History of Flight
On October 27, 2009, at 0842 eastern daylight time, a Beech A36TC, Canadian registration C-FFIH, was destroyed by impact forces and a post-impact fire following takeoff from runway 35 at Kalamazoo/Battle Creek International Airport (AZO), Kalamazoo, Michigan. The airplane was piloted by a private pilot and was on an instrument flight rules (IFR) flight plan under Title 14 CFR Part 91. The pilot was fatally injured. The flight originated at AZO and was destined for Muskoka Airport (CYQA) in Ontario, Canada.
Communications transcripts showed the pilot contacted AZO ground control at 0835 and received an IFR clearance, then taxied to runway 35. At 0840, the pilot contacted the tower and was cleared for takeoff. No further communications were received.
A handheld GPS receiver in the wreckage provided flight path data. At 0841:03, the takeoff roll began. At 0841:40, the airplane was over the runway at about 70 feet above ground level (agl) and began a right turn. At 0841:57, it reached a maximum altitude of about 156 feet agl with a groundspeed of 83 knots. Subsequent data points showed decreasing altitude and groundspeed: 148 feet at 70 knots, 126 feet at 64 knots, and 61 feet at 64 knots. The last recorded position was about 200 feet from the initial impact point.
Witnesses described the airplane's flight path consistently with the GPS data. Several witnesses reported no smoke or flames before impact. Air traffic control personnel reported that three controllers witnessed the sequence; two described hearing a reduction in engine power, one of whom saw a trail of black smoke.
Personnel Information
The pilot, age 60, held a Canadian private pilot license with ratings for non-high performance single- and multi-engine land and sea airplanes, and a group 3 instrument rating valid until October 1, 2010. He also held a FAA private pilot certificate based on his Canadian license, with single- and multi-engine land ratings. A Canadian category 3 medical certificate, issued July 17, 2008, required glasses available. His flight logbook was not recovered.
Aircraft Information
The airplane was a 1981 Beechcraft A36TC Bonanza, serial number EA-258, a single-engine low-wing monoplane with retractable landing gear, seating six. It was powered by a Teledyne Continental Motors TSIO-520-UB engine rated at 300 horsepower. FAA records indicated an off-airport landing due to engine power loss in July 2009, with no airframe damage. A 100-hour inspection was completed on September 28, 2009, at 3,167 hours airframe time, including re-installation of wings and horizontal stabilizer and installation of a newly manufactured engine (serial number 1000903). An annual inspection was also completed that day. Most recent maintenance on October 26, 2009, included oil change, throttle control replacement, control yoke chain re-clocking, right aileron trim tab straightening, and brake work.
Meteorological Information
At 0853, AZO weather reported wind 360° at 4 knots, visibility 6 statute miles, few clouds at 1,000 feet agl, overcast at 2,000 feet agl, temperature 9°C, dew point 7°C, altimeter 30.02 inches of mercury.
Wreckage and Impact Information
The airplane impacted the ground, an airport perimeter fence, and a pole about 1,400 feet and 27 degrees from the departure end of runway 35. Fuel tanks ruptured and fuel ignited, causing fire damage to vehicles in a north-side parking lot. The airplane came to rest upright facing north about 200 feet from initial impact. The cabin section, inboard left wing, and right wing sustained substantial fire damage.
The left wing was intact with minimal impact damage; the outboard third of the right wing separated. Flight control continuity was verified. Elevator trim tabs were found at 0° (left) and 3° tab down (right). Flaps were up. Landing gear was up. Mixture and propeller controls were forward; throttle was about 2.6 inches from full forward. The fuel selector was positioned for the right wing main tank; the auxiliary fuel pump switch was in the "HI" position. The pump was functional during testing. The engine crankshaft flange separated; the propeller was found about 50 feet from the wreckage. Engine examination showed no abnormal wear; compression and valve action were confirmed.
Medical and Pathological Information
An autopsy on October 28, 2009, listed cause of death as thermal injuries and inhalation of products of combustion. Toxicology detected 30% carbon monoxide in blood, 2.02 µg/ml cyanide, no ethanol, and quinine in urine.
Tests and Research
The engine was shipped to the manufacturer for examination. Due to a separated crankshaft flange and impact damage, the crankshaft was replaced for testing. Pitting was noted on intake valve lifter faces for cylinders 4, 5, and 6. The engine was reassembled with original components except the crankshaft, mounts, and damaged induction/exhaust tubes. An operational test was performed: the engine started normally, warmed up, produced rated power at full throttle, and responded to rapid throttle advancements without hesitation.
TCM issued Mandatory Service Bulletin MSB09-8 on November 3, 2009, regarding inspection and removal of certain hydraulic lifters due to accelerated wear, which included the accident engine. The FAA issued Airworthiness Directive 2009-24-52 on November 18, 2009, requiring removal of affected lifters.
The airplane was equipped with a Xerion Auracle II engine monitoring system. Data for the accident flight showed engine horsepower increased to over 300 hp for about 20 seconds, then reduced to about 275 hp for 10 seconds, then dropped below 50 hp, briefly rose to about 140 hp, and fell to about 75 hp. Corresponding changes in fuel flow and manifold air pressure were recorded. The power reduction was consistent with power reductions recorded during landing phases of previous flights.