreckage. The airplane remained largely intact, with crush damage noted to the entire cabin and nose cone area. Both wings remained partially attached to the fusela