NTSB Identification: LAX91FA282.
The docket is stored on NTSB microfiche number 45514.
Accident occurred Sunday, June 30, 1991 in PIONEER, CA
Probable Cause Approval Date: 06/02/1992
Aircraft: BEECH 65, registration: N713JB
Injuries: 6 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

A BEECH 65 COLLIDED WITH TREES IN MOUNTAINOUS TERRAIN AFTER AN INFLT LOSS OF CONTROL. A PILOT OBSERVED THE AIRPLANE START A TURN TO THE RIGHT, ROLL RIGHT AND CONTINUED UNTIL INVERTED AND ENTER INTO A SPIN. THE ACFT WAS IN A STEEP NOSE DOWN ATTITUDE WHEN IT BEGAN ITS PULL; OUT. THE ENGINES WERE HEARD BY A GROUND WITNESS WHO INITIALLY MISTOOK THEM FOR AN APPROACH MOTORCYCLE. THE PILOT INITIALLY FLEW THE ACFT 45 DAYS BEFORE THE ACCIDENT AND LOGGED 3.5 DUAL INSTRUCTION HOURS. THERE WAS NO RECORD IN THE PILOT'S LOGBOOK OF ANY ADDITIONAL FLT TRNG SINCE THE INITIAL FLT. THE PLT SATISFACTORILY COMPLETED A BFR IN A CESSNA 150 FOUR DAYS BEFORE THE ACCIDENT. EXAM OF THE WRECKAGE DSCLSD THE RT ENG HAD BROKEN EXHAUST VALVE, BUT THE LEFT PROP WAS FEATHERED. THERE WERE NO PREEXISTING MECH MALFUNCTIONS OR FAILURES FOUND WITH THE LEFT ENG.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

IMPROPER EMERGENCY PROCEDURES BY THE PILOT, WHEN HE INADVERTENTLY SHUT DOWN THE LEFT ENGINE AFTER ENCOUNTERING A PARTIAL LOSS OF POWER IN THE RIGHT ENGINE. FACTORS RELATED TO THE ACCIDENT WERE: IMPROPER INSTALLATION OF THE RIGHT ENGINE'S #6 EXHAUST VALVE SEAT BY OTHER MAINTENANCE PERSONNEL, FATIGUE FAILURE OF THE #6 EXHAUST VALVE, AND THE PILOT'S LACK OF FAMILIARITY WITH THE AIRCRAFT.

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