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AVIATION OCCURREN CE REPORT LOSS OF CON TROL BEECH B58P BARON C-FKSB TORON TO ISLAN D AIRPORT, ON TARIO 1.

8 nm W 09 OCTOBER 1993 REPORT N UMBER A93O0343

MANDATE OF THE TSB


The Canadian Transportation Accident Investigation and Safety Board Act provides the legal framework governing the TSB's activities. Basically, the TSB has a mandate to advance safety in the marine, pipeline, rail, and aviation modes of transportation by: ! ! ! ! ! conducting independent investigations and, if necessary, public inquiries into transportation occurrences in order to make findings as to their causes and contributing factors; reporting publicly on its investigations and public inquiries and on the related findings; identifying safety deficiencies as evidenced by transportation occurrences; making recommendations designed to eliminate or reduce any such safety deficiencies; and conducting special studies and special investigations on transportation safety matters.

It is not the function of the Board to assign fault or determine civil or criminal liability. However, the Board must not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board's findings.

INDEPENDENCE To enable the public to have confidence in the transportation accident investigation process, it is essential that the investigating agency be, and be seen to be, independent and free from any conflicts of interest when it investigates accidents, identifies safety deficiencies, and makes safety recommendations. Independence is a key feature of the TSB. The Board reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be fully objective in arriving at its conclusions and recommendations.

The Transp ortation Safety Board of Canad a (TSB) investigated this occu rrence for the p u rp ose of ad vancing transp ortation safety. It is not the fu nction of the Board to assign fau lt or d eterm ine civil or crim inal liability.

Aviation Occurrence Rep ort

Loss of Control Beech B58P Baron C-FKSB Toronto Island Airp ort, Ontario 1.8 nm W 09 October 1993 Rep ort N u m ber A93O0343

Synopsis
Shortly after take-off from Toronto Island Airp ort, Ontario, the pilot rep orted that he had an engine failu re and requ ested clearance to retu rn to the airp ort. The aircraft crashed into Lake Ontario, 1.8 nau tical m iles w est of the Toronto Island Airp ort. All fou r occu p ants of the aircraft w ere fatally inju red and the aircraft w as d estroyed w hen it struck the w ater. The Board d eterm ined that, after exp eriencing a pow er loss d u ring the initial clim b-out, the p ilot lost control of the overw eight aircraft w hile attem p ting to retu rn to the airp ort. The cau se of the pow er loss w as not d eterm ined ; how ever, both engines w ere found to be cap able of p rod u cing fu ll pow er w hen tested . Ce rap p ort est galem ent d isp onible en franais.

TA BLE O F C O N TEN TS

Table of Contents
Page

1.0

Factu al Inform ation


1.1 1.2 1.3 1.4 1.5 1.5.1 1.5.2 1.6 1.6.1 1.6.2 1.6.3 1.6.4 1.7 1.8 1.9 1.10 1.11 1.12 1.12.1 1.12.2 1.13 1.14 1.15 1.15.1 1.15.2 1.15.3

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1 1 2 2 2 2 3 3 4 4 5 5 5 6 6 7 7 7 8 8 8 8 9 9 9 9

H istory of the Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inju ries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dam age to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Dam age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personnel Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pilot H istory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Co-p ilot H istory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aircraft Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aircraft Maintenance H istory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aircraft Weight and Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aircraft Perform ance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aircraft Equ ip m ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Meteorological Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Com m u nications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aerod rom e Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Flight Record ers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rad ar Flight Path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wreckage and Im p act Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aircraft Stru ctu re . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Throttle Qu ad rant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Med ical Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Engines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prop ellers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cockp it Instru m ents and Sw itches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

2.0

Analysis
2.1 2.2 2.3 2.4

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Introd u ction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 The Pow er Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Aircraft Perform ance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Weather Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

TRA N SP O RTA TIO N SA FETY BO A RD

iii

TA BLE O F C O N TEN TS

3.0

Conclu sions
3.1 3.2

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Find ings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Cau ses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4.0 5.0

Safety Action Ap p end ices

Ap p end ix A - Rad ar Flight Path Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Ap p end ix B - List of Su p p orting Rep orts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Ap p end ix C - Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

List of Figu res


Figu re 1 - Flight Path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

iv

TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N

1.0 Factual Information


1.1 History of the Flight

At 0735 eastern d aylight saving tim e (EDT)1, the pilot, co-p ilot, and tw o p assengers d ep arted from Toronto Island Airp ort, Ontario, in a Beech B58P Baron for a pleasu re flight to Walker's Key, Baham as, w ith an en rou te fu el stop at Wilm ington, N orth Carolina. The trip w as originally p lanned for earlier in the w eek bu t w as d elayed w hen the aircraft becam e unserviceable after the installation of a new fu el m anagem ent system . When the first flight follow ing the installation w as attem p ted , the left engine ran roughly and d id not prod u ce fu ll p ow er; the aircraft w as returned to m aintenance. On the night before the accid ent flight, the aircraft w as su ccessfu lly grou nd ru n and test flow n after the m aintenance and rep airs w ere com p leted . Follow ing the test flight, the aircraft w as refu elled and parked in a hangar in p rep aration for the early m orning d epartu re.

p ilot taxied for take-off at 0730. Several w itnesses observed the aircraft d ep art at 0735 and rep orted that the take-off ap p eared norm al, w ith both engines op erating sm oothly and at w hat ap p eared to be fu ll pow er. Once airborne, the pilot contacted the Toronto Area Control Centre (ACC) d epartu re controller and w as given a d ep artu re instru ction, w hich he d id not acknow led ge. When the d ep artu re controller rep eated the d ep artu re instru ction, the pilot resp ond ed that he had an engine failu re and requ ested an im m ed iate retu rn to the airport. There w ere no fu rther rad io transm issions from the aircraft and it w as observed in a steep nosed ow n d escent w hen it stru ck the w ater at 0738 d u ring d aylight hou rs. Metro Toronto Police d ivers found the aircraft abou t 1.8 nau tical m iles (nm )3 w est of the airp ort in 50 feet of w ater at latitu d e 4337'37"N , longitu d e 07926'41"W. There w ere no su rvivors.

A ll tim es a r e ED T (C o o r d in a ted U n iv er sa l Tim e [U TC ] m in u s fo u r h o u r s) u n less o th er w ise sta ted . See G lo ssa r y fo r a ll a b b r ev ia tio n s a n d a cr o n y m s. U n its a r e co n sisten t w ith officia l m a n u a ls, d o cu m en ts, r ep o r ts, a n d in str u ctio n s u sed b y o r issu ed to th e cr ew .

2 3

At 0630, the aircraft w as parked on the ram p . The pilot w as observed load ing his baggage at abou t 0645. Shortly afterw ard s, the co-p ilot and tw o passengers arrived at the aircraft w ith their baggage and a sm all d og. At abou t 0720, the aircraft engines w ere started ; after receiving his instru m ent flight rules (IFR)2 clearance, the TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N

Figure 1 - Flight Path

1.2

Injuries to Persons
Crew Passengers Others Total 2 2 4 4

Fatal Serious Minor/ N one Total

2 2

Age Pilot Licence Med ical Exp iry Date Total Flying H ou rs H ou rs on Typ e H ou rs Last 90 Days H ou rs on Typ e Last 90 Days H ours on Duty Prior to Occu rrence H ours off Duty Prior to Work Period

46 ATPL 01 Mar 94 3,500 50 50 50 N/ A N/ A

49 PPL 01 Feb 94 700 145 18 18 N/ A N/ A

1.3

Damage to A ircraft

The aircraft w as d estroyed w hen it stru ck the w ater and su bsequ ently sank in Lake Ontario.

All the flying tim es for the pilot and co-p ilot are app roxim ate as no personal logbooks for either ind ivid u al w ere found .

1.4

Other Damage
1.5.1 Pilot History

There w as no other d am age.

1.5

Personnel Information
Pilotin-com m and Co-p ilot

The pilot obtained his private pilot licence on 02 Febru ary 1981 and his night rating on 07 Au gu st 1981 at Thu nd er Bay, Ontario. In 1984, he ad d ed a seaplane end orsem ent and m u lti-engine end orsem ent to his pilot qu alifications. The pilot w as unsu ccessful at his first attem p t to obtain an instru m ent rating d u ring a flight test on 02 May 1986.

TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N H e subsequ ently passed his instru m ent rating flight test on 27 Au gust 1986 and w as issu ed a class one instrum ent rating. On 15 Decem ber 1987, the pilot's instru m ent rating w as renew ed to class one stand ard s for six m onths only, becau se he exp erienced d ifficu lty w ith non-d irectional beacon (N DB) ap p roach proced u res and becau se he respond ed slow ly to a sim u lated pow er loss on a m issed app roach. The pilot up grad ed to an airline transp ort pilot licence (ATPL) on 26 Ap ril 1989. H e com p leted a pilot proficiency test on a Piper N avajo PA-31 aircraft in Sep tem ber 1989. On 28 Decem ber 1989, he failed his instru m ent renew al flight test w hen he flew in the w rong d irection to a final ap p roach fix. A m onth later, he failed his re-rid e w hen he d id not fly a su ccessful N DB ap p roach d u ring his flight test. On his third consecu tive instru m ent renew al flight test, he successfu lly renew ed his class one instru m ent rating on 06 Febru ary 1990. H e m aintained his instru m ent rating until 17 Ju ne 1992, w hen he failed his renew al flight test for flying a p roced u re tu rn 1,000 feet below the m inim u m altitu d e. On 04 Au gu st 1992, he successfu lly renew ed his class one instrum ent rating. All of his instru m ent flight tests w ere flow n in a Pip er Tw in Com anche PA-30 aircraft w hich he ow ned . The pilot had first flow n the accid ent aircraft on 09 Ju ly 1993, and had since accu m u lated 40 hou rs total flying tim e in it. Of these 40 hou rs, 11 hou rs had been flow n w ith the co-p ilot. The pilot w as aw are of the engine problem s the aircraft had exp erienced over the previou s d ays. The pilot had a valid class one m ed ical w ith the restriction that glasses m u st be available. 1.5.2 Co-pilot History m u lti-engine, night, and seaplane end orsem ent. H e obtained a class tw o instru m ent rating on 06 May 1983. On 17 Ju ne 1992, he obtained a class one instru m ent rating after letting his previous instru m ent rating exp ire. The co-p ilot w as a joint ow ner of the aircraft w ith an Ontario nu m bered com p any. The co-p ilot had a valid class three m ed ical w ith no restrictions.

1.6

A ircraft Information
Beech Aircraft Corporation 58P Baron 1977 TJ - 106 Valid 1,982 hou rs Teled yne Continental TSIO 520 - L (2) H artzell PH C - J3YF - 2UF (2) 6,100 pound s 100 LL, 100/ 130, 115/ 145 100 LL

Manu facturer Type and Mod el Year of Manu factu re Serial N u m ber Certificate of Airw orthiness (Flight Perm it) Total Airfram e Tim e Engine Typ e (nu m ber of) Propeller/ Rotor Type (nu m ber of) Maxim um Allow able Take-off Weight Recom m end ed Fu el Typ e(s) Fuel Typ e Used

1.6.1

A ircraft M aintenance History

The aircraft had been m aintained and serviced in accord ance w ith existing regulations and it w as m echanically and cosm etically w ell kep t. There had been tw o recent m od ifications to the aircraft. On 11 Ju ne 1993, a vortex generator system w as installed in accord ance w ith su p p lem ental type certificate (STC) SA4016N M. At that tim e, the aircraft had accum u lated 1,866.7 hours total airfram e tim e. The m od ification TRA N SP O RTA TIO N SA FETY BO A RD

The co-p ilot received his private pilot licence on 26 N ovem ber 1978. By 06 Decem ber 1979, he had com p leted a

FA C TU A L IN FO RM A TIO N is d esigned to m aintain lam inar airflow over the w ings and tail, and thereby enhance the hand ling and control of the aircraft at slow er sp eed s as w ell as im p rove the stall characteristics. The second m od ification w as the installation of a Shad in Digiflo-L d igital fu el m anagem ent system on 04 October 1993. Part of this m od ification inclu d ed the installation of a fu el flow transd u cer in the fu el lines of each engine. The second part of the installation includ ed a light-em itting d iod e (LED) d isp lay instru m ent w hich ind icated the fuel flow of each engine. The Shad in Digiflo-L d igital fu el m anagem ent system is d esigned so it can be cou p led w ith som e m od els of global positioning system (GPS) units and used to calcu late the fu el requ ired to proceed to any selected w ayp oint or d estination. The GPS installed in this aircraft w as not comp atible w ith the Digiflo-L and therefore w as not coup led to it. The selector sw itch on the LED d isp lay w as found in the end u rance position. On the first flight follow ing the installation of the Shad in Digiflo-L system , the pilot (not the accid ent pilot) rejected his take-off ru n becau se of a lack of engine p ow er from the left engine. When the engine w as exam ined by the aircraft m aintenance engineer (AME), it w as d eterm ined that there w ere tw o sep arate p roblem s: first, that the engine w as ru nning rou ghly, and second , that the engine w as not d evelop ing fu ll pow er. In trou ble shooting the first problem , the left magneto and ignition harness from the right engine w ere installed on the left engine. A new m agneto and ignition harness w ere installed on the right engine. This corrected the rough ru nning engine problem , but the left engine still d id not prod u ce fu ll pow er. The Bend ix servo fu el units w ere exchanged betw een engines. The left engine still d id not prod u ce fu ll pow er; the right engine d id prod u ce fu ll pow er. A fu el flow check revealed that one of the fu el injectors on the left engine w as partially p lu gged . When it w as cleaned , the left engine prod u ced fu ll pow er and ran sm oothly. Du ring the trou ble shooting p roced u re, the right engine m ixtu re control cable w as fou nd to be w orn and w as replaced . After all the w ork w as com p leted , and after an extend ed ground ru n, the aircraft w as test flow n for ap p roxim ately 30 m inu tes. There w ere no reported d iscrep ancies d u ring the ground ru n or flight. 1.6.2 A ircraft W eight and Balance

The m axim u m take-off and land ing w eight of the aircraft is 6,100 pound s, and the centre of gravity lim its at that w eight are betw een 78.4 inches and 84.5 inches aft of d atu m. The calcu lated take-off w eight for the flight w as 6,445.3 pound s w ith a centre of gravity of abou t 80.1 inches aft of d atu m . At im p act, the calculated w eight w as 6,337 p ou nd s and the centre of gravity w as virtu ally unchanged . The m axim u m w eight of the aircraft w as exceed ed by 345.3 p ou nd s at take-off. 1.6.3 A ircraft Performance

The aircraft flight m anu al (AFM) ind icates that the take-off and m axim u m continu ous p ow er setting is 38.0 inches of m ercu ry (in. H g) of m anifold pressu re and 2,700 engine rp m . The norm al cru ise clim b pow er setting is 34.0 in. H g and 2,400 rp m . When leaning the m ixture, the pow er is not to exceed the m axim u m cru ise pow er settings of 33.0 in. H g and 2,400 rpm , and a p eak tem peratu re of 1,650 d egrees Fahrenheit, as ind icated on the tu rbine inlet tem p eratu re (TIT) gau ge, is not to be exceed ed . The AFM ind icates that the clim b p erform ance for a norm al d ep arture w ith an ind icated airsp eed (IAS) of 115 knots, given the am bient cond itions at the tim e of the occu rrence and a take-off w eight of

TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N 6,100 pou nd s, w ou ld result in a 1,600 feet p er m inute (fp m ) clim b w ith a clim b grad ient of 11.0 per cent. If one engine becam e inop erative and the pilot follow ed the correct one-engine inop erative p roced u res, the rate of clim b w ou ld d ecrease to 230 fp m w ith a clim b grad ient of 1.50 per cent. Both clim b perform ances are based on the pow er set at m axim u m continu ou s w ith the flaps and land ing gear u p , the cow l flap (s) op en, and the inop erative prop eller feathered . Any d eviation from these cond itions and p roced u res cou ld red u ce the aircraft p erform ance. The pilot of the accid ent flight had a Digiflo-L d igital fu el m anagem ent system installed in his recently acqu ired Beechcraft B55 Baron aircraft. The pilot's B55 Baron aircraft is equ ip p ed w ith tw o Teled yne Continental IO 520-C, 285 H p engines. The sm aller 285 H p engines op erate on a low er fu el flow than the larger 310 H p engines that w ere on the accid ent aircraft. 1.6.4 A ircraft Equipment w ind 350 d egrees m agnetic at 10 knots gusting to 21 knots. The altim eter w as 29.96 in. H g. At 0800, about 22 m inu tes after the accid ent, the w eather observation at Toronto Island Airp ort w as sim ilar to the p revious hourly observation excep t that the overcast layer had changed to 2,500 feet agl, and the visibility had d ecreased to four m iles in light rain show ers and fog. The w ind had d ecreased to 330 d egrees m agnetic at 9 knots gu sting to 18 knots. The actu al w eather observations w ere consistent w ith the forecast w eather for this area.

1.8

Communications

The aircraft w as fully equ ip p ed for IFR flight. Ad d itional navigation equ ip m ent installed in the aircraft inclu d ed the follow ing: an Ap ollo GPS receiver w ith a N orth Am erica d ata card , a King KN 74 Area N avigation (RN AV) u nit, a d istance m easu ring equ ip m ent (DME) receiver, a Collins WXR-200 w eather rad ar, and a tw oaxis au top ilot.

The flight w as cleared to the Wilm ington, N orth Carolina, Airport via an "Island fou r" stand ard instru m ent d ep arture (SID), w ith rad ar vectors to intercep t the Victor 252 airw ay until the Genesseo very high frequ ency om ni-d irectional range (VOR) and then d irect to Wilm ington. The Island fou r SID for ru nw ay 26 requ ired the aircraft to clim b on the ru nw ay head ing to 650 feet above sea level (asl) and then m ake a left tu rn to 200 d egrees m agnetic for rad ar vectors to the assigned rou te w hile clim bing to maintain 2,000 feet asl. The pilot received and read back his IFR clearance prior to taxiing for d ep artu re. At 0734, the pilot contacted the tow er controller and ad vised him that the flight w as read y to go on ru nw ay 26. The tow er controller coord inated the IFR release of the flight w ith the Toronto ACC d ep artu re controller and then cleared the aircraft for take-off w ith instru ctions to contact the d ep artu re controller on the assigned rad io frequ ency. The aircraft took off at 0735 and contacted the d ep arture controller abou t a m inu te and a half later. The aircraft w as rad ar id entified and cleared to m aintain 5,000 feet asl and proceed d irect to the Bu lge intersection w hen able. The pilot d id TRA N SP O RTA TIO N SA FETY BO A RD

1.7

M eteorological Information

The 0700 actu al w eather observation for Toronto Island Airp ort w as broad cast on the au tom atic term inal inform ation service (ATIS). Inform ation alp ha, w hich the pilot acknow led ged receiving w hen he requ ested the taxi clearance, w as 1,200 feet above grou nd level (agl) scattered , measu red 1,500 feet agl broken, 2,000 feet agl overcast, visibility greater than 15 m iles w ith light rain show ers, tem p eratu re eight d egrees Celsiu s, d ew point six d egrees Celsiu s, and

FA C TU A L IN FO RM A TIO N not acknow led ge this transm ission. After a second transm ission by the d ep artu re controller at 0737, the pilot stated that he had an engine failu re and requ ested an im m ed iate retu rn to the airp ort. The d epartu re controller ap p roved the requ est and d irected the pilot to contact the airport tow er controller. The d epartu re controller also inform ed the tow er controller that the aircraft w as retu rning w ith an engine failu re. The pilot d id not state w hich engine had failed or the natu re of the engine failu re, and d id not re-establish com m u nications w ith either the tow er or d ep arture controller. At 0738, the d ep arture controller inform ed the tow er controller that all rad ar contact w ith the aircraft w as lost w hen the aircraft w as abou t tw o m iles w est of the airp ort. The tow er controller inform ed the d ep arture controller that the aircraft had gone d ow n into the w ater at 0738 after the d river of Red Tw o, an airp ort fire tru ck, ad vised the tow er controller of the occu rrence. The aircraft w as id entified at 0736 using the airp ort surveillance rad ar, ASR 5, located at Toronto International Airp ort, and w as tracked until all rad ar contact w as lost at 0737. The first rad ar contact ind icated that the aircraft w as at 700 feet asl on the initial clim b. The aircraft clim bed abou t 1,000 fpm to 1,050 feet asl, w ith the grou nd sp eed increasing from 96 knots at 700 feet asl to a m axim u m of 123 knots at 1,050 feet asl. The rad ar ind icated that the aircraft w as d rifting sou th of the extend ed ru nw ay centre line, althou gh no significant tu rn or change in aircraft head ing w as observed . At 1,050 feet asl, the grou nd sp eed began to d ecrease from 123 knots to 84 knots over a 15-second period . The 1,000 fpm clim b w as arrested as the aircraft tem porarily levelled off at 1,200 feet asl. Du ring the next 11 second s, the grou nd sp eed rem ained below 90 knots, and the 1,000 fp m clim b w as re-established as the aircraft clim bed to its m axim u m altitud e of 1,500 feet asl w hile m aintaining a fairly constant d ep artu re track. Du ring this p ortion of the clim b, at ap p roxim ately 1,300 feet asl, the pilot contacted the d ep artu re controller. The pilot received his initial d ep artu re instru ctions but d id not read them back. As the aircraft altitu d e reached 1,500 feet asl, the 1,000 fp m clim b w as arrested ; the aircraft began to d escend and m om entarily reached a m axim u m d escent rate of 4,000 fp m . In this nine-second flight segm ent, the aircraft track ind icated a significant tu rn to the northw est w hile the aircraft grou nd sp eed rem ained below 100 knots. The aircraft d escend ed to 600 feet asl before the rate of d escent w as arrested , and a 1,000 fp m clim b w as briefly re-established as the aircraft clim bed to an altitu d e of 900 feet asl and the grou nd speed d ecreased to 83 knots. Passing throu gh 800 feet asl, the pilot inform ed the d epartu re controller that he had an engine failu re and w anted to retu rn im m ed iately to the airp ort. This w as

1.9

A erodrome Information

The Toronto Island Airp ort, elevation 251 feet asl, is a p u blic airp ort op erated by the Toronto H arbou r Com m ission and is located on Centre Island in the Toronto harbou r. There are three paved ru nw ays, the longest being ru nw ay 08/ 26, w hich is 4,000 feet long by 150 feet w id e. H u m ber Bay is located on the north shore of Lake Ontario and is ad jacent to the w estern bound ary of the airport and und er the d ep artu re path of ru nw ay 26.

1.10 Flight Recorders


The aircraft w as not equ ip p ed w ith a flight d ata record er or a cockpit voice record er, nor w as either requ ired by regu lation.

1.11 Radar Flight Path

TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N the last com m u nication from the aircraft. The last rad ar target show ed the aircraft at 900 feet asl in a right turn, w ith the ground sp eed below 100 knots. ed ges had m elted slightly. There w as also som e soot staining and som e blistered paint on the em p ennage. 1.12.2 Throttle Quadrant

1.12 W reckage and Impact Information


1.12.1 A ircraft Structure The aircraft stru ck the w ater in a steep nose-d ow n, left-w ing-low attitu d e. Although the im p act w as severe, the aircraft cabin section rem ained intact except for the pilot's sid e w ind ow , w hich w as broken ou t, and the cockp it floor, w hich w as pu shed up . Other fu selage d am age inclu d ed the nose section, w hich d isintegrated on im p act, and the structu re behind the nose baggage comp artm ent, w hich w as d eform ed up w ard s and to the left. It w as not possible to op en the right sid e d oor becau se of the d eform ation. There w as no d eform ation at the back of the cabin, and the left rear d oor op ened freely. The tail section failed to the left at a p oint im m ed iately in front of the em p ennage. The em p ennage itself w as intact bu t w as attached to the fu selage only by the control cables. Both w ings failed in a rearw ard d irection at the fu selage attachm ent points and com p rom ised the w ing fuel tanks. The inboard w ing sections, comp lete w ith the engine nacelles and engines, rem ained attached to the fu selage by only the engine control cables. The ou tboard section of the left w ing lead ing ed ge w as rolled d ow n and u nd er. The ou tboard section of the right w ing had failed outboard of the right engine. This section of w ing w as bent up and back at the w ing tip. There w as som e soot staining along the left sid e of the fu selage. The broken ed ges of plexiglass in the left cockp it w ind ow fram e w ere heat blistered and the

The tw o front seats w ere com p ressed d ow nw ard , bu t the actu al seat positions w ere d isp laced up w ard s becau se the floor w as p ushed u p . The engine controls w ere consistent w ith the stand ard Beechcraft configu ration for this typ e of aircraft. All the engine control levers w ere fou nd in the fu ll forw ard positions and all had been bent over to the right. The prop eller controls w ere bent over in front of the throttles, w hich w ere bent over slightly behind the m ixtu re controls. An im p act m ark of unknow n origin on the control qu ad rant betw een the left and right prop eller controls w as consistent w ith the right propeller control being at or near the feathered position. It w as not possible to d eterm ine w hether this m ark w as m ad e prior to or at im p act. The left throttle w as behind the prop eller control and had hit the propeller control knob. N o conclu sive evid ence can be d raw n from the position of the throttle qu ad rant engine controls.

1.13 M edical Information


There w as no evid ence that incap acitation or p hysiological or p sychological factors affected the p ilot's or co-p ilot's p erform ance.

1.14 Fire
Witnesses rep orted that there w as no fire before the im p act, but they d id see a postim p act fire. There w as som e heat d am age to the w ind ow s on the left sid e of the aircraft and some scorching of paint on the p lastic fairing p ieces on the tail. The soot p atterns arou nd the rivets w ere consistent w ith a post-crash fire pattern for an aircraft TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N that w as nose d ow n and sinking in the w ater after the w ings and fu el tanks w ere com p rom ised . The m ost severely burnt com p onent w as the left-hand su n visor, w hich w as fou nd floating in the w ater. In the test cell, both engines w ere su ccessfully ru n to fu ll pow er. The left engine ran rou ghly d u ring the test ru ns, and this w as attribu ted to m oisture in the m agneto and im p act d am age to the ignition harness. 1.15.2 Propellers The aircraft had tw o H artzell constantsp eed , fu ll-feathering, three-blad ed p rop ellers. The pitch setting at the 30-inch station is from 15.3 d egrees (low pitch) to 84.0 d egrees (high pitch), w hich corresp ond s to the feathered position. The prop eller flange on the left engine had failed at im p act and the left p rop eller had sep arated from the left engine. Desp ite several und erw ater searches, the left propeller w as not found . The right prop eller w as d ism antled and exam ined . All three prop eller blad es w ere tw isted tow ard s a low pitch setting. Im p act m arks on the three prop eller blad e p reload plates ind icated that the blad e angles at im p act w ere 18, 18, and 19 d egrees respectively. Althou gh these blad e angles are consistent w ith a take-off or clim b p ow er setting, they m ay also exist in a constant speed prop eller system w hen engine pow er is red u ced w ithout a correspond ing red u ction in the selected p rop eller rpm . 1.15.3 Cockpit Instruments and Switches Exam ination of the flight and engine instru m ents revealed the follow ing ind ications at im p act: Tachom eter - left engine - 2680 rp m Tachom eter - right engine - 2450 rp m (red line is 2700 rp m )

1.15 Tests and Research


1.15.1 Engines Both of the engines w ere recovered from Lake Ontario and exam ined . The initial exam ination of the engines revealed no evid ence of any p re-im p act airflow restrictions w hich cou ld have ad versely affected the com bu stion and the engine p ow er prod u ced . There w as no ind ication that either of the air filters w as plu gged , and the alternate air d oors, w hich ensu re ad equ ate airflow to the inlet sid e of the turbo chargers, w ere fu nctional. Both of the tu rbo chargers turned freely and w ithout any restriction. Most of the ind u ction tu bes on both engines had been d am aged d u ring the im p act, bu t there w as no ind ication of any pre-im p act m alfu nction or cond ition in the ind u ction system . The engine ignition system s, w hich consisted of four m agnetos (tw o on each engine), ignition w iring harnesses, and spark plugs, w ere visu ally exam ined and w ere d eterm ined to be m echanically fit. It w as then d ecid ed to cond u ct a test of both engines at the Teled yne Continental Motors m anu factu ring facility in Mobile, Alabam a. The d am age cau sed by the accid ent w as rep aired , w hich entailed rep lacing the oil sum p s, rocker covers, ind u ction tu bes, exhau st stacks, and w eld ing on the left engine prop eller flange. Both engines w ere then installed in a test cell and ru n. The engine runs w ere cond u cted w ithou t any m od ifications or rep airs to either of the engine's fu el system s, ignition system s, or m echanical d rive trains, w hich w ere tested in an "as recovered " cond ition.

Manifold pressu re - left engine - 29 in. H g Manifold pressu re - right engine - no ind ication (red line is 38 in. H g)

TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N The attitu d e ind icator ind icated a 32- to 34-d egree nose-d ow n attitud e w ith a 20- to 30-d egree left bank. The d igiflo fu el gauge ind icated that 25.9 im p erial gallons of fu el had been used and 168 im p erial gallons w ere rem aining at the tim e of the accid ent. N o ind ication of the fu el flow s from the engine cou ld be obtained . The flap selector w as fou nd in the d ow n position and the flap ind icator w as at 15 d egrees flap d ow n. Exam ination of the w ing flap extension actu ator ind icated that no flap w as d ow n. The land ing gear hand le w as fou nd in the up p osition and the land ing gear m otor w as in the fu ll-travel up position, as w as the actu al land ing gear. The fu el selectors located on the cockp it floor betw een the tw o front seats w ere both in the crossfeed position. Both fu el selector valves in the w ings w ere in the off or fu ll-travel position. Both of the fu el boost pu m p sw itches w ere selected on. The fu el system of the aircraft w as com p rom ised d u ring the im p act; how ever, sm all resid u al sam p les of fu el trap p ed in the fu el lines and fu el system comp onents w ere collected and tested . The fu el tested w as fou nd to be clean and w as the prop er 100 low lead aviation gasoline for this aircraft. The alternator sw itches, battery sw itch, and right land ing light sw itch w ere fou nd in the on position. The tw o rotary m agneto sw itches w ere both found in the "both" position. The left electrical load m eter ind icated 0.4 on the load m eter scale. The right load m eter had no visible ind ication.

TRA N SP O RTA TIO N SA FETY BO A RD

A N A LYSIS

2.0 A nalysis
2.1 Introduction

The investigation revealed that both the p ilot and co-p ilot w ere prop erly licensed and qu alified , and the aircraft w as serviceable for the flight.

The rad ar d ata ind icated that the initial clim b w as norm al to 1,050 feet asl, at w hich tim e the grou nd sp eed d ecreased . This could have occu rred w hen the pilot w as red u cing to clim b pow er. Since the aircraft's rate of clim b w as a constant 1,000 fp m , the airsp eed w ou ld have d ecreased as a result of the low er pow er setting. The aircraft m om entarily levelled off at 1,200 feet asl. When the pilot m ad e his first call to the d ep artu re controller throu gh abou t 1,300 feet asl, he d id not ind icate that he w as having any engine problem s. Therefore, it is unlikely that the m om entary level-off at 1,200 feet asl w as a resu lt of the engine failu re or the loss of pow er. Since the pilot had d ifficu lty w ith IFR flight, he may have fou nd it ad vantageou s to use the au top ilot at this busy tim e of the flight. The m om entary level-off could have been cau sed by the p ilot engaging the au topilot if the au topilot w as set for level flight. If the pilot then activated the au top ilot trim w heel for a clim b, this could exp lain the clim b from 1,200 feet asl to 1,500 feet asl w ith a constant rate of clim b of 1,000 fp m w hile the airsp eed rem ained low . If the au topilot w as engaged , the pilot w ou ld have been free to call the d ep artu re controller, com p lete his after take-off checks, and ad ju st the pow er settings. If the pilot or co-p ilot leaned the m ixtu res using the new ly installed Shad in Digiflo-L fu el managem ent system d u ring this part of the clim b, a p ow er loss situ ation m ay have inad vertently occu rred . If the m ixtu res w ere red u ced to a fu el flow setting ap p ropriate to the sm aller 285 hp engines of the aircraft that the pilot ow ned and w as fam iliar w ith, then, given the greater fu el flow requ ired by the 310 hp engines on the accid ent aircraft, it is possible that the accid ent aircraft could have lost partial or total pow er on one or both engines. If this occu rred , and the aircraft autop ilot w as engaged , the pilot m ay have been d istracted

2.2

The Power Loss

In consid eration of the recent m aintenance history of the aircraft, the engines w ere insp ected and test runs w ere cond u cted to d eterm ine w hat cou ld have caused a total or partial pow er loss on one or both of the engines. The engine test runs ind icated that both engines w ere cap able of prod u cing fu ll p ow er even w hen tested in an alm ost "as recovered " cond ition. Based on the insp ection of the engines and their p erform ance d u ring the test ru ns, the cau se of the total or p artial pow er loss on one or both of the engines cou ld not be d u p licated or d eterm ined . The exam ination of the left prop eller engine flange, the right prop eller, and available cockp it engine instru m ents ind icated that neither prop eller w as feathered at imp act and that the left engine w as prod u cing at least partial pow er. The im p act m ark on the right engine tachom eter ind icated that the right prop eller w as at 2,450 rp m at im p act. It is m ost likely that the pow er loss exp erienced by the pilot w as not caused by a m echanical m alfu nction of the engines.

2.3

A ircraft Performance

Although the natu re and source of the p ow er loss experienced by the pilot cou ld not be d eterm ined , the exam ination of the rad ar d ata d id reveal several key asp ects abou t the aircraft's perform ance.

10

TRA N SP O RTA TIO N SA FETY BO A RD

A N A LYSIS in d ealing w ith the engine m alfu nction and not have noticed the airsp eed d ecrease. The rad ar d ata ind icated that, at 1,500 feet asl, the aircraft d escend ed rap id ly w ith no increase in grou nd sp eed ; this cou ld have resu lted from the overw eight aircraft stalling. The aircraft d escend ed to 600 feet asl before the rate of d escent w as arrested , then a 1,000 fp m clim b w as briefly reestablished as the aircraft clim bed to an altitu d e of 900 feet asl and the ground sp eed d ecreased to 83 knots. Passing through 800 feet asl, the pilot inform ed the d ep artu re controller that he had an engine failu re and w anted to im m ed iately return to the airp ort. This w as the last com m u nication from the aircraft. The last rad ar target show ed the aircraft w as at 900 feet asl in a right tu rn. The overw eight aircraft most likely stalled again, and the p ilot had insu fficient altitu d e to recover as it d escend ed steep ly ou t of control into Lake Ontario.

2.4

W eather Factors

The low est cloud near the airp ort at the tim e of the occu rrence w as a scattered layer at 1,450 feet asl. The next layer of cloud w as at 1,750 feet asl. Since the aircraft clim bed to 1,500 feet asl, it is possible that the aircraft entered clou d . The visibility at the tim e w as as low as four m iles in fog. These w eather cond itions cou ld have aggravated the pilot's ability to regain control of the aircraft; the lack of a d iscernible horizon w ou ld resu lt in d isorientation, particu larly since the pilot had w eak instru m ent flying skills.

TRA N SP O RTA TIO N SA FETY BO A RD

11

C O N C LU SIO N S

3.0 Conclusions
3.1
1.

Findings
The aircraft w as 345.3 pound s above the m axim u m gross take-off w eight w hen the flight d eparted , and the aircraft w as op erating ou tsid e of the ap p roved w eight and balance envelope at the tim e of the accid ent. Both the pilot and co-p ilot w ere p roperly licensed and qu alified to fly the aircraft. The aircraft w as m aintained in accord ance w ith ap p roved p roced u res and regu lations. The aircraft exp erienced a pow er loss d u ring the initial clim b-ou t. The extent and natu re of the pow er loss w as not d eterm ined ; how ever, the pow er loss m ay have been ind u ced by one of the pilots. The pilot lost control of the overw eight aircraft at 1,500 feet asl, w hile op erating in clou d , and d escend ed to 600 feet asl prior to regaining control of the aircraft. This w as follow ed by a second loss of control at 900 feet asl. Since the pilot had w eak instru m ent flying skills, the w eather cond itions at the tim e of the occu rrence m ay have aggravated the pilot's ability to recover the aircraft. The aircraft stru ck the w ater in a steep , nose-d ow n, left-w ing-low attitu d e.

p ow er loss w as not d eterm ined ; how ever, both engines w ere found to be cap able of p rod u cing fu ll pow er w hen tested .

2.

3.

4.

5.

6.

7.

3.2

Causes

After exp eriencing a pow er loss d u ring the initial clim b-out, the pilot lost control of the overw eight aircraft w hile attem p ting to return to the airp ort. The cau se of the

12

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SA FETY A C TIO N

4.0 Safety A ction


The Board has no aviation safety recom m end ations to issue at this tim e. This report concludes the Transportation Safety Board' s investigation into this occurrence. Consequently, the Board, consisting of Chairperson John W . Stants, and members Z ita Brunet and Hugh M acN eil, authorized the release of this report on 13 June 1995.

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SA FETY A C TIO N

TRA N SP O RTA TIO N SA FETY BO A RD

15

A P P EN D IC ES

A ppendix A - Radar Flight Path Data

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TRA N SP O RTA TIO N SA FETY BO A RD

A P P EN D IC ES

A ppendix B - List of Supporting Reports


The follow ing TSB Engineering Branch Laboratory Reports w ere com p leted : LP LP LP LP LP 138/ 93 Fu el Sam p le Analysis; 141/ 93 Instru m ent Analysis; 152/ 93 Tem p eratu re Analysis - Exhau st Stack Material; 5/ 94 Fu el Screen Contam ination; and 61/ 94 Fu el Flow Ind icator.

These rep orts are available up on requ est from the Transp ortation Safety Board of Canad a.

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A P P EN D IC ES

A ppendix C - Glossary
ACC AFM agl AME asl ATIS ATPL DME EDT fp m GPS hr IAS IFR in. H g lb LED N/ A N DB nm PPL rp m SID STC TIT TSB UTC VOR ' " Area Control Centre aircraft flight m anu al above grou nd level aircraft m aintenance engineer above sea level au tom atic term inal inform ation service Airline Transp ort Pilot Licence d istance m easu ring equ ip m ent eastern d aylight saving tim e feet per m inu te global positioning system hou r(s) ind icated airsp eed instru m ent flight ru les inches of m ercu ry p ou nd (s) light em itting d iod e not available non-d irectional beacon nau tical m iles Private Pilot Licence revolu tions per m inu te stand ard instrum ent d ep artu re su p p lem ental type certificate tu rbine inlet tem p eratu re Transp ortation Safety Board of Canad a Coord inated Universal Tim e very high frequ ency om ni-d irectional range d egrees m inu tes second s

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TSB OFFICES
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